Kaufhold, 1996 1

Renal Replacement Renal Replacement TherapyTherapy

PreparationOptions

Complications

Kaufhold, 1996 2

Preparation of the Preparation of the PatientPatient

Manage CRF Control BP Control glucose

stop oral agents! Prevent Hyper

PTH Vit D Calcium acetate Phosphate binder

Diet Education

Kaufhold, 1996 3

Preparation of the Preparation of the PatientPatient

Manage Fluids Dialysis education Access Placement Prevent anemia Prevent

Malnutrition

metolazone NKF program AV fistula, PD

cath Epogen, Iron This can get tricky

Kaufhold, 1996 4

Progression of CRFProgression of CRF

PTHclimbs

PO4rising

K, UrateUp

AnemiaSx

0

10

20

30

40

50

60

70

80

PTHclimbs

PO4rising

K, UrateUp

AnemiaSx

GFR

Kaufhold, 1996 5

Transition to End StageTransition to End StageEffect of MalnutritionEffect of Malnutrition

74

76

78

80

82

84

86

25 15 10 5

Edema

Body mass

GFR

Measured Wt = 85 Kg

Wt

Kaufhold, 1996 6

Indications for DialysisIndications for Dialysis

A acidosis E electrolyte abnormalities I intoxication/poisoning O fluid overload U uremia symptoms/complications

Kaufhold, 1996 7

Dialysis for IntoxicationsDialysis for Intoxications

T theophylline A aspirin B barbiturates L lithium E ethylene glycol, methanol

Kaufhold, 1996 8

Relative Relative ContraindicationsContraindications

Alzheimer’s disease Multi-infarct Dementia Hepatorenal syndrome Advanced cirrhosis with

encephalopathy Advanced malignancy HIV with dementia

Kaufhold, 1996 9

Types of Renal Types of Renal ReplacementReplacement

Acute RRT: Standard Hemodialysis Redy 2000 Acute Peritoneal Dialysis CAVHD CVVHD Hemoperfusion

Kaufhold, 1996 10

Acute RRT choicesAcute RRT choices

Volume Status Hemodynamic

status Access Bleeding Poisoning

CAVHD? Tolerate Hemo? Abdominal

surgery? Anticoagulation? How catabolic is

pt Hemoperfusion?

Kaufhold, 1996 11

Renal Replacement Renal Replacement TherapyTherapy

Chronic RRT Standard Hemodialysis Peritoneal Dialysis

Continuous vs Intermittent Ambulatory vs Cyclic Cycler Plus*

Combinations

Kaufhold, 1996 12

The Mystery of DialysisThe Mystery of Dialysis

Its no mystery! Clearance

simple diffusion Ultrafiltration

dialysate pump Monitors to make

sure nothing bad happens

blood in

blood out

dialysate in

dialysate plusUltrafiltrate out

Kaufhold, 1996 13

HemodialysisHemodialysis

Advantages standard

treatment widely used Pt has days off Good

reimbursement for Nephrologist

We have control

Kaufhold, 1996 14

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Kaufhold, 1996 16

HemodialysisHemodialysis

Disadvantages Pt has no control strict attn to diet travel restricted need for vascular

access Specific risks Inadequate

clearance

Kaufhold, 1996 17

Peritoneal DialysisPeritoneal Dialysis

Clearance How much fluid

the patient puts in Ultrafiltration

How much fluid comes out

Dextrose used as osmotic agent

Kaufhold, 1996 18

Kaufhold, 1996 19

Peritoneal DialysisPeritoneal Dialysis

Advantages continuous middle molecules pt has control vary tx with diet adjust to lifestyle no need for

vascular access no need for

anticoag.

Kaufhold, 1996 20

Peritoneal DialysisPeritoneal Dialysis

Disadvantages Abdominal

surgery limited clearance limited Uf Needs motivated,

compliant pt risk of peritonitis

Kaufhold, 1996 21

RRT ChoicesRRT Choices

Renal Transplant should be goal Peritoneal Dialysis for the right pt Hemodialysis for everyone else

Kaufhold, 1996 22

DialysisDialysisChronic ComplicationsChronic Complications

Not seen until after chronic access possible

1967 Alfree reported dialysis dementia

Due to impurities in water (100L/tx)

Kaufhold, 1996 23

DialysisDialysisComplicationsComplications

Bleeding disorders

Anemia

Bone disorders

Arthritis

Neuropathy

Cardiovascular

Kaufhold, 1996 24

Dialysis ComplicationsDialysis ComplicationsBleeding disorderBleeding disorder

Due to platelet dysfunction Prolonged bleeding time

Treatment: - more dialysis - dDAVP 0.3 microgm/Kg - Estrogen

Kaufhold, 1996 25

Dialysis ComplicationsDialysis ComplicationsAnemiaAnemia

Due to reduced Erythropoietin - blood loss, reduced response

Treatment: - more dialysis - rHuEPO 2,000 units/tx - Androgens

Kaufhold, 1996 26

Dialysis ComplicationsDialysis ComplicationsArthritisArthritis

Due to accumulation of - Beta-2-microglobulin

Treatment: - more dialysis - Biocompatable membranes - Joint replacement (Hips)

Kaufhold, 1996 27

Dialysis ComplicationsDialysis ComplicationsNeuropathyNeuropathy

Manifestations: - Peripheral Neuropathy - Autonomic dysfunction - Dementia - Dysequilibrium syndrome

Treatment - More dialysis - gradual start of tx - remove water impurities - prevention is best.

Kaufhold, 1996 28

Dialysis ComplicationsDialysis ComplicationsCardiovascularCardiovascular

Manifestations: - Accelerated atherogenesis - Lipid abnormalities - Associated disorders (DM etc) - Leading cause of mortality

Treatment - More dialysis - Treatment of lipid disorders - Control of HTN - Carnitine?

Kaufhold, 1996 29

Adequacy of DialysisAdequacy of Dialysis

Markers mortality hospitalization nutrition

NCDS Gotch and Sargent KT/V = clearance NPCR = nutrition

Kaufhold, 1996 30

SummarySummary

Incidence of ESRD Progression of CRF Indications and contraindications Choices of RRT Complications of CRF, dialysis Adequacy