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Chronic Kidney Disease and Dialysis Patient Care – What the Generalist Should Know. Nephrology Topic Review Clarian Arnett Hospital Lafayette Medical Education Foundation January 18, 2011. Stephen R. Ash, MD, FACP Clarian Arnett Health Director of Dialysis, Wellbound Director of R&D

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chronic kidney disease and dialysis patient care what the generalist should know

Chronic Kidney Disease and Dialysis Patient Care – What the Generalist Should Know

Nephrology Topic Review

Clarian Arnett Hospital

Lafayette Medical Education Foundation

January 18, 2011

Stephen R. Ash, MD, FACP

Clarian Arnett Health

Director of Dialysis, Wellbound

Director of R&D

Ash Access Technology and HemoCleanse, Inc.

Lafayette, IN

role of primary physicians in treatment of ckd patients and preparing for dialysis
Role of Primary Physicians in Treatment of CKD Patients and Preparing for Dialysis
  • Identify patients with CKD
  • Identify causes of kidney disease (diabetes, hypertension, obstruction, hyperuricemia, infections, obstruction, medications)
  • Treat the primary disease and prolong renal function, for example using ACE/ARB in diabetics with CKD
  • Refer to Nephrology at CKD Stage 3 (GFR=30-60 ml/min/1.73M2)
  • Observe for signs of uremia
  • Help to determine with patient, family and Nephrologist whether dialysis is indicated
  • Preserve arm veins for hemodialysis access
  • Expect and support access procedures at stage 4-5 (GFR<20 ml/min/1.73M2)
  • Avoid damage to fistula or graft in arm
  • Monitor graft and fistula function, report abnormalities
1 dialysis options and how they work
1. Dialysis Options and How They Work
  • Peritoneal dialysis
  • Hemodialysis
  • CVVHD
  • NxStage Home Dialysis Therapy
2 symptoms of renal failure uremia
2. Symptoms of Renal Failure (Uremia)
  • Gastritis: nausea, vomiting, gastritis, anorexia
  • Fluid Overload, CHF: shortness of breath, orthopnea
  • Encephalopathy: confusion, sleepiness, coma
  • Neuropathy: itching, weakness
  • Pericarditis: chest pain, shortness of breath
3 physical signs of renal failure
3. Physical Signs of Renal Failure
  • Vomiting
  • Edema
  • CHF, Rales
  • Confusion, Coma
  • Bleeding
  • Decreased urine output (sometimes)
  • Hypertension
  • Diminished inflammatory response and signs of infection
4 laboratory values in renal failure
4. Laboratory Values in Renal Failure
  • Creatinine elevation (normal is 0.6-1.4)
  • GFR decrease by MDRD or CG (normal for 70 year old of 70 kg is 70)
  • BUN increase (normal up to 22)
  • Phos increase (normal up to 4.5)
  • Potassium increase (normal up to 5.5)
  • Hemoglobin decrease (normal lower limit 13)
  • Bicarbonate decrease (normal lower limit 24)
  • Hundreds of other chemical and hormonal changes
5 medical therapy of chronic renal failure
5. Medical Therapy of Chronic Renal Failure
  • Potassium (bicarbonate, glucose & insulin, saline, β-agonists, Kayexelate, calcium, stop various meds)
  • Phosphorus (calcium acetate, calcium carbonate, Renvela, Fosrenol)
  • Urea (diet restriction, exclude GI bleed)
  • Optimize GFR (fluid load, fluid decrease, improve blood pressure, stop various meds)
  • Avoid nephrotoxic meds (nsaids, ACE, iodinated contrast agents)
  • Avoid or adjust other toxic meds (MRA contrast, Reglan, Digoxin, Amiodarone, Lovenox, etc).
6 when do we start dialysis in ckd which type
6. When do we start dialysis in CKD? Which Type?
  • Clearance
    • GFR < 15 ml/min for non-diabetics (MDRD)
    • GFR < 25 ml/min for diabetics
    • Downward trend in GFR
    • Upward trend in uremic toxins
  • Symptoms
  • Quality and length of expected life
  • Home patient potential: good patient historically, family support and partner, mobility, interest and capability
    • PD, especially for heart failure, diabetes, provides several years of support
    • Short daily Hemo: capability and interest
    • Overnight Hemo 8 hours every other night also possible
  • In-center patient potential
    • Must tolerate surgery or procedures for vascular access device
    • Must tolerate rapid fluid shifts and heart strain
    • Must cooperate with medical regimen
    • Transportation must be available for three treatments per week
7 requirements for hemodialysis access
7. Requirements for Hemodialysis Access
  • Blood flow rate of 400 ml/min for 4 hours treatment, without blockage
  • Blood flow rate in vicinity of access (like catheter or needle) must be at least 800 ml/min
  • Minimal infection risk
  • Low risk of bleeding
  • No tubes through the skin if possible
  • Longevity in years, not months
types of hemodialysis access
Types of Hemodialysis Access
  • AV Fistula
  • AV Graft
  • Tunneled Internal Jugular dialysis Catheter
fistula problems stenosis
Fistula Problems-Stenosis

Note enlargement of radial artery-to provide a liter per minute blood flow

slide53

Dacron Cuff is under the skin

Tips are at the entry to the heart

wardrobe requirements
Wardrobe Requirements

Natalie Cole, 2009

fibro epithelial fibrin sheath

L IJ

CVC

Fibro-

Epithelial

Sheath

SVC

RA

Fibro-Epithelial (Fibrin) Sheath

Courtesy, Arif Asif

slide62

KDOQI 2007

Risky!

Exchange? Balloon sheath? Brush?

30 minutes? Overnight?

can catheter outcomes be improved for sheathing new catheter designs might help
Can catheter outcomes be improved? For sheathing, new catheter designs might help…

Centros Tips form a flat plane; ports are held in middle of vein

centros tm preferred placement in svc
CentrosTM: Preferred Placement in SVC

art

art

ven

ven

The catheter tips are positioned in the lower third of the SVC rather than in the atrium…

centros a self centering catheter
Centros™: A Self Centering Catheter

tip

tip

Pacemaker leads

The ports are held in the middle of the SVC and away from the vein wall. These CT’s were performed after 4 months of catheter use.

slide66

CentrosTM: Preliminary Study Results

Flow rate of the CentrosTM Catheters was 400 ml/min, constant over time (7 weeks) and higher than with current Dual Lumen tunneled dialysis catheters.

infection in tunneled cvc for dialysis
Infection in Tunneled CVC for Dialysis
  • Incidence of 1-5/1000 patient days, or 3-15% of patients per month (higher in non-tunneled catheters)
  • Serious consequences, systemic and metastatic infections
  • Highly costly
  • Requires long-term systemic antibiotics and usually antibacterial catheter lock to resolve
  • For Staph Aureus or Pseudomonas organisms catheter must be removed/replaced
  • Prophylactic antibiotic or antiseptic locks can diminish incidence but have their own problems