4. 2. Treatment Options
īNo Treatment
īMonitoring & Predialysis
â Control symptoms
â Preserve Residual Renal Function
âĸ Control rising BP (Antihypertensives)
âĸ Control Renal Bone Disease (Ca2+
, Vit D)
âĸ Prevent/Treat Anaemias (Erythropoietin, Blood)
īDialysis
īRenal Transplantation
5. Dialysis
Definition
īArtificial process that partially replaces renal
function
īRemoves waste products from blood by
diffusion (toxin clearance)
īRemoves excess water by ultrafiltration
(maintenance of fluid balance)
īWastes and water pass into a special liquid â
dialysis fluid or dialysate
8. Ultrafiltration
īMade possible by osmosis
īMovement of water
īAcross semipermeable membrane
īFrom low osmolality to high osmolality
īOsmolality â number of osmotically active
particles in a unit (litre) of solvent
9. Selection for HD/PD
īClinical condition
īLifestyle
īPatient competence/hygiene (PD - high risk
of infection)
īAffordability / Availability
10. 1.
2.
Blood cells are too big to pass through the dialysis membrane,
but body wastes begin to diffuse (pass) into the dialysis solution.
3.
Diffusion is complete. Body wastes have diffused through the membrane,
and now there are equal amounts of waste in both the blood and the
dialysis solution.
11. The process of ultrafiltration in PD
11.
2
2.
Blood cells are too big to pass through the semi-permeable membrane,
but water in the blood is drawn into the dialysis fluid by the glucose.
3.
Ultrafiltration is complete. Water has been drawn through the peritoneum
by the glucose in the dialysis fluid by the glucose in the dialysis fluid. There is
now extra water in the dialysis
12. Haemodialysis
īDialysis process occurs outside the body in a
machine
īThe dialysis membrane is an artificial one:
Dialyser
īThe dialyser removes the excess fluid and
wastes from the blood and returns the filtered
blood to the body
īHaemodialysis needs to be performed three
times a week
īEach session lasts 3-6 hrs
13.
14. Requirements for HD
īGood access to patients circulation
īGood cardiovascular status (dramatic
changes in BP may occur)
15. Performing HD
HD may be carried out:
īIn a HD Unit
īAt a Minimal Care / Self-Care Centre
īAt Home
16. HD Unit
īSpecially designed Renal Unit within a hospital
īPatients must travel to the Unit 3x a week
īPatients are unable to move around while on
dialysis; may chat, read, watch TV or eat
īNursing staff prepare equipment, insert the
needles and supervise the sessions
17. Minimal / Self-Care Dialysis
īPatients take a more active role
īPatients prepare the dialysis machine, insert
the needles, adjust pump speeds and
machine settings and chart their progress
under the supervision of dialysis staff
īPatients must travel to the unit 3x / week
īPatients need to be on a fixed schedule
18. Home Haemodialysis
īUse of machines set up at home
īMachines have many safety devices inbuilt
īThorough patient training
īRequires the help of a partner at home every time
īSuitability is assessed by the haemodialysis team
īIdeal for patients who value their independence
and need to fit in their treatment around a busy
schedule
19. HD Access
ī2 types of access for HD:
â Must provide good flow
â Reliable access
īA fistula: arterio-venous (AV)
īVascular Access Catheter
23. AV Fistula Access
īMatures in about 6 weeks
īEnsure good working order
â Avoid tight clothing or wrist watch on fistula arm
â Assess fistula daily; notify immediately if not working
â Avoid BP cuff on fistula arm
â Avoid blood sampling on fistula arm (except daily
HD Rx)
â Avoid sleeping on fistula arm
â Grafts (synthetic) may be used to create an AV fistula
24. Vascular Access Catheter
īDouble lumen plastic tube
īMay be placed in Jugular, Subclavian or Femoral
vein
īMay be temporary or permanent
īTemporary â awaiting fistula or maturation
īPermanent â poor vessels for fistula creation e.g.
children and diabetics
īCatheters must be kept clean, dry and dressed to
prevent infection
25. Effects of HD on Lifestyle
ī Flexibility:
â Difficult to fit in with school, work esp if unit is far from home.
Home HD offers more flexibility
ī Travel:
â Necessity to book in advance with HD unit of places of travel
ī Responsibility & Independence:
â Home HD allows the greatest degree of independence
ī Sexual Activity:
â Anxiety of living with renal failure affects relationship with
partner
ī Sport & Exercise:
â Can exercise and participate in most sports
ī Body Image:
â Esp with fistula; patient can be very self conscious about it
26. Problems with HD
ī Rapid changes in BP
â fainting, vomiting, cramps, chest pain, irritability, fatigue, temporary loss of
vision
ī Fluid overload
â esp in between sessions
ī Fluid restrictions
â more stringent with HD than PD
ī Hyperkalaemia
â esp in between sessions
ī Loss of independence
ī Problems with access
â poor quality, blockage etc. Infection (vascular access catheters)
ī Pain with needles
ī Bleeding
â from the fistula during or after dialysis
ī Infections
â during sessions; exit site infections; blood-borne viruses e.g. Hepatitis, HIV
27. Peritoneal Dialysis (PD)
īUses natural membrane (peritoneum) for dialysis
īAccess is by PD catheter, a soft plastic tube
īCatheter and dialysis fluid may be hidden under
clothing
īSuitability
â Excludes patients with prior peritoneal scarring e.g.
