Hemodialysis Semipermeable membrane Solute removal via passive diffusion ◦ Inversely proportional to the size (ie effective removal of K, urea, C; not of PO4)
Ultrafiltration use of hydrostatic pressure gradient to induce convection (filtration of water) solvent drag (pulls dissolved solutes) across removal of excess fluid
CVVH highly permeable membrane fluid and solute removal via ultrafiltration filtrate is discarded replacement fluid is infused similar to plasma (but no K, urea, Cr, PO4) used in ICU, runs 12-24h, through double lumen catheter less drastic fluid shifts
Peritoneal Dialysis peritoneal membrane = partially permeable membrane dextrose dialysate diffusion and osmosis until equilibrium 3-10 dwells per night with L per dwell
Indications for Dialysis Acidosis Electrolytes Ingestions Overload Uremia
Common Admissions on Eckel Complications of missed HD ◦ SOB from fluid overload ◦ HTN crisis ◦ Hyperkalemia Line infections Access issues And everything else…
Eckel Pearls: presentation 75 yo AAM with ESRD 2/2 DM (HD MWF via RUE AVF, at CDC East, nephrologist Dr. Wish, dry weight 82kg, oligouric)
Eckel Pearls: history how did the last HD session go? complications since being started on HD? ◦ infections? ◦ multiple access points? medically compliant? get run sheets from dialysis center
Eckel Pearls: physical exam Vitals: no BP in the arm of the access Volume status Access: ◦ Infection? ◦ Aneurysms ◦ Bruits/thrills
Page 1 RN LK50: OMG’s K is 3.1. Can we replete? Had dialysis 3 rd shift. Finished 2hrs ago
Labs in ESRD Get labs before or 4h after HD Only the H/H is accurate Floor RNs can’t use HD lines Can ask to have cultures drawn at HD from the line
Page 2 RN LK20: New admit AMS on floor. Hard to arouse. Please eval ED presentation with abd pain Workup initiated since there are no beds… Pain meds: morphine 1mg, then 1mg, then 2 mg, then 3mg IVP Sent to the floor
Medications in ESRD Antibiotics ◦ Renally dose ◦ Loading dose, then maintenance dose No lovenox dvt ppx, use heparin No morphine ◦ Hepatic metabolism – but active metabolites ◦ Limit the other opioids Dilaudid: hepatic metabolism – but metabolites can cause neuroexcitiation constipation/GERD : avoid magnesium/phosphate containing agents
Page 3 RN: new admit OK. Called wound care for leg. After lunch you walk on over to the patient room. ESRD admitted for access. OK is doing ok. Vitals stable. Comfortable.
Calciphylaxis Calcinosis cutis
Page 4 RN LK20: Code white, WAA is hypoxic, 83% on RA. Now 92% on VM. Acutely SOB. Looks uncomfortable. Your co-NF points that one leg is bigger than the other. You ask, “have you had a blood clot before?” WAA nods yes. Hmmm….amongst other things, CTPE?
Imaging in CKD Avoid contrast in CKD patients If you have to, prep ◦ volume expansion: isotonic IVFs 3 cc/kg x 1h before 1cc/kg x 6h after ◦ ? alkalinization: sodium bicarbonate ◦ ? acetylcysteine ◦ radiology can give you the protocol (treat empirically)
Imaging in ESRD CT with contrast is ok MRI with gadolinium is NOT: ◦ Nephrogenic Systemic Fibrosis (NSF) ◦ IF you must: HD x 3 over 3 consecutive days, with the first right after
Page 5 RN LK20: Lost access on GRR. Can you order a PICC? Finally, an easy question. CKD. Sure, why not?
Access in CKD Avoid PICC/midlines in CKD stage 4-5 Try to preserve access Try for the feet/EJ But if you need to, order a midline PCP should refer CKD stage IV to nephrologists in anticipation of HD
Don’t treat them lightly
Resources UpToDate Lavinia Negrea. “Dialysis Access.” Microsoft Powerpoint. August Claire Sullivan. “Intern Boot Camp: Renal Disease and Dialysis (ie surviving Eckel).” Date last modified Microsoft Powerpoint. August Van Stone, JC. Hemodialysis: Hemodialysis apparatus. In: Handbook of Dialysis Daugirdas, JT, Ing, TS (Eds), Little, Brown, Boston, p53. Yassine Mrabetis. “Hemodialysis Diagram." Online image. Dialysis Definition. Creative Commons Attribution-Share Alike 3.0, Wikepedia. August “Peritoneal Dialysis Diagram.” Online Image. Alniche: Types of Dialysis. Alniche Life Sciences Pvt. Ltd. August Po Ming Teng. “Aneurysm.” Online Image. Chronic renal failure and dialysis. Surgical-tutor.org.uk. August “Calciphylaxis.” Online Image. The UK Calciphylaxis Study. The Renal Association. August Jonathan Z. Li and William Huen. “Calciphylaxis with Arterial Calcification.” Online Image N Engl J Med. August Shaofeng Yan. “Calciphylaxis Histology.” Online Image Mihm’s Dermatopathology: Calciphylaxis. Martin C. Mihm, Jr. August “Nephrogenic Systemic Fibrosis.” Online Image. Skin & Allergy News: Nephrogenic Fibrosis Is Tied to Contrast Agents : Moderate- to end-stage renal disease patients are most susceptible to the scleroderma-like syndrome. International Medical News Group, LLC. August Michael Shaw. “They’re willing to throw in their kidneys.” Online image New Yorker Cartoon. August Cartoons from August 2013.