8Preparation of the Patient Manage CRFControl BPControl glucosestop oral agents!Prevent Hyper PTHVit DCalcium acetatePhosphate binderDiet Education
9Presence of MAU Indicates a Potential Increased Risk for CV Events 1,000900Macroalbuminuria>300 mg/dayIncreased CV Risk and Presence ofRenal and Vascular Dysfunction800700Urinary Albumin (mg/day)600500400300MAUmg/dayIncreased CV Riskand VascularDysfunction200100NormalCardiovascular RiskGarg JP et al. Vasc Med. 2002;7: Eknoyan G et al. Am J Kidney Dis. 2003;42:
10Preparation of the Patient Most of this will be in Stage 4 metolazoneNKF programAV fistula, PD cathEpogen, IronThis can get trickyStop ACE?Manage FluidsDialysis educationAccess PlacementPrevent anemiaPrevent MalnutritionStart ACE?
11Transition to End Stage Effect of Malnutrition WtMeasured Wt= 85 KgGFR
12Indications for Dialysis A acidosisE electrolyte abnormalitiesI intoxication/poisoningO fluid overloadU uremia symptoms/complications
13Dialysis for Intoxications T theophyllineA aspirinB barbituratesL lithiumE ethylene glycol, methanolM Metformin
21Cardiovascular Risk of Patients with CKD Treat them as if they have already had their first MI.Should be on B-Blocker, ASA, Statin, and ACE or ARB.May need to stop the ACE/ARB as renal function declinesThink about restarting it once they are on dialysis.Be careful about writing “no ACE/ARB or Contrast” in these pts.
22Risk Factors for Contrast Nephropathy Age over 60DiabetesPre-Renal StatesCHFNSAIDS, ACE Inhibitors, DiureticsProteinuria Includes, but not limited to Myeloma.Pre-existing Renal Disease
26Policy / Recommendations Stop ACE/ ARB, NSAIDs, Diuretics day before procedureIVF for everyoneNS for low risk ptsBicarb for high risk pts?Urinalysis for all pts/ calculate Creat Clear for all pts.Proteinuria or creat clear < 40 considered High risk.Mucomyst for High risk ptsLimit volume of contrast in High Risk Pts.Consider Nephrology consult if considering Mannitol, Corlepam, or identified as high risk.
27Contrast Nephropathy GVH 2006 After Implementation of Policy%252015105All pts DM CHF Proteinuria CRF
28Good Control of All Three Percentage of Adults With Diabetes Who Achieved Recommended Levels of Vascular Risk Factors in NHANES100NHANES III9080NHANES IV706050%40302010Hb A1c <7%BP <130/80TC <200Good Control of All Threemm Hgmg/dLSaydah S et al. JAMA. 2004;291:
30Pain MedsHD patients usually require fewer narcotics than other patientsTypically, a patient will have an order for morphine 2-4 mg q 2-4 hoursAlternative choicesDilaudidFentanyl
31Pain Meds If the dose is inadequate, you can always give more. Giving more narcotics is always easier than treating with a narcan drip and pressorsAvoid demerol if possibleits metabolite normeperidine can cause seizures if it accumulates
32Pain MedsIf a patient has residual renal function, try to avoid NSAID’sRemember that overdosing NSAIDS can lead to salicylate toxicityPts present with tinnitus, headache, nausea, and feverHD patients have a narrow therapeutic range and develop salicylism with less drug
33DiabeticsAs kidney function declines and ceases, insulin is not cleared as quickly.The insulin and oral agent’s effects last longerSulfonylureasAvoid Metformin once GFR is less than 40 ml/min
34DiabeticsThe patient’s response to insulin and oral agents is a marker of getting close to dialysisPatients think their DM is doing greatneeds less insulin to control blood sugars.
35Diabetics What really happens is: The patient is uremic and loses his appetiteHe eats lessThe insulin hangs aroundNow the blood sugars look great and the patient needed a fistula last month
36HemostasisUremic plasma factors lead to abnormal platelet aggregation and adhesionDialysis removes these factorsUnfortunately, the dialysis membrane alters the platelet membrane receptors for vWF and fibrinogen
37HemostasisManifestation of this platelet dysfunction can range from oozing at a venipuncture site to GI hemorrhageIf a patient is bleeding after a simple procedure, start with the simple treatments
38Hemostasis DDAVP may be used if the bleeding cannot be controlled Use 0.3mcg/kg IV over about 20 minutes15 mcg in 50 cc NS over 15 min.DDAVP stimulates release of vWFincreases GPIIb platelet adhesion factor expression
39RemindersWhen you evaluate a patient keep in mind that HD patients are differentThese patients need the same workup for the same complaintsYour differential will be the sameYour treatment may be modified
40Hypotenstion Treat the HD patient with IV fluids 0.9% saline, 250cc bolusAlbumin / HespanCheck for responseYou have treated the HD patients like the other patientsAll you changed was the amount of fluid
42Meds to Avoid/Think About Contrast- IV contrast can be given in dialysis patientsKeep in mind that the osmotic effects of contrast can shift fluid into the intravascular space and cause pulmonary edema
43Advances in Artificial Kidneys Membraneless artificial kidneyUses fluid layer in microtubule for solute exchangeWorn on arm, connected to avf continuouslyThe fluid layer collects wastes and is exchanged periodicallyInfoscitex Inc and Columbia UniversityReach market in 2012
44Wearable Artificial Kidney Miniaturized dialysis machine worn around waist. Wt 5 lbs.Utilizes a unique battery powered pump for blood and dialysateSorbent cartridge based dialysateAlready proven for SCUF in CHF pts.UCLA Victor Gura, MD
45Human Nephron Filter Nanomembrane technology May be able to tailor dialysisWould lend itself to wearable, continuous modalitiesPhiltre, Alan Nissenson, MD
46Bioartificial KidneyUses cloned renal tubular cells from unusable donor kidneysCells line capillary tubules in a kidney similar to conventional dialysis kidneyRenal Assist Device can assume endocrine and metabolic functionsIn phase II study reduced mortality in ICU ARF pts from 61 to 34 %.University of Michigan David Humes, MD