ESRD And Diaylsis

Question 1

Definition of ESRD

Answer 1

CKD with the development of signs and symptoms of uremia

** most commonly occurs on eGFR <15, but need signs/symptoms of uremia

Question 2

Uremia

Answer 2

Build up metabolic toxins
- BUN, creatinine, urea, bilirubin, etc.

Signs/symptoms of uremia:

• anorexia/decreases appetite
• vomiting
• pericarditis
• peripheral neuropathy (burning feet or restless legs)
• metallic tastes
• CNS toxicity signs
• asterixis/AMS

Question 3

Complications of ESRD

Answer 3

Malnutrition

Uremic bleeding

Pericarditis

Uremic neuropathy

Bacterial infections (especially pneumonia)

Question 4

Treatment of ESRD

Answer 4

1) treat complications

2) kidney transplant list
- this is the treatment of choice
- **eligibility = eGFR <20 or on chronic dialysis
- if eligible, get them on the list ASAP

3) dialysis

sometimes patients can want conservative management which is palatative care

Question 5

Absolute Contraindications to kidney transplant

Answer 5

Active infections or malignancy

Active substance abuse

Reversible kidney failure

Uncontrolled psychiatric disease

Documented inability to adhere to treatments

Life expectancy currently <1-5 years

Question 6

How does dialysis work?

Answer 6

1) blood comes into the dialysis machine

2) machine is filled with dialysate fluid which makes a large osmotic gradient for toxins to move into the dialysate and out of blood
- Proteins DONT cross over since they are too big

Question 7

Who should get dialysis in acute kidney injuries

Answer 7

Know your vowels “AEIOU”

A = acidosis w/ pH <7.1

E = Electrolytes are >6.5 (especially potassium)

I = intoxications are present
“SLIME”
- Salicayltes, Lithium, Isopropanol, Methanol, Ethylene glycol

O = volume Overload and doesnt respond to diuretics

U = uremia is present

• uremic pericarditis and pleuritis
• uremic encephalopathy

Question 8

Who should get dialysis in chronic kidney injury/disease

Answer 8

Absolute

• uremic pericarditis/pruritus or encephalopathy
• GFR = <15

Relative (but pretty Much always)

• Declining nutritional status
• Fatigue and malaise
• Mild cognitive impairment
• Refractory acidosis
• hyperkalemia/hyperphosphatemia (especially if >6.5)

Question 9

Hemodialysis

Answer 9

Hemodialysis

• blood is pumped out of patients and into a machine with an artificial membrane to move toxins out of the body
• requires access and this is usually done via initiation of a AV fistula or AV graft or central line catheter in the arm (vascular surgeon does this manually)
• can be done at home (less common but better outcomes if they can afford it) or dialysis center (most common but worse outcomes)

Question 10

AV fistula vs AV graft vs Central venous catheter

Answer 10

AV fistula’s

• directly connection of an artery to a vein via surgery
• take 2-3 months to actual use though so is not used in very acute uremia
• need to see a sac like appearance in the arm that has bruit/thrill on auscultation
• DONT give BP checks or blood draws on the fistula arm

AV graft

• place artificial graft material between an artery and vein
• can be used within 24hrs-2 weeks option (quicker)
• Higher complication rates compared to fistula (especially clot rates go way up)

Central vascular catheter

• is usually done in conjunction with a fistula/graft in order to start dialysis immediately while waiting for the fistula/graft to form
• can use immediately and is preferred option in acute uremia**
• must be replaced frequently and very prone to complications (especially infections). Dont use for long term (this is why a fistula is often done at the same time)
• other complications = sepsis, venous stenosis which prevents use of that extremity for future AVF/G (from scarring due to central venous Cather placement)

Question 11

Peritoneal dialysis

Answer 11

Dialysis fluid is injected into the peritoneal space and uses the patients peritoneal membrane as the membrane for toxins to cross through

• the dialysis fluid is then removed from the peritoneal space after a select amount of time
• requires placement of a peritoneal catheter and only has to wait 2 weeks to use (similar to AV graft)

Is done at home or work and allows independence

Complications includes infections/peritonitis
cant use for significantly obese

Question 12

Two different types of peritoneal dialysis

Answer 12

1) continuous ambulatory peritoneal dialysis
- patients self-infuse dialysis fluid abdomen, leave it for 30-40 minutes than drain it.
- must be done 3-5x every day
- doesn’t require machine

2) automated peritoneal dialysis
- machine-driven infusion and draining of peritoneal dialysis fluid done once a day
- typically done every night while patient is sleeping
- must remain attached to the machine 9-12 hrs

Question 13

When do doctors discuss dialysis?

Answer 13

If a patient reaches stage 4

- also discuss kidney transplantation ad an option and sign up for donor list

Question 14

Nocturnal dialysis

Answer 14

Come into clinic at night and sleep at the clinic where the patient gets 2 4hrs sessions for a total 8 hrs

Question 15

Words of wisdom for dialysis patinets

Answer 15

1) be the captain of your own ship
2) doctors are there to help you but you get the final decision
3) dont be afraid to ask questions and demand answers and get information about alternative options