1. Chronic Kidney Disease and Dialysis Patient Care – What the Generalist Should Know Stephen R. Ash, MD, FACP Clarian Arnett Health Director of Dialysis, Wellbound Director of R&D Ash Access Technology and HemoCleanse, Inc. Lafayette, IN Nephrology Topic Review Clarian Arnett Hospital Lafayette Medical Education Foundation January 18, 2011

2. Role of Primary Physicians in Treatment of CKD Patients and Preparing for Dialysis Identify patients with CKD Identify causes of kidney disease (diabetes, hypertension, obstruction, hyperuricemia, infections, obstruction, medications) Treat the primary disease and prolong renal function, for example using ACE/ARB in diabetics with CKD Refer to Nephrology at CKD Stage 3 (GFR=30-60 ml/min/1.73M2) Observe for signs of uremia Help to determine with patient, family and Nephrologist whether dialysis is indicated Preserve arm veins for hemodialysis access Expect and support access procedures at stage 4-5 (GFR<20 ml/min/1.73M 2 ) Avoid damage to fistula or graft in arm Monitor graft and fistula function, report abnormalities

10. 1. Dialysis Options and How They Work Peritoneal dialysis Hemodialysis CVVHD NxStage Home Dialysis Therapy

11. Dialysis=Diffusion

13. Nighttime cyclers decrease the number of daytime exchanges needed.

15. The Hemodialysis Blood Side System

16. Fresenius K-Machine

18. NxStage Therapy System

19. 2. Symptoms of Renal Failure (Uremia) Gastritis: nausea, vomiting, gastritis, anorexia Fluid Overload, CHF: shortness of breath, orthopnea Encephalopathy: confusion, sleepiness, coma Neuropathy: itching, weakness Pericarditis: chest pain, shortness of breath

20. 3. Physical Signs of Renal Failure Vomiting Edema CHF, Rales Confusion, Coma Bleeding Decreased urine output (sometimes) Hypertension Diminished inflammatory response and signs of infection

21. 4. Laboratory Values in Renal Failure Creatinine elevation (normal is 0.6-1.4) GFR decrease by MDRD or CG (normal for 70 year old of 70 kg is 70) BUN increase (normal up to 22) Phos increase (normal up to 4.5) Potassium increase (normal up to 5.5) Hemoglobin decrease (normal lower limit 13) Bicarbonate decrease (normal lower limit 24) Hundreds of other chemical and hormonal changes

22. 5. Medical Therapy of Chronic Renal Failure Potassium (bicarbonate, glucose & insulin, saline, β-agonists, Kayexelate, calcium, stop various meds) Phosphorus (calcium acetate, calcium carbonate, Renvela, Fosrenol) Urea (diet restriction, exclude GI bleed) Optimize GFR (fluid load, fluid decrease, improve blood pressure, stop various meds) Avoid nephrotoxic meds (nsaids, ACE, iodinated contrast agents) Avoid or adjust other toxic meds (MRA contrast, Reglan, Digoxin, Amiodarone, Lovenox, etc).

23. 6. When do we start dialysis in CKD? Which Type? Clearance –GFR < 15 ml/min for non-diabetics (MDRD) –GFR < 25 ml/min for diabetics –Downward trend in GFR –Upward trend in uremic toxins Symptoms Quality and length of expected life Home patient potential: good patient historically, family support and partner, mobility, interest and capability –PD, especially for heart failure, diabetes, provides several years of support –Short daily Hemo: capability and interest –Overnight Hemo 8 hours every other night also possible In-center patient potential –Must tolerate surgery or procedures for vascular access device –Must tolerate rapid fluid shifts and heart strain –Must cooperate with medical regimen –Transportation must be available for three treatments per week

24. Stages of Chronic Kidney Disease StageDescriptioneGFR (ml/min/1.73m 2 ) I“Normal” Renal function>90 II“Mild” Renal Dysfunction60-89 III“Moderate” Renal Dysfunction30-59 IV“Severe” Renal Dysfunction15-29 V“End-Stage” Renal Disease<15

25. 7. Requirements for Hemodialysis Access Blood flow rate of 400 ml/min for 4 hours treatment, without blockage Blood flow rate in vicinity of access (like catheter or needle) must be at least 800 ml/min Minimal infection risk Low risk of bleeding No tubes through the skin if possible Longevity in years, not months

26. Types of Hemodialysis Access AV Fistula AV Graft Tunneled Internal Jugular dialysis Catheter

27. Scribner Shunt-1960

28. Short History of Hemodialysis Access after Scribner Shunt:

29. AV Fistula

30. Original Cimino-Brescia Fistula; side-by-side

32. Other types of fistulas

33. Finding Veins-Sometimes Easy, Sometimes Hard

34. Vein Mapping to Find Suitable Veins and Arteries

38. Fistula Problems-Stenosis Note enlargement of radial artery-to provide a liter per minute blood flow

39. Signs of Venous Stenosis in Vascular Access

40. Physical Exam..Detects Inflow Problems and Outflow Problems

41. Aneurysms are Weakened Areas, not Able to Receive More Needlesticks

42. But, 30-50% of fistulas don’t work in the first place….

43. AV Grafts

44. ArterioVenous Grafts Can Teflon be a Blood Vessel?

45. Grafts Become Covered by Body Tissues, Sometimes Too Much Tissue

46. And Stenosis Near the Connection of the Graft and Vein

47. Infection is Rare, Redness is Common

48. Pseudoaneurysms are Near Blowouts

50. Tunneled Permanent Central Venous Catheters for Dialysis The Third Choice

51. But as CMS Reports: We have a Continuing Dependence on CVCs…

52. BFRs w/ Vascular Accesses

53. Tips are at the entry to the heart Dacron Cuff is under the skin

54.  Wardrobe Requirements Natalie Cole, 2009

55. Did you notice this first?

56. Exact placement is sometimes difficult…

57. Vein entry is with Ultrasound

58. Problems Include Clotting

59. And Fibrous Sheathing

60. Catheter Sheaths develop at point of contact to vein or atrial wall…

61. Fibro-Epithelial (Fibrin) Sheath RA Fibro- Epithelial Sheath SVC L IJ CVC Courtesy, Arif Asif

62. KDOQI 2007 Risky! Exchange? Balloon sheath? Brush? 30 minutes? Overnight?

63. Can catheter outcomes be improved? For sheathing, new catheter designs might help… Centros Tips form a flat plane; ports are held in middle of vein

64. Centros TM : Preferred Placement in SVC art ven art The catheter tips are positioned in the lower third of the SVC rather than in the atrium…

65. Centros™: A Self Centering Catheter Pacemaker leads tip The ports are held in the middle of the SVC and away from the vein wall. These CT’s were performed after 4 months of catheter use.

66. Centros TM : Preliminary Study Results Flow rate of the Centros TM Catheters was 400 ml/min, constant over time (7 weeks) and higher than with current Dual Lumen tunneled dialysis catheters.

67. Infection in Tunneled CVC for Dialysis Incidence of 1-5/1000 patient days, or 3-15% of patients per month (higher in non-tunneled catheters) Serious consequences, systemic and metastatic infections Highly costly Requires long-term systemic antibiotics and usually antibacterial catheter lock to resolve For Staph Aureus or Pseudomonas organisms catheter must be removed/replaced Prophylactic antibiotic or antiseptic locks can diminish incidence but have their own problems