Renal Replacement Therapy

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Renal Replacement Therapy

• Preparation
• Options
• Complications

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Preparation of the Patient

• Manage CRF

• Control BP
• Control glucose
• stop oral agents!
• Prevent Hyper PTH
• Vit D
• Calcium acetate
• Phosphate binder
• Diet Education

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Preparation of the Patient

• Manage Fluids
• Dialysis education
• Access Placement
• Prevent anemia
• Prevent Malnutrition

• metolazone
• NKF program
• AV fistula, PD cath
• Epogen, Iron
• This can get tricky

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Progression of CRF
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Transition to End StageEffect of Malnutrition
Wt
Measured Wt 85 Kg
GFR
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Indications for Dialysis

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

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Dialysis for Intoxications

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

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Relative Contraindications

• Alzheimers disease
• Multi-infarct Dementia
• Hepatorenal syndrome
• Advanced cirrhosis with encephalopathy
• Advanced malignancy
• HIV with dementia

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Types of Renal Replacement

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

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Acute RRT choices

• Volume Status
• Hemodynamic status
• Access
• Bleeding
• Poisoning

• CAVHD?
• Tolerate Hemo?
• Abdominal surgery?
• Anticoagulation?
• How catabolic is pt
• Hemoperfusion?

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Renal Replacement Therapy

• Chronic RRT
• Standard Hemodialysis
• Peritoneal Dialysis
• Continuous vs Intermittent
• Ambulatory vs Cyclic
• Cycler Plus
• Combinations

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The Mystery of Dialysis

• Its no mystery!
• Clearance
• simple diffusion
• Ultrafiltration
• dialysate pump
• Monitors to make sure nothing bad happens

blood in
dialysate plus Ultrafiltrate out
dialysate in
blood out
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Hemodialysis

• Advantages
• standard treatment
• widely used
• Pt has days off
• Good reimbursement for Nephrologist
• We have control

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Hemodialysis

• Disadvantages
• Pt has no control
• strict attn to diet
• travel restricted
• need for vascular access
• Specific risks
• Inadequate clearance

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Peritoneal Dialysis

• Clearance
• How much fluid the patient puts in
• Ultrafiltration
• How much fluid comes out
• Dextrose used as osmotic agent

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Peritoneal Dialysis

• Advantages
• continuous
• middle molecules
• pt has control
• vary tx with diet
• adjust to lifestyle
• no need for vascular access
• no need for anticoag.

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Peritoneal Dialysis

• Disadvantages
• Abdominal surgery
• limited clearance
• limited Uf
• Needs motivated, compliant pt
• risk of peritonitis

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RRT Choices

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

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DialysisChronic Complications

• Not seen until after chronic access possible
• 1967 Alfree reported dialysis dementia
• Due to impurities in water (100L/tx)

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DialysisComplications

• Bleeding disorders
• Anemia
• Bone disorders
• Arthritis
• Neuropathy
• Cardiovascular

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Dialysis ComplicationsBleeding disorder

• Due to platelet dysfunction Prolonged bleeding
  time
• Treatment - more dialysis - dDAVP 0.3
  microgm/Kg - Estrogen

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Dialysis ComplicationsAnemia

• Due to reduced Erythropoietin - blood loss,
  reduced response
• Treatment - more dialysis - rHuEPO 2,000
  units/tx - Androgens

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Dialysis ComplicationsArthritis

• Due to accumulation of - Beta-2-microglobulin
• Treatment - more dialysis - Biocompatable
  membranes - Joint replacement (Hips)

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Dialysis ComplicationsNeuropathy

• Manifestations - Peripheral Neuropathy -
  Autonomic dysfunction - Dementia -
  Dysequilibrium syndrome
• Treatment - More dialysis - gradual start of
  tx - remove water impurities - prevention is
  best.

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Dialysis ComplicationsCardiovascular

• Manifestations - Accelerated atherogenesis -
  Lipid abnormalities - Associated disorders (DM
  etc) - Leading cause of mortality
• Treatment - More dialysis - Treatment of lipid
  disorders - Control of HTN - Carnitine?

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Adequacy of Dialysis

• Markers
• mortality
• hospitalization
• nutrition
• NCDS
• Gotch and Sargent
• KT/V clearance
• NPCR nutrition

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Summary

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