dialysis

Question 1

what are kidneys for?

Answer 1

 To filter blood
 Excretion
 Potassium metabolism
 Blood manufacture (EPO)
 Acid/base metabolism
 Salt/water/blood pressure
 Calcium metabolism

Question 2

how to measure excetion

Answer 2

 Glomerular filtration rate -
inulin
56-Cr-EDTA

 Creatinine

 eGFR – calculated from creatinine, age,
(race)

Question 3

creatinine an renal function

Answer 3

A raised creatinine (< 120)
often implies > 50% loss of
renal function

Question 4

kidney damage stagin

Answer 4

Question 5

how to treat hyperkalaemia

Answer 5

• K+
- ECG monitor
• No p waves, broad QRS or worse - IV calcium.
10ml calcium gluconate. Repeat until
complexes normalise. Give glucose & insulin.
• Peaked T’s - Glucose & insulin. 10 units
Actrapid in 50ml 50% glucose over 30 minutes.
Give as bolus if no pump available.

Question 6

treat EPO depletion

Answer 6

 Responds to pharmacological doses of ESA
– Erythropoiesis stimulating agents

ESA:

 Recombinant products
 s/c monthly to 3 times a week
 risk of hypertension/hyerpviscosity
 functional iron deficiency
 iv iron
 expense and funding issues

Question 7

when do you get poor ESA response?

Answer 7

 Intercurrent disease
 infection
 malignancy

 Functional iron deficiency
 Ferritin poor guide
 % hypochromasia
 Treat with INTRAVENOUS iron

Question 8

how to treat metabloic acidosis

Answer 8

 Consider treating with sodium bicarbonate
 may produce overload and hypertension

Question 9

renal bone diseases

Answer 9

 Untreated:
 Osteomalacia and Rickets
 Tertiary hyperparathyroidism
 Ectopic calcification

Question 10

bone biochemistry

Answer 10

 measure:
 Ca2+
 PO4
 Alkaline Phosphatase
 PTH

Question 11

how to manage renal bone disease

Answer 11

 When eGFR < , check PTH
 Treat if PTH > twice normal
 If phosphate is high, give phosphate binders
with food
 When phosphate is controlled or if normal, give
vitamin D analogue daily

Question 12

chronic implications of renal impairment

Answer 12

 Progression to end-stage renal failure
 Hypertension
 Renal bone disease
 Anaemia
 Acidosis
 Psychological
 Fluid balance (overload/dehydration)

Question 13

therapetic options

Answer 13

 Haemodialysis
 Peritoneal dialysis
 Transplantation
 Conservative therapy

Question 14

CAPD

Answer 14

Continuous Ambulatory
 Peritoneal Dialysis (CAPD)

 4 x 2 litre exchanges every day
 Can be done anywhere
 Less fluid restriction
 Fewer dietary restrictions

Question 15

malnutrition

Answer 15

 decreased intake
 uraemia/inadequate
dialysis
 depression
 absorbed glucose
(CAPD)
 abdominal fullness
(CAPD)
 altered taste
 haemodialysis

 intercurrent illness

 anaemia

 acidosis

 loss of protein in CAPD

Question 16

complications of dialysis

Answer 16

 infection and
immunosuppression
 line/cannula infections
 Clostridium difficile
 blood borne viruses

 skin
 pruritis
 nodular prurigo
 dry skin
 pigmentation

 Hypertension
 Volume
 pre-existing condition
 calcium
 non-volume dependent
hypertension

 Cardiovascular
 left ventricular
hypertrophy
 Vascular calcification
 ischaemic heart disease
 sudden cardiac death

 renal bone disease
 bone pain
 acute hot joint - pseudogout
 pathological fractures
 secondary hyperparathyroidism
 tertiary hyperparathyroidism
 ectopic calcification

Question 17

can we determin who will not benefit from renal replacement therapy:?

Answer 17

Functional status (Karnovsky?)
Comorbidity and associated
prognosis

Question 18

NSF standard 14

Answer 18

Each person approaching established renal
failure is given timely and understandable
information about their prognosis and the
choice of therapies available to them
including the option of choosing not to
dialyse. They are made aware of the relative
burdens and benefits of the different types of
dialysis

Question 19

renal failure symtpoms near the end of life?

Answer 19

 Anorexia, N+V, dry mouth, ammonia taste,
breath smells of urine, hiccups, myoclonic
jerks, constipation, diarrhoea ( uraemia )
 SOB, Oedema ( fluid overload )
 Itch ( multifactorial )
 Tiredness ( anaemia, uraemia, cachexia)
 Gastric problems ( gastrin levels )
 Psychosocial problems