What are you trying to accomplish? The Process: Indications

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The average kidney is smarter than the average
doctor.
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Intern Boot Camp Surviving Eckel!

• Hiloni Bhavsar, MD
• Pgr 35129
• UHCMC VAMC

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Outline

• The Patient
• The Process
• The Problems
• What not to do
• Proceeding with caution
• Some helpful info!

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The Patient

• Epidemiology
• Approximately 500,000 patients in the US are
  LIVING with ESRD, most of them on dialysis
• Disproportionately higher of them are African
  American
• Leading cause of ESRD?
• Diabetes (45)
• Hypertension (27)
• All other causes vascular disease, glomerular
  disease, polycystic kidney disease, obstructive
  uropathy and more..
• Leading cause of death in ESRD patients?
• Cardiovascular disease (50) this is still
  1!!!!
• Infections (15)

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The Patient CKD or ESRD?

• Chronic Kidney Disease
• Classified in stages by the GFR
• End Stage Renal Disease
• When GFR lt 15mL / min requiring renal replacement
  therapy (RRT)

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The Process Dialysis

• What is dialysis?
• What are you trying to accomplish?

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The Process Indications

• Hemodialysis
• A acidosis
• E electrolytes
• I ingestion/toxins
• O overload (fluid)
• U uremia

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The Process Types

• Types of dialysis
• Hemodialysis
• Peritoneal dialysis
• CVVH/HD/HDF

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The Process Hemodialysis

• 3 components
• Dialyzer
• Dialysate delivery
• Blood delivery
• Goal
• Solute/waste, salt and water removal

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The Process Access

• Fistula
• Best choice
• Direct native artery ? vein connection
• Graft
• 2nd best choice
• Artificial tubing vein-gttubing-gtartery
• Catheter
• TEMPORARY
• Tunneled
• Usually low on the chest wall
• It is not subclavian despite the location.
• If you feel the catheter and follow it you will
  see it goes OVER the clavicle and inserts in the
  IJ.

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ACCESS TYPES
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The Process Peritoneal Dialysis

• Dialysate dwells in the peritoneal cavity for a
  period of time
• Solute and water movement depends on movement
  into the peritoneal cavity vs absorption from the
  peritoneal cavity.
• Rate eventually stops when equilibration plasma
  and dialysate is reached.
• This rate depends on the patient and can be
  altered if there is infection, drugs/toxins and
  physical factors like position and exercise.
• MOST of the patients are on Hemodialysis.
• Peritoneal dialysis requires a motivated patient,
  is contraindicated in patient with significant
  abdominal surgery and is heavily dependent on
  patient as the operator.

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The Process Continuous Renal Replacement
Therapies (CRRT)

• Types
• CVVH Continuous Veno-Venous Hemofiltration
• CVVHD Continuous Veno-Venous Hemodialysis
• CVVHDF Countinous Veno-Venous Hemodiafiltration
• Not used often
• SCUF Slow Continuous Ultrafiltration - rare
• SLED Slow Low Efficiency Dialysis not here
• These types are only done through a temporary
  catheter
• So even for ESRD patients, if they need CVVH in
  the MICU then they will need a central line (woot
  procedure!)

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The Process CVVH

• Most common one you will see in MICU/CICU
• Usually in critically ill patients with AKI or
  those who cannot hemodynamically tolerate regular
  HD.
• CVVH offers
• Accurate volume control
• Hemodynamic stability
• Gradual and continuous removal of fluid and
  solutes
• Simply put Slow dialysis
• Special note, antibiotic dosing is a little
  different when on CVVH than hemodialysis.

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The Problems What to know!!!

• FOR EVERY ECKEL ADMISSION YOU SHOULD KNOW.
• ESRD or CKD?
• If ESRD on dialysis
• Reason for ESRD
• Days of dialysis MWF or TThS
• Route of dialysis fistula, graft, catheter
  (details)
• Location of dialysis CDC
• Dry weight patients should know this!
• Nephrologist
• Dialysis vintage (especially if Dr. Bodziak is
  your attending)

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WHEN YOU PRESENT YOU WOULD SAY

• Example
• 64 y/o male with ESRD secondary to diabetes and
  hypertension on HD MWF via right upper extremity
  AV fistula at CDC East presenting with .

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The Problems Common Admissions

• Hyperkalemia
• Hypotension
• Fever/chills
• Shortness of breath
• Access issues
• Hypertensive Crisis
• ED checked a troponin.

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The Problems A common approach

• Remember to do it
• A.L.L.
• ASK get a history (yupwe still do this as
  doctors ?)
• LISTEN to the patient/RN, they give better info
  than the chart (most of the time)
• LOOK at the VITALS PATIENT, always go examine
  the patient!

