The document discusses dialysis treatment for patients with end-stage renal disease, including the different modalities of hemodialysis and peritoneal dialysis. It covers the components of hemodialysis like the dialyzer, dialysate, blood delivery system and complications. The goals of dialysis treatment are also summarized regarding achieving adequate solute clearance and fluid removal.
This document defines and classifies hyperkalemia based on potassium levels. It discusses the clinical presentation, epidemiology, etiology, and pathophysiology of hyperkalemia. The diagnostic methods and management approaches are also outlined. Hyperkalemia is managed through non-pharmacological treatments like dialysis for severe cases. Pharmacological treatments work to antagonize potassium effects, redistribute potassium into cells, or remove excess potassium from the body using calcium, insulin, beta-agonists, cation exchange resins, and diuretics.
Mannitol is an osmotic diuretic that is freely filtered by the glomerulus but not reabsorbed by renal tubules. It works by increasing the osmolarity of renal tubular fluid and drawing fluid from intracellular to extracellular spaces. Main uses include prophylaxis of acute renal failure, treatment of acute oliguria and increased intracranial pressure. While it reduces ICP, mannitol provides limited benefit for oxygenation compared to hypertonic saline and risks cardiac failure and electrolyte imbalance with higher doses.
1. Dialysis adequacy refers to removing sufficient toxins and waste from the blood to prevent adverse health outcomes and is measured by urea clearance and nutritional intake.
2. Urea clearance is the standard measure and is expressed as Kt/V, with a target single pool Kt/V of at least 1.2 per session for patients receiving hemodialysis 3 times a week.
3. Other factors that determine adequacy include residual kidney function, nutrition as measured by normalized protein catabolic rate, and controlling symptoms like anemia, acidosis, and blood pressure.
This document discusses acute peritoneal dialysis. It notes that acute peritoneal dialysis provides a non-vascular alternative for dialysis that can be used in intensive care settings and is less expensive than other options. The advantages are that it is simpler than other dialysis methods and does not require specialized equipment or anticoagulation. However, it is less efficient than hemodialysis for acute issues and can cause substantial protein losses. Prescribing considerations include session length, exchange volume and time, dialysis solution dextrose concentration and additives, and monitoring fluid balance and clearance. Complications can include abdominal distention, peritonitis, hypotension, hyperglycemia, and hypoalbuminemia.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
This document discusses hyponatremia and hypernatremia. It begins by explaining sodium regulation and the physiological basis of serum sodium concentration. It then defines and describes the types and causes of hyponatremia, including hypovolemic, euvolemic, and hypervolemic hyponatremia as well as pseudo hyponatremia. Specific conditions like SIADH are explained in detail. The clinical features, diagnosis, and treatment of hyponatremia are outlined. Hypernatremia is also defined and its causes such as net water loss or hypertonic sodium gain are summarized. The clinical features of hypernatremia are said to be predominantly neurologic.
This document defines and classifies hyperkalemia based on potassium levels. It discusses the clinical presentation, epidemiology, etiology, and pathophysiology of hyperkalemia. The diagnostic methods and management approaches are also outlined. Hyperkalemia is managed through non-pharmacological treatments like dialysis for severe cases. Pharmacological treatments work to antagonize potassium effects, redistribute potassium into cells, or remove excess potassium from the body using calcium, insulin, beta-agonists, cation exchange resins, and diuretics.
Mannitol is an osmotic diuretic that is freely filtered by the glomerulus but not reabsorbed by renal tubules. It works by increasing the osmolarity of renal tubular fluid and drawing fluid from intracellular to extracellular spaces. Main uses include prophylaxis of acute renal failure, treatment of acute oliguria and increased intracranial pressure. While it reduces ICP, mannitol provides limited benefit for oxygenation compared to hypertonic saline and risks cardiac failure and electrolyte imbalance with higher doses.
1. Dialysis adequacy refers to removing sufficient toxins and waste from the blood to prevent adverse health outcomes and is measured by urea clearance and nutritional intake.
2. Urea clearance is the standard measure and is expressed as Kt/V, with a target single pool Kt/V of at least 1.2 per session for patients receiving hemodialysis 3 times a week.
3. Other factors that determine adequacy include residual kidney function, nutrition as measured by normalized protein catabolic rate, and controlling symptoms like anemia, acidosis, and blood pressure.
This document discusses acute peritoneal dialysis. It notes that acute peritoneal dialysis provides a non-vascular alternative for dialysis that can be used in intensive care settings and is less expensive than other options. The advantages are that it is simpler than other dialysis methods and does not require specialized equipment or anticoagulation. However, it is less efficient than hemodialysis for acute issues and can cause substantial protein losses. Prescribing considerations include session length, exchange volume and time, dialysis solution dextrose concentration and additives, and monitoring fluid balance and clearance. Complications can include abdominal distention, peritonitis, hypotension, hyperglycemia, and hypoalbuminemia.
Renal replacement therapy encompasses life-supporting treatments for renal failure such as hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. Hemodialysis uses diffusion and filtration across a semi-permeable membrane to remove waste and fluid. Peritoneal dialysis infuses dialysate into the peritoneal cavity. Continuous renal replacement therapy provides 24-hour treatment through diffusion, convection, or a combination. These therapies aim to replace normal kidney functions of waste removal and fluid balance.
This document discusses hyponatremia and hypernatremia. It begins by explaining sodium regulation and the physiological basis of serum sodium concentration. It then defines and describes the types and causes of hyponatremia, including hypovolemic, euvolemic, and hypervolemic hyponatremia as well as pseudo hyponatremia. Specific conditions like SIADH are explained in detail. The clinical features, diagnosis, and treatment of hyponatremia are outlined. Hypernatremia is also defined and its causes such as net water loss or hypertonic sodium gain are summarized. The clinical features of hypernatremia are said to be predominantly neurologic.
This document discusses fluid balance, dry weight, and intradialytic hypotension in hemodialysis patients. It defines dry weight as the ideal post-dialysis weight that allows a patient to remain normotensive without medications until their next dialysis session. Achieving the correct dry weight is important for controlling blood pressure. Intradialytic hypotension can occur if ultrafiltration is too rapid or the patient's dry weight is too low. Preventive measures include monitoring blood pressure during dialysis and pausing ultrafiltration if needed.
This document provides an overview of principles of haemodialysis. It describes the components of haemodialysis including the blood circuit, dialysate circuit and dialyzer. It explains how diffusion and convection work to remove solutes and fluid across the dialyzer membrane. High water purity standards are required for patient safety. Haemodiafiltration combines diffusive and convective clearances and may provide benefits over standard haemodialysis.
This document discusses sustained low-efficiency daily dialysis (SLEDD) for treating acute kidney injury (AKI) in critically ill patients. SLEDD is a hybrid therapy that combines aspects of continuous renal replacement therapy and intermittent hemodialysis. It allows for a reduced ultrafiltration rate and prolonged treatment duration to maximize dialysis dose while maintaining hemodynamic stability. The document outlines the indications for SLEDD, including patients at risk of disequilibrium or with borderline cardiovascular stability. Preliminary studies suggest SLEDD is a safe and effective option for AKI patients otherwise unsuitable for standard therapies.
