Post on 04-Jun-2018
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Christopher Keller
Nephrology Fellow
January 11, 2008
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Principles of renal replacement therapy
Hemodialysis access
Q&A session
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A dialysate containing electrolytes runs
countercurrent on the outside of the
microfibersSolute removal occurs through diffusion
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Volume removal occurs by applyingnegative pressure on the dialysate
Managed by a dialysis nurse
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PUF = Pure Ultrafiltration
Uses an HD machine with an HD filter
Does not run a dialysateSimply removes volume through
negative pressure from the dialysate
space
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Continuous VenoVenous Hemofiltration
Solute removal occurs through
convectionVolume and electrolytes removed are
replaced with a replacement fluid
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Requires ICU care (not managed by HD
nurses)
Requires central access; cannot usearm grafts and fistulas
– Why?
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Old Machine… New Machine!
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Uses the peritoneal membrane as afilter
Two forms – Manual exchanges every 6 hours
– Mostly at night with a cycler machine
Usually used when a patient hasresidual renal function
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Can give intraperitoneal antibiotics (IP)
Call renal fellow when a PD patient is
admitted
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HD is fast and efficient, but requiresadequate BP and causes significant rapid
fluid shifts
CVVH is gentle, provides hour-by-houradjustments for fluid intake, and provides
better renal replacement over time
PD should be continued in house unless
the patient is unstable or the peritoneum is
compromised
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Femoral lines should be removed within3-7 days
IJ lines should be removed within 14days
Patients can go home with a temporary
IJ
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Two types: the “Tesio” and the“PermCath”
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Both are tunneled, usually into the IJ
Tunneling provides a barrier to infection
Lines can stay in for over a year
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Why is it better to have a fistula than a
tunneled line?
Blood flow is faster (400-450 vs 300-350ml/min)
Infection rate is much lower
Mortality benefit to having either a fistula
or a graft versus a line
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We can draw labs (tell the fellow)We can give an erythropoetin analog
(Epogen® or Aranesp®)
We can give a vitamin D analog(Hectorol®, Zemplar®, or Calcijex®)
We can give IV iron (Ferrlecit®,
INFeD®, Venofer®) If urgent, we can give antibiotics