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hemodialysis

Indications: 1) uremia a) uremic pericarditis b) *uremic neuropathy c) *uremic seizures d) uremic encephalopathy e) *bleeding from uremia-induced platelet dysfunction 2) acute renal failure a) *hypervolemia b) *hyperkalemia c) *severe acidosis 3) intractable malignant hypertension 4) *congestive heart failure - *refractory hypervolemia 5) *chronic renal failure - end-stage renal disease - GFR < 0.5 mL/min/1.73m2 6) acute intoxication with toxin removed by dialysis - methanol, aspirin, ethylene glycol, lithium, sodium, mannitol, theophylline - NOT used for tricyclic antidepressants, benzodiazepines, digoxin, dilantin, phenothiazines Contraindications: 1) severe, irreversible dementia 2) severe, irreversible chronic debilitating disease Principle: 1) hemodialysis works by diffusion of ions & small molecular weight molecules across a semipermeable membrane 2) fluid removal is accomplished through ultrafiltration Procedure: 1) preparation 1) avoid venipucture & intravenous catheterization above the level of the hand when GFR drops below 60 mL/min/1.73 m2 2) avoid peripherally-inserted central-venous catheters (PICC lines) in patients considering dialysis 3) dialysis should be initiated before symptoms of advanced uremia develop 2) access a) central venous catheter (temporary) - immediate use - highest rate of infection, inadequate flow b) autologous AV fistula vs AV plastic graft c) AV fistula (anastomosis) - place 1-6 months before use - place 2 months before eGFR drops below 15 mL/min (CDK5 threshold) [3] - long maturation time; may fail to develop - lowest rate of infection; high patency [4] d) arteriovenous graft (AV graft) - place 1-21 days before use - easy cannulation - higher rate of infection & thrombosis than AV fistula - Aggrenox may extend AV graft patency. [8] e) autologous AV fistulas cannot always be created, particularly in older patients or those with major comorbidities; plastic grafts are the alternative, but incur relatively high rates of thrombosis and infection. f) grafts vs fistulas associated with higher all-cause mortality (RR=1.18, 1.09-1.27) & fatal infection (RR=1.36, 1.17-1.58), but not risk for cardiovascular events (RR=1.07, 0.95-1.21) [27] g) bioengineered blood vessels may provide means of AV fistulas in patients for whom an AV graft would othersise be needed [29] 3) General recommendations: a) 3 times per week adequate [7] - intermittent vs continuous hemodialysis comparable [4] - an increase in weekly hours of dialysis from 12 to > 20 during pregnancy - 6x vs 3x/week associated with favorable outcomes of death & change in left ventricular mass but necessitates more frequent interventions related to vascular access [26] b) increase intake of dietary protein 1.0-1.2 g/kg/day c) fluid intake should be adjusted to allow a weight gain of 2 kg between dialysis sessions d) anti-hypertensive agents may need to be reduced or held on days of hemodialysis e) medications - ampicillin & cephalosporins are helpful in conjunction with dialysis - AVOID: tetracyclines, nitrofurantoin, probenecid, neomycin, bacitracin, methenamine, nalidixic acid, clofibrate, lovastatin, magnesium, oral hypoglycemic agents, antiplatelet agents - CAUTION: ACE inhibitors & other K+ sparing agents, metoclopramide, NSAIDs, acyclovir, long-acting Ca+2 channel blockers, beta-blockers f) cardioselective beta-1 adrenergic receptor antagonists may diminish risk of heart failure [5] g) management of anemia - more aggressive management of anemia during pregnancy Complications: 1) active bleeding &/or coagulopathy a) systemic anticoagulation necessary in hemodialysis 1] can be minimized with low heparin protocols (500 U/dialysis) 2] no heparin protocols with saline flushes of lines every 30 min b) IV DDAVP 0.3 ug/kg in 50 mL of saline every 4-8 hours c) conjugated estrogen 0.6 mg/kg/day IV for 5 days d) intranasal DDAVP 3.0 ug/kg every 4-6 hours e) fresh frozen plasma (FFP) 2) dialysis disequilibrium a) may occur during 1st few treatments of profoundly uremic patients b) results from CNS edema due to rapid osmolar shifts c) clinical manifestations - nausea/vomiting, headache, confusion, seizures d) prevented by low blood flows & shortened duration of dialysis during initial sessions 3) pericarditis a) separate entity from uremic pericarditis b) management 1] dialysis 6-7 times/week 2] cardiac tamponade a] intrapericardial steroids b] pericardiectomy 3] minimize anticoagulation until pericarditis resolves 4) hypotension, orthostatic hypotension, syncope a) etiology 1] volume depletion 2] low dialysate sodium content 3] anti-hypertensive agents before dialysis 4] allergic reactions to the dialyzer 5] intolerance to dialysate containing acetate - bicarbonate-based dialysate is most common 6] left ventricular dysfunction 7] autonomic insufficiency 8] myocardial infarction 9] cardiac tamponade 10] sepsis 11] bleeding 12] beta-blockers, alpha-blockers, ACE inhibitors, ARBs & diuretics associated with increased risk of intrahemodialysis hypotension relative to calcium channel blockers [37] b) management [35] 1] general measures a] IV normal saline b] reduction of dialyzer blood flow c] reduction of ultrafiltration rate d] cooling of dialysate 2] specific measures for specific causes - use of