Dialysis

Question 1

Clinical features of EPS

Answer 1

> 4yrs on dialysis, weight loss, ascites, low albumin

Question 2

How do you clear more phosphate

Answer 2

Increase length of dialysis / number of sessions
Cleared most effectively with nocturnal dialysis

Question 3

Max UF

Answer 3

13 ml/kg/hr

Question 4

Reasons for Home HD patients to have an acidosis

Answer 4

Lactate is used as a buffer in HHD in place of HCO3
Just after HHD patients will be acidotic

Question 5

What is a low urea pre dialysis suggestive of?

Answer 5

Malnutrition - Protein catabolic rate can be determined by urea excretion and residual renal function

Question 6

Causes of raised arterial pressure and venous pressure

Answer 6

Arterial pressure (becomes more negative) = needle issues / kink in the line / hypotension
Venous pressure = central stenosis

Question 7

Anticoagulation for CVVH

Answer 7

Regional citrate = unless contraindicated in which cause use unfractionated or LMWH
Note - citrate can accumulate in liver disease = causes metabolic acidosis and low ionised calcium - this is an indication to stop

Question 8

Anticoagulation options for HIT

Answer 8

Results in thrombocytopenia, thrombosis and infarction
Use instead Argatroban or Fondaparinux (= which can be used during CRRT)

Question 9

What is meant by the ‘conductivity measure’

Answer 9

Composition of the dialysate / acid base balance in the machine

Question 10

Reducing toxins on dialysis and key things

Answer 10

RO - removes infections / endotoxins
Carbon filter - if defective can lead to cyanosis in patients and methemoglobinaemia
High TMPT = dialysate pressure to high and suggests leak in the system

Question 11

Water levels for HDF - ultrapure

Answer 11

Bacterial level <0.1
Endotoxin level <0.03

Question 12

Average AVF fistula blood flow

Answer 12

Approx 1L/min

If >1L - may need echo ? steal syndrome causing ccf
If <1L - then poor AVF and needs intervention

Question 13

HHD versus PD

Answer 13

Similar outcomes
PD has higher risk of hospitalizations in the first year

Question 14

What is the recommended Dialysis catheter

Answer 14

Straight, double cuff

Question 15

PD peritonitis

Answer 15

Culture negative - think fungal PD
Multiple organisms - ? colonic malignancy
WCC >1000 on day 3 - Treatment failure and needs removal

Question 16

Icodextrin and raised BMs

Answer 16

Icodextrin can cross react with glucose readers - causes falsely high BMs

It can also cause falsely low serum amylase so if acute pancreatitis is considered then do serum lipase test

Question 17

Treatment of PD infusion pain

Answer 17

Switch to neutral / lactate and buffered solution

Question 18

PD Dialysis prescription if patient has inguinal hernia

Answer 18

Switch to APD - laying flat at night, small volume, dry days - this will reduce intra abdominal pressures

Question 19

Key things for MDT discussion in PD

Answer 19

PROMS / Fluid status / Nutrition / Removal toxins (Kt/v)

Question 20

Treatment of dialysis disequilibrium syndrome

Answer 20

Mainly supportive
Can give mannitol, hypertonic dextrose, oxygenation, intravenous phenytoin for fits, and in severe cases intubation and ventilation.

Question 21

Types of dialysis reactions

Answer 21

Type A - acute, instant, anaphylactic like reaction
Often secondary to medications e.g heparin.

Type B - Non specific, occurs 15-30mins into dialysis
Symptoms of nausea and vomiting.

Question 22

Indications for TNL removal

Answer 22

Staph aureus bacteremia / line culture
Infected tunnelling

Question 23

Commonest cause of PD peritonitis

Answer 23

1) Coagulase neg staph
2) Staph aureus
2) Enterococcus or pseudomonas

10% will be culture negative

Question 24

What is Ultrafiltration coefficient (KUK)

Answer 24

Ultrafiltration coefficient / KUF - determines the ultrafiltration rate

It indicates the volume of ultrafiltration expected per hour for each 1 mmHg of transmembrane pressure. For example KUF of 3 ml/hour/mmHg, = 3 ml of ultrafiltrate per hour, In order to achieve 1 L of ultrafiltrate per hour, the transmembrane pressure would be 333 mmHg (3ml/hr/mmHg X 330 mmHg=1000 ml/hour).

Transmembrane pressures that exceed 250 mmHg are dangerous because they can result in membrane rupture and blood leak to the dialysate compartment. By increasing the KUF, you can take off the same 1L per hour with a lower transmembrane pressure e.g (8 ml/hr/mmHg X 125 mmHg =1000 ml/ hour).

Question 25

Features and how to deliver Intradialytic parenteral nutrition

Answer 25

Intradialytic parenteral nutrition to boost protein/ energy intake, although the evidence is weak.
Nutrition is given during dialysis, starting with slow infusion and increasing progressively and continued as long as the patient needs it. It has the advantages of utilizing the dialysis time for the infusion and ability to UF extra fluid.

Question 26

Key dialysis trials: FHN, HEMO, Evolve

Answer 26

FHN Trial: compared 3x a week dialysis with short daily dialysis and found that daily dialysis has favourable outcomes but more access issues.

The HEMO study = no mortality difference between Kt/v of 1.2 vs Kt/v of 1.7. and no difference in the high flux vs low flux dialyzer.

NCDS = showed that the KT/V > 1 was associated with a significant mortality benefit.

MPO trial =looked at the high flux dialyzers vs low flux dialyzer and found no overall mortality benefits.

EVOLVE = the effect of cinacalcet on cardiovascular outcomes in haemodialysis patients - cinacalcet did not significantly reduce the risk of death or major cardiovascular events

Question 27

Vitamin A in dialysis patients

Answer 27

Vitamin A accumulates in chronic kidney disease and it is not removed by dialysis.
It can build up with chronic use to toxic levels.
Causes Hypercalcaemia, deranged liver enzymes, and pseudotumour cerebri
Patients complain of loss of appetite, generalized joint and bone pain, and weight loss. dryness of his skin and lips, and hair loss. recurrent morning headaches and papilloedema

Question 28

Intradialytic hypertension

Answer 28

Often due to clinically undetectable fluid overload
Patients tend to have too high target weights and fail to achieve enough UF.
tX = Reduce target weight, reduce Na dialysate and carvediolol

Question 29

Advantages / disadvantages of button hole technique

Answer 29

Advantages = reducing pain, unsuccessful attempts, bleeding, hematoma, and aneurysm formation.

Disadvantages = Increased infection risk

Question 30

Complications from first dialysis session

Answer 30

Dialysis disequilirbrium syndrome

In cases of acidosis - rapid correction using dialysis can cause reduction in ionised calcium - leading hypocalcemia = seizures etc. Can give IV calcium