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The Problems Hyperkalemia

• Find out
• Missed dialysis
• Was dialysis cut short
• What they have been eating
• Changed or new medications
• CHECK AND ECG!!!
• To treat
• Make sure it is not hemolyzed.
• Do it A.L.L.
• Follow C a bIG K Drop
• (Calcium, b-agonist/bicarbonate, Insulin,
  Glucose, Kayexalate, Dialysis)

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The Problems Hypotension

• Find out
• Cardiac issues
• If they have a catheter hypotension ? think
  infection as a cause!
• New or old?
• What is their DRY WEIGHT, are they too under?
• Too much fluid taken too fast?
• Sepsis?!?!?!?!
• To treat
• Do it A.L.L.
• Eh..its a little complicated!
• Remember its a CLOSED SYSTEM!! What you put in
  you cant always get out!
• Go to Varuns talk on Hypotension/Sepsis
• 7/7 UH
• 7/8 VA

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The Problems Fever/chills

• COMMON THINGS BEING COMMON!
• Find out
• If they have a catheter, how long its been there
• The catheter site signs of inflammation/infection
  ?
• To treat
• Do it A.L.L.
• ALWAYS GET CULTURES BEFORE ANTIBIOTICS!!
• ALWAYS GET CULTURES from the LINE PERIPHERAL!
  
• Antibiotics depend on the patientand youll get
  more detail when you start the rotation.
• Most commonly, we treat with Vancomycin
  Gentamycin RENALLY DOSED !!
• Go to Monicas talk on Antibiotics
• 7/26 VA
• 7/28 UH

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The Problems Shortness of Breath

• Find out
• Missed or incomplete HD session?
• If they make urine, have they been taking their
  diuretics?
• Dietary/fluid indiscretion?
• Most likely it is fluid overload
• To treat
• Do it A.L.L.
• Check vitals, examine the patient, CXR, ABG if
  needed.
• If they make urine, given them diuretic (may need
  a higher dose b/c of CKD, 20mg Lasix wont do
  much)
• REMEMBER always think of the same things that
  cause SOB in non-HD patients too!
• Go to Brandons talk on Hypoxia
• 7/5 VA
• 7/26 UH

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The Problems Access Issues

• Stenosis or clotting problem
• Find out
• Remember to always do it A. L. L.
• Check a fistula or graft for thrill and bruit.
• If you dont hear one or are not sure, you can
  use a doppler to amplify any sound if present.
• To treat
• Call vascular surgery.
• Usually you will order either ultrasound or
  angiography for evaluation.
• Notify your attending.

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The Problems The ED checked a troponin.

• Persistent elevation of troponin can be seen in
  both CKD and ESRD patients.
• Always put it in the clinical context.
• A.L.L.
• Evaluate for chest pain, typical, atypical.
• ECG changes?
• Go to Sunits talk on Chest Pain
• 7/6 UH
• 7/15 VA

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The Problems Hypertensive Crisis

• Find out
• Have they been taking their medications?
• Dry weight over or under?
• Missing dialysis?
• Dietary indiscretions (fluid/salt intake)
• To treat
• Do it A.L.L.
• Restart home medications first.
• Surprisingly not all of our patients take the
  meds as prescribed!
• Short acting PRN medications with one time doses
  only. Always follow up the vitals!

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WHAT NOT TO DO!!

• MEDS TO AVOID
• Avoid laxatives with magnesium, citrate or
  phosphate
• Example Fleets enema (high phosphate), Magnesium
  Citrate, Maalox
• MORPHINE!! Big no no! (for any kidney disease)
• Dont check/correct potassium right after
  dialysis
• Dont be aggressive with repleting K/Mg/Phos
• Dont check blood pressures in the access arm
  (fistula or graft).

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ALWAYS BE CAREFUL WITH..

• Always check RENAL DOSING for medications!!
• Examples
• Antibiotics
• Digoxin, Atenolol
• Neurontin (often overdosed in renal patients)
• IF IN DOUBT.LOOK IT UP or ask the Pharmacist
  (they are there 24/7).
• Up-to-date/Micromedex/Epocrates ALL ARE AT YOUR
  FINGER TIPS!!!

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ALWAYS .

• Make sure all ESRD patients have Nephrocaps
  (renal multivitamins).
• Check daily renal function panels.
• When you cross cover and get called on a patient,
  always write short note.
• ALWAYS better to go to the patient and see them.
• ALWAYS ASK FOR HELP.

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WHEN YOU DONT KNOW.

• ALWAYS CALL FOR HELP!!!!!
• Fellow intern
• Your senior resident
• ANY senior resident
• Night float resident
• DACR/NACR 30512
• ATTENDING!

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Where does it all happen?

• UH Dialysis Unit
• Lakeside 20
• VA Dialysis Unit
• 2nd floor close to Atrium area (Room B-100)
• MICU/CICU/SICUany CU and sometimes on Tower 5.
• Home!

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IMPORTANT NUMBERS

• Melissa the all-knowing and uber helpful
  HD/Vascular access coordinator
• Ext 41219
• Pgr 33968
• Peritoneal Dialysis RN
• Ext 48305 or 45703
• Dialysis Unit
• UH 41586
• VA 5181

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FUTURE TALKS
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THANKS!!!

• Hiloni Bhavsar
• Pager 35129
• Email hiloni.bhavsar_at_uhhospitals.org