Dialysis

Dialysis

1. Indications for dialysis

   • Persistent anorexia, N/V
   • Weight loss
   • Fatigue
   • Declining serum albumin
   • Uncontrolled HTN or fluid overload, heart failure
   • Nuerologic deficits
   • Pruritis
   • Critical Lab values
     • Uncontrolled hyperkalemia/hyperphosphatemia
     • Avoid in acute problems.

2. Hemodialysis

   • Advantages
     • Intermittent treatment 3-5x /week
     • Easier to manage/adjust
     • Lower technique failure rate
     • Hemostasis parameters easier to correct
     • Allow closer monitoring of patient by health care contact
   • Disadvantages
     • Requires multiple weekly clinical visits
     • Intradialytic complications are common
     • Vascular access frequently associated with infection/thrombosis
     • Decline of residual renal function more rapid
   • Complications
     • HYpotension
       • Reposition patient
       • Decrease flow rate
       • take blood pressure meds after HD
       • fluid resuscitation
       • midodrine for prevention
     • Muscle cramps
       • Message, stretch, flex
       • decrease flow rate
       • fluid resuscitation
       • Prevention with vitamin E or quinine
     • N/V
     • HA
     • Chest and back pain
     • Pruritis
     • Fever/chills
     • Vascular access complications
     • Catheter Thrombosis
       • Saline flush
       • Alteplase (tpa)
       • Fill catheter with heparin "lock"
     • Infection
       • Blood cultures
       • catheter tip cultures
       • Empiric antibiotics with gram + coverage
       • Streamline antibiotics based on culture results

3. Peritoneal Dialysis

   • Advantages
     • Hemodynamic stability (slow rate)
     • Good clearance of larger solutes (allows good clinical status)
     • Better preservation of residual renal function
     • Convenient administration route for other medications (not IV iron)
     • Works for those who cannot tolerate HD
     • Freedom from dialysis machine to allow patient independence
     • Less blood loss and iron deficiency than HD
   • Disadvantages
     • Higher rates of malnutrition (protein/amino acid losses, continuous glucose load, and abdominal fullness)
     • Risk of peritonitis
     • Risk of mechanical problems (catheter malfunction, exit site/tunnel site infection, hernias, leaks, back pain)
     • Inadequate for larger body habitus
     • High rate of technique failure
     • risk of obesity due to excessive glucose absorption
   • Complications
     • Mechanical
       • Catheter obstruction
         • Clear catheter obstruction
       • Cather movement
         • Adjust catheter position
       • Pain
         • Slow dialysate infusion
     • Medical
       • Glucose load
         • insulin as needed
       • Fluid overload
         • increase ultrafiltration
       • Electrolyte abnormalities
         • Alter electrolytes in dialysate if possible
       • Malnutrition
         • Dietary changes
       • fibrin formation in dialysate
         • intraperitoneal heparin
     • Infectious
       • Peritonitis
       • Exit site infections
       • Antibiotics with gram + and gram - coverage as appropriate