Dialysis dose prescription (the basics) dr ujjawalUjjawal Roy
The document discusses key aspects of dialysis dose prescription, including:
1) Components of the dialysis prescription include dialyzer choice, time, blood and dialysate flow rates, ultrafiltration rate, dialysate composition, temperature, and anticoagulation.
2) Prescription goals are to restore the body's fluid and electrolyte balance and remove waste and excess water from patients with end-stage renal disease.
3) Important considerations for dialysis prescription include a patient's dry weight and risk of intradialytic hypotension.
Chronic kidney disease-mineral bone disorder (CKD-MBD) is a common complication in chronic kidney disease caused by reduced kidney function and mineral metabolism abnormalities. This leads to high phosphate, activation of parathyroid hormone, and bone abnormalities from renal osteodystrophy to vascular calcification. Treatment focuses on controlling phosphate levels through binders like sevelamer and cinacalcet to reduce parathyroid hormone in order to prevent bone disease and fractures while minimizing cardiovascular risks.
This document provides an overview of anticoagulation options for hemodialysis. It discusses conventional anticoagulants like unfractionated heparin and low molecular weight heparins. It also covers newer direct thrombin inhibitors and regional anticoagulation methods using citrate or prostacyclin. The risks and benefits of each option are evaluated based on bleeding risks, reversibility, cost, and ability to prevent clotting during hemodialysis procedures. Monitoring requirements and dosing protocols are also reviewed for different anticoagulant regimens.
Dialysis is a technique where substances move across a semipermeable membrane from the blood into a dialysate solution. It has evolved historically from early Roman baths for removing urea to the modern use of hemodialysis machines and peritoneal dialysis. Dialysis works through diffusion, osmosis, and ultrafiltration to remove waste and excess fluid for patients with renal failure or other indications. Complications can include infections, hypotension, and various electrolyte abnormalities for both hemodialysis which uses an external machine, and peritoneal dialysis which uses the peritoneal membrane.
This document discusses guidelines for prescribing hemodialysis for acute kidney injury patients. It covers key elements of the prescription including session length and blood flow rate, dialyzer selection, dialysate composition, and ultrafiltration orders. The presentation emphasizes starting more frequent but shorter sessions at lower intensity initially and gradually increasing session length and clearance as the patient stabilizes to prevent dialysis disequilibrium syndrome.
Renal replacement therapy replaces the normal filtering function of the kidneys using modalities like hemodialysis, peritoneal dialysis, or renal transplantation. Peritoneal dialysis uses the peritoneal membrane for diffusion and ultrafiltration of solutes and fluid, while hemodialysis uses an external dialyzer to filter the blood via diffusion and convection. Both therapies aim to control uremia, electrolyte abnormalities, and fluid balance. Choice of modality depends on factors like age, cardiovascular status, and expertise available. Continuous renal replacement therapy is preferred for critically ill patients who are hemodynamically unstable.
This document discusses the prescription of peritoneal dialysis, including the choice of modality (CAPD vs APD), clearance targets, and measurement of clearance through Kt/V and creatinine clearance. It also covers factors that determine clearance like residual renal function, body size, and transport characteristics. For CAPD and APD, prescription factors include exchange frequency and volume, and dwell times. Nutritional monitoring for PD patients includes nPNA, serum albumin, subjective global assessment, and lean body mass. Treatment of malnutrition may include dietitian support, supplements, promotility agents, steroids, and amino acids.
Hemodialysis is a medical procedure that removes waste and excess fluid from the blood of patients with kidney failure. It uses a hemodialysis machine and an artificial kidney called a dialyzer to filter the blood outside of the body. Blood flows through the dialyzer where diffusion and ultrafiltration remove waste and regulate electrolytes, and is then returned to the patient. Hemodialysis is usually done three times a week for four hours each session through an arteriovenous fistula, graft, or catheter. Potential complications include hypotension, muscle cramps, nausea, and disequilibrium syndrome.
Dialysate is the fluid used during dialysis that draws waste and excess fluid from the blood. It has a similar composition to plasma with electrolytes like sodium, chloride, calcium, potassium, and either acetate or bicarbonate. Dialysate prevents the removal of essential electrolytes and excess water from the blood during dialysis. There are two main types - acetate dialysate, which can cause side effects from acetate accumulation, and bicarbonate dialysate, which uses a two-component mixing process and has a shorter stability than acetate dialysate. The dialysate delivery system controls the dialysate temperature, composition, pressure and flow rate through the dialyzer during the dialysis
Crystalloid solutions are aqueous solutions of low-molecular-weight ions (salts) with or without glucose. They are used to provide maintenance of water, electrolytes, and intravascular fluid volume. Common crystalloid solutions include normal saline (0.9% NaCl), Ringer's lactate, dextrose 5% in water, and dextrose normal saline. Each solution has different properties and indications/contraindications depending on its electrolyte content and osmolarity. Crystalloids are distributed between intravascular and extracellular fluid spaces after administration and have a more transient hemodynamic effect than colloid solutions.
Fluid balance is an aspect of the homeostasis of body in which the amount of water in the body needs to be controlled, via osmoregulation and behavior, such that the concentrations of electrolytes (salts in solution) in the various body fluids are kept within healthy ranges.
The core principle of fluid balance is that the amount of water lost from the body must equal the amount of water taken in; for example, in humans, the output (via respiration, perspiration, urination, defecation, and expectoration) must equal the input (via eating and drinking, or by parenteral intake).
Understand principles of fluids, fluid compartments and composition
Identify role of kidneys in fluid management
Establishing Target Weight
Understand consequences of fluid overload
Assessing and implementing successful fluid overload management practices according to guidelines
Chronic renal failure is a gradual loss of kidney function over time that cannot be reversed. It affects approximately 290,000 people in the United States. The kidneys gradually lose their ability to filter waste and excess fluid from the blood. Chronic renal failure is caused by conditions like hypertension, diabetes, kidney infections, and can lead to complications that affect many organ systems if not managed properly through treatments like dialysis and kidney transplantation. Proper management includes monitoring fluid and electrolytes, reducing metabolic rate, preventing infections, and providing nutritional therapy and skin care.
This document summarizes key aspects of hemodialysis adequacy and dose. It discusses:
- Early studies that showed a correlation between dialysis dose and patient outcomes. The NCDS study in 1981 was the first randomized controlled trial showing higher Kt/V values were associated with better outcomes.
- Methods for measuring dialysis dose including Kt/V, eKt/V, URR. The preferred method is formal kinetic urea modeling.
- Guidelines recommend a minimum Kt/V of 1.2 or eKt/V of 1.2. Studies like HEMO showed no additional benefit to higher doses above 1.3-1.4.
