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Dialysis in ESRD
Velma Herwanto
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ESRD Treatment Options
Hemodialysis
Peritoneal dialysis:
less efficient in soluteclearance
Transplantation
Outcomes aresimilar
preference andquality-of-lifeconsideration
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Epidemiology
Mortality rate on dialysis in US: 1820%/year, 5-year survival rate 3035%
Deaths are due mainly to cardiovascular
diseases (50%) and infections (15%)
Important predictors of death: age >, male,nonblack race, DM, malnutrition, underlyingheart disease
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Initiation on Maintenance Dialysis
Uremic symptoms: encephalopathy, neuropathy,pericarditis, pleuritis
Persistent ECV expansion despite diuretic therapy
Bleeding diathesis
Hypertension poorly responsive to antihypertensivemedications
Persistent metabolic disturbances that are refractory tomedical therapy
Persistent nausea and vomiting
Evidence of malnutrition
CrCl or eGFR < 10 mL/min/ 1.73 m2
Do not delay the initiation of dialysisuntil one of this is present!
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Relative Indications to InitiateDialysis
Decreased attentivenessand cognitive tasking
Depression Persistent pruritus
Restless leg syndrome
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hemodialysis
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Hemodialysis
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Scheme for Hemodialysis
Extracorporeal circuit indialysis machine
Dialysis access
Blood pump: 250-500 mL/min,negative hydrostatis pressure ultrafiltration
Dialysis solution delivery system
Safety monitor
DIALYZER
Bundles of capillarytube: 1,5-2 m2
Cellulose vs.synthetic
Reprocessed and
reused
DIALYSATEK+ 0-4 mmol/LCa2+ 1.25 mmol/L: modification in hypocalcemiaNa+ 140 mmol/L lower hypotension,cramping, nausea, vomiting, fatigue, dizziness
Water 120 L: reverse osmosis
BLOOD DELIVERY
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Hemodialysis Membrane
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Chronic Dialysis Access
Fistula, graft, or tunneled catheter
AV fistula:
Brescia-Cimino fistula: radiocephalic/ brachiocephalic/brachiobasiclic arterialization of the vein
The highest long-term patency rate and lower complication
Synthetic graft: PTFE straight/ looped forearm,straight/ looped upper arm
Smaller-caliber veins/ veins have been damaged
Complication: thrombosis, infection, steal, aneurysms,venous hypertension, seromas, heart failure, and localbleeding
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Chronic Dialysis Access
Dual-lumen tunneled catheter
Indication:
To allow maturation of fistulas/ grafts
CVC(require HD
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Chronic Dialysis Access
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Dialysis in Series
CVC: Entire systemic compartment is available forurea extraction urea removal would be maximized
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Dialysis in Parallel
AV access: reduce extraction of urea < theoreticalclearance urea removal is limited (the capillaries where
this blood refills with urea)
- 60-70%
- 5-15%
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Goals of Dialysis
Removing both low- and high-molecular-weight solutes
Heparinized blood300-500mL/min
Dialysate500-800mL/min
Efficiency of dialysis
blood and dialysate flowand dialyzer characteristics
Adequacy of dialysis:fractional removal of urea
nitrogen and derivationsthereof
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The effect of increasing dialyzer blood flow (Qb) ontotal body urea clearance (Ktb) during HD
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Movement of Waste Product
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Dialytic Clearance of Solute
Diffusion Ultrafiltration
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Convective Clearance
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Membrane:Flux, Permeability, and Efficiency
Komass transfer coefficient; Asurface area
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Dialysis Prescription (KDOQI 2006)
Urea removal normalized for a measure ofbody size
Kt/V
K = dialyzer urea clearance data dialysismembrane size, Qb, Qd
t = duration of dialysis in minutes modifiable!
V = patient's urea space
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Adequacy of HD (KDOQI 2006)
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Delivering Adequate Dose ofDialysis
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Urea Equilibration in HD
Degree of urea removal rateof urea equilibration between
IC and the ECSlow equilibrators lower BUN but a slower rate of total
urea removal
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Organ Reservoirs of Urea
Low ratio of blood flow to urea content sequester upto 80% of the total body urea rebound and
dialysis efficiency
15-20% CO
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HD Increase in... (KDOQI 2006)
Minimally adequate dose
, any body size
Smaller patients
BW 20% less or fluid is removed at the beginning)
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Complication During HD
Muscle cramp:
Excessively aggressive volume removal (>dry weight)
Use of low-sodiumcontaining dialysate
Management:
volume removal
UF profiling
Higher concentrations of sodium in thedialysate or sodium modeling
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Sodium Modelling
Intracellularmovement of water
+UF of water hypotension
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Complication During HD
Anaphylactoid reaction to dialyzer
Type A: IgE-mediated hypersensitivityreaction to ethylene oxide within the
first few minutes steroids orepinephrine
Type B: nonspecific chest and back pain,
from complement activation andcytokine release several minutes,resolve over time
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Dialysis Disequilibrium Syndrome
Central nervous system disorder in dialysis patients
Pathophysiology: cerebral edema
Reverse osmotic shift
Fall in cerebral intracellular pH
