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If dialysis can only be this easy

If dialysis can only be this easy. Sanela Redzepagic Renal 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

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If dialysis can only be this easy

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  1. If dialysis can only be this easy SanelaRedzepagic Renal Advanced trainee RPAH/ CRGH

  2. 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

  3. Medical history

  4. Medical history

  5. Medical history

  6. 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

  7. Issues on this admissions • Abdominal sepsis • PD associated Peritonitis - >PD fluid – Pseudomonas Aeruginosa • IV Timentin IPCephalothin, 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

  8. Plan? • Treat infection • Remove PD catheter • Convert to HD • ?now • Wait a bit • ? Put in an access • Start HD with a temporary catheter

  9. 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

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

  11. Water treatment

  12. Water standards Standard Water Ultrapure Water Chemical Resistivity > 5MOhm/cm Microbiology <100 CFU/mL Endotoxin - undetectable • Chemical • Resistivity - >1MOhm/cm • Microbiology • AAMI - <200CFU/mL • European - <100CFU/mL • Endotoxin <0.1EU/mL

  13. “The Kidney”

  14. Structure of the Dialyzer Low Flux High Flux

  15. 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

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

  17. Dialysate

  18. 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

  19. Dialysis • HD commenced • Headaches • Nausea • Confusion • Restlessness • What's going on?

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

  21. 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

  22. 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

  23. 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....

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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)

  30. 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

  31. Haemolysis • Mechanical • Tubing/Roller pumps • Osmotic • Improper proportioning of dialysate • Water contamination • Chloramines – Oxidation/intravascular haemolysis • Bleach • Copper

  32. 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

  33. 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

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