Indication of dialysis in Acute Renal Failure

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Indication of dialysis in Acute Renal Failure
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Indications of dialysis in ARF

• Severe fluid overload
• Refractory hypertension
• Uncontrollable hyperkalemia
• Nausea, vomiting, poor appetite, gastritis with
  hemorrhage
• Lethargy, malaise, somnolence, stupor, coma,
  delirium, asterixis, tremor, seizures,
• Pericarditis (risk of hemorrhage or tamponade)
• bleeding diathesis (epistaxis - GI bleeding and
  etc..)
• Severe metabolic acidosis
• BUN gt 70 100 mg/dl

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Indications of Dialysis in Chronic RF

• Pericarditis
• Fluid overload or pulmonary edema refractory to
  diuretics
• Accelerated hypertension poorly responsive to
  antihypertensives
• Progressive uremic encephalopathy or neuropathy
  such as confusion, asterixis, myoclonus, wrist or
  foot drop, seizures
• Bleeding diathesis attributable to uremia

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Indications of Dialysis in Chronic RF

• Persistent nausea and vomiting
• Plasma creatinine concentration gt10-12 mg/dl or
  BUN gt100 mg/dl
• Anorexia
• Depression, decreased attentiveness and cognitive
  tasking
• Severe anemia unresponsiveness to erythropoietin
• Persistent pruritus or restless leg syndrome

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Drugs and dialysis patients

• Hypotension in HD
• 1- 0.9 saline gt 100 ml
• 2- hypertonic saline
• 3- hypertonic glucose
• 4- mannitol albumin
• 5- midodrine (alfa adrenergic agonist)
  10mg orally 30 min before HD.

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Drugs and dialysis patients

• Muscle cramps
• 1- 0.9 saline
• Prevention
• 1-Vitamin E 400 IU at bedtime
• 2- Quinine 325 mg at bedtime
• 3- Carnitine
• 4- Oxazepam 5-10 mg 2 hours before dialysis.

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Drugs and dialysis patients

• Anticoagulation
• 1- Heparin 2000 U bolus , 1000-1200 U/h
  until 1 hour before dialysis.
• Side effects of heparin hyperlipidemia ,
  thrombocytopenia , itching, hyperkalemia
• 2- Heparin free dialysis with periodic saline
  rinse 100-200 ml/ 30 min
• 3- regional citrate anticoagulation.

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Drugs and dialysis patients

• Low molecular weight heparin as a single dose at
  the beginning of dialysis.
• It ameliorates hyperlipidemia.
• Vitamins loss into the dialysate, poor
• nutrition, decreased absorption .
• 1- Folic acid and B vitamins as supplements
• 2- vitamin C 60-100 mg/day (hyperoxalemia)

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Drugs and dialysis patients

• Vitamin A serum vitamin A concentration are
  almost always elevated due to decreased renal
  catabolism, increased concentration of retinol
  binding protein and dialysis can not remove it.
• Side effects of hypervitaminosis A anemia,
  abnormalities in lipid and Ca metabolism.
• Multivitamin drugs have vitamin A and should
  not be used in patients with renal failure.

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Drugs and dialysis patients

• Vitamin D is necessary for patients with
  secondary hyperparathyroidism and used as
  calcitriol or rocaltrol.
• Vitamin E increased red cell survival.
• Vitamin K vitamin K deficiency can occur in
  patients receiving antibiotics that suppress
  vitamin K production by intestinal bacteria. In
  this condition 7.5 mg/wk vi.K is beneficial.

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Drugs and dialysis patients hemorrhage

• Desmopressin a synthetic form of vasopressin
  increases release of von Willebrand factor. a
  dose of 0.3 ug/kg in the form of injection or 3
  ug/kg in the form of spray.
• Cryopreciptate high concentration of von
  Willebrand factor leads to temporary improvement
  in uremic platelet function.
• Conjugated Estrogen a single dose of 25 mg
  improves platelet function for 10 days.

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Drugs and dialysis patientsAntibiotics

• Aminoglycosides and Vancomycin cause autotoxicity
  and dose must be decreased.
• Nalidixic Acid, Nitrofurantoin ,Neomycin and
  Methenamin mandelate should not be used in
  dialysis patients.

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Drugs and dialysis patientshyperphosphatemia

• Aluminum hydroxide previously used for high
  phosphate, causes aluminum toxicity, anemia, bone
  pain and bone fracture and CNS dysfunction,
  dementia, seizures, coma and death. If serum
  phosphorus is high and can not decreased with
  other drugs, Aluminum used for a limited time.
• Carbonate Calcium is widely used but in severe
  hyper P causes Ca deposit in tissues and should
  not be used.
• Sevelamer a new drug for hyper P without side
  effects of Aluminum and Ca, but is very
  expensive.

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Drugs and dialysis patients Antihyperglycemic
agents

• Chlorpropamide and Glibenclamide have risk of
  hypoglycemia in dialysis patients, their
  metabolism partly is in the kidney, and their use
  should be avoided.
• Insulin can be used in dialysis patients.
• Tolbutamide and Glipizide also can be used.

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Drugs and dialysis patientsAnalgesics

• Morphin and other opiate drugs should be used
  with caution in dialysis patients and dose must
  be decreased.
• Meperidine (Pethidine) metabolizes to
  normeperidine and it is toxic, causes seizures.
• Acetaminophen can be used in renal failure
  patients.
• Aspirin and NSAIDs have risk of GI bleeding.

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