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Progression of Chronic Kidney Disease

Progression of Chronic Kidney Disease. Preparation Options Complications. Manage CRF. Control BP Control glucose stop oral agents! Prevent Hyper PTH Vit D Calcium acetate Phosphate binder Diet Education. Preparation of the Patient. Manage Fluids Dialysis education Access Placement

jedidiah-braylon
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Progression of Chronic Kidney Disease

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  1. Progression of Chronic Kidney Disease Preparation Options Complications

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

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

  4. Progression of CRF

  5. Transition to End StageEffect of Malnutrition Wt 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. Volume Status Hemodynamic status Access Bleeding Poisoning CAVHD? Tolerate Hemo? Abdominal surgery? Anticoagulation? How catabolic is pt Hemoperfusion? Acute RRT choices

  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.

  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 • How much fluid the patient puts in • Ultrafiltration • How much fluid comes out • Dextrose used as osmotic agent

  18. 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.

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

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

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

  22. DialysisComplications • Bleeding disorders • Anemia • Bone disorders • Arthritis • Neuropathy • Cardiovascular

  23. Dialysis ComplicationsBleeding disorder • Due to platelet dysfunction Prolonged bleeding time • Treatment: - more dialysis - dDAVP 0.3 microgm/Kg - Estrogen

  24. Dialysis ComplicationsAnemia • Due to reduced Erythropoietin - blood loss, reduced response • Treatment: - more dialysis - rHuEPO 2,000 units/tx - Androgens

  25. Dialysis ComplicationsArthritis • Due to accumulation of - Beta-2-microglobulin • Treatment: - more dialysis - Biocompatable membranes - Joint replacement (Hips)

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

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

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

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

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