[04.06] Kidney Replacement Theory V2.pdf

Refractory metabolic acidosis

What does the 'A' stand for in the AEIOU mnemonic for emergency dialysis initiation?

Severe or refractory hyperkalemia

What does the 'E' stand for in the AEIOU mnemonic for emergency dialysis initiation?

Ingestion or poisoning of dialyzable substances

What does the 'I' stand for in the AEIOU mnemonic for emergency dialysis initiation?

Salicylates, lithium, and ethylene glycol

What are three common dialyzable ingestions or poisons included in the 'I' of the AEIOU mnemonic?

Fluid overload refractory to high-dose diuretics

What does the 'O' stand for in the AEIOU mnemonic for emergency dialysis initiation?

Uremic manifestations

What does the 'U' stand for in the AEIOU mnemonic for emergency dialysis initiation?

Pericarditis, encephalopathy, bleeding diathesis, and severe anorexia or vomiting

What are four severe uremic manifestations that serve as absolute indications for starting dialysis?

Overall clinical cause and uremic manifestations

Rather than relying solely on a cutoff serum creatinine value, on what basis should the clinical decision to initiate dialysis be made?

IDEAL Trial

Which clinical trial demonstrated that starting dialysis earlier in asymptomatic patients provides no survival benefit?

eGFR 10–14 mL/min/1.73m² vs eGFR 5–7 mL/min/1.73m²

What were the two eGFR comparison groups evaluated in the IDEAL trial?

800,000

How many Americans are estimated to have End-Stage Kidney Disease?

Top 10 causes of morbidity and mortality

What is the epidemiological ranking of End-Stage Kidney Disease in the Philippines?

Diabetes mellitus

What is the single most common cause of End-Stage Kidney Disease worldwide, accounting for 45% of cases?

45%

What percentage of ESKD cases worldwide is caused by diabetes mellitus?

Hypertension

What is the second most common cause of End-Stage Kidney Disease, accounting for 30% of cases?

30%

What percentage of ESKD cases is attributed to primary or secondary hypertension?

Glomerulonephritis, ADPKD, and urinary tract obstruction

Name three additional non-diabetic, non-hypertensive etiologies of ESKD.

APOL1 gene

Which gene alleles found predominantly in African Americans are linked to a high risk for developing ESKD?

Hypertensive nephrosclerosis and Focal Segmental Glomerulosclerosis (FSGS)

Which two specific renal pathologies are associated with APOL1 gene risk alleles?

Residual Renal Function (RRF)

What term describes the kidneys' remaining ability to filter waste, produce urine, and balance fluids and electrolytes after the onset of ESKD?

Cardiovascular disease

What is the leading cause of death in patients with End-Stage Kidney Disease?

Dialysis patients

Are cardiovascular mortality rates higher in patients undergoing chronic dialysis or in post-kidney transplant recipients?

Volume-dependent hypertension

What is the primary pathophysiological mechanism underlying hypertension in chronic dialysis patients?

Inadequate dialytic volume removal

What underlying problem should be suspected when a patient on chronic dialysis exhibits refractory hypertension?

Pulmonary edema, engorged neck veins, and peripheral edema

What three physical exam findings indicate fluid overload as the cause of hypertension in a dialysis patient?

Hemodialysis, Peritoneal Dialysis, and Kidney Transplantation

What are the three primary modalities of kidney replacement therapy?

Kidney transplantation

Which kidney replacement modality is the ONLY one capable of fully replacing both excretory and endocrine functions?

Erythropoiesis

What endocrine function of the kidney is restored by kidney transplantation but cannot be replaced by HD or PD?

Solute clearance and removal of excess water

To what two physical processes are the therapeutic actions of hemodialysis and peritoneal dialysis limited?

2 to 3 times per week, lasting 4 hours per session

What is the standard frequency and session duration for maintenance hemodialysis?

Diffusion and Ultrafiltration

What are the two physical principles upon which hemodialysis operates?

Diffusion

Which process removes solutes across a semi-permeable membrane from an area of higher concentration to lower concentration?

Patient's blood

In hemodialysis, which side of the semi-permeable membrane represents the high concentration compartment for urea, creatinine, and potassium?

Small molecules

Which molecular size class (e.g., urea, 60 Da) is cleared rapidly by diffusion during hemodialysis?

