Title: Progression of Chronic Kidney Disease
1Progression of Chronic Kidney Disease
- Preparation
- Options
- Complications
2Preparation of the Patient
- Control BP
- Control glucose
- stop oral agents!
- Prevent Hyper PTH
- Vit D
- Calcium acetate
- Phosphate binder
- Diet Education
3Preparation 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
4Progression of CRF
5Transition to End StageEffect of Malnutrition
Wt
Measured Wt 85 Kg
GFR
6Indications for Dialysis
- A acidosis
- E electrolyte abnormalities
- I intoxication/poisoning
- O fluid overload
- U uremia symptoms/complications
7Dialysis for Intoxications
- T theophylline
- A aspirin
- B barbiturates
- L lithium
- E ethylene glycol, methanol
8Relative Contraindications
- Alzheimers disease
- Multi-infarct Dementia
- Hepatorenal syndrome
- Advanced cirrhosis with encephalopathy
- Advanced malignancy
- HIV with dementia
9Types of Renal Replacement
- Acute RRT
- Standard Hemodialysis
- Redy 2000
- Acute Peritoneal Dialysis
- CAVHD
- CVVHD
- Hemoperfusion
10Acute RRT choices
- Volume Status
- Hemodynamic status
- Access
- Bleeding
- Poisoning
- CAVHD?
- Tolerate Hemo?
- Abdominal surgery?
- Anticoagulation?
- How catabolic is pt
- Hemoperfusion?
11Renal Replacement Therapy
- Chronic RRT
- Standard Hemodialysis
- Peritoneal Dialysis
- Continuous vs Intermittent
- Ambulatory vs Cyclic
- Cycler Plus
- Combinations
12The 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
13Hemodialysis
- Advantages
- standard treatment
- widely used
- Pt has days off
- Good reimbursement for Nephrologist
- We have control
14Cuffed Tunnelled Hemodialysis Catheters.
15Tesio catheter
16Hemodialysis
- Disadvantages
- Pt has no control
- strict attn to diet
- travel restricted
- need for vascular access
- Specific risks
- Inadequate clearance
17Peritoneal Dialysis
- Clearance
- How much fluid the patient puts in
- Ultrafiltration
- How much fluid comes out
- Dextrose used as osmotic agent
18(No Transcript)
19Peritoneal Dialysis
- Advantages
- continuous
- middle molecules
- pt has control
- vary tx with diet
- adjust to lifestyle
- no need for vascular access
- no need for anticoag.
20Peritoneal Dialysis
- Disadvantages
- Abdominal surgery
- limited clearance
- limited Uf
- Needs motivated, compliant pt
- risk of peritonitis
21RRT Choices
- Renal Transplant should be goal
- Peritoneal Dialysis for the right pt
- Hemodialysis for everyone else
22DialysisChronic Complications
- Not seen until after chronic access possible
- 1967 Alfree reported dialysis dementia
- Due to impurities in water (100L/tx)
23DialysisComplications
- Bleeding disorders
- Anemia
- Bone disorders
- Arthritis
- Neuropathy
- Cardiovascular
24Dialysis ComplicationsBleeding disorder
- Due to platelet dysfunction Prolonged bleeding
time - Treatment - more dialysis - dDAVP 0.3
microgm/Kg - Estrogen
25Dialysis ComplicationsAnemia
- Due to reduced Erythropoietin - blood loss,
reduced response - Treatment - more dialysis - rHuEPO 2,000
units/tx - Androgens
26Dialysis ComplicationsArthritis
- Due to accumulation of - Beta-2-microglobulin
- Treatment - more dialysis - Biocompatable
membranes - Joint replacement (Hips)
27Dialysis ComplicationsNeuropathy
- Manifestations - Peripheral Neuropathy -
Autonomic dysfunction - Dementia -
Dysequilibrium syndrome - Treatment - More dialysis - gradual start of
tx - remove water impurities - prevention is
best.
28Dialysis 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?
29Adequacy of Dialysis
- Markers
- mortality
- hospitalization
- nutrition
- NCDS
- Gotch and Sargent
- KT/V clearance
- NPCR nutrition
30Summary
- Incidence of ESRD
- Progression of CRF
- Indications and contraindications
- Choices of RRT
- Complications of CRF, dialysis
- Adequacy