Dialysis in ESRD

7/30/2019 Dialysis in ESRD

1/59

Dialysis in ESRD

Velma Herwanto


2/59

ESRD Treatment Options

Hemodialysis

Peritoneal dialysis:

less efficient in soluteclearance

Transplantation

Outcomes aresimilar

preference andquality-of-lifeconsideration


3/59

Epidemiology

Mortality rate on dialysis in US: 1820%/year, 5-year survival rate 3035%

Deaths are due mainly to cardiovascular

diseases (50%) and infections (15%)

Important predictors of death: age >, male,nonblack race, DM, malnutrition, underlyingheart disease


4/59

Initiation on Maintenance Dialysis

Uremic symptoms: encephalopathy, neuropathy,pericarditis, pleuritis

Persistent ECV expansion despite diuretic therapy

Bleeding diathesis

Hypertension poorly responsive to antihypertensivemedications

Persistent metabolic disturbances that are refractory tomedical therapy

Persistent nausea and vomiting

Evidence of malnutrition

CrCl or eGFR < 10 mL/min/ 1.73 m2

Do not delay the initiation of dialysisuntil one of this is present!


5/59

Relative Indications to InitiateDialysis

Decreased attentivenessand cognitive tasking

Depression Persistent pruritus

Restless leg syndrome


6/59

hemodialysis


7/59

Hemodialysis


8/59

Scheme for Hemodialysis

Extracorporeal circuit indialysis machine

Dialysis access

Blood pump: 250-500 mL/min,negative hydrostatis pressure ultrafiltration

Dialysis solution delivery system

Safety monitor

DIALYZER

Bundles of capillarytube: 1,5-2 m2

Cellulose vs.synthetic

Reprocessed and

reused

DIALYSATEK+ 0-4 mmol/LCa2+ 1.25 mmol/L: modification in hypocalcemiaNa+ 140 mmol/L lower hypotension,cramping, nausea, vomiting, fatigue, dizziness

Water 120 L: reverse osmosis

BLOOD DELIVERY


9/59


10/59

Hemodialysis Membrane


11/59

Chronic Dialysis Access

Fistula, graft, or tunneled catheter

AV fistula:

Brescia-Cimino fistula: radiocephalic/ brachiocephalic/brachiobasiclic arterialization of the vein

The highest long-term patency rate and lower complication

Synthetic graft: PTFE straight/ looped forearm,straight/ looped upper arm

Smaller-caliber veins/ veins have been damaged

Complication: thrombosis, infection, steal, aneurysms,venous hypertension, seromas, heart failure, and localbleeding


12/59


Dual-lumen tunneled catheter

Indication:

To allow maturation of fistulas/ grafts

CVC(require HD


13/59



14/59

Dialysis in Series

CVC: Entire systemic compartment is available forurea extraction urea removal would be maximized


15/59

Dialysis in Parallel

AV access: reduce extraction of urea < theoreticalclearance urea removal is limited (the capillaries where

this blood refills with urea)

- 60-70%

- 5-15%


16/59

Goals of Dialysis

Removing both low- and high-molecular-weight solutes

Heparinized blood300-500mL/min

Dialysate500-800mL/min

Efficiency of dialysis

blood and dialysate flowand dialyzer characteristics

Adequacy of dialysis:fractional removal of urea

nitrogen and derivationsthereof


17/59


18/59

The effect of increasing dialyzer blood flow (Qb) ontotal body urea clearance (Ktb) during HD


19/59

Movement of Waste Product


20/59

Dialytic Clearance of Solute

Diffusion Ultrafiltration


21/59

Convective Clearance


22/59

Membrane:Flux, Permeability, and Efficiency

Komass transfer coefficient; Asurface area


23/59

Dialysis Prescription (KDOQI 2006)

Urea removal normalized for a measure ofbody size

Kt/V

K = dialyzer urea clearance data dialysismembrane size, Qb, Qd

t = duration of dialysis in minutes modifiable!

V = patient's urea space


24/59

Adequacy of HD (KDOQI 2006)


25/59

Delivering Adequate Dose ofDialysis


26/59

Urea Equilibration in HD

Degree of urea removal rateof urea equilibration between

IC and the ECSlow equilibrators lower BUN but a slower rate of total

urea removal


27/59

Organ Reservoirs of Urea

Low ratio of blood flow to urea content sequester upto 80% of the total body urea rebound and

dialysis efficiency

15-20% CO


28/59

HD Increase in... (KDOQI 2006)

Minimally adequate dose

, any body size

Smaller patients

BW 20% less or fluid is removed at the beginning)


35/59

Complication During HD

Muscle cramp:

Excessively aggressive volume removal (>dry weight)

Use of low-sodiumcontaining dialysate

Management:

volume removal

UF profiling

Higher concentrations of sodium in thedialysate or sodium modeling


36/59

Sodium Modelling

Intracellularmovement of water

+UF of water hypotension


37/59

Complication During HD

Anaphylactoid reaction to dialyzer

Type A: IgE-mediated hypersensitivityreaction to ethylene oxide within the

first few minutes steroids orepinephrine

Type B: nonspecific chest and back pain,

from complement activation andcytokine release several minutes,resolve over time


38/59

Dialysis Disequilibrium Syndrome

Central nervous system disorder in dialysis patients

Pathophysiology: cerebral edema

Reverse osmotic shift

Fall in cerebral intracellular pH

At risk: new HD patients (with >> BUN), severe metabolicacidosis, older age, pediatric, presence of CNS disease

Headache, nausea, disorientation, restlessness, blurred vision,asterixis, muscle cramps, anorexia, dizziness

