Renal Disease and Dialysis 101
Shalini Bumb
August 2013
Objectives
CKD
 Dialysis
 Access
 Eckel pearls
 Scenarios

Chronic Kidney Disease
Types of dialysis
1.
2.
3.
4.
Hemodialysis (HD)
Ultrafiltration (UF)
Continuous Veno-Venous hemofiltration
(CVVH)
Peritoneal Dialysis
Hemodialysis
Semipermeable membrane
 Solute removal via passive diffusion

◦ Inversely proportional to the size (ie effective
removal of K, urea, C; not of PO4)
Ultrafiltration
use of hydrostatic pressure gradient to
induce convection (filtration of water)
 solvent drag (pulls dissolved solutes)
across
 removal of excess fluid

CVVH
highly permeable membrane
 fluid and solute removal via ultrafiltration
 filtrate is discarded
 replacement fluid is infused similar to
plasma (but no K, urea, Cr, PO4)
 used in ICU, runs 12-24h, through double
lumen catheter
 less drastic fluid shifts

Peritoneal Dialysis
peritoneal
membrane =
partially permeable
membrane
 dextrose dialysate
 diffusion and
osmosis until
equilibrium
 3-10 dwells per
night with 2-2.5 L
per dwell

Indications for Dialysis
Acidosis
 Electrolytes
 Ingestions
 Overload
 Uremia

Access
Arteriovenous fistula (AVF)
 Graft
 Tunneled catheter

Arteriovenous Fistula
◦ Highest patency
◦ Lowest risk of infection
◦ Low risk of thrombus
◦ Maturation time (3-4mo)
◦ Steal syndrome (poor
blood supply to the rest
of the limb)
◦ Aneurysm formation
Arteriovenous Graft






Easier to create
Maturation time 3-6
weeks
Poor patency (often
requires thrombectomy
or angioplasty)
Infection
Aneurysms
Steal syndrome
Tunneled Catheter
Immediate use
 Bridge to AVF/AVG

Poor flow (decreased
HD efficiency)
 High infection risk
 Venous stenosis
 Thrombosis

Dialysis Rx:
Time: 2-5 hours
 Bath
 Blood flow rate: 400-450cc/min
 Dialysate flow rate: 500-800cc/min
 Anticoagulant
 Additives:

◦ Anemia (EPO, blood)
◦ Bone metabolism (vit D, calcitriol, etc)
◦ Meds (antibiotics)
Dialysate Bath
Common Admissions on Eckel

Complications of missed HD
◦ SOB from fluid overload
◦ HTN crisis
◦ Hyperkalemia
Line infections
 Access issues
 And everything else…

Eckel Pearls: presentation
75 yo AAM with ESRD 2/2 DM (HD MWF
via RUE AVF, at CDC East, nephrologist
Dr. Wish, dry weight 82kg, oligouric)
Eckel Pearls: history
how did the last HD session go?
 complications since being started on HD?

◦ infections?
◦ multiple access points?
medically compliant?
 get run sheets from dialysis center

Eckel Pearls: physical exam
Vitals: no BP in the arm of the access
 Volume status
 Access:

◦ Infection?
◦ Aneurysms
◦ Bruits/thrills
Page 1

RN LK50: OMG’s K is 3.1. Can we
replete?
•Had dialysis 3rd shift. Finished 2hrs ago
Labs in ESRD
Get labs before or 4h after HD
 Only the H/H is accurate
 Floor RNs can’t use HD lines
 Can ask to have cultures drawn at HD
from the line

Page 2

RN LK20: New admit AMS on floor. Hard to
arouse. Please eval
ED presentation with abd pain
 Workup initiated since there are no beds…
 Pain meds: morphine 1mg, then 1mg, then 2
mg, then 3mg IVP
 Sent to the floor

Medications in ESRD

Antibiotics
◦ Renally dose
◦ Loading dose, then maintenance dose
No lovenox dvt ppx, use heparin
 No morphine

◦ Hepatic metabolism – but active metabolites
◦ Limit the other opioids
 Dilaudid: hepatic metabolism – but metabolites can
cause neuroexcitiation

constipation/GERD : avoid
magnesium/phosphate containing agents
Page 3

RN: new admit OK. Called wound care for
leg.

After lunch you walk on over to the patient
room. ESRD admitted for access.
OK is doing ok. Vitals stable. Comfortable.

Calciphylaxis
Calcinosis cutis
Page 4

RN LK20: Code white, WAA is hypoxic, 83% on
RA. Now 92% on VM.
Acutely SOB. Looks uncomfortable.
Your co-NF points that one leg is bigger than the
other.
 You ask, “have you had a blood clot before?”
 WAA nods yes.
 Hmmm….amongst other things, CTPE?


Imaging in CKD
Avoid contrast in CKD patients
 If you have to, prep

◦ volume expansion: isotonic IVFs
 3 cc/kg x 1h before
 1cc/kg x 6h after
◦ ? alkalinization: sodium bicarbonate
◦ ? acetylcysteine
◦ radiology can give you the protocol

(treat empirically)
Imaging in ESRD
CT with contrast is ok
 MRI with gadolinium is NOT:

◦ Nephrogenic Systemic Fibrosis (NSF)
◦ IF you must: HD x 3 over 3 consecutive days,
with the first right after
Page 5

RN LK20: Lost access on GRR. Can you
order a PICC?
Finally, an easy question.
 CKD. Sure, why not?

Access in CKD
Avoid PICC/midlines in CKD stage 4-5
 Try to preserve access
 Try for the feet/EJ
 But if you need to, order a midline


PCP should refer CKD stage IV to
nephrologists in anticipation of HD
Don’t treat them lightly
The end.
Resources













UpToDate
Lavinia Negrea. “Dialysis Access.” Microsoft Powerpoint. August 2013.
Claire Sullivan. “Intern Boot Camp: Renal Disease and Dialysis (ie surviving Eckel).” Date last modified
2012. Microsoft Powerpoint. August 2013.
Van Stone, JC. Hemodialysis: Hemodialysis apparatus. In: Handbook of Dialysis Daugirdas, JT, Ing, TS (Eds),
Little, Brown, Boston, 1994. p53.
Yassine Mrabetis. “Hemodialysis Diagram." Online image. Dialysis Definition. Creative Commons
Attribution-Share Alike 3.0, Wikepedia. August 2013.
“Peritoneal Dialysis Diagram.” Online Image. Alniche: Types of Dialysis. Alniche Life Sciences Pvt. Ltd.
August 2013.
Po Ming Teng. “Aneurysm.” Online Image. Chronic renal failure and dialysis. Surgical-tutor.org.uk. August
2013.
“Calciphylaxis.” Online Image. The UK Calciphylaxis Study. The Renal Association. August 2013.
Jonathan Z. Li and William Huen. “Calciphylaxis with Arterial Calcification.” Online Image. 2007. N Engl J
Med. August 2013.
Shaofeng Yan. “Calciphylaxis Histology.” Online Image. 2006. Mihm’s Dermatopathology:
Calciphylaxis. Martin C. Mihm, Jr. August 2013.
“Nephrogenic Systemic Fibrosis.” Online Image. Skin & Allergy News: Nephrogenic Fibrosis Is Tied to
Contrast Agents : Moderate- to end-stage renal disease patients are most susceptible to the
scleroderma-like syndrome. International Medical News Group, LLC. August 2013.
Michael Shaw. “They’re willing to throw in their kidneys.” Online image. 2008. New Yorker Cartoon.
August 2013.
Cartoons from www.lightersideofdialysis.com. August 2013.