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Renal > Renal Replacement Therapy > Flashcards

Renal Replacement Therapy Flashcards

1
Q

When do we start planning for dialysis?

A

Stage 4 CKD

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2
Q

What is the primary concern for dialysis initiation?

A

Clinical status

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3
Q

What are the criteria for initiation of dialysis?

A

One or more of the following:
Sx or signs attributable to kidney failure (serositis, acid base or electrolyte abnormalities, pruritus)
Inability to control volume status or BP
A progressive deterioration in nutritional status refractory to dietary intervention
Cognitive impairment

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4
Q

What factors should be considered when initiating dialysis?

A 
Dialysis accessibility
Transplantation option
Vascular access
Age
Declining health
Compliance with diet and medications
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5
Q

What are the types of dialysis?

A

HD
PD
Continuous renal replacement
Hybrid

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6
Q

Which types of dialysis are for chronic use?

A

HD

PD

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7
Q

Which types of dialysis are for acute use?

A

Continuous renal replacement

Hybrid

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8
Q

What are the advantages of HD?

A

Higher solute clearance -> intermittent use
Low technique failure rate
Closer patient monitoring

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9
Q

What are the disadvantages of HD?

A

Requires multiple weekly visits to dialysis center
Disequilibrium, hypotension, muscle cramps are common
Vascular access complications (infections and thrombosis)

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10
Q

What are the advantages of PD?

A

More hemodynamic stability
Suitable for pt that cannot tolerate HD
Sense of independence

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11
Q

What are the disadvantages of PD?

A 
Protein and aa loss and decreased appetite -> malnutrition
Catheter malfunction and/or infection
Patient burnout (decreased compliance)
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12
Q

What type of membrane is in HD?

A

Semipermeable that separates blood and dialysate

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13
Q

What type of current is used in HD?

A

Countercurrent

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14
Q

What is another name for convection?

A

Ultrafiltration

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15
Q

What are the two ways HD is performed?

A

Convection and diffusion

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16
Q

What does diffusion rate in HD depend on?

A

Concentration gradient, solute characteristics, dialyzer composition, and flow rates (blood and dialysate)

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17
Q

What does convection rate in HD depend on?

A

Hydrostatic pressure gradient across the membrane and dialyzer composition

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18
Q

What are the types of vascular access?

A

AV fistula
AV graft
Cuffed or tunneled venous catheters

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19
Q

What is the preferred type of vascular access?

A

AV fistula

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20
Q

How long does it take for an AV fistula to “mature”?

A

2 months

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21
Q

Which type of vascular access has the lowest rate of complications?

A

AV fistula

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22
Q

What is the 2nd line option for vascular access?

A

AV graft

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23
Q

How long does it take before an AV graft can be used?

A

2-3 weeks to endothelialize

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24
Q

Where is a cuffed or tunneled venous catheter placed?

A

Subclavian or internal jugular vein

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25
Q

Which vascular access has the most complications?

A

Cuffed or tunneled venous catheters

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26
Q

What are the characteristics of the dialysate in HD?

A

Purified water and electrolytes

Heated to body temperature

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27
Q

What is the most conventional type of dialysis membrane in HD?

A

Low-flux

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28
Q

How is an anticoagulant administered in HD?

A

Bolus 3-5 minutes before HD, d/c 1 hour before HD ends

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29
Q

Why are anticoagulants administered in HD?

A

To prevent blood from clotting to tubing

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30
Q

What type of anticoagulant is typically used in HD?

A

IV heparin

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31
Q

What is a common HD regimen?

A

3-4 hours 3 times a week

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32
Q

What are the goals for HD?

A

Achieve dry weight

Adequate removal of endogenous waste products

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33
Q

What are complications of HD?

A 
Hypotension
Muscle cramps
Thrombosis
Infection
Dialyzer reactions
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34
Q

What is the most common complication of HD?

A

Hypotension

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35
Q

What are predisposing factors for hypotension?

