Hemodialysis

chronic kidney disease (CKD)

defined as either kidney damage or glomerular filtration rate (GFR) <60 for >3 months

end-stage renal disease (ESRD)

Treatment for __________
1. kidney transplant (ideal)
2. Renal Replacement Therapy (RRT)
3. Hospice/palliative care (end-of-life care)

glomerular filtration rate (GFR)

measure how much blood passes through the glomeruli each minute

end-stage renal disease (ESRD)

Etiology of _________
1. Diabetes
2. Hypertension
3. Glomerulonephritis (infection, autoimmune disease, minimal change disease, focal segmental glomerulosclerosis (FSGS)
4. Interstitial Nephritis (infections/chronic disease, Wegener’s granulomatosis)
5. Autoimmune (IgA nephropathy, lupus nephritis, Anti-GBM -Goodpasture syndrome)

-polycystic kidney
- Alport syndrome
- benign prostate hyperplasia (BPH)
-amyloidosis/multiple myeloma

stage 3a

When to refer to nephrology for chronic kidney disease (CKD) patients?
→ nephrology manages transition through end-stage renal disease (stages 3b-5)

labs

renal panel
-BUN, Creatinine, GFR, potassium/electrolytes
-albumin
-CBC, iron studies (Hgb, HCT, ferritin)
-”spot" urine specimen (morning)

AKI: 24 hour creatinine clearance (CrCl)

ESRD
-renal panel: electrolytes, albumin, calcium/phosphate
-CBC, iron studies, HGB, Tsat, ferritin
-iPTH, vitamin D

_____ for managing chronic kidney disease (CKD)
→ most tests completed monthly

central venous catheter (CVC)

Which dialysis access type has the biggest risk for infection?

central venous catheter (CVC)

Which dialysis access type can be used the soonest?

dialysis access

All forms of renal replacement therapy (RRT) need a _______

Types
1. Hemodialysis
- uses a vascular access to clean the body via blood
-maximum age 75

2. Peritoneal Dialysis
- uses a peritoneal catheter and the peritoneum to clean the body
→can be done at home, rural locations

peritoneal dialysis

involves instillation of a hypertonic solution into the peritoneal cavity
→dialysate solution fills the peritoneal cavity, coming into contact with capillaries in peritoneum and viscera
→peritoneum serves as the filtration membrane, diffuses toxins and excess fluid from the blood
→toxins and excess fluid cross the membrane into the dialysis solution, are drained out of the body

peritoneal dialysis

1. CAPD (Continuous Ambulatory Peritoneal Dialysis) - Daytime
- Frequent passive exchanges using gravity

2. CCPD (Continuous Cycle Peritoneal Dialysis) - Nighttime
- Overnight exchanges with use of an automated machine

Limitations: often daily treatments, done at home, no swimming/submerge in water, infection is highest failure risk

hemodialysis

Cleans the blood of waste products and controls fluids by passing the blood through an artificial kidney, called a dialyzer
→Patients must have a vascular access (AV fistula, AV graft, tunnel direct catheter)
→can be done in a dialysis center or at home (3x week schedule)

arteriovenous fistula (AVF)

surgical connection or “anastomosis” between an artery and a vein
→connection causes turbulence and vein wall to thicken
→providing a spot that can be punctured repeatedly with dialysis needles + rapid blood flow rate

Limitations:
-minimum 6 weeks maturation period before use
-Requires good vessels

Advantages:
-native vessel, no reaction to synthetic material
-Long life
-Low risk of thrombosis
-low infection risk

central venous catheter (CVC)

direct access to heart "central line"

arteriovenous graft (AVG)

a piece of artificial vessel created as an access; one end is connected to an artery and the other to a vein

Limitations:
- shorter lifespan (<5 years)
- HIGH thrombosis rate
- HIGH infection rate

Advantages:
-short maturation period (2 weeks)
-easier cannulation

central venous catheter (CVC)

Placed as temporary (non-cuffed - lasts days) or long-term (cuffed, tunnel direct catheter - lasts weeks-months)
→typically older patients, last resort option

Location:
- internal jugular vein is preferred site (over subclavian vein)

Limitations
- HIGH risk thrombosis
- HIGH risk for infection (serious heart)
-recirculation
-decreased flow rate on hemodialysis
-no showers (sponge bath only)

Advantages:
- hemodialysis can be initiated immediately

choice

_____ of vascular access
1. Demographics/co-morbidities
2. Time of need (emergent vs planned)
3. Surgeon preference
4. Vein mapping / vessel quality

complications

______ of vascular access
1. Thrombosis
2. Stenosis
3. Infection
4. Aneurysm/Pseudoaneurysm
5. Primary non-function (fail for fistula to mature)

cardiovascular disease

What is the most common complication of CKD?
*coronary heart disease, cerebrovascular diagnosis, peripheral vascular diagnosis, CHF

Other Complications
- Anemia
- Fluid overload
- Bone ds, altered mineral metabolism
- Neuropathy
- hypertension
- Malnutrition

anemia

______ is present in the majority of chronic kidney disease (CKD) patients

Causes
→insufficient production of erythropoietin (EPO) by the kidneys
→iron deficiency, blood loss & chronic inflammation

bone mineral disease (BMD)

occurs when kidneys damaged by CKD cannot filter blood and regulate hormones (calcium/phosphorus) appropriately
→hormone levels and levels of minerals, such as calcium and phosphorus become imbalanced, leading to damage

→Abnormal calcium-phosphorus metabolism may also lead to calciphylaxis or extraosseous calcification of soft tissue & vascular tissue

calcitriol

active form of vitamin D (normally converted by kidneys)

→controls calcium absorption in the gut, decreased PTH synthesis, aids in calcification of osteoid tissue (bone formation)

bone mineral disease

Hyperphosphatemia/Hypocalcemia
1. Dietary phosphate restriction
2. Phosphate Binders
- Tums
- Phoslo
- Velphoro

Secondary Hyperparathyroidism
1. Vitamin D analogs (Calcitriol)
2. Calcinmimetics

Calciphylaxis (extraosseous calcification of soft tissue which leads to skin necrosis)

diet restrictions

Dialysis patient _______:
- Potassium (fruits & veggies)
- Phosphorus (dairy, nuts, processed foods)
- Sodium (meats, fast food, processed foods)
- Fluids (limit to 1L/day)

Recommendation
- Protein (to maintain albumin levels): 60-80g/day, protein drinks and bars