great ppt for beginners

1. ASSESSMENT OF CKD
PATIENT FOR
HEMODIALYSIS
INITIATION

2. PREDICTION OF THE START OF DIALYSIS
• Renal function is routinely measured by an estimate of the glomerular
filtration rate (eGFR) .
• Graphs of eGFR against time make it easy to identify those patients
whose renal function is deteriorating at a rate that predicts they will
require dialysis in the next 1 to 2 years

4. THE CHOICE BETWEEN PERITONEAL DIALYSIS
AND HEMODIALYSIS
•
• It is difficult to envisage an ethically acceptable trial in which patients are
allocated randomly to PD or HD.
• Retrospective comparative studies have failed to indicate a consistent survival
advantage for either modality.

5. • A prospective cohort study from 81 U.S. dialysis clinics
• No significant difference in outcomes was found between HD and PD during the first year
of treatment; but in the second year, the risk of death was significantly greater in those on
PD.
• The increased risk was mainly in patients with cardiovascular comorbidity
• When making their choice, patients should be aware that the chances of a change in
treatment modality may be up to fivefold greater for PD (to HD) than for HD (to PD) and
that change in treatment from PD to HD is associated with an increased risk of
hospitalization and mortality.

7. ASSESSMENT OF CKD PATIENTS
1.Volume overload
2.Hyperkalemia
3.Metabolic acidosis
4.Anemia
5.Ckd-Mbd
6.Nutrition
7.Vaccination
8.Vascular access

8. VOLUME OVERLOAD
• Sodium and intravascular volume balance are usually maintained via homeostatic
mechanisms until the eGFR falls below 10 to 15 mL/min/1.73 m2.
• CKD Pts. is less able to respond to rapid intake of sodium and is therefore prone
to fluid overload.
• Patients with volume overload respond to the combination of dietary sodium
restriction and diuretic therapy, usually with a loop diuretic.
• KDIGO guidelines that, among all adults with CKD, sodium intake should be
restricted to <2 g/day unless contraindicated.

9. HYPERKALEMIA
• Oliguric patients
• High-potassium diet
• Increased tissue breakdown
• Hypoaldosteronism
• ACE inhibitor or ARB
• Acidosis

10. Preventing hyperkalemia in CKD pts.
• Low-potassium diet <40 to 70 mEq/day or 1500 to 2700 mg/day
• Avoiding, drugs, such as NSAIDs ,ACE Inhibitor or ARB, Nonselective beta
blockers
• .

11. METABOLIC ACIDOSIS
• CKD pts. tends to retain H+ ions .

12. • Metabolic acidosis, even when mild, should be treated with dietary acid reduction

17. • SIDE EFFECTS OF NaHCO3:
High blood sodium levels
Metabolic Alkalosis
Belching
Bloating
Hyperosmolality
Milk Alkali syndrome

18. ANEMIA IN CKD

20. • Absolute iron deficiency anemia:
• The total body iron stores are depleted, limiting the production of RBCs.Require
EPO
• Functional iron deficiency anemia: inefficient utilization of iron stores
a. anemia of chronic inflammation( reticuloendothelial cell iron blockade),in
absence of EPO
b. use of exogenous EPO->faster deplection of iron stores->existing iron
stores are able to release->demand supply mismatch

21. • Anemia in adults and children >15 years with CKD when the Hb concentration is<
13.0 g/dl in males and <12.0 g/dl in females
• Testing should be done at least annually in patients with CKD stage 3 and at least
twice per year in patients with CKD 4–5ND
• Complete blood count , Absolute reticulocyte count , Serum ferritin level ,Serum
transferrin saturation (TSAT) ,Serum vitamin B12 and folate levels
• Treatment: For adult CKD patients with anemia not on iron or ESA therapy,
trial of IV iron to increase in Hb concentration without starting ESA ,
• TSAT is <30% and ferritin is <500 ng/ml.
• Avoid administering IV iron to patients with active systemic infections.

