NP36 Nephrology

End Stage Renal Disease/Renal Replacement Therapy

Essential Med Notes 2015

Complications
CNS: decreased LOC, stupor, seizure
CVS: cardiomyopathy, CHF, arrhythmia, pericarditis, atherosclerosis
GI: peptic ulcer disease, gastroduodenitis, AVM
hematologic: anemia, bleeding tendency (platelet dysfunction), infections
endocrine
decreased testosterone, estrogen, progesterone
increased FSH, LH
metabolic
renal osteodystrophy: secondary increased PTH due to decreased Ca2+, high PO43-, and low
active vitamin D
osteitis fibrosa cystica
hypertriglyceridemia, accelerated atherogenesis
decreased insulin requirements, increased insulin resistance
dermatologic: pruritus, ecchymosis, hematoma, calciphylaxis (vascular Ca2+ deposition)

Renal Replacement Therapy

Dialysis
Indications for Dialysis in Chronic Kidney Disease
Table 14. Indications for Dialysis
Absolute Indications

Relative Indications

Volume overload*
Hyperkalemia*
Severe metabolic acidosis*
Neurologic signs or symptoms of uremia (encephalopathy,
neuropathy, seizures)
Uremic pericarditis
Refractory accelerated HTN
Clinically significant bleeding diathesis
Persistent severe N/V
Plasma Cr >12 mg/dL (1060 mol/L) or
Urea >100 mg/dL (36 mEq/L; clinical picture also important)

Anorexia
Decreased cognitive functioning
Profound fatigue and weakness
Severe anemia unresponsive to erythropoietin
Persistent severe pruritus
Restless leg syndrome

*Unresponsive to medications

hemodialysis: blood is filtered across a semipermeable membrane removing accumulated

toxic waste products, solutes, excess fluid (ultrafiltration), and restoring buffering agents to the
bloodstream
available as intermittent (e.g. 3x/wk), continuous (CVVHD) or sustained low efficiency
(SLED)
can be delivered at home or in-center, nocturnal
vascular access can be achieved through a central line, an artificial graft, or an AV fistula
patients with CKD should be referred for surgery to attempt construction of a primary AV
fistula when their eGFR is <20 mL/min, the serum Cr level quoted as >4.0 mg/dL (>350
mol/L), or within 1 yr of an anticipated need
peritoneal dialysis: peritoneum acts as a semipermeable membrane similar to hemodialysis
filter
advantages: independence, fewer stringent dietary restrictions, better rehabilitation rates
available as continuous ambulatory (CAPD; four exchanges per day) or cyclic (CCPD;
machine carries out exchanges overnight)
refer patients with chronic renal disease to a nephrologist early on to facilitate treatment and
plan in advance for renal replacement therapy (RRT)

How to Write Dialysis Orders

(MUST BE INDIVIDUALIZED)
Filter Type (e.g. F8O)
Length (e.g. 4 h 3x/wk or 2 h daily)
Q Blood Flow (max 500 cc/min)
Ultrafiltration (e.g. 2 L or to target dry
weight)
Na+ 140 (can be adjusted by starting
at 155 and ramping down to
minimize cramping)
K+ (based on serum K+)
Serum K+ Dialysate
4-6
1.5
3.5-4
2.5
<3.5
3.5
Ca2+ 1.25
HCO3 40
Heparin (none, tight [500 U/h]
or full [1000 U/h])
IV fluid to support BP (e.g. N/S)