Renal Replacement Therapies

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  • Exogenous : contrast and drugs , endogenous : rhadomyolysis , haemolysis. Tumor lysis syndrome
  • a) Information screen b) pumps 4 in number for diasylate , blood , fluid , effluent c) filter d) effluent bag e) replacement fluid
  • Blood and dialysate circulate in countercurrent direction / small molecules are removed : mechanism , diffusion
  • Combine diffusion and convective methods , most popular in ICU . Small and middle molecules removed . Replacment fluid required. RF contains electrolytes , lactate or bicarbonate diffusion : m/m of solutes down concentration gradient across semiper mb , Convection water is pushed together with dissolved solutes along pressure gradient .
  • Renal Replacement Therapies

    1. 1. Renal Replacement Therapies<br />Dr Phyo AungEmergency Medicine Registrar <br />
    2. 2. This presentation will include<br />Causes of renal failure Dialysis Techniques Complications of dialysis Common problems in dialysis patients Download link : will be posted in <br />
    3. 3. Why renal failure talk?<br />Common patients population <br />10th leading cause of death (2008 data) : 3224 deaths <br />One in nine Australians over 25 years has reduced renal function<br />Patients receiving dialysis treatment per year ( 2009)=10341<br />Leading cause of death in Aboriginal populations , 10 times higher than rest of populationEconomic impact of ESKD $ 800 millions per year <br /> ( All facts and numbers from Kidney Health Australia )<br />
    4. 4. Acute renal failure defination <br />Acute Kidney Injury Network (AKIN) www.akinnet.org criteria<br />Abrupt reduction ( within 48 hours ) in renal function<br />Absolute increase in serum creatinine (> or = 100 umol/L)Percentage increase in serum creatinine > or = 50% from base line ( 1.5 fold from the base line )<br />Reduction in urine output ( < 0.5 ml/kg per hour for more than six hours)<br />
    5. 5. Causes of Acute Renal Failure<br />Pre Renal ( Renal Hypo perfusion)<br />Intravascular volume depletion ( dehydration , blood loss)<br />Severe hypotension ( drug overdose , sepsis , shock )pump failure ( myocardial causes) Renal artery emboli<br />Renal <br />ATN ( Acute Tubular Necrosis from a/c pancreatitis ,burn ,sepsis , toxins including exogenous and endogenous )<br />Interstitial nephritis / AGN Hepatorenal syndrome<br />Post Renal <br />Renal vein thrombosis , Ureteric stones , Prostate , retroperitoneal f fibrosis , increased intra abdominal pressure )<br />
    6. 6. ECG Changes <br />
    7. 7.
    8. 8. Hyperkalemia Treatment<br />
    9. 9. Indications for renal dialysis<br />Hyperkalemia ( refractory Rx , persistently > 6.5 mmol/L)Pulmonary Odema ( Refractory Rx )<br />Severe Acidosis ( pH < 7.1 )<br />Uraemic complications ( pericarditis , encephalopathy )Anuria or oliguria ( urine < 200ml in 12 hours ) Drug Overdoses<br /> Removable drugs ( Lithium , Barbiturates , Salicylates , Methanol , cephalosporins , aminoglycosides )<br /> Non removable drugs ( Digoxin , tricyclic antidepressants , pheyntoin, benzodiazepines , beta blockers , OHAs)<br />
    10. 10. Types of dialysis<br />IHD ( Intermittent Haemodialysis ) : day procedure setting .<br /> 3 times per week : mostly for ESRD patients<br />Peritoneal Dialysis : home dialysis , 4 -5 exchange times per day or overnight procedure . Less effective than HD<br />Continuous Renal Replacement Therapy <br /> CVVH – Continuous Venovenous Hemofiltration CVVHD – Contiouous venovenous Hemodialysis CVVHDF – Continuous venovenous Hemodaifiltration<br />
    11. 11. Different types <br />
    12. 12. Typical dialysis machine<br />
    13. 13. Diffusion<br />Convection<br />
    14. 14. CVVH<br />
    15. 15. CVVHD<br />
    16. 16. CVVHFD<br />
    17. 17. VasCath for dialysis<br />Mahurkar Double Lumen Catheter<br />Medcomp Duo Flo IJ Catheter<br />
    18. 18. Advantages and disadvantages<br />Advantages Haemodynamic Stability – patients who cannot tolerate IHD are candidate for CRT Slower electrolyte and fluid shifts effective removal of larger molecules<br />Disadvantagesneeds skills for vascular access continuous anticoagulation => risk of bleedingICU support needed<br />
    19. 19. Complications in IHD patients<br />Vascular Complications<br />AV fistula = lifeline for ESRD patients<br /> 1) Bleeding common complication , from minor trauma or after HD Rx : firm gentle pressure x 10 -15 minutes<br /> topical gel foam to avoid vigorous pressure<br /> IV DDAVP or Protamine sulfate for heparin reversal<br /> 2) loss of thrill or bruit over fistula – thrombosis <br /> Rx : urgent vascular consult for clot removal<br /> Avoid : BP cuff , IV cannula , Central line over access arm<br /> 3) Infection over vascular access : common <br /> Rx : needs admission for IV anti Single loading dose of Vancomycin and loading dos e of aminoglycoside followed by cephalosporin<br />