22. ESA THERAPY:
Not to initiate when Hb concentration is 10.0 g/dl in ckd 5ND
For adult CKD ND patients with Hb concentration <10.0 g/dl ESA therapy be
individualized based on the
 Rate of fall of Hb concentration
 Prior response to iron therapy
 Risk of needing a transfusion
 Risks related to ESA therapy and
 Presence of symptoms attributable to anemia
Not to be given in (CONTRA INDICATION)
Patients who have an active malignancy
Patients who have had a stroke.
Patients who have certain comorbidities being bedbound or with very limited functional
capacity, dementia.

23. • Route of administration: subcutaneously(20-30% bioavailability)
• Dosing:
• Side effects of ESA:

24. During the initiation phase of ESA therapy, measure Hb concentration at least
monthly.
 For CKD ND patients, during the maintenance phase of ESA therapy measure Hb
concentration at least every 3 months.
For CKD 5D patients, during the maintenance phase of ESA therapy measure Hb
concentration at least monthly.

26. IRON THERAPY
Oral iron :
preparation Tablet size Elemental iron per
tablet
Usual adult dosage
Ferrous sulphate
hydrated
325 mg 65 mg 2-4
Ferrous sulphate
desiccated
200 mg 65 mg 2-4
Ferrous gluconate 325 mg 36 mg 3-4
Ferrous fumarate 325 mg 106 mg 2-3

27. • Several intravenous iron preparations are available worldwide,
including iron dextran, iron sucrose, iron gluconate, and the newer
iron preparations ferric carboxymaltose, ferumoxytol, and iron
isomaltoside .

28. • Target hemoglobin value :Hb levels between 10 and 11.5 g/dL using the lowest
possible ESA dose.
• individualize therapy in some patients who may have improvements in quality of
life at Hb ≥11.5 g/dl
• We do not target Hb concentration >13 g/dL.

29. • Newer agents:
• Hypoxia-inducible factor prolyl hydroxylase inhibitors
• Vadadustat
• Roxadustat
• Daprodustat
• Enarodustat
• Desidustat

30. CKD-MBD
Biochemical abnormality,
Soft tissue calcification
Renal osteodystrophy

34. PHOSPHATE BINDERS

35. NUTRITION

36. • The optimal diet
• for individual chronic kidney disease (CKD) patients varies depending
upon the estimated glomerular filtration rate (eGFR),
• type of kidney disease (ie, proteinuric or nonproteinuric), and the
presence of other
• comorbidities such as hypertension or heart failure.

37. • No dietary restriction for patients with eGFR ≥60 mL/min/1.73 m2
• In pts. eGFR <60 mL/min/1.73 m2 not on dialysis and do not have nephrotic
syndrome, restrict daily protein intake to approximately 0.8 g/kg.
• patients with eGFR <60 mL/min/1.73 m2 who have hypertension, volume
overload, or increased protein excretion, we restrict sodium intake to <2 g/day (5
g/day of salt).
• patients with reduced eGFR who do NOT have hypertension, volume overload, or
increased protein, we use a more mild sodium restriction to 2.3 g/day (5.75 g/day
of salt [NaCl]

38. • potassium restriction is not required until the eGFR decreases to <30 mL/min/1.73
m2
• patients with eGFR <60 mL/min/1.73 m2, restrict total calcium intake to 1500
mg/day
• patients with a normal serum phosphate concentration, we restrict dietary
phosphorus intake to 0.8 to 1 g/day.
• Sources rich in inorganic phosphate, such as highly processed foods, should be
avoided as much as possible.
• caloric intake of 30 to 35 kcal/kg/day.
• Fat should be restricted to <30 percent of daily energy intake
• The recommended daily dietary fiber intake for CKD patients with eGFR <60
mL/min/1.73 m2 is 5 to 38 g/day

40. VACCINATION
• Reduced response to vaccination because of the general suppression of the
immune system associated with uremia.
• Dialysis patients have a lower antibody titer and an inability to maintain adequate
antibody titers over time.
• Relatively low antibody response to a vaccine correlate with the degree of renal
failure but not specific mode of dialysis
• Disturbances in T lymphocytes and antigen-presenting cells may be responsible
for the altered acquired immunity in ESRD patients.
• Live vaccines are contraindicated in immunocompromised patients due to risk of
vaccine-induced infections.

