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Renal Replacement Therapy Optimal Pre-ESRD Management 1. Preventing or slowing progression 2. Preventing complications of uremia such as anemia, ROD & malnutrition 3. Preparing the patient for the RRT 4. Planning for the creation of a permanent access for hemodialysis 5. Planning for hemodialysis initiation before major symptoms of uremia arise Renal Replacement Therapy Dialysis Hemodialysis In-center Home Peritoneal dialysis IPD CAPD Cycler dialysis Transplantation History Dialysis is a Greek word meaning "loosening from something else". Dialysis is referred to as "selective diffusion." Diffusion is the movement of material from higher concentration to lower concentration through a given membrane Thomas Graham, Chairman of Chemistry at University College, London, first discovered this idea of selective diffusion Dialysate A chemical bath used in dialysis to draw fluids and toxins out of the bloodstream and supply electrolytes and other chemicals to the bloodstream. Composition of HD concentrate solute Acetate dialysis Bicarbonate dialysis Na (mEq/L) K (mEq/L) Chloride (mEq/L) Mg (mEq/L) Acetate (mEq/L) Bicarbonate (mEq/L) Glucose (g/dL) 130-145 0-4.0 96-111.5 0-4.0 33-42 0 0-0.25 137-143 0-4.0 100-111 0-2.5 2-4.5 30-35 0-0.25 10 AVF Creation in CRF Cr clearance < 25 ml/min Serum Cr > 4 mg/dl Within 1 year of the anticipated need for maintenance dialysis therapy 12 13 14 Starting HD IN CRF HD should be initiated at a level of residual renal function above which the major symptoms of uremia usually supervene: 9 < Cr cl < 14 ml/min It may be necessary to initiate patients even earlier in their course if they have otherwise uncorrectable symptoms or signs of renal failure Hemodialysis Treatment Progress in Therapy and Technology Increases Quality of Life for the Patients 16 Hemodialysis Treatment by Fresenius Medical Care 18 Initiation of dialysis in patients with ARF 1. Refractory fluid overload 2. Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels 3. Metabolic acidosis (pH < 7.1) 4. Azotemia (BUN > 80 to 100 mg/ dl) Initiation of dialysis in patients with ARF 5. Signs of uremia, such as pericarditis, or an otherwise unexplained decline in mental status 6. Severe dysnatremias (155 < Na < 120 meq/L) 7. Hyperthermia 8. Overdose with a dialyzable drug/toxin Indications For Heparin-Free dialysis Pericaditis Recent surgery, with bleeding complications or risk. Especially: Vascular & cardiac surgery (within 7 days) Eye surgery (retinal & cataract) Renal transplant Brain surgery (within 14 days) Indications For Heparin-Free dialysis Coagulopathy Thrombocytopenia ICH Active bleeding Routine use for dialysis of acutely ill patients by many centers In Hospital Management of Patients with CRF & ESRF 1. Diet regimen 2. Prevention of ARF 3. Restriction of blood sampling 4. Restriction of blood transfusion 5. Treatment of uremic bleeding defects 6. Dose adjustments of drugs 7. Pre-operation dialysis Risk Factors of ARF 1. 2. 3. 4. 5. Renal Hypoperfusion Preexisting Azotemia Sepsis Nephrotoxins Electrolyte Disorders Treatment of uremic bleeding defects Dialysis DDAVP 0.3 μg/kg IV 3 μg/kg IN Cryoprecipitate RBC Transfusion Conjugated estrogens FFP Drug Doses in Renal Failure Drug Acetamin ophen Amikacin Dose GFR method >50 I D,I GFR Suppl GFR 10after CAPD CRRT <10 50 HD q4h q6h q8h None 60 90% q12h 30 70% q1218h Dose for None GFR 10-50 Dose 20 for 2/3 15-20 30% normal mg/l/ GFR q2410-50 dose d 48h 26 Renal Transplantation Cadaveric Donor Living Donor Non related Related Spouse 28 29 30 Exclusionary Conditions for Renal Transplantation Patient will not live more than 1 year Metastatic malignancy, not responsive to therapy Acute or chronic infections that are not controlled Severe psychiatric disease that impairs patient's consent & compliance Medical incompliance Substance abuse Immunologic incompatibilities Criteria That Exclude a live Donor Age < 18 Severe HTN DM Hx of nephrolithiasis Impaired renal function Morbid obesity Strong family history of DM FHx of hereditary nephritis or polycystic kidney disease 9. Hypercoagulability 10. HIV, HB, HC infection 11. Uncontrolled psychiatric disorders 1. 2. 3. 4. 5. 6. 7. 8. Drugs Used in Maintenance Immunosuppression Calcineurin Inhibitors Cyclosporine Tacrolimus Azathioprine Mycophenolate Mofetil Glucocorticoids In Hospital Management of Renal Transplant Patients 1. Diet regimen 2. Prevention of ARF 3. Restriction of blood sampling 4. Restriction of blood transfusion 5. Drugs interactions 6. Secondary adrenal insufficiency 7. Prevention of infection 8. Transplant drugs usage HD in ARF CAN DIALYSIS DELAY RECOVERY OF RENAL FUNCTION? There is at least theoretical concern that dialysis might have detrimental effects on renal function. Three factors may be important in this regard: a reduction in urine output induction of hypotension complement activation resulting from a blood-dialysis membrane interaction. Dry Weight The lowest weight a patient can tolerate without the development of signs or symptoms of intravascular hypovolemia. Dry Weight Estimating dry Weight: Liters of actual body water = 142 × liters of NTBW Predialysis serum Na = 142 × (60% × 60) = 38.72 132 38.72 – 36 = 2.72 lit NTBW= Normal Total Body Water