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If dialysis can only be this easy Sanela Redzepagic Renal Advanced trainee RPAH/ CRGH.

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Presentation on theme: "If dialysis can only be this easy Sanela Redzepagic Renal Advanced trainee RPAH/ CRGH."— Presentation transcript:

1 If dialysis can only be this easy Sanela Redzepagic Renal Advanced trainee RPAH/ CRGH

2 Ms. P. A 53 year old Aboriginal lady from Byron Bay, transferred to RPAH for further investigations 5/7 worsening symptoms – Lethargy, nausea, vomiting, intermittent fevers – Lower abdominal pain, diarrhoea then constipation – Cloudy PD fluid – Pruritis CT abdomen with contrast – Small foci of free gas under the right haemidiaphragm with no definite evidence of bowel perforation. Occasional ‘holiday from PD’ Herbal Medicine as advised by naturopath specialist

3 Medical history ESRF HT Interstitial nephritis due to NSAIDS + ?herbal Rx CRF  ESRF august 2010 – Tenckhoff CatheterTenckhoff Catheter APD – 2x 6L 2.5% -- Nil peritonitis Left Brachio-cephalic fistula created – reversed due to Steel syndrome  Lost to follow up’ Anaemia - Hb ?on Aranesp Calcium & Phosphate metabolism

4 Medical history IHD NSTEMI 2011 precipitated by infection TTE - LVEF ~ 55%, Left atrium mildly dilated Clopidogrel ceased due to anaemia Paroxismal AF – on aspirin Hypercholesterolaemia ‘Borderline DM’ diet controlled GORD on PPI Diverticular disease, no diverticulitis Hypothyroidism PMR – on Prednisone

5 Medical history Medications Aspirin100 mg daily Metoprolol 25 mg BD Rosuvastatin 5 mg daily Frusemide 120 mg daily Rabeprazole Prednisone 5 mg daily Thyroxine 50 mcg daily Caltrate Aranesp 40 mcg /?forthnight Allergy – sulphur SH Aboriginal artist, lives with her husband Smokes Etoh – inconsistent “Alternative lifestyle” O/E Low grade temp, BP 150/ 70, HR 94, o2 sats 94% RA JVP raised, HS dual + PSM Crackles lower zones Abdomen – PD cath insitu Distended – tender, guarded BS present Old L) Arm AVF – nil thrill Peripheral oedema mid shins BSL 14 ‘dry weight 67kg’ – current wt 74 kg

6 Investigations FBC – Wbc 14.4 (n-12.4), Hb 96 EUC – K 6.1, bicarb 15, urea 75 / Creatinine 1058 CMP – corr. ca 1.9 / ph 3.1 / mg 0.51 CRP – 276 TFT – within normal level Blood cultures – negative PD fluid culture - M/c/s Gram (-) rods, gram (+) rods ECG – rapid AF, ST-segment depressions

7 Issues on this admissions Abdominal sepsis PD associated Peritonitis - >PD fluid – Pseudomonas Aeruginosa » IV Timentin  IP Cephalothin, Metronidazole » ID advice  Ciprofloxacin for 3/52 » PD catheter removal Progress: » PD catheter tip culture – Pseud. Aeruginosa Intermediate sensitivity to Ciprofloxacin Timentin IV Fluid Overloaded / “Uremic” – Concern about amount of dialysis she has been doing

8 Plan? Treat infection Remove PD catheter Convert to HD – ?now – Wait a bit – ? Put in an access Start HD with a temporary catheter

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17 What’s in your Water? Contaminated by – Particulate matter Clay,sand,silica,iron – Chemicals Inorganic - Na, Cl, Al, Fl, Ca Organic – fertilizers, pesticides etc – Micro-organisms Bacteria/endotoxin Protozoa,fungi,viruses,spores

18 Bacterial Contamination – Endotoxin fragments Febrile reaction, Hypotension, Headache, Nausea Chronic inflammation

19 Water treatment

20 Water standards Standard Water Chemical – Resistivity - >1MOhm/cm Microbiology – AAMI - <200CFU/mL – European - <100CFU/mL – Endotoxin <0.1EU/mL Ultrapure Water Chemical – Resistivity > 5MOhm/cm Microbiology – <100 CFU/mL – Endotoxin - undetectable

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22 “The Kidney”

23 Structure of the Dialyzer Low FluxHigh Flux

24 Dialyzers – things to consider Size – surface area Material – Biocompatibility Complement activation Activation of clotting cascade Cellular activation - neutophills/monocytes/Plts – Protein/cytokine absorption Efficiency – small solute clearance Flux – Ultrafiltration capacity – Low = 20ml/Hr/mmHg Permeability – middle molecule clearance Clearance - KoA

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27 The Prescription Duration Frequency Kidney/Dialyzer Blood flow (pump speed) Qb Dialysate flow Qd Ultrafiltration Anticoagulation Dialysate composition