42. HEPATITIS B VACCINE
• Higher vaccine dosages or an increased number of doses are recommended for subjects
with CKD (eGFR <30 ml/min).
• Patients should receive four doses of hepatitis B vaccine as early in the course of disease
as possible
• Recombinant hepatitis B vaccine is recommended
• Use special formulations of vaccine (40 mcg/ml) or two 1 ml 20 mcg doses given at one
site. Dose schedule should be 0, 1, 2, and 6 months
• Vaccine should be given intramuscular in deltoid regions
• Assess antibody titer to hep B surface antigen (anti-HBs). First titer should be done 1-2
months after the primary course is completed and annually thereafter
• Booster dose should be given if anti-HBs titer falls below 10 mU/ml
• Revaccination with full doses is recommended for persons who do not develop protective
antibody titer after primary course.

43. PNEUMOCOCCAL VACCINE
• CKD patients over the age of 19 should receive a dose of PCV13 first, followed
by a dose of PPSV23 at least 8 weeks later.
• Specifically, the second PPSV23 dose is recommended 5 years after the first
PPSV23 dose for persons aged 19-64 years.

44. INFLUENZA VACCINE
• Influenza vaccine should be given annually before the beginning of the influenza
season for persons 6 months of age or older on dialysis.
• Household contacts and health care workers should also be vaccinated annually to
decrease the transmission to high-risk CKD patients.
• The vaccine dose is 0.25 ml by intramuscular route for those between the ages of 6
and 35 months, and 0.5 ml thereafter.
• To those <9 years of age, 2 doses of influenza vaccine are administered at least 1
month apart and at 9-12 years, one dose of split virus vaccine should be given
• After the age of 12 years, one dose of whole or split virus vaccine should be
given.

46. THE IMPORTANCE OF DIALYSIS ACCESS
• Ideally, every patient would make an informed choice between PD and HD after a
period of in-depth counseling and preparation, and dialysis access would be
established in advance of starting dialysis.
• Dialysis is frequently started in less than ideal circumstances.

47. • Patients starting dialysis as an emergency usually receive HD through a catheter.
• Compared with nonemergency patients, their length of hospital stay is
significantly greater, and during this time, there is a higher incidence of major
complications and death.
• International data from the Dialysis Outcomes and Practice Patterns Study showed
a 37% increase in the relative risk of death in patients dialyzing through a catheter
and a 19% increase in patients using a graft compared with a native AV fistula.

48. • The detrimental effects of central venous catheters persist even after the catheter
has been removed.
• The survival rate of subsequent AV fistulas is significantly worse in patients who
have had a previous catheter in place compared with those who started directly on
a fistula.
• If a radio cephalic fistula can be created swiftly and used as soon as it is mature.

49. VASCULAR ACCESS

50. • planning should start in CKD stage IV e [GFR] 15–30 mL/min),
• Pt. education about CKD and modalities of RRT should be discussed.
• Classification:
1. Arterio venous fistula
2.arterio venous graft
3.Temporary catheter
a.cuffed
b. non cuffed
AVF->AVG->Hd catheter
Location placed distally and moved to proximal

51. • Hemodialysis requires vascular access which is life line for ckd pts.
• Ideal vascular access features
• Delivers adequate flow rate
• Long life
• Low rate of complications
• Cannulated easily