- Maximizing
Metabolic alkalosis Dr. Mohamed Abdelhafeznephro mih
This document summarizes metabolic alkalosis. It defines metabolic alkalosis and describes the pathophysiology, including bicarbonate transport in the kidney and causes. The major causes are vomiting or nasogastric drainage, diuretic use, and genetic disorders impairing chloride transport like Bartter and Gitelman syndromes. These lead to chloride depletion, stimulating collecting duct ion transport and sustaining the metabolic alkalosis.
differences & indications of ringers (solution/buffered with lactate & acetate) Vs Normal saline in different medical conditions
Presented as lecture at 25th.July 2022
This document discusses fluid balance, dry weight, and intradialytic hypotension in hemodialysis patients. It defines dry weight as the ideal post-dialysis weight that allows a patient to remain normotensive without medications until their next dialysis session. Achieving the correct dry weight is important for controlling blood pressure. Intradialytic hypotension can occur if ultrafiltration is too rapid or the patient's dry weight is too low. Preventive measures include monitoring blood pressure during dialysis and pausing ultrafiltration if needed.
This document provides an overview of principles of haemodialysis. It describes the components of haemodialysis including the blood circuit, dialysate circuit and dialyzer. It explains how diffusion and convection work to remove solutes and fluid across the dialyzer membrane. High water purity standards are required for patient safety. Haemodiafiltration combines diffusive and convective clearances and may provide benefits over standard haemodialysis.
This document discusses sustained low-efficiency daily dialysis (SLEDD) for treating acute kidney injury (AKI) in critically ill patients. SLEDD is a hybrid therapy that combines aspects of continuous renal replacement therapy and intermittent hemodialysis. It allows for a reduced ultrafiltration rate and prolonged treatment duration to maximize dialysis dose while maintaining hemodynamic stability. The document outlines the indications for SLEDD, including patients at risk of disequilibrium or with borderline cardiovascular stability. Preliminary studies suggest SLEDD is a safe and effective option for AKI patients otherwise unsuitable for standard therapies.
Dialysis dose prescription (the basics) dr ujjawalUjjawal Roy
The document discusses key aspects of dialysis dose prescription, including:
1) Components of the dialysis prescription include dialyzer choice, time, blood and dialysate flow rates, ultrafiltration rate, dialysate composition, temperature, and anticoagulation.
2) Prescription goals are to restore the body's fluid and electrolyte balance and remove waste and excess water from patients with end-stage renal disease.
3) Important considerations for dialysis prescription include a patient's dry weight and risk of intradialytic hypotension.
Chronic kidney disease-mineral bone disorder (CKD-MBD) is a common complication in chronic kidney disease caused by reduced kidney function and mineral metabolism abnormalities. This leads to high phosphate, activation of parathyroid hormone, and bone abnormalities from renal osteodystrophy to vascular calcification. Treatment focuses on controlling phosphate levels through binders like sevelamer and cinacalcet to reduce parathyroid hormone in order to prevent bone disease and fractures while minimizing cardiovascular risks.
This document provides an overview of anticoagulation options for hemodialysis. It discusses conventional anticoagulants like unfractionated heparin and low molecular weight heparins. It also covers newer direct thrombin inhibitors and regional anticoagulation methods using citrate or prostacyclin. The risks and benefits of each option are evaluated based on bleeding risks, reversibility, cost, and ability to prevent clotting during hemodialysis procedures. Monitoring requirements and dosing protocols are also reviewed for different anticoagulant regimens.
Dialysis is a technique where substances move across a semipermeable membrane from the blood into a dialysate solution. It has evolved historically from early Roman baths for removing urea to the modern use of hemodialysis machines and peritoneal dialysis. Dialysis works through diffusion, osmosis, and ultrafiltration to remove waste and excess fluid for patients with renal failure or other indications. Complications can include infections, hypotension, and various electrolyte abnormalities for both hemodialysis which uses an external machine, and peritoneal dialysis which uses the peritoneal membrane.
This document discusses guidelines for prescribing hemodialysis for acute kidney injury patients. It covers key elements of the prescription including session length and blood flow rate, dialyzer selection, dialysate composition, and ultrafiltration orders. The presentation emphasizes starting more frequent but shorter sessions at lower intensity initially and gradually increasing session length and clearance as the patient stabilizes to prevent dialysis disequilibrium syndrome.
Renal replacement therapy replaces the normal filtering function of the kidneys using modalities like hemodialysis, peritoneal dialysis, or renal transplantation. Peritoneal dialysis uses the peritoneal membrane for diffusion and ultrafiltration of solutes and fluid, while hemodialysis uses an external dialyzer to filter the blood via diffusion and convection. Both therapies aim to control uremia, electrolyte abnormalities, and fluid balance. Choice of modality depends on factors like age, cardiovascular status, and expertise available. Continuous renal replacement therapy is preferred for critically ill patients who are hemodynamically unstable.
This document discusses the prescription of peritoneal dialysis, including the choice of modality (CAPD vs APD), clearance targets, and measurement of clearance through Kt/V and creatinine clearance. It also covers factors that determine clearance like residual renal function, body size, and transport characteristics. For CAPD and APD, prescription factors include exchange frequency and volume, and dwell times. Nutritional monitoring for PD patients includes nPNA, serum albumin, subjective global assessment, and lean body mass. Treatment of malnutrition may include dietitian support, supplements, promotility agents, steroids, and amino acids.
Hemodialysis is a medical procedure that removes waste and excess fluid from the blood of patients with kidney failure. It uses a hemodialysis machine and an artificial kidney called a dialyzer to filter the blood outside of the body. Blood flows through the dialyzer where diffusion and ultrafiltration remove waste and regulate electrolytes, and is then returned to the patient. Hemodialysis is usually done three times a week for four hours each session through an arteriovenous fistula, graft, or catheter. Potential complications include hypotension, muscle cramps, nausea, and disequilibrium syndrome.
Dialysate is the fluid used during dialysis that draws waste and excess fluid from the blood. It has a similar composition to plasma with electrolytes like sodium, chloride, calcium, potassium, and either acetate or bicarbonate. Dialysate prevents the removal of essential electrolytes and excess water from the blood during dialysis. There are two main types - acetate dialysate, which can cause side effects from acetate accumulation, and bicarbonate dialysate, which uses a two-component mixing process and has a shorter stability than acetate dialysate. The dialysate delivery system controls the dialysate temperature, composition, pressure and flow rate through the dialyzer during the dialysis
Crystalloid solutions are aqueous solutions of low-molecular-weight ions (salts) with or without glucose. They are used to provide maintenance of water, electrolytes, and intravascular fluid volume. Common crystalloid solutions include normal saline (0.9% NaCl), Ringer's lactate, dextrose 5% in water, and dextrose normal saline. Each solution has different properties and indications/contraindications depending on its electrolyte content and osmolarity. Crystalloids are distributed between intravascular and extracellular fluid spaces after administration and have a more transient hemodynamic effect than colloid solutions.
Fluid balance is an aspect of the homeostasis of body in which the amount of water in the body needs to be controlled, via osmoregulation and behavior, such that the concentrations of electrolytes (salts in solution) in the various body fluids are kept within healthy ranges.
The core principle of fluid balance is that the amount of water lost from the body must equal the amount of water taken in; for example, in humans, the output (via respiration, perspiration, urination, defecation, and expectoration) must equal the input (via eating and drinking, or by parenteral intake).
