Renal Replacement Therapy
Preparation
Options
Complications
Kaufhold, 1996
1
Preparation of the Patient
 Manage
CRF
 Control
BP
 Control glucose
 stop
oral agents!
 Prevent
Hyper PTH
 Vit
D
 Calcium acetate
 Phosphate binder
 Diet
Kaufhold, 1996
Education
2
Preparation of the Patient
 Manage
Fluids
 Dialysis education
 Access Placement
 Prevent anemia
 Prevent
Malnutrition
Kaufhold, 1996
 metolazone
 NKF
program
 AV fistula, PD cath
 Epogen, Iron
 This can get tricky
3
Progression of CRF
80
70
60
50
40
GFR
30
20
10
0
PTH
climbs
Kaufhold, 1996
PO4
rising
K, Urate
Up
Anemia
Sx
4
Transition to End Stage
Effect of Malnutrition
Wt
86
Measured Wt
= 85 Kg
84
82
Edema
Body mass
80
78
76
74
25
15
10
5
GFR
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Indications for Dialysis
A
acidosis
 E electrolyte abnormalities
 I intoxication/poisoning
 O fluid overload
 U uremia symptoms/complications
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Dialysis for Intoxications
T
A
B
L
E
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theophylline
aspirin
barbiturates
lithium
ethylene glycol, methanol
7
Relative Contraindications
 Alzheimer’s
disease
 Multi-infarct Dementia
 Hepatorenal syndrome
 Advanced cirrhosis with
encephalopathy
 Advanced malignancy
 HIV with dementia
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Types of Renal Replacement
 Acute
RRT:
 Standard
Hemodialysis
 Redy 2000
 Acute Peritoneal Dialysis
 CAVHD
 CVVHD
 Hemoperfusion
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Acute RRT choices
 Volume
Status
 Hemodynamic
status
 Access
 Bleeding
 Poisoning
Kaufhold, 1996
 CAVHD?
 Tolerate
Hemo?
 Abdominal surgery?
 Anticoagulation?
 How catabolic is pt
 Hemoperfusion?
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Renal Replacement Therapy
 Chronic
RRT
 Standard
Hemodialysis
 Peritoneal Dialysis
 Continuous
vs Intermittent
 Ambulatory vs Cyclic
 Cycler Plus*
 Combinations
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The Mystery of Dialysis
 Its
no mystery!
 Clearance
 simple
blood in
diffusion
dialysate plus
Ultrafiltrate out
 Ultrafiltration
 dialysate
pump
 Monitors
to make
sure nothing bad
happens
Kaufhold, 1996
dialysate in
blood out
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Hemodialysis
 Advantages
 standard
treatment
 widely used
 Pt has days off
 Good
reimbursement for
Nephrologist
 We have control
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Hemodialysis
 Disadvantages
 Pt
has no control
 strict attn to diet
 travel restricted
 need for vascular
access
 Specific risks
 Inadequate clearance
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Peritoneal Dialysis
 Clearance
 How
much fluid the
patient puts in
 Ultrafiltration
 How
much fluid
comes out
 Dextrose used as
osmotic agent
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Kaufhold, 1996
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Peritoneal Dialysis
 Advantages
 continuous
 middle
molecules
 pt has control
 vary tx with diet
 adjust to lifestyle
 no need for vascular
access
 no need for anticoag.
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Peritoneal Dialysis
 Disadvantages
 Abdominal
surgery
 limited clearance
 limited Uf
 Needs motivated,
compliant pt
 risk of peritonitis
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RRT Choices
 Renal
Transplant should be goal
 Peritoneal Dialysis for the right pt
 Hemodialysis for everyone else
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Dialysis
Chronic Complications
Kaufhold, 1996

Not seen until after
chronic access possible

1967 Alfree reported
dialysis dementia

Due to impurities
in water (100L/tx)
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Dialysis
Complications
Kaufhold, 1996

Bleeding disorders

Anemia

Bone disorders

Arthritis

Neuropathy

Cardiovascular
23
Dialysis Complications
Bleeding disorder
Kaufhold, 1996

Due to platelet dysfunction
Prolonged bleeding time

Treatment:
- more dialysis
- dDAVP 0.3 microgm/Kg
- Estrogen
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Dialysis Complications
Anemia
Kaufhold, 1996

Due to reduced Erythropoietin
- blood loss, reduced response

Treatment:
- more dialysis
- rHuEPO 2,000 units/tx
- Androgens
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Dialysis Complications
Arthritis
Kaufhold, 1996

Due to accumulation of
- Beta-2-microglobulin

Treatment:
- more dialysis
- Biocompatable membranes
- Joint replacement (Hips)
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Dialysis Complications
Neuropathy
Kaufhold, 1996

Manifestations:
- Peripheral Neuropathy
- Autonomic dysfunction
- Dementia
- Dysequilibrium syndrome

Treatment
- More dialysis
- gradual start of tx
- remove water impurities
- prevention is best.
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Dialysis Complications
Cardiovascular
Kaufhold, 1996

Manifestations:
- Accelerated atherogenesis
- Lipid abnormalities
- Associated disorders (DM etc)
- Leading cause of mortality

Treatment
- More dialysis
- Treatment of lipid disorders
- Control of HTN
- Carnitine?
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Adequacy of Dialysis
 Markers
 mortality
 hospitalization
 nutrition
 NCDS
 Gotch
and Sargent
 KT/V = clearance
 NPCR = nutrition
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Summary
 Incidence
of ESRD
 Progression of CRF
 Indications and contraindications
 Choices of RRT
 Complications of CRF, dialysis
 Adequacy
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