52. VESSEL PRESERVATION.
• Preserve superficial and deep veins of both arms
• minimize venipunctures
• Due to risk of central vein stenosis, the subclavian vein should not be cannulated
• Use of percutaneously inserted central catheter (PICC) lines and midline catheters
should be rejected
• Preserve radial and brachial arteries
• Placement of endovascular leads for a cardiac implantable electronic device
(CIED) should be avoided

53. WHEN TO PREPARE FOR AV FISTULA
• gfr<30ml/min/1.73m2
• Ckd stage 4
• Best if prepared 6 months before hd(reason: timing allows for access evaluation
and additional time for revision and to ensure a proper working fistula is available
at the time of initiation of hd.)
• A graft in most cases be placed at least 3-6 weeks before start of HD
• AVG (PTFE)should not be canulated before 2 weeks
• AVG(polyurethane) can be canulated before 24 hour.

54. IMPORTANT HISTORY BEFORE CREATION OF
AVF
• H/O
• previous cvc,
• pacemaker use
• severe CHF
• arterial or venous peripheral catheter
• diabetes mellitus
• anticoagulant therapy or coagulation disorder
• presence of CAD,malignancy
• surgery of neck ,arm,or chest

55. PHYSICAL EXAMINATION
• All pulses in upper extremity should be evaluated and recorded.
• Blood pressure in both arms should be measured, the difference between the arms
should be graded as normal if less than 10 mmhg,borderline 10-20 mmhg,
problematic if >20 mm Hg
• Allen test.
• using pulse oximetry as an aid to the Allen test as this makes the test objective
increase in effectiveness

57. REQUIREMENTS BEFORE CREATING
FISTULA
ARTERIAL
• Size>2 mm
• Lack of calcification
• Flow pattern
VEIN
• Size 2.5 mm
• No evidence of stenosis/thrombosis
• Depth
• Central venous patency

58. MAIN FEATURES ADDRESSED BY DUPLEX
ULTRASOUND VASCULAR EXAMINATION
Arterial System
• Artery size from the axilla to hand including the palmar arch
• Dual arteries in upper arm high bifurcation
• Degree of arterial wall calcification
• Arterial stenotic lesions
• Blood flow at defined segments
Venous System
• Detailed venous anatomy in arm and leg as needed
• Vein size mapping from wrist to axilla
• Vein patency and presence or lack of stenosis
• Patency and flow pattern of subclavian vein
• Presence of diving venous branch at antecubital fossa

59. VASCULAR IMAGING
• Duplex ultrasound for vascular mapping
• measure flow velocity as well as the inner diameter of the brachial and radial
arteries and peripheral veins.
• poor visualization of central veins on Doppler ultrasonography is a limitation of
this method
• Vein dilation test:proximal vein is occluded using a tourniquet and the increase in
size is recorded. An average increase in internal diameter of 50% has been
associated with successful fistula outcome.
• Arterial dilation test:pulse contour of the artery is normally triphasic, due to high
peripheral resistance. The patient is asked to clench the fist for 2 minutes, and then
to open the hand; the resulting hyperemic response normally converts the triphasic
arterial pulse contour to a biphasic pattern in patients capable of a healthy arterial
dilation.

60. Venography: reserved for evaluating the central veins, especially in patients with a
history of transvenous placement of a pacemaker, physical findings of upper
extremity edema, collateral veins around the shoulder or on chest wall.
30 ml or less of non ionic ,low omolality contrast, diluted 1:4, should be used to
avoid nephrotoxicity. Full-strength contrast is usually not required for venography
Arteriography:Arteriography is indicated when pulses in the desired access
location are markedly diminished or absent or there is a >20 mm Hg difference in
mean arterial pressure between the two arms.

61. Ferumoxytol-enhanced imaging: an ultra-small paramagnetic iron oxide
embedded in a carbohydrate coating that has been approved by the US Food and
Drug Administration as a therapeutic iron supplement.
It is cleared from the circulation by reticuloendothelial system macrophages of the
liver, spleen, and bone marrow.
Because of its iron content, ferumoxytol has been used as a contrast agent for
magnetic resonance (MR) imaging ("off label"). Ferumoxytol has a long half-life
(15 hours), which allows for imaging of both venous and arterial vasculature
without the need for bolus timing, and imaging of the peripheral and central veins
and arteries is excellent.

