Renal: RRT

Higher solute clearance -> intermittent use

Better defined monitoring parameters

Low technique failure rate

Better control of hemostasis parameters

Closer patient monitoring

Requires multiple weekly visits to dialysis center

Disequilibrium, hypotension, muscle cramps are common

Infections (higher risk)

Vascular access complications (infections and thrombosis)

Decline of residual renal function more rapid

More hemodynamic stability

Increased clearance of larger solutes

Better preservation of residual renal function

Convenient drug administration

Suitable for pt that cannot tolerate HD

Sense of independence (no machine)

Less blood loss and iron deficiency

No systemic heparinization

Protein and amino acid loss and decreased appetite -> malnutrition

Risk of peritonitis

Catheter malfunction and/or infection

Inadequate ultrafiltration

Patient burnout (decreased compliance)

Mechanical problems: hernias, dialysate leaks, hemorrhoids, back pain

AV Fistula (pref)

AV graft (shorter duration, more complications)

Cuffed/Tunneled Venous Catheter (short-term)

Purified H₂O and Electrolytes

Heated to body temp

Pumped countercurrent to blood

Usu. IV heparin bolus

Initiate 3-5min before HD

d/c 1 hour before end of HD

Usu. 3-4 hrs 3 x weekly

Achieve dry weight and adequate waste removal

Can calculate desired urea level

(PreHD BUN – PostHD BUN)/PreHD BUN x 100

Trendelenburg position

Decrease ultrafiltrate rate

100-200 mL NS bolus

Adj. dry weight

Buffer soln. w/bicarb

Avoid food PreHD

Midodrine 2.5-10 mg PO 30 min PreHD

• 100-200 mL NS bolus
• OR
• 10-20 mL 23.4% NaCl over 3-5 min
• OR
• 50 mL (1 amp) D50 in non-diabetics

Adjust dry weight

Stretching exercises

Vit E 400 IU qhs

Catheters > grafts or fistulas

Forced saline flush

Surgical thrombectomy

Exchange catheter

Alteplase OR Reteplase

Catheter > graft > fistula

S. aureus most common

Fever during HD -> get culture

• Localized w/o drainage -> topical Abx
• Localized w/drainage -> systemic v. Gram(+)

Bacterememia -> Gram (+) coverage, @ 36 hrs w/symptoms remove catheter, else change catheter and continue Tx x 3 wks

Local infxn -> Empiric Abx, narow w/ cultures and continue x 2-4 wks

Extensive infxn -> as local + resection graft

As bacterial endocarditis (x 6wks)

Hypersensitivity to sterilizing agent

Usu. on initial exposure

Usu. bioincompatible membranes or some high-flux membranes w/ACEi use

Chest pain

Back pain

Compliment activation

Permanent indwelling catheter

40-45 cm (20-22 cm internal)

Luer-lock at external end

Hyperosmolar Dextrose (4-6h dwell)

Icodextrin (8-16h dwell)

1-3 L of dialysate over ~ 15 minutes

~4-6 hours dwell -> drain -> replace

Repeated 3-4 times a day

Single exchange w/ high conc. soln. over night

Pts unable/unwilling to use aseptic technique

Automated cycler performs exchanges

Set up in evening & catheter attached QHS

Nocturnal intermittent peritoneal dialysis (NIPD)

Continuous cycling peritoneal dialysis (CCPD)

Nocturnal tidal peritoneal dialysis (NTPD)

Kt/Vd quantifies body H₂O cleared of urea

Goal Kt/Vd > 2

weekly CrCl > 60L/week/1.73 m²

Catheter kinking/obstruction

DM exacerbation (~60% of Glu is absorbed)

Peritonitis

Abdominal pain/tenderness

Cloudy effluent

Dialysate WBC > 100 & 50%+ neutrophils

Fever/Chills

N/V

Intraperitoneal Abx

Init. empiric Tx -> narrow w/cultures

Tx x 14-21d

Vanc may cause chem peritonitis