what to watch out for to see if need acute/emergency dialysis
- Acid base imbalance
- Electrolyte imbalance
- Intoxication (drug overdose)
- Overload (fluid)
- Uremia
Places for HD access
- AV fistula (best one) –> longest survival, lowest complication but take 2 wweks to set up
- AV graft –> synthetic graft
- Venous catheter –> for AKI and emergenct/ short term access, highest risk of complications (cleaning and care is required)
Goals of hemodialysis
- removal of waste
SE of HD
- Hypotension
- N/V, headache
- Pruritis
- Fever / chills (infection!!)
- cramps
- loss of conciousness
causes of hypotension in HD
- hypovolemia (lack of fluids)
- excessive ultrafiltration
- anti HTN meds
- target dry weight is too low
- Diastolic , autonomic dysfunction
- Low Na and Ca in dialysate
- Meal (blood flow to gut)
Management of intradialytic hypotension
- administer fluids for hypovolemia
- turn off ultrafiltration
- decrease temp to 35 -36 to cause vasoconstriction
- put in trendelburg position
- reduce vasodilation: use bicarbonate buffered dialysate, use midocrine (alpha 1 agonist)
administer O2 if pt has anemia
Causes of cramps due to HD
- IDH and muscle hypoperfusion
- electrolyte/acid base imbalance
Management of cramps
- correct volume contraction/electrolyte imbalance
- massage
- vit E
- muscle relaxants
Management of catheter related thrombosis (CRT) in HD
- forced saline flush
- catheter removal / exchange over guide wire
- Pharmacological (Intraluminal thrombolytics): Alteplase (r-tPA), Urokinase, Reteplase
- Risk in decreasing order: Catheters > grafts > fistulas
- Intrinsic (inside lumen) VS extrinsic (outside lumen)
Presentation of Catheter-related blood stream infection (CRBSI) in HD
- Fever, chills, rigors, elevated WBC count
risk factors for bacteremia from CRBSI
- DM
- immunosuppressed
- history of catheter infections
- S.aureus in nasal carriage
How to treat catheter-related bacteremia
- empiric therapy
- take a culture
- streamline therapy –>ABx for min 3 weeks
- if >36h/unstable: remove catheter
Do not place permanent access until blood cultures (performed after stopping Abx) have been -ve for 48h
What antibiotics are used in CRBSI
what bacteria use what antibiotic
- MSSA (methicillin-susceptible S. aureus) –> cefazolin
- MRSA (methicillin-resistant S.aureus) –> vancomycin. Can be used when pt has past history of catheter infections
- Gram -ve : gentamicin (nephrotoxic but pt id on HD so issok) or ceftazidime (3rd gen cephalosporin)
vancomycin for MRSA: can be used when pt has past history of catheter infections
Whats Abx lock therapty
and function and how to do it
- function: to salvage catheter
- instil catheter lumen with Abx solution at the end of dialysis
- Solution is withdrawn before next HD and this process is repeated after every HD.
- Abx solution usually mixed with heparin or NS to fill catheter lumen (2-5ml)
- Usually used in combi with systemic Abx for 7-14 days
How to manage HTN in HD
- Between dialysis session, excess fluid accumulation , fluid restriction (800ml), Na restriction.
- increase dialysis ultrafiltration/ length / frequency
- ACE/ARB, DHP CCB can be restarted
- Anti HTN drugs taken at night to reduce nocturnal surge of BP and minimise IDH.
- Some drugs are not dialysed out so consider dose adjustment
- can take anti htn med on non dialysis days to prevent hypotension
- Diuretics only if they have sufficient urine output (~250ml)
who are PD suitable for:
- hemodynamically unstable. These pts have lower BP or weaker cardiac function who cannot tolerate HD
- with significant residual kidney function
- ambulant and disciplined to self care, practise proper hygiene
- must not have major abdominal surgeries in the past
Complications of PD
- Kinking of cathter
- inflow/outflow obstruction
- impacted stools
- Peritonitis (infection!!)
- Fluid overload
- electrolyte abnormalities (esp hypokalemia)
- Malnutrition
- ## High glucose load
Hypokaelmia: PD dialysate no K, PD is done multiple times a day, dextrose can stimulate insulin pdtn –> K shift from ECF to ICF
Clinical presentation of Peritonitis
and lab abnormalities
- Elevated dialysate WBC >100/mm3 + >50% neutrophils
- Abdominal pain, cloudy effluent, fever, N/V, chills
- Gram +ve due to involvement of skin. However, sterile culture peritonitis can occur
- Can be gram -ve since peritoneum is near the GIT which is full of gram -ve bacteria
How to prevent Peritonitis
- Systemic prophylactic Abx given immediately before catheter placement: cefazolin, vancomycin, gentamicin.
- Use antifungal prophylaxis during Abx therapy (Nystatin PO 500,000 units QDS or Fluconazole 200mg q48h)
- Avoid/treat hypokalemia
- Avoid/limit use of H2RAs -> GIT decreased ability to kill bacteria
- Avoid/treat GI problems e.g. constipation
How to treat Peritonitis
- IP Abx
- Empiric therapy: Cefazolin, vancomycin, gentamicin, ceftazidime (gram -ve), cefepime (!! 4th gen cephalosporin is both gram +&-)
- IP AG -> intermittent dose recommended to avoid risk of ototoxicity
- Donot put AG and penicillin in the same bag
- If no improvement in 5 days remove catheter, initiate HD, IV ABx for 2 weeks
allow Abx to dwell for at least 6h
How to treat fungal peritonitis
- Remove catheter immediately
- Treatment: azoles (fluconazole), echinocandins (caspofungin), amphotericin B
Catheter related infection (CRI) in PD
types, causes, risk factors
- exit-site and tunnel infection
- mostly caused by S. aureus
- risk: DM, immunosuppress, nasal carriers of S. aureus
- Frequency of exit site infection ~every 24-48 months
Clinical presentation of CRI in PD
Purulent discharge (most likely exit site), erythema (at exit site), fever, chills
Prevention and treatment of CRI in PD
- Prophylactic Abx (e.g. nasal Abx for nasal carriers of S.aureus) before catheter insertion
- Leave exit site dressing intact for 7 days after catheter insertion
- Train and educate pts and caregivers on care of exit site
- treatment: oral Abx