bicarbonate-based dialysate for acetate-sensitive patients 5) vascular access infection (10-25%) a) signs/symptoms 1] local or systemic manifestations may be present 2] may be asymptomatic b) laboratory: 1] blood cultures 2] abscess cultures c) radiology: ultrasound of access site d) management 1] coverage for Staphylococci (60-90%) 2] continue therapy for 4 weeks 3] removal of infected access - exception: AV fistula infection NOT involving suture line 4] if there is no evidence of infection of the catheter tunnel, dialysis catheters can be exchanged over a wire in asymptomatic patients on antibiotics for >= 48 hours [3] 6) vascular access thrombosis a) recanalization by balloon catheter embolectomy b) urokinase under pressure c) access can be used immediately after declotting 7) dialysis dementia a) etiology: 1] CNS accumulation of aluminum 2] aluminum-containing phosphate binders b) signs/symptoms 1] dyspraxia 2] myoclonus b) management 1] monitoring blood & dialysate aluminum levels 2] deferoxamine may improve progression of dialysis dementia 8) carpal tunnel syndrome & diffuse arthropathy may occur with long-term dialysis secondary to amyloid deposition of beta-2 microglobulin 9) pulmonary a) pleural effusion - generally transudative b) pulmonary calcification - chest X-ray shows soft infiltrates that mimick pulmonary edema - diagnosis made by Tc-99 diphosphonate radionuclide scan demonstrating Tc-99 uptake c) loss of CO2 through the dialysis membrane results in compensatory hypoventilation & hypoxemia d) dialysis may increase risk of sleep apnea 10) pancreatitis 0.6%, 3 fold less than peritoneal dialysis [6] 11) hyperparathyroidism secondary to chronic renal failure - calcitriol is effective in lowering PTH - monitor serum calcium, serum phosphate, serum PTH [9] 12) transmission of infectious agents - transmission of hepatitis C [25] 13) cystic kidney disease [3] - risk increases with duration of hemodialysis - 30-fold increased risk in renal cell carcinoma [3] 14) iron-deficiency anemia [36] - absolute: frequent blood testing & blood lost from the procedure - functional: transferrin saturation < 30% [36] 15) increased risk of mortality a) increased risk of cardiovascular mortality [3] - rosuvastatin lowers LDL cholesterol but not mortality [21] b) increased all-cause mortality c) digoxin associated with 28% further increase in mortality - higher serum digoxin & lower serum potassium predialysis associated with increased mortality [12] Management: - maintain BUN < 100 mg/dL in acute renal failure - home hemodialysis may be an option for some [15] - elderly with multiple comorbidities are best managed medically [35] - diabetics undergoing dialysis - better glycemic control does not translate to lower mortality [11] - early initiation of dialysis may be harmful [17] - delaying dialysis has a negative impact on clinical parameters but does not affect survival once dialysis is initiated [14] - hemodialysis generally (3X/week) on MWF - mortality highest on Monday after 2 days without dialysis - 50% of deaths due to cardiovascular events [18] - treat hypertension - most important objective is control of volume overload - if predialysis blood pressure > post dialysis blood pressure, attempt more aggressive dialysis (a lower post-dialysis weight) [35] - treat anemia of chronic renal failure [19] - etelcalcetide (Parsabiv) FDA-approved for treatment of secondary hyperparathyroidism in adults with chronic renal failure on hemodialysis - dialysate calcium concentration of 1.25-1.5 mmol/L [30] - calcitriol may be of benefit [30] - statins may be of no benefit [21] - anticoagulation - continue anticoagulation for atrial fibrillation with caution - all-cause mortality, cardiovascular mortality, & bleeding requiring hospitalization are increased by use of oral anticoagulants - CHADS2 score predicts risk of stroke in dialysis patients with atrial fibrillation patients - GI bleeding in the past 12 months predicts major bleeding - for patients with previous GI bleed, major bleeding exceeds stroke by at least twofold across all categoriesof CHADS2 score [22] - anticoagulation for treatment of venous thromboembolism - prophylaxis for venous thromboembolism - LMW heparin & unfractionated heparin with similar risks for bleeding [23] - apixaban safe with close monitoring in patients with ESRD [3] - avoid central venous catheters including PICC lines if possible [28] - central venous stenosis most commonly occurs from endothelial damage from central venous catheters - use peripheral venous access if possible [3] - use hands for venipuncture & peripheral venous access if possible [3] - use internal jugular vein for antibiotic therapy of weeks duration [3] - hemodialysis on the day of surgery - longer intervals between hemodialysis & surgery associated with higher risk of postoperative mortality [33] - advance care planning in preparation for end-of-life decisions of benefit for surrogates [24] Notes: - treatment by nephrologists that own their own dialysis facilities is not associated with excess adverse outcomes [34]

Related

peritoneal dialysis; continuous abdominal/ambulatory (cycling) peritoneal dialysis (CAPD, CCPD)

Specific

continuous renal replacement therapy (CRRT)

General

renal dialysis

References

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