Understand principles of fluids, fluid compartments and composition
Identify role of kidneys in fluid management
Establishing Target Weight
Understand consequences of fluid overload
Assessing and implementing successful fluid overload management practices according to guidelines
Chronic renal failure is a gradual loss of kidney function over time that cannot be reversed. It affects approximately 290,000 people in the United States. The kidneys gradually lose their ability to filter waste and excess fluid from the blood. Chronic renal failure is caused by conditions like hypertension, diabetes, kidney infections, and can lead to complications that affect many organ systems if not managed properly through treatments like dialysis and kidney transplantation. Proper management includes monitoring fluid and electrolytes, reducing metabolic rate, preventing infections, and providing nutritional therapy and skin care.
This document summarizes key aspects of hemodialysis adequacy and dose. It discusses:
- Early studies that showed a correlation between dialysis dose and patient outcomes. The NCDS study in 1981 was the first randomized controlled trial showing higher Kt/V values were associated with better outcomes.
- Methods for measuring dialysis dose including Kt/V, eKt/V, URR. The preferred method is formal kinetic urea modeling.
- Guidelines recommend a minimum Kt/V of 1.2 or eKt/V of 1.2. Studies like HEMO showed no additional benefit to higher doses above 1.3-1.4.
- Maximizing
Metabolic alkalosis Dr. Mohamed Abdelhafeznephro mih
This document summarizes metabolic alkalosis. It defines metabolic alkalosis and describes the pathophysiology, including bicarbonate transport in the kidney and causes. The major causes are vomiting or nasogastric drainage, diuretic use, and genetic disorders impairing chloride transport like Bartter and Gitelman syndromes. These lead to chloride depletion, stimulating collecting duct ion transport and sustaining the metabolic alkalosis.
differences & indications of ringers (solution/buffered with lactate & acetate) Vs Normal saline in different medical conditions
Presented as lecture at 25th.July 2022
ARTIFICIAL KIDNEY , DIALYSIS AND RENAL TRANSPLANT.pptPandian M
This document discusses dialysis, artificial kidneys, and renal transplantation. It begins by outlining the objectives and providing definitions of dialysis and indications for when it is needed, both acutely and chronically. It then describes the two main types of dialysis - hemodialysis, which uses an artificial kidney machine, and peritoneal dialysis, which uses the peritoneum. The principles, procedures, requirements, compositions and potential complications of each type of dialysis are explained in detail. Finally, the document covers renal transplantation as the treatment of choice for end-stage renal disease, outlining the benefits, risks, types of donors, compatibility testing, immunosuppressant drugs used, and the transplantation procedure and potential
CRRT (continuous renal replacement therapy) involves using an extracorporeal circuit connected to the patient via catheters to slowly remove fluid and toxins over 24 hours, mimicking the function of the kidneys. It was developed for critically ill patients who cannot tolerate the fluid shifts of intermittent hemodialysis. CRRT uses a semipermeable membrane to filter fluids and small molecules from the blood based on hydrostatic pressure gradients. It provides more hemodynamic stability than intermittent hemodialysis and allows for better nutrition support by preventing fluid overload. CRRT is indicated for patients who cannot tolerate intermittent dialysis due to hemodynamic instability from their critical illness.
Hemodialysis is a type of dialysis that relies on diffusion of solutes across a semipermeable membrane. It is used to treat end-stage kidney disease and involves circulating blood through a dialyzer while dialysate fluid passes on the outside of the fibers. Peritoneal dialysis infuses dialysate fluid into the peritoneal cavity, allowing diffusion and ultrafiltration of solutes. Both have risks like infections, metabolic complications, and encapsulating peritoneal sclerosis. Kidney transplantation is the treatment of choice for advanced kidney failure and has better outcomes than long-term dialysis, but requires lifelong immunosuppression.
This document discusses oncological emergencies, including tumor lysis syndrome, malignant hypercalcemia, superior vena cava syndrome, and others. It provides details on the definitions, causes, clinical presentations, diagnostic criteria, and treatment approaches for these time-sensitive cancer complications. Tumor lysis syndrome can result from cell lysis releasing uric acid and electrolytes, and requires aggressive hydration, allopurinol or rasburicase, and renal replacement therapy if severe. Malignant hypercalcemia is most common in breast and lung cancers and multiple myeloma, presenting with nausea, fatigue, and neurological symptoms, treated initially with hydration and bisphosphonates. Superior vena cava syndrome ob
The document discusses chronic kidney disease (CKD) prognosis and factors that impact it, including cause of CKD, glomerular filtration rate (GFR) category, albuminuria category, and comorbidities. It also discusses guidelines for initiating renal replacement therapy (RRT), specifically dialysis, noting that recent evidence suggests late initiation may be safe for some patients and associated with improved survival compared to early initiation. The document outlines RRT modality options including transplantation, hemodialysis, peritoneal dialysis, and discusses preserving residual renal function for dialysis patients.
1. The document discusses various methods for estimating kidney function, including the MDRD and Cockroft-Gault equations. It also covers the significance of proteinuria and common risk factors for chronic kidney disease.
2. Details are provided on interventions to slow progression of CKD, including glycemic control, blood pressure control, and proteinuria reduction. Treatment targets and guidelines for managing hypertension, lipids, anemia, and mineral metabolism in CKD patients are outlined.
3. Renal replacement therapies for end-stage kidney disease including hemodialysis, peritoneal dialysis, and transplantation are described in detail, along with their advantages, disadvantages, and complications.
Cirrhosis is irreversible scarring of the liver caused by various chronic liver injuries and diseases. It is a major global health issue and the 13th leading cause of death worldwide. The major causes of cirrhosis are hepatitis B, hepatitis C, alcoholism, and non-alcoholic fatty liver disease. Patients with cirrhosis have progressive liver damage and fibrosis that leads to complications including portal hypertension, ascites, variceal bleeding, hepatic encephalopathy, and liver cancer. Without treatment, survival is typically 10-13 years after diagnosis but can decrease to just 2 years once complications develop.
Electrolyte and fluid balance in elderly.pptxMkindi Mkindi
The body maintains electrolyte and fluid balance through carefully regulated input and output. As people age, the kidneys undergo changes that impair this regulation. There is a 20-25% loss of renal mass and decline in glomerular filtration rate. This impairs the kidneys' ability to concentrate and dilute urine. As a result, elderly people are more prone to fluid and electrolyte disorders like hyponatremia, hypernatremia, and hypertension. Close monitoring of fluid, sodium, and medication intake is needed to prevent issues from imbalances.
Renal replacement therapy (RRT) refers to life-supporting treatments for renal failure and includes hemodialysis, peritoneal dialysis, and continuous renal replacement therapy. The choice of RRT depends on factors like the patient's cardiovascular status, availability of resources, and clinical considerations. Common complications include those related to vascular access and electrolyte imbalances. RRT aims to correct fluid overload, metabolic abnormalities, and remove waste through diffusion or convection.
Hemodialysis treatment in patients with severe electrolyte disorders manageme...Kamlesh74
This document discusses strategies for managing severe electrolyte disorders like hyperkalemia and hyponatremia in patients undergoing hemodialysis. It outlines approaches for correcting sodium and potassium levels in both acute and chronic settings. For sodium, the key strategies are using a dialysate concentration slightly below serum levels and lowering blood flow rate to slowly correct chronic hyponatremia. For potassium, dialysate concentration is selected based on pre-dialysis levels, with lower concentrations used to rapidly reduce high potassium levels. Close monitoring is important with any aggressive electrolyte corrections.