    20. 20.
    21. 21.
    22. 22. Non vascular complications in IHD patients<br />Hypotension<br />Most common cause = sudden reduction in circulating volume during and after HD<br />Other important causes <br />Acute haemorrhage from various sited due to qualitative platelet defect , Rx administration of DDAVP<br />Occult GI Bleeding Anaphalytic reaction t o contents in dialysateSevere Hyper kalemiaPericardial tamponade due t o pericardial h’age or worsening pericardial effusion<br />
    23. 23. Dyspnoeain ESRD<br />Volume Overload Congestive Heart Failure<br /> 10-30% higher prevalence in dialysis patients<br /> ESRD+CHF = 83% mortality at 3 yearsOther Causes of dyspnoea <br /> Pleural Effusion <br /> Pleural Haemorrhage <br />Air Embolism <br /> less common with newer dialysis machines<br /> more common in usage of subclavian catheters<br /> “ Mill wheel murmur “ crunching sound on auscultation<br /> Rx : clamp the catheter and stop dialysis place patient in the left lateral decubitus position if continued decompensation : aspirating air backwards <br />
    24. 24. Altered Mental State in IHD Patients<br />Dialysis Disequilibrium Syndrome e (DDS )<br /> mostly occurred during or immediately after haemodialysis<br /> Symptoms included headache , nausea , vomiting , muscle cramps , confusion , seizures or coma .<br /> The syndrome is triggered by rapid movement of water into brain cells following the development of transient plasma hypoosmolality as solutes are rapidly cleared from the bloodstream during dialysis .<br /> Rx : supportive ( usually self limiting ) resolved after fluid and solutes are re distributed across cell membranes.<br />
    25. 25. Differential Diagnosis of confusion in IHD <br />Uremia Hypertensive EncephalopathyHypocalcaemiaHypoglycaemiaHyperkalemiaHypovolemiaIntracranial haemorrhage : high risk of spontaneous bleeding Subdural Haemorrhage are common Have a low threshold for CT scan<br />Dialysis Dementia chronic dialysis patient . Due to aluminium or phosphate binding in brain<br /> Rx : Desfuroxamine<br />
    26. 26. Chest Pain in CRF <br />Pericarditis <br /> occur 6 to 10 % of ESRD pt usually those who have yet to start dialysis<br /> lacks the typical ECG changes * <br /> Rx : hemodialysis <br />Acute Coronary Syndrome <br /> 50% of all death in ESRD due to cardiovascular disease <br /> 25 to 40 % have LV dysfunction <br /> risk factor usually present ( DM , HT , hyperlipidaemia ) <br /> Silent ischemia is also common<br /> chest pain during dialysis is ISCHEMIC until proven otherwise<br /> dialysis is like a stress test , should delay HD in patients with unstable angina for at least 24 hours.<br />
    27. 27. Troponins<br />Regulatory proteins found in cardiac and skeletal musclethree subunits T , I and C <br />Genes encoding for both cardiac and skeletal isoform Tn C is identical : so not useful for TnC.<br />Theories for elevation Tn in CRF <br /> inflammatory response to CRF<br /> uremic myopathy<br /> subclinical myocardial injury from chronic fluid overload<br /> reduced renal clearance <br />CK MB will be elevated up t o 50% of CKD patients <br />
    28. 28. EMCREG Recommendations<br />Emergency Medicine Cardiac Research &Education Group<br />Elevations of Tr T or I likely represent myocardial injury and should not be considered non specific due to CRF<br />Patients with elevated Tr , no matter how minor , are at higher risk for cardiovascular mortality and over all mortality.<br />Elevated Tr may not be secondary to ACS , patients with CKD are higher risk . Any elevation in Troponin should warrant further cardiac evaluation.<br />Patient with CKD having chronic low level trop require s measuring a typical rise in Tr over a period of hours improves diagnostic accuracy . ( with serial blood and ECGs)<br />
    29. 29. Peritoneal Dialysis Complications<br />Peritonitis is the most common complicationPt present with abdomen pain , fever , malaise and dialysis effluent become cloudy.<br />Peritoneal fluid sent for Gram’s stain , culture , Total and DC.<br />Dx : > 100 WBC/mm3 with neutrophils predominant or culture positive.<br />Rx : loading dose of Vancomycin IP +/- gentamicin IP follow ed by once daily dose IP at the time of exchange.<br />
    30. 30. THANK YOU<br />

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