A

Excessive ultra-filtration
Target dry weight is too low
Take anti-hypertensive medications or eating food before HD
Diastolic dysfunction

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36
Q

What is the acute treatment of hypotension in HD?

A

Trendelenburg position
Decreates ultra-filtrate rate
Give IV fluids

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37
Q

What are the IV fluid options for patients with hypotension in HD?

A

100-200 mL Bolus of 0.9% NaCl
10-20 mL hypertonic (23.4%) solution over 3-5 minutes
12.5 g mannitol

38
Q

What is the most common IV fluid option for patients with hypotension in HD?

A

100-200 mL bolus of 0.9% NaCl

39
Q

What are non-pharmacologic preventions for hypotension in HD?

A

Adjust dry weight
Use bicarbonate buffer solutions
Avoid food before HD pulls blood flow to the gut

40
Q

What are pharmacologic preventions for hypotension in HD?

A

Midodrine 2.5 - 10 mg PO 30 minutes prior to HD

Less studied: caffeine, levocetirizine, fludricortisone

41
Q

What is the cause of muscle cramps in HD?

A

May be related to plasma volume contraction and decreased muscle perfusion

42
Q

What are the acute treatments for muscle cramps in HD?

A

IV fluids:
100 - 200 mL bolus 0.9% NaCl
10 - 20 mL hypertonic (23.4%) solution over 3-5 minutes
50 mL D50 - non-diabetic patients

43
Q

What are the non-pharmacologic prevention strategies for muscle cramps in HD?

A

Adjust dry weight

Stretching exercises

44
Q

What are the pharmacologic prevention strategies for muscle cramps in HD?

A

Vitamin E 400 IU QHS

Less studied: oxazepam, prazosin, hydroquinine

45
Q

What is the most problematic type of thrombosis?

A

Catheter thrombosis

46
Q

What are the non-pharmacologic treatment for thrombosis in HD?

A

Forced saline flush
Surgical thrombectomy
Exchange of catheter over guidewire

47
Q

What are the pharmacologic treatments for thrombosis in HD?

A

Alteplase

Reteplase

48
Q

What is the order of prevelance of infection in vascular access in HD?

A

Venous catheters > AV grafts > AV fistulas

49
Q

What do we do if patient experiences fever during HD?

A

Culture blood immediately

If temporary catheter -> remove tip and send for culture

50
Q

What are the medications for empiric coverage of gram positive abx in HD?

A

Vanc

Cefazolin

51
Q

What are the medications for empiric coverage of gram-negative abx in HD?

A

Gent

3rd generation cephalosporin

52
Q

What is the predominant cause of infections in HD?

A

S. aureus

53
Q

What is the treatment for tunneled catheter infections that are localized to the catheter exit site with no drainage?

A

Topical abx

54
Q

What is the treatment for tunneled catheter infections that are localized to catheter exit site with drainage?

A

Systemic gram positive coverage

55
Q

What is the treatment for tunneled catheter infections that has bacteremia w/ or w/o systemic sx?

A

Gram positive coverage

56
Q

What is the treatment for tunneled catheter infections that has bacteremia w/sx in 36 hours?

A

Remove catheter

57
Q

What is the treatment for tunneled catheter infections that has bacteremia and is stable w/no sx?

A

Change catheter and give culture-specific abx for a minimum of 3 weeks

58
Q

What is the treatment for AV graft infections that are local?

A

Empiric abx

Narrow once cultures return and treat for 2-4 weeks

59
Q

What is the treatment for AV graft infections that are extensive?

A

Empiric abx
Narrow once cultures return and treat for 2-4 weeks
Total resection of graft

60
Q

What is the treatment for AV fistula infections?

A

Empiric abx x 6 weeks

61
Q

What are the types of dialyzer reactions?

A

Anaphylactic (Type A)

Nonspecific (Type B)

62
Q

What are type A dialyzer reactions?