28 Dialysate

29 The Prescription Duration Frequency Kidney/Dialyzer Blood flow (pump speed) Qb Dialysate flow Qd Anticoagulation Ultrafiltration Dialysate composition 2 hours Daily Low Flux, SA 1.3m 2 150ml/min 500ml/min (Concurrent) Heparin 500/ ml/Hr

30 Dialysis HD commenced – Headaches – Nausea – Confusion – Restlessness What's going on?

31 Altered Mental State Disequilibrium Uremia Subdural hematoma, Cerebral infarction or intracerebral haemorrhage, Cerebral infection - meningitis, encephalitis etc Metabolic disturbances Drug-induced encephalopathy Psychiatric Illness

32 Dialysis Disequilibrium Classic Symptoms – headache, nausea, disorientation, restlessness, blurred vision, and asterixis. – severe form (rare)- confusion, seizures, coma Probable milder form (common) – muscle cramps, anorexia, and dizziness at the end of a dialysis treatment Aetiology – Rapid reduction in serum urea creates an osmotic gradient – Promotes intracellular shift of water = cerebral oedema – Paradoxical intracellular acidosis Displaced Na/K promote shift of water to intracellular compartment

33 Dialysis Disequilibrium Management Prevention – “gentle” initiation of dialysis Small kidney/low flux Reduce Qb – ml/min Reduce duration Concurrent dialysate flow Daily dialysis – gradually/steadily reduce Urea

34 Progress.... Next few sessions going ok Starting to feel better – Eating/drinking more – Increasing interdialytic weight gain Monday am HD – BP drops to 70/ What now....

35 Hypotension on Dialysis Differential – Excessive UF Dry weight changed – Acute medical event Cardiac/Infection – Antihypertensive meds – Any other cause of low BP Helpful considerations – Relationship to duration of treatment – Recurrent or unusual problem Manage the event – Reduce/stop UF/stop treatment – Fluid bolus – Ix appropriately – cultures/ECG – Rx as appropriate

36 Hypotension on Dialysis Common problem Ultra filtration - dependent on – vascular refilling – CV compensation – Increase HR/PVR Multifactorial – Volume removal – Autonomic dysfunction – Underlying cardiac disease – Antihypertensive meds – Diffusion of Na (reduced osmotic pressure) – Thermal energy transfer from dialysate – Biocompatibility Acute events – Sepsis/CV etc

37 Hypotension management Check the pt/situation – is there an acute event Manage the event – Reduce/stop UF/stop treatment – Fluid bolus – Ix appropriately – cultures/ECG Review dry weight Review medications Review UF prescription – >1.5L/hr associated with poor outcomes – Longer hours/more frequent HD

38 Hypotension - other options Dialysate – Na – Ca Isolated UF – no diffusion of Na Lower dialysate temp Play with the newer toys – UF profiling – Na profiling – Blood volume monitoring

39 Progress New dry weight established Education about fluid intake Access remains vascular catheter – Recent surgery for access Doing reasonably well (misses odd session) – Missed Monday due to recent storms/heavy flooding Wed am – Sudden onset central chest pain/SOB

40 Chest pain on Dialysis Cardiac Disease IHD Arrhythmia Pericardial Disease Sepsis – (Catheter) Haemolysis Dialyzer reaction Air embolism rare in haemodialysis patients, in part because of the presence of air detectors in haemodialysis machines. Pulmonary embolism – (recent access sx)

41 Cardiovascular Disease Uraemic Heart is venerable – High prevalence of traditional CV risk factors – LVH + Arteriosclerosis – reduced coronary flow reserve How dialysis may influence this – Recurrent hypotension/ischaemia – Arrhythmia – Rapid changes in electrolytes (K, Ca, Mg) Long break is bad – Chronic inflammation = enhanced atherosclerosis/sticky endothelium Membrane compatibility Endotoxin/Bacterial fragments leaking into dialysate Other effects on nutrition – Myocardial Stunning Development regional wall motion abnormalities during HD ? Related to UF rate

42 Haemolysis Mechanical – Tubing/Roller pumps Osmotic – Improper proportioning of dialysate Water contamination Chloramines – Oxidation/intravascular haemolysis Bleach Copper

43 Dialyzer Reactions Rare now Reaction to membranes (cellulose) or sterilizing agents Anaphylactoid type reaction Complement activation – release of anaphylatoxins (C3a and C5a – formation of the membrane attack complex (C5b-9) – activation of neutrophils and monocytes, – intense vascular smooth muscle contraction, increased vascular permeability, and the release of histamines from mast cells

44 Other complications Bleeding – Anticoagulation – leak from catheters – Access issues – needle displacement Infection – Use of catheters/Grafts – Recurrent cannulation – Uraemic milieu – Contamination of water/equipment Dialysate leak – Exposure of blood to non sterile dialysate Thrombocytopenia – HITTS – Reaction to dialyzer Air Embolism


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