Red blood cells, cytokines, and TNF-alpha

Name three blood components or large proteins that are NOT cleared by diffusion during hemodialysis due to their large size.

Hydrostatic pressure

What force drives ultrafiltration across the dialyzer membrane?

Solvent drag

What term describes the convective movement and removal of water alongside dissolved solutes during ultrafiltration?

Hollow fiber dialyzer

What component containing biocompatible membranes serves as the artificial kidney in a hemodialysis circuit?

Isotonic to plasma

How does the osmolality/tonicity of standard hemodialysis dialysate compare to human plasma?

135 to 140 mEq/L

What is the standard sodium concentration in hemodialysis dialysate?

1.25 mmol/L

What is the standard calcium concentration in hemodialysis dialysate?

0 to 4 mmol/L

What is the standard potassium concentration range in hemodialysis dialysate?

Risk of cardiac arrhythmias and sudden cardiac death

Why are 0 mEq/L and 1 mEq/L potassium dialysate baths strictly avoided in routine hemodialysis?

Native Arteriovenous Fistula (AVF)

Which vascular access modality offers the highest long-term patency and lowest intervention rate?

Brescia-Cimino fistula

What is a classic named anatomical example of a native arteriovenous fistula?

2 to 6 months

What is the required maturation time for a native arteriovenous fistula?

Rule of 6s

What clinical rule of thumb governs the assessment of native AV fistula maturation?

Primary non-maturation and arterial steal syndrome

What are two primary complications unique to native AV fistulas?

Palpating a thrill and auscultating a bruit

What two physical examination steps must be routinely performed to assess a functional AV fistula?

Arteriovenous Graft (AVG)

Which vascular access utilizes a PTFE prosthetic bridge to connect an artery and a vein when native veins are unsuitable?

2 to 3 weeks

What is the maturation time for an arteriovenous graft before early cannulation?

Venous anastomotic intimal hyperplasia and thrombosis

What are the two main vascular complications associated with arteriovenous grafts?

Catheter-directed thrombectomy

What procedure is performed to salvage a thrombosed arteriovenous graft?

Tunneled Central Venous Catheter (CVC)

Which vascular access features a Dacron cuff, provides immediate access for emergency use, but carries the highest morbidity and mortality?

Bacteremia/sepsis and central venous stenosis

What are the two major long-term complications of tunneled central venous catheters?

Right Internal Jugular Vein (IJV)

What is the preferred primary anatomical site for placing a tunneled CVC?

Right IJV > Femoral vein > Subclavian vein

What is the order of priority for anatomical site selection when inserting a central venous catheter for hemodialysis?

Causes central venous stenosis, destroying the ipsilateral arm for future fistula creation

Why is placement of a central venous catheter in the subclavian vein strictly discouraged or avoided?

Kt/V = 1.2

What is the target minimum Kt/V value per session for adequate hemodialysis?

Urea Reduction Rate (URR) > 65% to 70%

What is the target Urea Reduction Rate per hemodialysis session?

Subtracting post-dialysis BUN from pre-dialysis BUN and dividing by pre-dialysis BUN

How is the Urea Reduction Rate (URR) calculated mathematically?

HEMO Study

Which clinical trial showed that increasing Kt/V target beyond 1.2 to 1.6 offered no improvement in mortality or hospitalization rates?

Volume control, nutritional status, and metabolic control

Besides small solute (urea) clearance, what three clinical parameters determine true hemodialysis adequacy?

9 to 12 hours per week

What is the total recommended duration of hemodialysis per week, split into 2 to 3 sessions?

Long weekend hazard

What term describes the increased rate of cardiovascular events, hospitalizations, and deaths during the 2-day dialysis-free interval?

Severe hyperkalemia and fluid overload

What are the two main metabolic triggers for emergency hospitalization following a 2-day dialysis-free interval?

Intradialytic hypotension

What is the most common acute complication encountered during a hemodialysis session?

High ultrafiltration targets exceeding 13 mL/kg/hour

What technical factor during hemodialysis primarily drives intradialytic hypotension?

Stop ultrafiltration / fluid removal

What is the immediate first step in managing intradialytic hypotension?

Trendelenburg positioning, 100–250 mL normal saline bolus, dialysate cooling, and sodium modeling

Name four supportive interventions for treating intradialytic hypotension after stopping ultrafiltration.

