Chronic Kidney Disease and Dialysis Patient Care – What the Generalist Should Know - PowerPoint PPT Presentation

JasminFlorian
chronic kidney disease and dialysis patient care what the generalist should know l.
Skip this Video
Loading SlideShow in 5 Seconds..
Chronic Kidney Disease and Dialysis Patient Care – What the Generalist Should Know PowerPoint Presentation
Download Presentation
Chronic Kidney Disease and Dialysis Patient Care – What the Generalist Should Know

play fullscreen
1 / 67
Download Presentation
Chronic Kidney Disease and Dialysis Patient Care – What the Generalist Should Know
404 Views
Download Presentation

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

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  1. 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

  2. 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

  3. 1. Dialysis Options and How They Work • Peritoneal dialysis • Hemodialysis • CVVHD • NxStage Home Dialysis Therapy

  4. Dialysis=Diffusion

  5. Nighttime cyclers decrease the number of daytime exchanges needed.

  6. The Hemodialysis Blood Side System

  7. Fresenius K-Machine

  8. NxStage Therapy System

  9. 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

  10. 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

  11. 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

  12. 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).

  13. 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

  14. Stages of Chronic Kidney Disease

  15. 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

  16. Types of Hemodialysis Access • AV Fistula • AV Graft • Tunneled Internal Jugular dialysis Catheter

  17. Scribner Shunt-1960

  18. Short History of Hemodialysis Access after Scribner Shunt:

  19. AV Fistula

  20. Original Cimino-Brescia Fistula; side-by-side

  21. Other types of fistulas

  22. Finding Veins-Sometimes Easy, Sometimes Hard

  23. Vein Mapping to Find Suitable Veins and Arteries

  24. Fistula Problems-Stenosis Note enlargement of radial artery-to provide a liter per minute blood flow

  25. Signs of Venous Stenosis in Vascular Access

  26. Physical Exam..Detects Inflow Problems and Outflow Problems

  27. Aneurysms are Weakened Areas, not Able to Receive More Needlesticks

  28. But, 30-50% of fistulas don’t work in the first place….

  29. AV Grafts

  30. ArterioVenous GraftsCan Teflon be a Blood Vessel?

  31. Grafts Become Covered by Body Tissues, Sometimes Too Much Tissue

  32. And Stenosis Near the Connection of the Graft and Vein

  33. Infection is Rare, Redness is Common

  34. Pseudoaneurysms are Near Blowouts

  35. Tunneled Permanent Central Venous Catheters for DialysisThe Third Choice