62. ACCESS SITE LOCATION
• Preserve and use every site available to extend the patient’s ESKD “lifeline.”
• An “upper extremity first,” followed by a “distal to proximal” approach,

64. • Veins with adequate diameter but inadequate length: the addition of harvested
veins, such as saphenous veins, can be used to provide extra length that may be
required
• Tunneling and transposition of veins may allow the approximation required to
create an arteriovenous anastomosis.
• Deep veins with inadequate diameter: a two-stage approach can be used in this
situation. The first stage is to connect the artery and the vein. A period of time is
given to allow the vein to “arterialize” or mature. If successful, the second stage is
to transpose the matured vein to a subdermal location to allow for cannulation.

65. • Fistulas in the leg:
• Created rarely
• higher complication rate and poorer outcome
• option once all potential sites in the upper extremity have been exhausted.
• fistulas connect the superficial femoral artery to the femoral vein or the saphenous
vein to the popliteal artery.

66. OPERATIVE PROCEDURE FOR AN AV FISTULA.
• Regional anesthesia.
• side of artery to side of vein or side of artery to end of vein.
• Red hand syndrome: side-to- side method, higher pressures may sometimes be
transmited to the distal veins in the hand, causing swelling.
• The side-of-artery to end-of-vein anastomosis prevents venous hypertension in the hand
because the distal vein is ligated off.
• Piggyback slot technique
• reduce torsion in the anastomosed vein and to
• reduce juxta anastomotic stenosis

67. Measuring radial artery fistula blood flow at time of
surgery
• Radial artery normal flow rate 20-30 ml/min
• Increases to 200-300 ml/min after anastomosis
• Less than 120ml/min highly predictive of subsequent fistula failure

68. FISTULA MATURATION.

69. ARTERIOVENOUS GRAFTS.
• prosthetic interposition between an artery and a vein.
• synthetic or biologic.
• Wrist. Straight forearm: a straight graft from the radial artery to the median cubital
vein.
• Forearm. Loop forearm: a loop graft connecting the distal brachial artery or
proximal radial artery to the median cubital vein.
• Upper arm. Straight or curved upper arm: grafts of various configurations can
connect the brachial artery with the basilic, brachial, or axillary vein.

71. PHYSICAL EXAMINATION OF AV FISTULAS AND
GRAFTS
• Inspection:(look)
• Swelling
• collateral veins
• Scars
• Hematoma
• Sign of ischemia(steal syndrome)
• Aneurysm
• Arm elevation test

72. PALPATION AND AUSCULTATION
• Pulse

78. CENTRAL VENOUS CATHETER
• used in urgent or emergent situations

79. • CVC may be placed in the following locations in order of preference:
• Internal jugular
• External jugular
• Femoral
• Subclavian
• Lumbar

80. Pradhan Mantri National Dialysis Programme
• Rolled out in 2016 as part of the National Health Mission
• Public Private Partnership
• Since every Dialysis has an additional expenditure tag of about Rs.2000, it results
in a monthly expenditure for patients to the tune of Rs.3-4 Lakhs annually.
• Financial catastrophe for poor people
• As per the guidelines, the private partner is to provide medical human resource,
dialysis machine along with Reverse Osmosis (RO) water plant infrastructure,
dialyzer and consumables, while the space, power, and water supply within
District Hospitals is to be provided by the State Government

81. • under NHM 100 % of the service procedure fees for patients from below poverty
line (BPL) economic group is covered.
• BPL families registered under RSBY, the cost of dialysis care shall be catered
through RSBY funding upto its maximum coverage.
• The additional resources required would be provided to the state under the
National Health Mission.

82. THANK YOU