- An arteriovenous fistula is associated with better outcomes for patients undergoing hemodialysis compared to other types of vascular access.
- Patients with chronic kidney disease can be referred to a transplant center when their glomerular filtration rate (GFR) falls below 20 mL/min/1.73m2. Pre-emptive and live donor kidney transplants are associated with better graft survival compared to other types of transplants.
- Primary care providers play an important role in managing patients with kidney disease and those undergoing renal replacement therapies like dialysis and transplantation. This includes educating patients about treatment options and managing comorbidities.
Management of acute kidney injury (AKI) involves several common principles including optimizing hemodynamics, correcting fluid and electrolyte imbalances, discontinuing nephrotoxic medications, and dose adjusting other medications. Treatment depends on the underlying cause of AKI and may involve managing life-threatening complications, diagnosing and treating the underlying condition, and renal replacement therapies like hemodialysis or peritoneal dialysis. Prevention efforts focus on recognizing at-risk patients and using preventive measures to avoid AKI. The prognosis of AKI depends on the specific cause and presence of other factors, with prerenal azotemia and postrenal azotemia generally having a better prognosis than other forms of intrinsic AKI.
Nephrogenic Diabetes Insipidus is a condition characterized by the inability to concentrate urine due to kidney insensitivity to vasopressin. It results in excessive urine output and thirst. There are two main types - central, caused by vasopressin deficiency, and nephrogenic, caused by kidney insensitivity. Nephrogenic DI can be genetic, drug-induced, or due to other kidney conditions. Diagnosis involves testing urine and plasma osmolality during water deprivation or vasopressin stimulation. Treatment focuses on fluid management, low-solute diets, and medications to reduce urine output like thiazide diuretics. A recent study found directly measuring copeptin levels during hyper
Alcoholic liver disease is a result of over-consuming alcohol that damages the liver, leading to a buildup of fats, inflammation, and scarring. It can be fatal.
- Renal replacement therapies are important in critical care for managing complications of renal failure such as fluid, electrolyte and acid-base imbalances. There are many questions around optimal therapy including timing, dose and modality.
- Acute kidney injury is common in the ICU and associated with worse outcomes. Continuous renal replacement therapies may provide more stable volume and chemistry control compared to intermittent therapies.
- High volume hemofiltration shows promise for removing inflammatory mediators in sepsis but optimal dose is still unclear. Renal replacement therapies have an important role beyond renal support as blood purification techniques.
This document provides information about Chronic Obstructive Pulmonary Disease (COPD). It defines COPD as a group of lung disorders that cause airflow blockage and breathing-related problems. The main causes of COPD are cigarette smoking, exposure to secondhand smoke, and air pollution. Symptoms include a chronic cough, sputum production, shortness of breath, and wheezing. Diagnosis involves pulmonary function tests, chest x-rays, and arterial blood gas tests. Treatment focuses on quitting smoking, using bronchodilators and steroids, receiving supplemental oxygen, and managing exacerbations.
COPD is a chronic lung disease characterized by airflow limitation caused by damage to the lungs. An acute exacerbation of COPD occurs when symptoms like dyspnea, cough, and sputum production worsen beyond normal day-to-day variations. Diagnosis relies on clinical presentation and assessment of symptom severity. Treatment focuses on restoring oxygen levels, bronchodilation with nebulized bronchodilators, corticosteroids, antibiotics if an infection is present, IV fluids, ventilation support if needed, and smoking cessation counseling.
Pain and sedation in critically ill patientsDeepiKaur2
The document discusses pain and sedation management in critically ill patients. It defines pain and outlines various pain assessment scales used in intensive care settings. It also discusses the purposes, types, and complications of sedation. The key principles of optimizing analgesia and sedation include individualizing treatment, using guidelines to standardize care, regularly assessing pain and sedation levels, and tapering medications daily. Behavioral pain scales can help assess pain in sedated or nonverbal patients. Benzodiazepines are commonly used sedative medications but have risks of accumulation and prolonged effects that must be monitored.
The document discusses decision making in nursing administration. It defines decision making and differentiates it from problem solving. It describes various types of decisions including mechanistic, analytical, judgmental, and adaptive decisions. It also discusses models of decision making such as the descriptive model, bounded rationality model, and normative model. Finally, it outlines steps in the decision making process and factors that influence decision making for nurses.
The document discusses coronary artery disease (CAD). It begins with an introduction to coronary circulation and the importance of the coronary arteries in delivering blood to the heart muscle. It then discusses atherosclerosis, the primary cause of CAD. CAD is defined as the narrowing of one or more coronary arteries due to atherosclerotic plaque buildup, reducing blood flow to the heart. Risk factors, pathophysiology, clinical manifestations, diagnostic tests, medical and surgical management, and lifestyle changes are summarized. Nursing assessment and management of patients with CAD are also outlined.
fluid and electrolyte imbalance
normal physiology of fluid regulation
FLUID IMBALANCES- fluid volume excess, fluid volume deficit, third spacing,
ELECTROLYTE IMBALANCES- hypo and hypernatremia, hypo and hyperkalemia, hypo and hypercalcemia
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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1. DIALYSIS TREATMENT
Presented To-
Mrs. Shivani Kalra
Asst. Prof., MSN
College of Nursing,
Dayanand Medical College
& Hospital, Ludhiana
Presented By- Haranjan kaur
Msc (N) 2nd YEAR
Critical Care Nursing,College of Nursing,
Dayanand Medical College & Hospital, Ludhiana
Punjab, India
2. Introduction
• Dialysis may be required for the treatment of either acute
or chronic kidney disease (CKD).
• The use of continuous renal replacement therapies (CRRT)
and prolonged intermittent renal replacement therapy
(PIRRT)/slow low-efficiency dialysis (SLED) is specific to the
management of acute renal failure.
• These modalities are performed continuously (CRRT) or
over 6–12 h per session (PIRRT/SLED), in contrast to the 3–
4 h of an intermittent hemodialysis session.
3. • Peritoneal dialysis is rarely used in developed countries for
the treatment of acute renal failure because of the increased
risk of infection and less efficient clearance per unit of ti
• With the widespread availability of dialysis, the lives of
hundreds of thousands of patients with ESRD have been
prolonged.
• In the United States alone, there are now ~675,000 patients
with treated ESRD (kidney failure requiring dialysis or
transplantation), the vast majority of whom require dialysis.
4. • Since 2000, the prevalence of treated ESRD has increased 74%,
which reflects both a small increase in the incidence rate and
marginally enhanced survival of patients receiving dialysis.
• The incidence rate for treated ESRD in the United States is 370
cases per million population per year; ESRD is disproportionately
higher in African Americans (875 per million population per year) as
compared with white Americans (285 per million population per
year).
• In the United States, the leading cause of ESRD is diabetes mellitus,
currently accounting for almost 45% of newly diagnosed cases of
ESRD.
5. • Approximately 30% of patients have ESRD that has been
attributed to hypertension, although it is unclear whether in
these cases hypertension is the cause or a consequence of
vascular disease or other unknown causes of kidney failure.
