Dialysis Basics
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Outline
Indications
Modalities
Apparatus Access Complications of dialysis access Acute complications of dialysis Questions
Indications
Pericarditis or pleuritis
Progressive uremic encephalopathy or
neuropathy (AMS, asterixis, myoclonus, seizures) Bleeding diathesis Fluid overload unresponsive to diuretics Metabolic disturbances refractory to medical therapy (hyperkalemia, metabolic acidosis, hyperor hypocalcemia, hyperphosphatemia) Persistent nausea/vomiting, weight loss, or malnutrition Toxic overdose of a dialyzable drug
Goals of Dialysis
Solute clearance Diffusive transport (based on countercurrent flow of blood and dialysate) Convective transport (solvent drag with ultrafiltration) Fluid removal
Modalities
Peritoneal dialysis
Intermittent hemodialysis
Hemofiltration Continuous renal replacement therapy
Decision of modality determined by catabolic rate,
hemodynamic stability, and whether primary goal is fluid or solute removal
Hemodialysis Apparatus
Dialyzer (cellulose, substituted cellulose,
synthetic noncellulose membranes) Dialysis solution (dialysate water must remain free of Al, Cu, chloramine, bacteria, and endotoxin) Tubing for transport of blood and dialysis solution Machine to power and mechanically monitor the procedure (includes air monitor, proportioning system, temperature sensor, urea sensor to calculate clearance)
Hemodialysis Access
Acute dialysis catheter (vascular catheter, i.e.
Quentin catheter) Cuffed, tunneled dialysis catheter (Permcath) Arteriovenous graft Arteriovenous fistula
Arteriovenous Fistula
Preferred form of dialysis access
Typically end-to-side vein-to-artery anastamosis
Types
Radiocephalic (first choice) Brachiocephalic (second choice) Brachiobasilic (third choice, requires
superficialization of basilic vein, i.e. transposition)
Lower extremity fistulae are rare
Radiocephalic AVF
Brachiocephalic AVF
Arteriovenous Graft
Synthetic conduit, usually polytetrafluoroethylene
(PTFE, aka Gortex), between an artery and a vein Either straight or looped Common sites
Straight forearm : Radial artery to cephalic vein Looped forearm : brachial artery to cephalic vein Straight upper arm : brachial artery to axillary vein
Looped upper arm : axillary artery to axillary vein
Arteriovenous Graft contd
Rare sites
Leg grafts Looped chest grafts Axillary-axillary (necklace) Axillary-atrial grafts
Arteriovenous Graft
Tunneled Cuffed Catheters
Dual lumen catheters
Most commonly placed in the internal jugular
vein, exiting at the upper, anterior chest Can also be placed in the femoral vein Subclavian catheters should be avoided given the risk of subclavian stenosis
Cuffed Dialysis Catheter
Dialysis Access : Time to use
Graft
Usually cannulated within weeks
Vectra or flexine grafts can safely be cannulated after
~12 hours
Fistula
Median period of 100 days before cannulation in the
U.S. and U.K. Initial cannulation should be performed with small gauge needles and low blood flow
Dialysis Access : Longevity
Native fistulas have a high rate of primary failure,
but long-term patency is superior to grafts if they mature R-C fistulas 5- and 10-year patency are 53 and 45%, respectively PTFE grafts 1-, 2-, and 4-year patency are 67, 50, and 43%, respectively
Tunnel Cuffed Catheters : Bacteremia
Clinical manifestations
Fevers or chills in catheter-dependent dialysis
patients associated with positive blood cultures in 60 to 80% Less commonly : hypotension, altered mental status, catheter dysfunction, hypothermia, and acidosis
Acute Complications of Dialysis
Hypotension (25-55%)
Cramps (5-20%)
Nausea and vomiting (5-15%) Headache (5%) Chest pain (2-5%) Back pain (2-5%) Itching (5%) Fever and chills (<1%)
Acute Complications of Dialysis
Chest pain
Can be associated with hypotension and dialysis
disequilibrium syndrome Always consider angina, hemolysis, and (rarely) air embolism Consider pulmonary embolism if recent manipulation of thrombus and/or occlusion of the dialysis access
Acute Complications of Dialysis
Hemolysis
Suggestive findings include port wine appearance
of the blood in the venous line, a falling hematocrit, or complaints of chest pain, SOB, and/or back pain Usually due to dialysis solution problems, including overheating, hypotonicity, and contamination with formaldehyde, bleach, chloramine, or nitrates in the water, or copper in the dialysis tubing Treatment includes discontinuation of dialysis without blood return to the patient, and evaluation for hyperkalemia with medical treatment as necessary
Acute Complications of Dialysis
Arrhythmias
Common during, and between, dialysis treatments Controversial whether due to disturbances in
plasma potassium Treatment is similar to the non-dialysis population, except for medication dosing adjustments
Questions
