HD: Troubleshooting

Fever with hemodialysis catheter

• If well appearing, can obtain CBCd, CRP and culture and give antibiotics after HD as an outpatient. If requires outpatient antibiotics, need to set up appointments and therapy plan for SSU or Bass Center

• If ill appearing can send to ED or direct admit of IV abx inpatient

• Usually vanc and ceftaz (can dose qod)

Fluids = Insensibles (400 ml/m2/day (~⅓ “maintenance”)) + UOP/Other losses

Pruritus (itching):

• Dialyzer reaction

  • Less likely in era where we are not reprocessing dialyzers, but not unheard of

• Transfusion reaction if blood prime used

• Reaction to dialysate water

  • If other dialysis patients also affected

  • Infection

  • Endotoxin

  • Chlorine contamination

• Clearance of anti-pruritus medications

• Inadequate dialysis (not acute)

• Hyperparathyroidism

  • If hyperphosphatemia and high calcium bath is used, can precipitate with phosphate

• Paraneoplastic reactions

• Drug reactions

  • Heparin

  • Iron

  • ESA

  • Other medications, e.g., hydroxychloroquine

• Food allergy

Pain on HD

• Typically musculoskeletal pain from aggressive fluid removal. Cramping pain. Can be in legs, arms, sometimes chest muscles. HD nurses usually triage pretty well and will back off on fluid removal to see if improves

Fluid Overload on HD - pt is over their DW by multiple kilos. Usually requires an ok to do additional treatment the next day.

• Sometimes, you will have to take a good look at pt to see if the dry weight target is too low. Have their BPs been running low? Have they had cramping on dialysis? Are they eating better?

Dialysis catheter

• HD line high pressures - Sometimes will improve with running reversed (arterial port to venous line, venous port to arterial line)

• HD catheter exit site infection/inflammation - depending on the exam (purulence, cellulitis or just excoriation), may need presumptive coverage while we culture any pus.

• HD line cuff exposed - needs CXR and likely IR to replace. Call IR to help schedule next HD catheter replacement

• HD catheter not drawing back/flushing - CXR to evaluate if line has moved/displaced.

• HD catheter broken, leaking, etc etc. - Eval by IR for replacement. Pt may need Kayexalate to keep K low if can’t be done same day.

Lines sluggish despite tPA after each session

• Can increase tPA dose to 110% if having clotting issues between sessions

Clotting with heparin-free dialysis:

• Increase blood flow

• Frequent saline flushes

• Consider low dose heparin if ok per primary team

• Heparinized saline rinse of circuit before starting dialysis

• Can do citrate but we usually don't

CRBSI

• CRBSI is not the same thing as a CLABSI

  • CLABSI = [***]

    • likely overestimates true number of CRBSIs

• CRBSI definition: from 2009 IDSA guidelines

  • Culture catheter tip + peripheral vein

    • Catheter tip means catheter must be removed

  • Alternatively: culture catheter hub + peripheral vein

    • Want to avoid peripheral sticks to for vessel preservation

  • Alternatively: culture 2 catheter lumens

    • Preferred

      • [***]

• Management: per IDSA guidelines

  • Start empiric antibiotics

  • Antibiotic locks***

• Indication for catheter removal [***]

• For other pathogens, resolution of symptoms and bacteremia within 2-3 days

  • Keep CVC, antibiotic locks

• Prevention:

  • Limit the use of CVCs where possible

  • Good hand hygiene, aseptic technique

  • SCOPE collaborative demonstrated sustained improvement in CRBSI rates with adherence to these guidelines

• Exit site infection:

  • Definition: [***]

  • Tunnel infection: [***]

Impact on siblings [Rebecca Johnson @ CMKC]

• Lots of variability across youth, but generally small effects

• May be more helpful to think of these effects as variations in normal development rather than maladjustment [Alderfer et al., 2010]

• Across all chronic medical conditions

  • Meta analysis in 2002 (Sharpe & Rossiter) showed a small but significant negative effect on siblings

    • Higher day to day caregiver demands associated with worse outcome

    • At the time, recent studies were suggesting that the effect was getting smaller

  • Meta-analysis in 2012 (Vermaes et al) confirmed a small but significant negative effect

    • More internalizing symptoms (anxiety, depression, worry), externalizing symptoms (e.g., acting out), some negative impacts on self attributes (e.g., self confidence, self esteem)

    • No moderating effects of gender, birth order, or type of chronic health condition

    • Younger siblings left vulnerable to negative impact on self attributes than older siblings

    • Siblings of children with life threatening or more intrusive day to day treatments saw greater impact

• Specific to ESKD

  • Siblings of children on dialysis (Batte et al., 2006): structured interviews

    • 90% reported disruption to family routines

    • 80% reported feeling jealous or left out

    • 50% reported they could not openly share problems or concerns with parents

      • Feeling their parents had enough on their plate

  • Siblings of children with kidney transplant (Velasco et al., 2019)

    • Reported slightly lower health related quality of life than control group - statistical but not clinically meaningful difference

  • Vance et al (1980): structured interviews

    • Siblings of children with nephrotic syndrome reported decreased social confidence and decreased academic performance (effects small but significant)

• Research needs:

  • Mechanisms of risk and resilience

    • Who is at highest risk?

    • What intrapersonal and/or socio-ecological factors are protective?

  • What interventions are most helpful for siblings

  • More investigation of potential benefits and opportunities

    • Improve empathy, compassion, independence, self-efficacy

• Supporting siblings

  • Screening: especially for siblings of children with intrusive/life-threatening chronic health conditions

  • Evidence-based interventions for anxiety, depressive symptoms

  • Interventions to promote coping and adjustment

  • Communication: developmentally appropriate education and information

  • Engagement: child life, hospital/unit, camp, virtual

  • Social support: developmental needs, school-based support

    • Identify other adults who can be there for the siblings' needs

    • For older kids, help to facilitate social engagements outside the home

  • Maintain routines, minimize disruptions as much as possible