renal replacement therapy lecture
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Mahesh Raj Sigdel
Aug 29, 2014
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When to think of/discuss RRT in CKD !!!
CKD 4
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Definition of CKD
• Duration
– GFR
– Kidney damage – Abnormality in urine
– USG renal biopsy
– Transplant
• Stages of CKD
• KDIGO 2012: CGA
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Stages of CKD
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Signs & symptoms of CKD
Functions of CKD:
1. Excretory
2. Regulatory
3. Endocrine
4. Metabolic
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When in CKD 5, options:
1. Dialysis
• Hemodialysis
• Peritoneal dialysis
2. Transplant
3. Supportive care, only
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Availability
•
Money•Kidney
Wish of the
patient
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Other issues to consider…
Vision
Manual dexterity
Willingness to do self careSupport available at home
Access to Hemodialysis facility
Tolerance to any of the modality
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Which modality of RRT is the best ?
• Having considered everything,
– Kidney TX
Cheap
Prolonged life
Quality life
• Why ???
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When to initiate Dialysis in CKD ie
maintenance dialysis ???
CKD 5
A patient of CKD 5 who in absence of acute
reversible factors has indications foremergency hemodialysis
eGFR around 7-10; may be higher in diabeticsand selected patients
Symptomatic• Clinically
• biochemically
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Emergency indications for HD:
1. Hyperkalemia, esp associated with
ECG changes
2. Significant metabolic acidosis
3. Medically refractory pulmonary
edema
4. Uremic encephalopathy
5. Uremic pericarditis
6. Uremic bleeding
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Water treatment plant
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Vascular access
1. Temporary
2. Permanent
AV fistulaAV graft
Central venous catheters (jugular,femoral, subclavian) – Simple (non cuffed)
– Tunnelled (cuffed/permcath)
• Avoid subclavian catheters
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Principles of Dialysis
Diffusion
Ultrafiltration
Counter current flow
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Maintenance HD
Three times/week, life long
4 hours/each session
With adequate blood flow
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Complications of HD
Hypotension
Cramps
Nausea vomiting
Chest pain
Allergic manifestations
Infection, fever
Dialysis disequilibrium syndrome,DDS
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Different types of PD
Intermittent peritoneal dialysis (IPD)
Continuous ambulatory peritoneal dialysis
(CAPD)Nocturnal intermittent peritoneal dialysis
(NIPD)
Continuous cyclic peritoneal dialysis (CCPD)Automated peritoneal dialysis (APD)
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Complications of PD
Infection:Peritonitis
Tunnel
Exit site
Hernia Backache
Hydrothorax
Hyperglycemia
Hypertriglyceridemia/dyslipidemia Chronic encapsulating peritonitis
Ultrafiltration failure
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Compare HD vs PD
Cost
Accessibility
Finding slots
Vascular access
Freedom of mobility
Hemodynamic instability
Freedom to drink water, diet, protein
Problem of anemia
Issues of peritonitis
Preservation of residual renal function
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How to monitor a patient on dialysis?
Clinically ie symptoms
Fluid overload
BP
Weight: dry weight
Anemia Serum albumin
Skin fold thickness
Ca, Phosphorus, iPTH & bone health
Frequency of infection Patient satisfaction
Quality of life
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Which RRT modality will you propose
to your patient ???
• That chosen by the well informed patient
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Thank you !!!
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