More severe: confusion, seizures, coma, death


39/59

DDS: Treatment and Prevention

Qb, consider stop the dialysis session

Hypertonic mannitol or 23% saline

Prevention: slow urea removal

Initial HD: 2 hours, Qb 150-250 mL/min, small surfacearea dialyzer, concurrent blood and dialysate flow 3-4days 50 mL/min (up to 300-400 mL/min),duration 30 minute

Marked fluid overload: UF followed by a short period ofHD

PD

Prophylactic phenytoin and/ or mannitol


40/59

Peritoneal Dialysis


41/59

Normal Anatomy

Peritoneal contains 100 ml fluid

Adult can tolerate > 2 L fluid withoutpain or alteration to the respiratory

function : peritoneal cavity is closed

: peritoneal cavity is continuous

with the Fallopian tubes

PD fluidbecome blood-stained during amenstrual period


42/59

Principles of Peritoneal Dialysis

Jeremy Levy et al, Oxford Handbook of Dialysis, 2003


43/59

Solute and Water Transport Mechanism in PD

Diffusion Solute(e.g. Ur,Cr, K)

Via mid-size pores Most important

High concentration (blood) low concentration(dialysate)

to the concentration gradient

Best for clearance of small molecules

Convection Solute(e.g.protein,Na)

In response to a positive transmembrane pressure

Less dependent on molecular size

Ultrafiltratio

n

Water Low osmotic concentration (blood) high osmotic

concentration (dialysate), via aquaporin-1 Highest at the beginning, ceases when osmolarity hasdecreased to equal serum osmolarity

Reabsorbtion of water if dialysate is allowed to dwellbeyond the time past when osmotic equilibrium isreached


44/59

Access to Peritoneal Cavity

Peritoneal catheter: silicon rubberwith numerous side holes at thedistal end

Dacron cuffs: promote fibroblastproliferation, granulation, andinvasion of the cuff

Seal from bacteria from the skin surface

Prevents external leakage of fluid


45/59

Types of PD Catheter


46/59


47/59

PD Solutions

Ideal osmotic agents:

Metabolized easily with non-toxic degradation products

Poorly absorbed

Inert and non-toxic to the peritoneal membrane Inexpensive

Effective osmotic agent at low concentration

No metabolic consequences of absorption

Must be of nutritional value

Not difficult to manufacture

Should not inhibit peritoneal defenses


48/59

PD Solutions

High molecular weight Glucose polymer (icodextran 7.5%): Polypeptides (5%): Glucose-containing (dextrose monohydrate 1.5, 2.5, 4.25%): Amino acid (1.1%): Glycerol:Low molecular weight Glucose polymer (icodextran 7.5%): Polypeptides (5%): Glucose-containing (dextrose monohydrate 1.5, 2.5, 4.25%): Amino acid (1.1%): Glycerol:


49/59

PD Solutions

Solutions: 1.5 to 6.0 L

Lactate is the preferred buffer, other:acetate, bicarbonate

Electrolyte: Na, Ca, Mg, K

Additives: heparin, antibiotics, insulin


50/59

CAPD3-5x/ day

CCPD

DAPD

NIPD


51/59

Adequacy of PD: K/ DOQI 2006

T Peritoneal


52/59

Calculation of Solute Clearance

, 70 kg on CAPD has a drain volumeof 10.5 L/day, and D/P urea of 0.95

Kt = 10.5 x 0.95 = 10 L

The urea volume of distribution (V) =42 L (60% of lean body weight inmen, 55% in women)

Daily Kt/Vurea = 10 42 = 0.24

Weekly Kt/Vurea = 0.24 x 7 = 1.68


53/59

Adequacy of PD

Efficiency of solute clearance volume of dialysate (> volumes > solute clearance), physical activity

Peritoneal equilibrium test: measures the transfer rates ofcreatinine and glucose across the peritoneal membrane

Low transporter: fewer exchanges

Lowaverage transporter

Highaverage transporter

High transporters: absorb > glucose, lose efficiency of UF with longdaytime dwells, lose > albumin require more frequent, shorter dwell

time exchanges

PET: 3-4 weeks after catheter insertion and on complication

U i T t T t


54/59

Using Transport Type toSelect PD Regimen

High


55/59

Indication to Repeat PeritonealMembrane Transport Testing

KDOQI 2006

Unexplained volume overload

Decreasing drain volume on: overnight dwell (CAPD)

or daytime dwell (APD)Increasing clinical need for hypertonic dialysatedwells to maintain DV

Worsening of HTN

Change in measured peritoneal solute removal(Kt/Vurea)

Unexplained signs/ symptoms of uremia

PD P i ti T t d


56/59

PD Prescription Target andMeasurement (KDOQI 2006)

If a patient is not thriving + no otheridentifiable cause, consider to

increase dialysis dose.

Patient with minimal RKF

continuous 24 h/day of PD dwell tomaximize middle molecule clearance


57/59

Fluid Balance

The 2006 NKF-KDOQI guidelines: oneshould achieve euvolemia andoptimal BP control

Maintenance of euvolemia: PD drainvolume, RKF, blood pressure

The 2005 European Best PracticesGuidelines: in anuric patients,minimum UF target is 1.0 L/day


58/59

Complications During PD

Peritonitis: peritoneal fluid leukocytes 100/mm3 (at least50% are PMN) pain, cloudy dialysate, fever

Gram-positive cocci, gram-negative rod, fungal, mycobacterial

Intraperitoneal/ oral antibiotics

Due to hydrophilic gram negative rods (e.g.,Pseudomonas

sp.) oryeast: require catheter removal

Catheter-associated nonperitonitis infections

Weight gain

Hypoproteinemia: dietary protein intake

Hyperglycemia

Hypertriglyceridemia

Residual uremia (esp. in patients with no residual kidneyfunction)


59/59

Terima Kasih

Dialysis in ESRD

Documents

Transcript of Dialysis in ESRD