1. Progression of Chronic Kidney Disease
Preparation
Options
Complications

2. Preparation of the Patient
Manage CRF
Control BP
Control glucose
stop oral agents!
Prevent Hyper PTH
Vit D
Calcium acetate
Phosphate binder
Diet Education

3. Preparation of the Patient
Manage Fluids
Dialysis education
Access Placement
Prevent anemia
Prevent Malnutrition
metolazone
NKF program
AV fistula, PD cath
Epogen, Iron
This can get tricky

4. Progression of CRF

5. Transition to End Stage Effect of MalnutritionWt
Measured Wt
= 85 Kg
GFR

6. Indications for Dialysis
A acidosis
E electrolyte abnormalities
I intoxication/poisoning
O fluid overload
U uremia symptoms/complications

7. Dialysis for Intoxications
T theophylline
A aspirin
B barbiturates
L lithium
E ethylene glycol, methanol

8. Relative Contraindications
Alzheimer’s disease
Multi-infarct Dementia
Hepatorenal syndrome
Advanced cirrhosis with encephalopathy
Advanced malignancy
HIV with dementia

9. Types of Renal Replacement
Acute RRT:
Standard Hemodialysis
Redy 2000
Acute Peritoneal Dialysis
CAVHD
CVVHD
Hemoperfusion

10. Acute RRT choices Volume Status Hemodynamic status Access Bleeding
Poisoning
CAVHD?
Tolerate Hemo?
Abdominal surgery?
Anticoagulation?
How catabolic is pt
Hemoperfusion?

11. Renal Replacement Therapy
Chronic RRT
Standard Hemodialysis
Peritoneal Dialysis
Continuous vs Intermittent
Ambulatory vs Cyclic
Cycler Plus*
Combinations

12. The Mystery of Dialysis
Its no mystery!
Clearance
simple diffusion
Ultrafiltration
dialysate pump
Monitors to make sure nothing bad happens
blood in
dialysate plus
Ultrafiltrate out
dialysate in
blood out

13. Hemodialysis Advantages standard treatment widely used Pt has days off
Good reimbursement for Nephrologist
We have control

14. Cuffed
Tunnelled
Hemodialysis
Catheters.
Picture of catheters

15. Tesio catheter

16. Hemodialysis Disadvantages Pt has no control strict attn to diet
travel restricted
need for vascular access
Specific risks
Inadequate clearance

17. Peritoneal Dialysis Clearance Ultrafiltration
How much fluid the patient puts in
Ultrafiltration
How much fluid comes out
Dextrose used as osmotic agent

18. PD Cath

19. Peritoneal Dialysis Advantages continuous middle molecules
pt has control
vary tx with diet
adjust to lifestyle
no need for vascular access
no need for anticoag.

20. Peritoneal Dialysis Disadvantages Abdominal surgery limited clearance
limited Uf
Needs motivated, compliant pt
risk of peritonitis

21. RRT Choices Renal Transplant should be goal
Peritoneal Dialysis for the right pt
Hemodialysis for everyone else

22. Dialysis Chronic Complications
Not seen until after chronic access possible
1967 Alfree reported dialysis dementia
Due to impurities in water (100L/tx)

23. Dialysis Complications
Bleeding disorders
Anemia
Bone disorders
Arthritis
Neuropathy
Cardiovascular

24. Dialysis Complications Bleeding disorder
Due to platelet dysfunction Prolonged bleeding time
Treatment: - more dialysis - dDAVP 0.3 microgm/Kg - Estrogen

25. Dialysis Complications Anemia
Due to reduced Erythropoietin - blood loss, reduced response
Treatment: - more dialysis - rHuEPO 2,000 units/tx - Androgens

26. Dialysis Complications Arthritis
Due to accumulation of - Beta-2-microglobulin
Treatment: - more dialysis - Biocompatable membranes - Joint replacement (Hips)

27. Dialysis Complications Neuropathy
Manifestations: - Peripheral Neuropathy - Autonomic dysfunction - Dementia - Dysequilibrium syndrome
Treatment - More dialysis - gradual start of tx - remove water impurities - prevention is best.

28. Dialysis Complications Cardiovascular
Manifestations: - Accelerated atherogenesis - Lipid abnormalities - Associated disorders (DM etc) - Leading cause of mortality
Treatment - More dialysis - Treatment of lipid disorders - Control of HTN - Carnitine?

29. Adequacy of Dialysis Markers NCDS mortality hospitalization nutrition
Gotch and Sargent
KT/V = clearance
NPCR = nutrition

30. Summary Incidence of ESRD Progression of CRF
Indications and contraindications
Choices of RRT
Complications of CRF, dialysis
Adequacy