If dialysis can only be this easy

Sanela RedzepagicRenal Advanced trainee RPAH/ CRGH

Ms. P. A• 53 year old Aboriginal lady from Byron Bay,

transferred to RPAH for further investigations• 5/7 worsening symptoms

– Lethargy, nausea, vomiting , intermittent fevers – Lower abdominal pain, diarrhoea then constipation– Cloudy PD fluid– Pruritis

• CT abdomen with contrast – Small foci of free gas under the right haemidiaphragm with no

definite evidence of bowel perforation.

• Occasional ‘holiday from PD’ • Herbal Medicine as advised by naturopath specialist

Medical historyESRF •HT •Interstitial nephritis due to NSAIDS + ?herbal Rx •CRF ESRF august 2010 – Tenckhoff Catheter

APD – 2x 6L 2.5% -- Nil peritonitis

Left Brachio-cephalic fistula created – reversed due to Steel syndrome Lost to follow up’

Anaemia - Hb 105 - ?on AranespCalcium & Phosphate metabolism

Medical historyIHD

NSTEMI 2011 precipitated by infection TTE - LVEF ~ 55%, Left atrium mildly dilatedClopidogrel ceased due to anaemia

Paroxismal AF – on aspirinHypercholesterolaemia‘Borderline DM’ diet controlledGORD on PPIDiverticular disease, no diverticulitis HypothyroidismPMR – on Prednisone

Medical historyMedicationsAspirin100 mg dailyMetoprolol 25 mg BDRosuvastatin 5 mg dailyFrusemide 120 mg daily

RabeprazolePrednisone 5 mg dailyThyroxine 50 mcg daily

CaltrateAranesp 40 mcg /?forthnight

Allergy – sulphur

SHAboriginal artist, lives with her husband SmokesEtoh – inconsistent“Alternative lifestyle”

O/ELow grade temp, BP 150/ 70, HR 94, o2 sats 94% RAJVP raised, HS dual + PSMCrackles lower zones

Abdomen –PD cath insituDistended – tender, guardedBS present

Old L) Arm AVF – nil thrill

Peripheral oedema mid shins

BSL 14

‘dry weight 67kg’ – current wt 74 kg

Investigations• FBC – Wbc 14.4 (n-12.4), Hb 96• EUC – K 6.1 , bicarb 15 , urea 75 / Creatinine 1058 • CMP – corr. ca 1.9 / ph 3.1 / mg 0.51• CRP – 276

• TFT – within normal level

• Blood cultures – negative• PD fluid culture - M/c/s

• Gram (-) rods, gram (+) rods

• ECG – rapid AF, ST-segment depressions

Issues on this admissions• Abdominal sepsis

• PD associated Peritonitis - >PD fluid – Pseudomonas Aeruginosa

» IV Timentin IP Cephalothin, Metronidazole» ID advice Ciprofloxacin for 3/52» PD catheter removal

Progress:» PD catheter tip culture – Pseud. Aeruginosa

• Intermediate sensitivity to Ciprofloxacin• Timentin IV

• Fluid Overloaded / “Uremic”– Concern about amount of dialysis she has been doing

Plan?

• Treat infection• Remove PD catheter• Convert to HD– ?now– Wait a bit– ? Put in an access

• Start HD with a temporary catheter

What’s in your Water?• Contaminated by– Particulate matter• Clay,sand,silica,iron

– Chemicals• Inorganic - Na, Cl, Al, Fl, Ca• Organic – fertilizers, pesticides

etc– Micro-organisms• Bacteria/endotoxin• Protozoa,fungi,viruses,spores

Bacterial Contamination – Endotoxin fragments• Febrile reaction, Hypotension, Headache, Nausea• Chronic inflammation

Water treatment

Water standards

Standard Water

• Chemical– Resistivity - >1MOhm/cm

• Microbiology– AAMI - <200CFU/mL– European - <100CFU/mL– Endotoxin <0.1EU/mL

Ultrapure Water

• Chemical– Resistivity > 5MOhm/cm

• Microbiology– <100 CFU/mL– Endotoxin - undetectable

“The Kidney”

Structure of the Dialyzer

Low Flux High Flux

Dialyzers – things to consider• Size – surface area• Material

– Biocompatibility• Complement activation• Activation of clotting cascade• Cellular activation - neutophills/monocytes/Plts

– Protein/cytokine absorption• Efficiency – small solute clearance• Flux – Ultrafiltration capacity

– Low = < 10ml/Hr/mmHg, High = >20ml/Hr/mmHg• Permeability – middle molecule clearance• Clearance - KoA

The Prescription

• Duration• Frequency• Kidney/Dialyzer• Blood flow (pump speed) Qb• Dialysate flow Qd• Ultrafiltration• Anticoagulation• Dialysate composition

Dialysate

The Prescription

• Duration• Frequency• Kidney/Dialyzer• Blood flow (pump

speed) Qb• Dialysate flow Qd• Anticoagulation• Ultrafiltration• Dialysate composition

• 2 hours• Daily• Low Flux, SA 1.3m2

• 150ml/min

• 500ml/min (Concurrent)• Heparin 500/500• 500ml/Hr

Dialysis

• HD commenced– Headaches– Nausea– Confusion– Restlessness

• What's going on?