At risk: new HD patients (with >> BUN), severe metabolicacidosis, older age, pediatric, presence of CNS disease
Headache, nausea, disorientation, restlessness, blurred vision,asterixis, muscle cramps, anorexia, dizziness
More severe: confusion, seizures, coma, death
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DDS: Treatment and Prevention
Qb, consider stop the dialysis session
Hypertonic mannitol or 23% saline
Prevention: slow urea removal
Initial HD: 2 hours, Qb 150-250 mL/min, small surfacearea dialyzer, concurrent blood and dialysate flow 3-4days 50 mL/min (up to 300-400 mL/min),duration 30 minute
Marked fluid overload: UF followed by a short period ofHD
PD
Prophylactic phenytoin and/ or mannitol
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Peritoneal Dialysis
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Normal Anatomy
Peritoneal contains 100 ml fluid
Adult can tolerate > 2 L fluid withoutpain or alteration to the respiratory
function : peritoneal cavity is closed
: peritoneal cavity is continuous
with the Fallopian tubes
PD fluidbecome blood-stained during amenstrual period
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Principles of Peritoneal Dialysis
Jeremy Levy et al, Oxford Handbook of Dialysis, 2003
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Solute and Water Transport Mechanism in PD
Diffusion Solute(e.g. Ur,Cr, K)
Via mid-size pores Most important
High concentration (blood) low concentration(dialysate)
to the concentration gradient
Best for clearance of small molecules
Convection Solute(e.g.protein,Na)
In response to a positive transmembrane pressure
Less dependent on molecular size
Ultrafiltratio
n
Water Low osmotic concentration (blood) high osmotic
concentration (dialysate), via aquaporin-1 Highest at the beginning, ceases when osmolarity hasdecreased to equal serum osmolarity
Reabsorbtion of water if dialysate is allowed to dwellbeyond the time past when osmotic equilibrium isreached
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Access to Peritoneal Cavity
Peritoneal catheter: silicon rubberwith numerous side holes at thedistal end
Dacron cuffs: promote fibroblastproliferation, granulation, andinvasion of the cuff
Seal from bacteria from the skin surface
Prevents external leakage of fluid
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Types of PD Catheter
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PD Solutions
Ideal osmotic agents:
Metabolized easily with non-toxic degradation products
Poorly absorbed
Inert and non-toxic to the peritoneal membrane Inexpensive
Effective osmotic agent at low concentration
No metabolic consequences of absorption
Must be of nutritional value
Not difficult to manufacture
Should not inhibit peritoneal defenses
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PD Solutions
High molecular weight Glucose polymer (icodextran 7.5%): Polypeptides (5%): Glucose-containing (dextrose monohydrate 1.5, 2.5, 4.25%): Amino acid (1.1%): Glycerol:Low molecular weight Glucose polymer (icodextran 7.5%): Polypeptides (5%): Glucose-containing (dextrose monohydrate 1.5, 2.5, 4.25%): Amino acid (1.1%): Glycerol:
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PD Solutions
Solutions: 1.5 to 6.0 L
Lactate is the preferred buffer, other:acetate, bicarbonate
Electrolyte: Na, Ca, Mg, K
Additives: heparin, antibiotics, insulin
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CAPD3-5x/ day
CCPD
DAPD
NIPD
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Adequacy of PD: K/ DOQI 2006
T Peritoneal
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Calculation of Solute Clearance
, 70 kg on CAPD has a drain volumeof 10.5 L/day, and D/P urea of 0.95
Kt = 10.5 x 0.95 = 10 L
The urea volume of distribution (V) =42 L (60% of lean body weight inmen, 55% in women)
Daily Kt/Vurea = 10 42 = 0.24
Weekly Kt/Vurea = 0.24 x 7 = 1.68
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Adequacy of PD
Efficiency of solute clearance volume of dialysate (> volumes > solute clearance), physical activity
Peritoneal equilibrium test: measures the transfer rates ofcreatinine and glucose across the peritoneal membrane
Low transporter: fewer exchanges
Lowaverage transporter
Highaverage transporter
High transporters: absorb > glucose, lose efficiency of UF with longdaytime dwells, lose > albumin require more frequent, shorter dwell
time exchanges
PET: 3-4 weeks after catheter insertion and on complication
U i T t T t
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Using Transport Type toSelect PD Regimen
High
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Indication to Repeat PeritonealMembrane Transport Testing
KDOQI 2006
Unexplained volume overload
Decreasing drain volume on: overnight dwell (CAPD)
or daytime dwell (APD)Increasing clinical need for hypertonic dialysatedwells to maintain DV
Worsening of HTN
Change in measured peritoneal solute removal(Kt/Vurea)
Unexplained signs/ symptoms of uremia
PD P i ti T t d
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PD Prescription Target andMeasurement (KDOQI 2006)
If a patient is not thriving + no otheridentifiable cause, consider to
increase dialysis dose.
Patient with minimal RKF
continuous 24 h/day of PD dwell tomaximize middle molecule clearance
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Fluid Balance
The 2006 NKF-KDOQI guidelines: oneshould achieve euvolemia andoptimal BP control
Maintenance of euvolemia: PD drainvolume, RKF, blood pressure
The 2005 European Best PracticesGuidelines: in anuric patients,minimum UF target is 1.0 L/day
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Complications During PD
Peritonitis: peritoneal fluid leukocytes 100/mm3 (at least50% are PMN) pain, cloudy dialysate, fever
Gram-positive cocci, gram-negative rod, fungal, mycobacterial
Intraperitoneal/ oral antibiotics
Due to hydrophilic gram negative rods (e.g.,Pseudomonas
sp.) oryeast: require catheter removal
Catheter-associated nonperitonitis infections
Weight gain
Hypoproteinemia: dietary protein intake
Hyperglycemia
Hypertriglyceridemia
Residual uremia (esp. in patients with no residual kidneyfunction)
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Terima Kasih