An approach to the dialysis patient

With Doctor Kate Wyburn Senior Staff Specialist at Royal Prince Alfred Hospital and Associate Professor at the Clinical
School of Medicine, Sydney University

Introduction
Associate Professor Wyburn discusses an approach to managing a dialysis patient on the wards. A helpful
topic for those interested in renal medicine and anyone cover a renal ward after hours.
1. Overview
There are two main types of dialysis:
o Haemodialysis
Removing excess fluid and toxins extra-corporeally on a dialysis machine
Through an arterio-venous fistula or using a vas-cath central line
Can be done at home, in centre or at a satellite unit
Can be completed nocturnally
o Peritoneal dialysis
Uses the peritoneal membrane as the dialyser
Fluid through a catheter is placed in the peritoneal cavity
Excess water and toxins are removed down the gradient across the membrane
Can be done at home, overnight or intermittently throughout the day
2. What factors influence the choice of dialysis method?
Neither one is necessarily superior to the other, the decision depends on the patient; lifestyle,
preferences and contraindications.
o Haemodialysis
Advantages
Usually only dialysing 3 times a week
Disadvantages
Using needles infection risk
Occasionally difficult to access fistulas
o Peritoneal Dialysis
Advantages
More flexible able to be performed at home and overnight
No needles
Disadvantages
Glucose in the bag may cause problems especially for diabetics
Difficult in patients with large abdomens
3. What are the differences between dialysis on the wards vs. dialysis in the Intensive Care Unit?
Patients routinely dialysed tend to be more stable than those in ICU who tend to be more complex
requiring inotropic support etc.
In ICU we are able to do peritoneal and regular haemodialysis, however often the patients do not
have the cardiovascular reserve to support this and therefore require a more gentle continuous
form of dialysis
Summarised by Dr James Paterson, Intern, Royal Prince Alfred Hospital. October 2015

o For example
CVVHD: Continuous veno-venous haemodialysis runs 24 hours a day with less
dramatic fluid shift
CCRT: Continuous renal replacement therapy
4. What are the most common causes and indications for Dialysis?
The two most common underlying causes for ESRF are hypertension and diabetes.
Common indications are acid-base issues, fluid overload or anuria, uraemia and electrolyte
imbalances especially hyperkalaemia.
A simple way to remember the indications for dialysis is A, E, I, O, U:
o Acid-base balance
o Electrolytes
o Ingestibles ie some overdoses/ toxins
o Overload of fluid
o Uraemia

Case 1 - You are an intern on the wards and you get asked to review a patient receiving dialysis with low
blood pressure of 80/40. What is your initial approach over the phone and when you finally go to review
the patient?
This is quite a common scenario for patients on dialysis, however the approach is not too dissimilar
to managing hypotension with any other patient.
o Lie the patient flat or head down
o Give small boluses of normal saline (250ml)
o Rule out sinister causes ie. bleeding or chest pain
o Common cause rapid fluid removal manage by slowing down dialysis
5. How do you assess fluid status in a patient with end stage renal failure?
Ideal body weight dialysis patients all know their dry weight
Inter-dialysis weight gain
Baseline blood pressure
Other than that usual assessment, pulse, BP, JVP, pedal oedema and so on
6. What are the common causes of hypotension in renal patients on dialysis?
The most common cause, as alluded to before, is removing too much fluid via dialysis or
ultrafiltration.
Other common causes are:
o Cardiac failure/ IHD
o Sepsis particular with vascular lines or fistulas
o Diabetic autonomic neuropathy
o Medications/ iatrogenic may have changed recently with the addition of dialysis
7. What are some of the complications of hypotension in renal patients?
Will often feel awful and nauseous
The other complication is that the patient may clot off their fistula with low perfusion, which may
just be that patients life-line
Also if they have concomitant cardiac disease it may also compromise their cardiac status

Summarised by Dr James Paterson, Intern, Royal Prince Alfred Hospital. October 2015

8. Youve mentioned in this case, positioning the patient, slowing dialysis and small boluses of fluids
are all helpful. Is there anything else a junior doctor should be doing in this scenario, with a special
focus on investigations?
It really depends on your differential diagnoses:
o Sepsis - blood cultures
o Cardiac - ECG
o Changing the ultrafiltration rate
o Discuss the case with the renal team
o Renal registrars and consultants are always around and happy to discuss their patients

Case 2 - You are asked to review a patient who has presented directly to the renal ward from home, who
is having peritoneal dialysis and is complaining of cloudy bags. What does this mean and what is its
clinical significance?
Usually a sign of infection
Could be peritonitis and is quite often associated with abdominal pain
First point of call is to culture that bag and make sure the patient is clinically stable
Take a history from the patient and particularly ask about any previous episodes
Drain the bag and take a sample
Blood cultures
Commenced antibiotics usually given intra-peritoneally (within the bag) most hospitals have
local guidelines or protocols re empirical antibiotic choices ie. Cephazolin and Gentamycin (2 doses)
at RPA for at least 2 weeks
Commence nystatin orally
1. Is it helpful to look at previous culture and sensitivities when choosing antibiotics for this
complication?
Quite often patients with recurrent infections will grow the same bug, however, it is better to start
on empirical therapy and switch to less broad-spectrum therapy when a specific pathogen is
detected
2. Do these patients often require admission to hospital?
Not necessarily, if the patient is systemically well they may go home with pre-prepared bags and
come back each day to receive a new dose
Take Home Messages
Renal terms are great to learn about lines and electrolytes
Never take blood or put cannula in a fistula arm
Know patients electrolytes post-operatively
Think about medications, as some renal patients require different doses

Summarised by Dr James Paterson, Intern, Royal Prince Alfred Hospital. October 2015