• Other prevalent causes of ESRD include glomerulonephritis,
polycystic kidney disease, and obstructive uropathy.
• A fraction of the excess incidence of ESRD in African
Americans is likely related to transmission of high-risk alleles
for the APOL1 gene.
6. • Globally, mortality rates for patients with ESRD are lowest in Europe
and Japan but very high in the developing world because of the
limited availability of dialysis.
• In the United States, the mortality rate of patients on dialysis has
decreased slightly but remains extremely high, with a 5-year
survival rate of ~40% for patients receiving dialysis.
• Deaths are due mainly to cardiovascular diseases and infections
(~40 and 10% of deaths, respectively).
• Older age, male sex, nonblack race, diabetes mellitus, malnutrition,
and underlying heart disease are important predictors of death.
7. TREATMENT OPTIONS FOR
PATIENTS WITH ESRD
• Commonly accepted criteria for initiating patients on
maintenance dialysis include the presence of uremic
symptoms, the presence of hyperkalemia unresponsive
to conservative measures, persistent extracellular
volume expansion despite diuretic therapy, acidosis
refractory to medical therapy, a bleeding diathesis, and
a creatinine clearance or estimated glomerular filtration
rate (GFR) <10 mL/min per 1.73 m2.
8. TREATMENT OPTIONS FOR
PATIENTS WITH ESRD
• Timely referral to a nephrologist for advanced planning and
creation of a dialysis access, education about ESRD treatment
options, and management of the complications of advanced CKD,
including hypertension, anemia, acidosis, and secondary
hyperparathyroidism, is advisable. Recent data have suggested that
a sizable fraction of ESRD cases result following episodes of acute
renal failure, particularly among persons with underlying CKD.
• Furthermore, there is no benefit to initiating dialysis preemptively
at a GFR of 10–14 mL/min per 1.73 m2 compared to initiating
dialysis for symptoms of uremia.
9. TREATMENT OPTIONS FOR
PATIENTS WITH ESRD
• In ESRD, treatment options include hemodialysis (in center or
at home); peritoneal dialysis, as either continuous ambulatory
peritoneal dialysis (CAPD) or continuous cyclic peritoneal
dialysis (CCPD); or transplantation.
• Although there are significant geographic variations and
differences in practice patterns, in-center hemodialysis
remains the most common therapeutic modality for ESRD
(>90% of patients) in the United States. In contrast to
hemodialysis, peritoneal dialysis is continuous, but much less
efficient, in terms of solute clearance.
10. TREATMENT OPTIONS FOR
PATIENTS WITH ESRD
• While no large-scale clinical trials have been completed
comparing outcomes among patients randomized to
either hemodialysis or peritoneal dialysis, outcomes
associated with both therapies are similar in most
reports, and the decision of which modality to select is
often based on personal preferences and quality-of-life
considerations.
11. HEMODIALYSIS
• Hemodialysis relies on the principles of solute diffusion
across a semipermeable membrane. Movement of
metabolic waste products takes place down a
concentration gradient from the circulation into the
dialysate.
• The rate of diffusive transport increases in response to
several factors, including the magnitude of the
concentration gradient, the membrane surface area, and
the mass transfer coefficient of the membrane.
12. HEMODIALYSIS
• The latter is a function of the porosity and thickness of
the membrane, the size of the solute molecule, and the
conditions of flow on the two sides of the membrane.
• According to laws of diffusion, the larger the molecule,
the slower its rate of transfer across the membrane.
• A small molecule, such as urea (60 Da), undergoes
substantial clearance, whereas a larger molecule, such as
creatinine (113 Da), is cleared less efficiently.
13. HEMODIALYSIS
• In addition to diffusive clearance, movement of waste
products from the circulation into the dialysate may occur
as a result of ultrafiltration.
• Convective clearance occurs because of solvent drag, with
solutes being swept along with water across the
semipermeable dialysis membrane.
14. THE DIALYZER
• There are three essential components to hemodialysis:
the dialyzer, the composition and delivery of the dialysate,
and the blood delivery system.
• The dialyzer is a plastic chamber with the ability to
perfuse blood and dialysate compartments
simultaneously at very high flow rates.
• The hollow-fiber dialyzer is the most common in use in
the United States.
15. THE DIALYZER
• These dialyzers are composed of bundles of capillary
tubes through which blood circulates while dialysate
travels on the outside of the fiber bundle.
• Virtually all dialyzers now manufactured in the United
States are “biocompatible” synthetic membranes derived
from polysulfone or related compounds (versus older
cellulose “bioincompatible” membranes that activated
the complement cascade).
16. THE DIALYZER
• The frequency of reprocessing and reuse of hemodialyzers
and blood lines varies across the world.
• In general as the cost of disposable supplies has
decreased, their use has increased. In the United States,
reprocessing of dialyzers is now extremely rare.
• Formaldehyde, peracetic acid–hydrogen peroxide,
glutaraldehyde, and bleach have all been used as
reprocessing agents.
17. DIALYSATE
• The potassium concentration of dialysate may be varied
from 0 to 4 mmol/L depending on the predialysis serum
potassium concentration.
• The use of 0 or 1 mmol/L potassium dialysate is
becoming less common owing to data suggesting that
patients who undergo treatments with very low
potassium dialysate have an increased risk of sudden
death, perhaps due to arrhythmias in the setting of
potassium shifts.
18. DIALYSATE
• The usual dialysate calcium concentration is 1.25 mmol/L
(2.5 mEq/L), although modification may be required in
selected settings (e.g., higher dialysate calcium
concentrations may be used in patients with
hypocalcemia associated with secondary
hyperparathyroidism or with “hungry bone syndrome”
following parathyroidectomy).
• The usual dialysate sodium concentration is 136–140
mmol/L.
19. DIALYSATE
• In patients who frequently develop hypotension during
their dialysis run, “sodium modeling” to counterbalance
urea-related osmolar gradients may be employed.
• With sodium modeling, the dialysate sodium
concentration is gradually lowered from the range of 145–
155 mmol/L to isotonic concentrations (136–140 mmol/L)
near the end of the dialysis treatment, typically declining
either in steps or in a linear or exponential fashion.
20. DIALYSATE
• However, higher dialysate sodium concentrations and sodium
modeling may predispose patients to positive sodium balance
and increased thirst; thus, these strategies to ameliorate
intradialytic hypotension may be undesirable in patients with
hypertension or in patients with large interdialytic weight
gains.
• Because patients are exposed to ~120 L of water during each
dialysis treatment, water used for the dialysate is subjected to
filtration, softening, deionization, and, ultimately, reverse
osmosis to remove microbiologic contaminants and dissolved
ions.
21. BLOOD DELIVERY SYSTEM
• The blood delivery system is composed of the
extracorporeal circuit and the dialysis access. The dialysis
machine consists of a blood pump, dialysis solution
delivery system, and various safety monitors. The blood
pump moves blood from the access site, through the
dialyzer, and back to the patient.
• The blood flow rate typically ranges from 250 to 450
mL/min, depending on the type and integrity of the
vascular access.
22. BLOOD DELIVERY SYSTEM
• Negative hydrostatic pressure on the dialysate side can
be manipulated to achieve desirable fluid removal or
ultrafiltration. Dialysis membranes have different
ultrafiltration coefficients (i.e., mL removed/min per
mmHg) so that along with hydrostatic changes, fluid
removal can be varied.
