ICARE Renal: Acute Dialysis

True or False: Acidosis is commonly an isolated indication for RRT

False

What are some secondary indications that go along with acidosis?

-Intoxication

-ARF/AKI

What are the characteristics of metabolic acidosis requiring acute dialysis?

-Positive anion gap

-Positive osmolar gap

What are some things that can cause anion gap metabolic acidosis?

-Methanol

-Uremia

-DKA

-Propylene glycol

-Isoniazid/IV iron

-Lactic acidosis

-Ethanol/Ethylene glycol

-Salicylates/Starvation

What are some things that can cause lactic acidosis?

-Metformin

-Beta blockers

-Salicylates

-Nitroprusside

-Propofol

-Antiretrovirals

-Alcohols

-Lactated ringers (decreased liver function)

What is the effect of IHD on acid-base balance?

-Remove nonvilatile acids and primary causes of acidosis

-Provide buffer in dialysate

What is the effect of CRRT on acid-base balance?

-Same as IHD

-Replacement solutions contain lactate or bicarbonate

-Citrate based regional anticoagulation

-Risk of overcompensating causing metabolic alkalosis

When is RRT indicated for hyperkalemia and hypermagnesemia?

-Severe, symptomatic cases with limited response to less invasive measures

-ARF/CKD with severely impaired renal function

-ESRD/RRT patients where diuretics are ineffective and SPS is dangerous

How can RRT be used to correct potassium?

-Dialysate K bath at low levels will help pull K out of the blood and into the dialysate

-Less efficient if intracellular shifting agents were utilized prior to HD

What are some intracellular shifting agents of K?

-Insulin

-Albuterol

-Bicarbonate

True or False: RRT yields the fastest and most reliable removal of K

True

True or False: Some patients when given intracellular shifting agents can have rebound hyperkalemia after HD

True

True or False: Magnesium disorders are very common in the absence of ARF/CKD

False

When may RRT be necessary for hypermagnesemia?

Severe symptomatic cases in patients with renal impairment

When do symptoms of hypermagnesemia occur (Mg levels)?

4 mEq/L to 15 mEq/L or higher

How long does it take RRT to correct hypermagnesemia when compared with diuretics?

-4 hours with RRT

-6-12+ hours with diuretics

What are some toxic alcohols that may lead someone to need acute RRT?

-Methanol

-Ethylene glycol

When are toxic alcohols suspected in cases of acute RRT?

-Metabolic acidosis with positive anion gap

-Positive osmolar gap

What are the signs and symptoms of methanol toxicity?

-Inebriation

-Drowsiness

-Dilated pupils

-Blindness

-N/V

-Vertigo

-Bradycardia

-Delirium

-Agitation

What are the signs and symptoms of ethylene glycol toxicity 30 minutes to 12 hours after ingestion?

-Inebriation

-Seizures

-Nystagmus

-Paralysis of eye muscles

What are the signs and symptoms of ethylene glycol toxicity 12-24 hours after ingestion?

-Calcium oxalate deposition

-Tissue destruction characterized by ARF

-Tachycardia

-Hypotension

-Pulmonary edema

-HF

What are the signs and symptoms of ethylene glycol toxicity 24 hours or more after ingestion?

-Flank pain and tenderness

-Oliguric ATN

What class of medications can be used to treat toxic alcohol intoxications?

Alcohol dehydrogenate inhibitors

What are some examples of alcohol dehydrogenase inhibitors?

-Ethanol

-Fomepizole

Serum levels of either methanol or ethylene glycol above __ mg/dL must be treated with EtOH or fomepizole

20

Hemodialysis is needed in toxic alcohol intoxications under what conditions?

-Serum levels greater than 50 mg/dL

-Serum levels 20-50 mg/dL with severe symptoms, refractory acidosis, or known significant ingestion

What is the initial dose of EtOH used to treat toxic alcohol intoxications?

600-750 mg/kg IV

What is the maintenance dose of EtOH for a non-drinker?

-66 mg/kg/hr

-169 mg/kg/hr if on HD

What is the maintenance dose of EtOH for a chronic drinker?

-154 mg/kg/hr

-275 mg/kg/hr if on HD

What is the goal when using EtOH for toxic alcohol intoxications?

Titrate to maintain a serum ethanol level of 100-150 mg/dL

What is the loading dose of fomepizole?

15 mg/kg IV

What is the maintenance dose for fomepizole?

-10 mg/kg Q12H for 4 doses, then 15 mg/kg Q12H until levels are undetectable

-Levels less than 20 mg/dL and patient is asymptomatic

What things can bring about lithium toxicity?

-Renal failure

-Use of diuretics

-Use of NSAIDs

-Use of ACEis

-Massive overdoases

-Sodium restriction

-Dehydration

Any lithium level above ___ mEq/L is considered supratherapeutic

1.5

Mild lithium toxicity is characterized by a serum level of ___-___ mEq/L

1.5 - 2.5

Moderate lithium toxicity is characterized by a serum level of ___ - ___ mEq/L

2.6 - 3.5

Severe lithium toxicity is characterized by a serum level of greater than ___ mEq/L

3.5

What are some CNS signs and symptoms of lithium toxicity?

-Tremor

-Confusion

-Somnolence

-Stupor

-Seizure

-Permanent neurological deficit

-Spasticity/hyperreflexia

-Dystonia

-Rigidity

-Death

What are some renal signs and symptoms of lithium toxicity?

-DI

-Hypernatremia

How do you treat lithium toxicity?

-D/C lithium and interacting medications

-Hydration +/- LD or K+ sparing diuretics

-HD

When should HD be used for lithium toxicity?

-Levels greater than 3.5

-Levels 2.5-3.5 with symptoms, renal failure, expectation of rising levels, not expected to decline to less than 0.6 mEq/L in 36 hours

What are some signs and symptoms of a salicylate intoxication?

-Tinnitus

-Deafness

-Profuse sweating

-Flushing

-Confusion

-Lethargy

-Acid-base disorders

-Bleeding

-Pulmonary edema and failure

-Convulsions

-Cardiovascular collapse

-Renal failure

What are the 2 treatments for salicylate toxicity?

-Bicarbonate/forced alkaline diuresis

-HD

Bicarbonate/forced alkaline diuresis is used for salicylate toxicity when levels are over __ mg/dL

40

When is bicarbonate/forced alkaline diuresis contraindicated for salicylate toxicity?

-Alkalosis

-Pulmonary edema

When is HD warranted for salicylate toxicity?

-Levels over 80 mg/dL (60 if chronic exposure)

-Renal failure

-CNS dysfunction

-Pulmonary edema

Theophylline toxicity can be seen when levels are greater than __ mcg/mL, despite being at goal

15

What are some signs and symptoms of theophylline toxicity?

-N/V

-Tachycardia

-Metabolic acidosis

-Electrolyte disorders

-Seizures

-Dysrhythmias

-Hypotension

How do you treat theophylline toxicity?

-D/C theophylline

-Symptomatic and supportive care

HD

When is HD considered for theophylline toxicity?

Levels greater than 80-100 mcg/mL (lower levels in neonates, elderly, or pts with preeixsting cardiac or hepatic failure)

True or False: Volume overload can be a primary indication in cases of pulmonary edema or HF in the settings of ARF or ESRD

True

What is the treatment for volume overload in ARF?

HD with ultrafiltration

What is the treatment for volume overload in ESRD on HD?

HD with ultrafiltration OR ultrafiltration only

What can a rapid decline in BUN cause?

Disequilibrium syndrome

What is disequilibrium syndrome?

Cerebral edema similar to rapid correction of hypernatremia

How do you treat uremia?

Short HD sessions