Muscle cramps

Which intradialytic complication is caused by muscle hypoperfusion from rapid volume removal combined with acute osmolar shifts?

Review dry weight, utilize ultrafiltration profiling, and avoid aggressive fluid removal

What three strategies prevent intradialytic muscle cramps?

IgE-mediated anaphylactic reaction to ethylene oxide gas

What is the underlying mechanism of a Type A dialyzer reaction?

Within the first few minutes of starting dialysis

When during a hemodialysis session does a Type A dialyzer reaction manifest?

Dyspnea, wheezing, and angioedema

What three classic symptoms signal a Type A dialyzer reaction?

Immediately stop the blood pump and disconnect without returning blood to the patient

What is the critical management step when a Type A dialyzer reaction occurs?

Complement activation

What is the underlying mechanism driving a Type B dialyzer reaction?

Vague chest pain and back pain occurring 15 to 30 minutes into the session

What are the clinical manifestations and timing of a Type B dialyzer reaction?

Usually resolves spontaneously with continued dialysis

What is the management approach for a Type B dialyzer reaction?

Instilling hypertonic dialysate solution into the peritoneal cavity via an indwelling catheter

How is peritoneal dialysis physically performed at home?

Effluent

What term is given to the drained peritoneal fluid containing cleared waste products and excess water?

Peritoneal membrane

What anatomical structure functions as the semi-permeable membrane in peritoneal dialysis?

Hypertonic dextrose/glucose-based solution

What type of dialysate solution creates the osmotic gradient required for ultrafiltration in peritoneal dialysis?

Deep Dacron cuff

Which cuff of a silicone PD catheter is placed in the peritoneal muscular plane to anchor the catheter and create a fluid-tight seal?

Superficial Dacron cuff

Which cuff of a PD catheter is positioned 2 cm subcutaneous to the skin exit site to prevent skin bacteria from tracking internally?

1.5%, 2.5%, and 4.25%

What are the three standard concentrations of dextrose-based peritoneal dialysis solutions?

Higher dextrose concentrations generate a steeper osmotic gradient, increasing ultrafiltration

How does increasing dextrose concentration affect peritoneal ultrafiltration?

Icodextrin

Which non-absorbable glucose polymer derived from starch provides sustained osmosis during long peritoneal dialysis dwells?

Amino acid-based PD solution

Which specialized PD solution is designed to assist patients with protein-energy malnutrition but is expensive and unavailable in the Philippines?

Continuous Ambulatory Peritoneal Dialysis (CAPD)

What is the most common form of peritoneal dialysis, characterized by manual exchanges throughout a 24-hour period without dry intervals?

Continuous Cyclic Peritoneal Dialysis (CCPD) / Automated Peritoneal Dialysis (APD)

Which form of peritoneal dialysis utilizes an automated cycler machine to perform shorter dwell exchanges, often overnight?

Presence of significant residual renal function

What patient factor allows for prescribed dialysis-free intervals during the day in automated peritoneal dialysis?

Peritoneal Equilibration Test (PET)

Which test evaluates the transport characteristics of the peritoneal membrane regarding fluid and solute clearance?

High / Fast Transporters

Which PET category is characterized by a highly vascular peritoneal surface area, rapid solute equilibration, and fast absorption of dextrose?

Rapid dissipation of the osmotic gradient leading to fluid reabsorption during long dwells

Why do High/Fast Transporters perform poorly on long-dwell CAPD regimens?

Automated Peritoneal Dialysis (APD) with rapid short-dwell cycles plus optional icodextrin

What is the optimal peritoneal dialysis regimen for a High/Fast Transporter?

Significant loss of albumin and protein across the peritoneal membrane into effluent

What protein abnormality is characteristically seen in High/Fast Transporters?

Low Transporters

Which PET category maintains a steep osmotic gradient for many hours, producing sustained ultrafiltration during long dwells?

Continuous Ambulatory Peritoneal Dialysis (CAPD) with large-volume (2.5–3 L) manual daytime exchanges and a long overnight dwell

What is the optimal peritoneal dialysis regimen for a Low Transporter?

ADEMEX Trial

Which clinical trial demonstrated that increasing peritoneal Kt/V from 1.6 to 2.2 did not reduce mortality or uremic complications?