peritonitis, laparotomy
â Excludes patients unable to care for self
28. Addendum to Principles (PD)
īFluid across the membrane faster than solutes;
therefore longer dwell times are needed for solute
transfer
īProtein loss in PD fluid is significant ~ 8-9g/day
īProtein loss âs during peritonitis
īPD patients require adequate daily protein
averaging 1.2 â 1.5g/kg/day
īOther substances lost in the dialysate
â Amino acids, water soluble vitamins, some
medications and hormones
īCalcium and dextrose are absorbed from the
dialysate fluid into the circulation
29. Addendum to Principles (PD)
īStandard dialysis solution contains:
âĸ Na+
â 132 mEq/l
âĸ Cl-
â 96 -102 mEq/l
âĸ Ca2+
â 2.5 â 3.5 mEq/l
âĸ Mg2+
â 0.5 -1.5 mEq/l
īDialysis solution buffer:
â Sodium lactate
â Pure HCo3
-
â HCo3
-
/Lactate combinations
īLactate is absorbed and converted to HCo3
-
by the
liver
īDextrose solution strengths: 1.5%, 2.5%, 4.25%
31. CAPD
īDialysis takes place 24hrs a day, 7 days a week
īPatient is not attached to a machine for treatment
īExchanges are usually carried out by patient after
training by a CAPD nurse
īMost patients need 3-5 exchanges a day i.e.
â 4-6 hour intervals (Dwell time) 30 mins per exchange
īMay use 2-3 litres of fluid in abdomen
īNo needles are used
īLess dietary and fluid restriction
33. APD
īUses a home based machine to perform exchanges
īOvernight treatment whilst patient sleeps
īThe APD machine controls the timing of
exchanges, drains the used solution and fills the
peritoneal cavity with new solution
īSimple procedure for the patient to perform
īRequires about 8-10 hrs
īMachines are portable, with in-built safety features
and requires electricity to operate
35. DIET
īWhy is diet important?
â Managing the diet can slow renal disease
â The need for dialysis can be delayed
â The diet affects how patients feel
36. CONTROLLING YOUR
DIET
Foods to control are those containing:
ī Protein
ī Potassium
ī Sodium
ī Phosphorous
ī Fluid
39. SODIUM
īRegulates blood volume and pressure
īAvoid salt
Use Alternate food seasonings: lemon and limes,
spices, seafood seasoning, Italian seasoning,
vinegars, peppers
41. PHOSPHOROUS
īPhosphorus is a mineral which combines with
calcium to keep bones and teeth strong
īToo little calcium and too much phosphorus
īNeed to control the phosphorus in the diet
īNeed to take a phosphate binder or a calcium
supplement
45. Lifestyle Changes with PD
īFlexibility
â Can be performed almost anywhere
â Least impact on work / school life (esp APD)
īTravel
â Dialysis supplies can be delivered to most parts of the
world; travel more flexible. APD machines are portable;
will fit into a car boot, can be carried by train/air
īResponsibility
â Requires more responsibility from patient but more
independence
46. Lifestyle Changes with PD
īSports/Exercise
â Most are possible
â Advice on swimming, lifting, contact sports
īSexual Activity
â May affect relations based on patient anxiety
īDelivery & Storage of Supplies
â Home delivery and storage
â A monthâs supplies â 40 boxes; space to store
â Specially recruited and trained delivery staff
47. Problems with Treatment
īMonotomy of treatment
â The treatment never goes away against days off with HD
īBody Image Problems
â Esp with a permanent catheter
â Abdominal stretching
īFluid Overload
â Much less a problem than with HD
īDehydration
â Less common than fluid overload
īAbdominal Discomfort
â Bloated feeling
48. Problems with Treatment
īPoor drainage
â Common problem esp with new patients
â Fibrin plug
â Catheter displacement
īLeakage
â Fluid may leak around catheter exit site. (May leak
into scrotum)
â Stop PD temporarily
â Resite catheter (use new one)
īInfections
â Exit site infections
â Tunnel infection
â peritonitis
49. Problems with Treatment
īHernia
â Aggravation of pre-existing herniae (repair)
â Evolution of new herniae
īDeclining effectiveness of the peritoneum
â e.g. repeated infection
â Effect of glucose in the dialysis fluid
50. Comparison of Dialysis Treatment Options
PD Unit HD Home HD
Home Dialysis â Ã â
Convenient Sessions â Ã â
Socializn with other CRF pats à â Ã
Home Equipment/Supplies â Ã â
Special diet/fluid allowance â â â
Sports/exercises participation Most Most Most
Full day activity -work/school â Not alwys â
Direct assistâpartner/family à à â
Travel â Delivery of
supplies to most
destins easy.
Some notice req
â Prior
arrangements
must be made
well in advance
à Prior
arrangements must
be made well in
advance