A

Hypersensitivity to sterilizing agent
Usually on initial exposure
Usually bioincompatibile membranes or certain high-flux membranes with ACEi use

63
Q

What are type B dialyzer reactions?

A

Chest pain
Back pain
Compliment activation

64
Q

What type of membrane is used in PD?

A

The peritoneal membrane acts as the semipermeable membrane

65
Q

What are the differences in PD from HD?

A

No intimate contact between dialysate and blood
-Waste products have to travel through bleed vessels to get to peritoneal membrane
No countercurrent flow
No way to control blood flow rates
Slower process
-Must be virtually continuous to achieve acceptable waste removal

66
Q

How is PD installed?

A

Permanent indwelling catheter
Tunneled inside abdominal cavity
Most of the peritoneal catheter is on the outside of the body with Luer-lock at the end

67
Q

What are the characteristics of the dialysate in PD?

A

Electrolytes
Osmotic gradients
-Dextrose in hyperosmolar concentrations (monitor in pts with DM)
-Icodextrin (alternative to dextrose)

68
Q

What are the types of PD?

A

Continuous ambulatory peritoneal dialysis (CAPD)

Automated peritoneal dialysis (APD)

69
Q

What is the procedure for CAPD?

A

1-3 L of dialysate flows into peritoneal cavity under gravity over 15 minutes
Dwells in peritoneal cavity 4-6 hours -> drain -> replace with fresh dialysate
Repeated 3-4 times a day

70
Q

What are the types of APD?

A

Nocturnal intermittent peritoneal dialysis (NIPD)
Continuous cycling peritoneal dialysis (CCPD)
Nocturnal tidal peritoneal dialysis (NTPD)

71
Q

With whom are APDs used?

A

When patients unable or unwilling to perform aseptic technique manipulations to catheter

72
Q

When are APDs used?

A

Device set up in the evening -> catheter attached at bedtime

73
Q

What are the goals of PD?

A

Achieve dry weight

Adequate removal of endogenous waste products

74
Q

What is the CrCl goal in PD?

A

> 60

75
Q

What does Kt/Vd explain?

A

Quantitates fraction of total body water cleared of urea during dialysis

76
Q

What is the goal Kt/Vd in PD?

A

> 2

77
Q

What are the types of complications in PD?

A

Mechanical
Exacerbation of DM
Peritonitis
Catheter site infections

78
Q

What are the types of mechanical PD complications?

A

Kinking of catheter

Catheter obstruction

79
Q

What is the cause of exacerbations of DM as PD complications?

A

Glucose load from the dialysate

~60% of glucose absorbed by patient during each exchange

80
Q

What are the sx of peritonitis?

A

Abdominal pain/tenderness
Cloudly effluent
Fever and chills
N/V

81
Q

What are the signs of peritonitis?

A

Cloudy effluent

Dialysate: WBC > 100 with at least 50% neutrophil

82
Q

What is the most common bacteria in peritonitis?

A

S epidermis

83
Q

What is the route of administration for abx in peritonitis?

A

Intraperitoneal

84
Q

What type of abx are used for gram positive coverage for peritonitis?

A

First generation cephalosporin or vancomycin

85
Q

What type of abx are used for gram negative coverage for peritonitis?

A

Third generation cephalosporin or AG

86
Q

What is the treatment duration of peritonitis?

A

14 - 21 days

87
Q

Do you treat patients with catheter site infections with systemic or local abx?

A

Systemic

88
Q

What type of abx are used for gram positive coverage in catheter site infections?

A

Penicillinase-resistant penicillin or first generation ceph

89
Q

What type of abx are used for gram negative coverage in catheter site infections?

A

FQs

90
Q

What is the treatment duration for catheter site infections?

A

At least 14 days

91
Q

What is the exit site care for the prevention of peritonitis and catheter site infections?

A

Topical abx
Intranasal abx
Both

Renal (8 decks)

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