Dialysis- HD

• • ESRD causes: DM, HTN, others include GN, PKD, obstructive uropathy

  • Mortality from HD due to: cardiovascular dz (50%), and infections

Hemodialysis Indications:

• • Hyperkalemia (refractory)

  • Volume overload - CHF

  • pH <7.2 (metabolic acidemia)

  • Uremic encephalopathy

  • Uremic pericarditis with or without cardiac tamponade

  • GFR is <10 ml/min in non diabetics or <15 ml/min in diabetics

  • Progressive motor neuropathy

  • KT/V = 1.2 per HD Tx is the minimum standard

  • URR (urea reduction ratio) of 65%

  • URR = pre-HD BUN x post-HD BUN divided by pre-HD BUN. Multiply by 100.

Complications during HD and Mgmt

• • Hypotension - most common cause. 2° excessive fluid removal, impaired vasoactive and autonomic responses, osmolar shifts, food ingestion, impaired cardiac reserve, use of anti-HTN meds, vasodilation due to warm dialysate, nitrates, allergic reaction to dialyzer.

    • R/o other causes: MI, cardiac tamponade, PE.

  • Active bleeding & coagulopathies: reduce heparin during HD. DC heparin in uremic pericarditis, platelet dysfunction

  • Dialysis dysequilibrium syndrome: occurs during first few HD Tx in uremic Pts 2° CNS edema from rapid osmolar shift: N/V/HA, confusion/Sz

  • Muscle cramps

  • Pt. on chronic medications: cardiac, warfarin, chemotherapy, etc. dramatically drop their serum drug levels during dialysis.

  • Dialysis Pts are frequently instrumented and combined with their impaired immunity, infection is common. Subacute bacterial endocarditis may occur if the infections are not recognized early and treated correctly.

  • Viral hepatitis: frequent blood transfusions

  • Psychologically, dialysis can be extremely burdensome.

Management:

• • D/C ultrafiltration, 0.9% NS bolus IV, give salt poor albumin to pts with hypoalbuminemia, check daily dry weight, hold anti-HTN 1 day prior and day of HD, avoid heavy meals during HD.

  • For muscle cramps: reduce volume of fluid removal during HD, use higher conc. of Na+ in dialysate, Quinine sulfate, 260 mg PO x 1, 2-h before HD.

  • Increase protein intake 1 - 2 g/kg/day

  • Adjust fluid intake to permit wt. gain ~2 kg between HD sessions.

  • AVF optimal form of HD access: reduced risk of inf. and thrombosis, should be placed 3 - 6 mo prior to anticipated HD because it takes time to mature.

  • AVG/shunt placed 1 - 3 mo ahead of anticipated HD.

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Urea Reduction Ratio: ~65%

URR = (pre-HD BUN - post-HD BUN)/pre-HD BUN) x 100