• The dialysis solution delivery system dilutes the
concentrated dialysate with water and monitors the
temperature, conductivity, and flow of dialysate.
25. ■■ GOALS OF DIALYSIS
• The hemodialysis procedure consists of pumping heparinized blood
through the dialyzer at a flow rate of 250–450 mL/min, while
dialysate flows in an opposite counter-current direction at 500–800
mL/min. T
• he efficiency of dialysis is determined by blood and dialysate flow
through the dialyzer as well as dialyzer characteristics (i.e., its
efficiency in removing solute).
• The dose of dialysis, which is currently defined as a derivation of
the fractional urea clearance during a single treatment, is further
governed by patient size, residual kidney function, dietary protein
intake, the degree of anabolism or catabolism, and the presence of
comorbid conditions.
26. • Since the landmark studies of Sargent and Gotch relating the
measurement of the dose of dialysis using urea concentrations
with morbidity in the National Cooperative Dialysis Study, the
delivered dose of dialysis has been measured and considered as
a quality assurance and improvement tool.
• While the fractional removal of urea nitrogen and derivations
thereof are considered to be the standard methods by which
“adequacy of dialysis” is measured, a large multicenter
randomized clinical trial (the HEMO Study) failed to show a
difference in mortality associated with a large difference in per-
session urea clearance.
27. • Current targets include a urea reduction ratio (the fractional
reduction in blood urea nitrogen per hemodialysis session) of >65–
70% and a body water–indexed clearance × time product (Kt/V) >1.2
or 1.05, depending on whether urea concentrations are
“equilibrated.”
• For the majority of patients with ESRD, between 9 and 12 h of dialysis
are required each week, usually divided into three equal sessions.
• Several studies have suggested that longer hemodialysis session
lengths may be beneficial (independent of urea clearance), although
these studies are confounded by a variety of patient characteristics,
including body size and nutritional status.
28. • Hemodialysis “dose” should be individualized, and factors other
than the urea nitrogen should be considered, including the
adequacy of ultrafiltration or fluid removal and control of
hyperkalemia, hyperphosphatemia, and metabolic acidosis.
• A randomized clinical trial comparing 6 versus 3 times per week
hemodialysis (the “Frequent Hemodialysis Network Daily Trial”)
demonstrated improved control of hypertension and
hyperphosphatemia, reduced left ventricular mass, and
improved self-reported physical health with more frequent
hemodialysis.
29. • Secondary analyses also demonstrated improvements in other metrics of
health-related quality of life, including improved self-reported general
health and a reduced “time to recovery” (time until usual activities can be
resumed) among patients randomized to more frequent hemodialysis.
• A companion trial in which frequent nocturnal hemodialysis was compared
to conventional hemodialysis at home showed no significant effect on left
ventricular mass or self-reported physical health.
• Finally, an evaluation of the U.S. Renal Data System registry showed a
significant increase in mortality and hospitalization for heart failure after
the longer interdialytic interval that occurs over the dialysis “weekend.”
30. COMPLICATIONS DURING
HEMODIALYSIS
• Hypotension is the most common acute complication of
hemodialysis, particularly among patients with diabetes
mellitus.
• Numerous factors appear to increase the risk of
hypotension, including excessive ultrafiltration with
inadequate compensatory vascular filling, impaired
vasoactive or autonomic responses, osmolar shifts,
overzealous use of antihypertensive agents, and reduced
cardiac reserve.
31. COMPLICATIONS DURING
HEMODIALYSIS
• Patients with arteriovenous fistulas and grafts may develop
high-output cardiac failure due to shunting of blood through the
dialysis access; on rare occasions, this may necessitate ligation
of the fistula or graft.
• The management of hypotension during dialysis consists of
discontinuing ultrafiltration, the administration of 100–250 mL
of isotonic saline, or administration of salt-poor albumin.
• Hypotension during dialysis can frequently be prevented by
careful evaluation of the dry weight and by ultrafiltration
modeling, such that more fluid is removed at the beginning
rather than the end of the dialysis procedure.
32. COMPLICATIONS DURING
HEMODIALYSIS
• Excessively rapid fluid removal (>13 mL/kg per h) should be
avoided, as rapid fluid removal has been associated with
adverse outcomes, including cardiovascular deaths.
• Additional maneuvers to prevent intradialytic hypotension
include the performance of sequential ultrafiltration followed
by dialysis, cooling of the dialysate during dialysis treatment,
and avoiding heavy meals during dialysis.
• Midodrine, an oral selective a1 adrenergic agent, has been
advocated by some practitioners, although there is insufficient
evidence of its safety and efficacy to support its routine use.
33. • Muscle cramps during dialysis are also a common complication.
• The etiology of dialysis-associated cramps remains obscure.
• Changes in muscle perfusion because of excessively rapid
volume removal or targeted removal below the patient’s
estimated dry weight often precipitate dialysis-associated
cramps.
• Strategies that may be used to prevent cramps include reducing
volume removal during dialysis, ultrafiltration profiling, and the
use of sodium modeling.
34. • Anaphylactoid reactions to the dialyzer, particularly on its first
use, have been reported most frequently with the
bioincompatible cellulosic-containing membranes.
• Dialyzer reactions can be divided into two types, A and B. Type
A reactions are attributed to an IgE- mediated intermediate
hypersensitivity reaction to ethylene oxide used in the
sterilization of new dialyzers.
• This reaction typically occurs soon after the initiation of a
treatment (within the first few minutes) and can progress to
full-blown anaphylaxis if the therapy is not promptly
discontinued.
35. • Treatment with steroids or epinephrine may be
needed if symptoms are severe. The type B reaction
consists of a symptom complex of nonspecific chest
and back pain, which appears to result from
complement activation and cytokine release.
• These symptoms typically occur several minutes into
the dialysis run and typically resolve over time with
continued dialysis.
36. PERITONEAL DIALYSIS
• In peritoneal dialysis, 1.5–3 L of a dextrose-containing solution
is infused into the peritoneal cavity and allowed to dwell for a
set period of time, usually 2–4 h.
• As with hemodialysis, metabolic byproducts are removed
through a combination of convective clearance generated
through ultrafiltration and diffusive clearance down a
concentration gradient.
• The clearance of solutes and water during a peritoneal dialysis
exchange depends on the balance between the movement of
solute and water into the peritoneal cavity versus absorption
from the peritoneal cavity.
37. PERITONEAL DIALYSIS
• The rate of diffusion diminishes with time and eventually stops
when equilibration between plasma and dialysate is reached.
• Absorption of solutes and water from the peritoneal cavity
occurs across the peritoneal membrane into the peritoneal
capillary circulation and via peritoneal lymphatics into the
lymphatic circulation.
• The rate of peritoneal solute transport varies from patient to
patient and may be altered by the presence of infection
(peritonitis), drugs, and physical factors such as position and
exercise.
38. FORMS OF PERITONEAL
DIALYSIS
• Peritoneal dialysis may be carried out as CAPD, CCPD, or a
combination of both.
