Christopher Keller Nephrology Fellow January 11, 2008

Principles

of renal replacement therapy Hemodialysis access Q&A session

A

dialysate containing electrolytes runs countercurrent on the outside of the microfibers Solute removal occurs through diffusion

 Volume

removal occurs by applying negative pressure on the dialysate Managed by a dialysis nurse

 PUF

= Pure Ultrafiltration Uses an HD machine with an HD filter Does not run a dialysate Simply removes volume through negative pressure from the dialysate space

 No

effective solute removal

Why is this?

Managed

by a dialysis nurse Easier to remove fluid because BPs usually drop less than in HD

 Continuous

VenoVenous Hemofiltration Solute removal occurs through convection Volume and electrolytes removed are replaced with a replacement fluid

 Requires

ICU care (not managed by HD

nurses) Requires central access; cannot use arm grafts and fistulas
Why?

Old Machine

New Machine!

 Uses

the peritoneal membrane as a

filter Two forms

Manual exchanges every 6 hours Mostly at night with a cycler machine

Usually

used when a patient has residual renal function

 Can

give intraperitoneal antibiotics (IP) Call renal fellow when a PD patient is admitted

HD is fast and efficient, but requires adequate BP and causes significant rapid fluid shifts CVVH is gentle, provides hour-by-hour adjustments for fluid intake, and provides better renal replacement over time PD should be continued in house unless the patient is unstable or the peritoneum is compromised

Are there randomized trials for CVVH vs HD in the ICU? AJKD 2004; 44: 1000-1007: no difference Nephrol Dial Transplant 2005; 20: 16301637: no difference Lancet 2006; 368: 379-385: no difference

 Temporary

hemodialysis catheter =

Quinton Can be placed in the IJ or femoral veins Subclavian veins are avoided if possible
Why is this?

 Femoral

lines should be removed within

3-7 days IJ lines should be removed within 14 days Patients can go home with a temporary IJ

 Two

types: the Tesio and the PermCath

 Tesio:

two separate lines

 PermCath:

one line with two ports

 Both

are tunneled, usually into the IJ Tunneling provides a barrier to infection Lines can stay in for over a year

 Ideal

access is a fistula or graft, usually in the arm Nondominant arm is preferred

Why is this?

 Fistula:

arterial anastomosis to vein Graft: plastic segment connects artery to vein Grafts much more likely to become infected than fistulas

Why is it better to have a fistula than a tunneled line? Blood flow is faster (400-450 vs 300-350 ml/min) Infection rate is much lower Mortality benefit to having either a fistula or a graft versus a line

 We

can draw labs (tell the fellow) We can give an erythropoetin analog (Epogen or Aranesp) We can give a vitamin D analog (Hectorol, Zemplar, or Calcijex) We can give IV iron (Ferrlecit, INFeD, Venofer) If urgent, we can give antibiotics