Altered Mental State

• Disequilibrium• Uremia • Subdural hematoma, • Cerebral infarction or intracerebral haemorrhage, • Cerebral infection - meningitis, encephalitis etc • Metabolic disturbances • Drug-induced encephalopathy• Psychiatric Illness

Dialysis Disequilibrium• Classic Symptoms

– headache, nausea, disorientation, restlessness, blurred vision, and asterixis.

– severe form (rare)- confusion, seizures, coma• Probable milder form (common)

– muscle cramps, anorexia, and dizziness at the end of a dialysis treatment

• Aetiology– Rapid reduction in serum urea creates an osmotic gradient – Promotes intracellular shift of water = cerebral oedema– Paradoxical intracellular acidosis

• Displaced Na/K promote shift of water to intracellular compartment

Dialysis DisequilibriumManagement

• Prevention– “gentle” initiation of dialysis• Small kidney/low flux• Reduce Qb – 150-175ml/min• Reduce duration• Concurrent dialysate flow• Daily dialysis – gradually/steadily reduce Urea

Progress....

• Next few sessions going ok• Starting to feel better– Eating/drinking more– Increasing interdialytic weight gain

• Monday am HD – BP drops to 70/• What now....

Hypotension on Dialysis• Differential

– Excessive UF• Dry weight changed

– Acute medical event• Cardiac/Infection

– Antihypertensive meds– Any other cause of low BP

• Helpful considerations– Relationship to duration of treatment– Recurrent or unusual problem

• Manage the event– Reduce/stop UF/stop treatment– Fluid bolus– Ix appropriately – cultures/ECG– Rx as appropriate

Hypotension on Dialysis• Common problem• Ultra filtration - dependent on

– vascular refilling– CV compensation – Increase HR/PVR

• Multifactorial– Volume removal– Autonomic dysfunction– Underlying cardiac disease– Antihypertensive meds– Diffusion of Na (reduced osmotic pressure)– Thermal energy transfer from dialysate– Biocompatibility

• Acute events– Sepsis/CV etc

Hypotension management• Check the pt/situation – is there an acute event• Manage the event– Reduce/stop UF/stop treatment– Fluid bolus– Ix appropriately – cultures/ECG

• Review dry weight• Review medications• Review UF prescription– >1.5L/hr associated with poor outcomes– Longer hours/more frequent HD

Hypotension - other options• Dialysate– Na– Ca

• Isolated UF – no diffusion of Na• Lower dialysate temp• Play with the newer toys– UF profiling– Na profiling– Blood volume monitoring

Progress

• New dry weight established• Education about fluid intake• Access remains vascular catheter– Recent surgery for access

• Doing reasonably well (misses odd session)– Missed Monday due to recent storms/heavy flooding

• Wed am– Sudden onset central chest pain/SOB

Chest pain on Dialysis• Cardiac Disease

• IHD• Arrhythmia• Pericardial Disease

• Sepsis – (Catheter)• Haemolysis• Dialyzer reaction• Air embolism

• rare in haemodialysis patients, in part because of the presence of air detectors in haemodialysis machines.

• Pulmonary embolism – (recent access sx)

Cardiovascular Disease• Uraemic Heart is venerable

– High prevalence of traditional CV risk factors– LVH + Arteriosclerosis – reduced coronary flow reserve

• How dialysis may influence this– Recurrent hypotension/ischaemia– Arrhythmia – Rapid changes in electrolytes (K, Ca, Mg)

• Long break is bad – Chronic inflammation = enhanced atherosclerosis/sticky endothelium

• Membrane compatibility• Endotoxin/Bacterial fragments leaking into dialysate• Other effects on nutrition

– Myocardial Stunning• Development regional wall motion abnormalities during HD• ? Related to UF rate

Haemolysis

• Mechanical– Tubing/Roller pumps

• Osmotic– Improper proportioning of dialysate

• Water contamination• Chloramines – Oxidation/intravascular haemolysis• Bleach• Copper

Dialyzer Reactions

• Rare now• Reaction to membranes (cellulose) or sterilizing agents• Anaphylactoid type reaction• Complement activation – release of anaphylatoxins (C3a and C5a– formation of the membrane attack complex (C5b-9)– activation of neutrophils and monocytes, – intense vascular smooth muscle contraction, increased

vascular permeability, and the release of histamines from mast cells

Other complications• Bleeding

– Anticoagulation – leak from catheters– Access issues – needle displacement

• Infection– Use of catheters/Grafts– Recurrent cannulation– Uraemic milieu – Contamination of water/equipment

• Dialysate leak– Exposure of blood to non sterile dialysate

• Thrombocytopenia– HITTS– Reaction to dialyzer

• Air Embolism