• In CAPD, dialysate is manually infused into the peritoneal
cavity and exchanged three to five times during the day.
• A nighttime dwell is frequently instilled at bedtime and
remains in the peritoneal cavity through the night.
39. FORMS OF PERITONEAL
DIALYSIS
• In CCPD, exchanges are performed in an automated
fashion, usually at night; the patient is connected to an
automated cycler that performs a series of exchange cycles
while the patient sleeps.
• The number of exchange cycles required to optimize
peritoneal solute clearance varies by the peritoneal
membrane characteristics; as with hemodialysis, solute
clearance should be tracked to ensure dialysis “adequacy.”
40. FORMS OF PERITONEAL
DIALYSIS
• Peritoneal dialysis solutions are available in volumes typically
ranging from 1.5 to 3L.
• The major difference between the dialysate used for peritoneal
rather than hemodialysis is that the hypertonicity of peritoneal
dialysis solutions drives solute and fluid removal, whereas
solute removal in hemodialysis depends on concentration
gradients, and fluid removal requires transmembrane pressure.
• Typically, dextrose at varying concentrations contributes to the
hypertonicity of peritoneal dialysate.
41. FORMS OF PERITONEAL
DIALYSIS
• Icodextrin is a nonabsorbable carbohydrate that can be used in
place of dextrose. Studies have demonstrated more efficient
ultrafiltration with icodextrin than with dextrose-containing
solutions.
• Icodextrin is typically used as the “last fill” for patients on CCPD
or for the longest dwell in patients on CAPD.
• The most common additives to peritoneal dialysis solutions are
heparin to prevent obstruction of the dialysis catheter lumen
with fibrin and antibiotics during an episode of acute peritonitis.
• Insulin may also be added in patients with diabetes mellitus.
42. ACCESS TO THE PERITONEAL
CAVITY
• Access to the peritoneal cavity is obtained through a peritoneal
catheter.
• Catheters used for maintenance peritoneal dialysis are flexible, being
made of silicone rubber with numerous side holes at the distal end.
• These catheters usually have two Dacron cuffs.
• The scarring that occurs around the cuffs anchors the catheter and
seals it from bacteria tracking from the skin surface into the
peritoneal cavity; it also prevents the external leakage of fluid from
the peritoneal cavity.
• The cuffs are placed in the preperitoneal plane and ~2 cm from the
skin surface.
43. ACCESS TO THE PERITONEAL
CAVITY
• The peritoneal equilibrium test is a formal evaluation of
peritoneal membrane characteristics that measures the transfer
rates of creatinine and glucose across the peritoneal membrane.
• Patients are classified as low, low–average, high–average, and
high transporters.
• Patients with rapid equilibration (i.e., high transporters) tend to
absorb more glucose and lose efficiency of ultrafiltration with
long daytime dwells. High transporters also tend to lose larger
quantities of albumin and other proteins across the peritoneal
membrane.
44. ACCESS TO THE PERITONEAL
CAVITY
• In general, patients with rapid transporting characteristics
require more frequent, shorter dwell time exchanges, nearly
always obligating use of a cycler. Slower (low and low–average)
transporters tend to do well with fewer exchanges.
• The efficiency of solute clearance also depends on the volume
of dialysate infused.
• Larger volumes allow for greater solute clearance, particularly
with CAPD in patients with low and low–average transport
characteristics.
45. • As with hemodialysis, the optimal dose of peritoneal dialysis is
unknown.
• Several observational studies have suggested that higher rates
of urea and creatinine clearance (the latter generally measured
in L/week) are associated with lower mortality rates and fewer
uremic complications.
• However, a randomized clinical trial (Adequacy of Peritoneal
Dialysis in Mexico [ADEMEX]) failed to show a significant
reduction in mortality or complications with a relatively large
increment in urea clearance.
ACCESS TO THE
PERITONEAL CAVITY
46. • In general, patients on peritoneal dialysis do well when they retain
residual kidney function.
• Rates of technique failure increase with years on dialysis and have
been correlated with loss of residual function to a greater extent than
loss of peritoneal membrane capacity.
• For some patients in whom CCPD does not provide sufficient solute
clearance, a hybrid approach can be adopted where one or more
daytime exchanges are added to the CCPD regimen.
• While this approach can enhance solute clearance and prolong a
patient’s capacity to remain on peritoneal dialysis, the burden of the
hybrid approach can be overwhelming.
ACCESS TO THE
PERITONEAL CAVITY
47. COMPLICATIONS
DURING PERITONEAL
DIALYSIS
• The major complications of peritoneal dialysis are peritonitis,
catheter- associated nonperitonitis infections, weight gain and other
metabolic disturbances, and residual uremia (especially among
patients with little or no residual kidney function).
• Peritonitis typically develops when there has been a break in sterile
technique during one or more of the exchange procedures.
• Peritonitis is usually defined by an elevated peritoneal fluid leukocyte
count (100/mm3, of which at least 50% are polymorphonuclear
neutrophils); these cutoffs are lower than in spontaneous bacterial
peritonitis because of the presence of dextrose in peritoneal dialysis
solutions and rapid bacterial proliferation in this environment
without antibiotic therapy.
48. COMPLICATIONS
DURING PERITONEAL
DIALYSIS
• The clinical presentation typically consists of pain and cloudy
dialysate, often with fever and other constitutional symptoms.
• The most common culprit organisms are gram-positive cocci,
including Staphylococcus, reflecting the origin from the skin.
• Gram-negative rod infections are less common; fungal and
mycobacterial infections can be seen in selected patients,
particularly after antibacterial therapy.
• Most cases of peritonitis can be managed either with
intraperitoneal or oral antibiotics, depending on the organism;
many patients with peritonitis do not require hospitalization.
49. COMPLICATIONS
DURING PERITONEAL
DIALYSIS
• In cases where peritonitis is due to hydrophilic gram-negative
rods (e.g., Pseudomonas sp.) or yeast, antimicrobial therapy is
usually not sufficient, and catheter removal is required to
ensure complete eradication of infection.
• Nonperitonitis catheter-associated infections (often termed
tunnel infections) vary widely in severity.
• Some cases can be managed with local antibiotic or silver
nitrate administration, while others are severe enough to
require parenteral antibiotic therapy and catheter removal.
50. • Peritoneal dialysis is associated with a variety of metabolic
complications.
• Albumin and other proteins can be lost across the
peritoneal membrane in concert with the loss of metabolic
wastes.
• Hypoproteinemia obligates a higher dietary protein intake
in order to maintain nitrogen balance.
• Hyperglycemia and weight gain are also common
complications of peritoneal dialysis.
COMPLICATIONS
DURING PERITONEAL
DIALYSIS
51. • Several hundred calories in the form of dextrose are absorbed
each day, depending on the concentration of dextrose
employed.
• Patients receiving peritoneal dialysis, particularly those with
diabetes mellitus, are prone to other complications of insulin
resistance, including hypertriglyceridemia.
• On the positive side, the continuous nature of peritoneal
dialysis usually allows for a more liberal diet, due to continuous
removal of potassium and phosphorus—two major dietary
components whose accumulation can be hazardous in ESRD.
COMPLICATIONS
DURING PERITONEAL
DIALYSIS