Renal Replacement therapy

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What are the complications of Stage 5 CKD (GFR<15)?

Anemia
HTN
Mineral metabolism abnormalities (osteodystrophy, Calciphylaxis)
metabolic abnormalities
Fluid overlaod
Cardiovascular disease

How should anemia be managed in CKD5?

Treat the Fe defeciency
EPO analogues
Maintain Hb between 90-110

What is the BP target for HTN in CKD?

<130/80

What drugs should be used for management of CKD in diabetics or non-diabetic proteinuria?

Preferred agents: ACEi or ARB
Drugs reducing CVD risk: Diuretic, CCB or BB

What are the mineral abnormalities in CKD?

Minerals abnormal usually when GFR<40
Decreased phosphate excretion (Hyperphosphatemia)
Reduced Vitamin D activation (Hypocalcemia)
Reduced Vitamin D levels
Increased PTH hyperplasia

What are the bone abnormalities in CKD?

Adynamic bone disease --> Osteitis fibrosa cystica
Weakness, bone pain, fractures, anemia
Joint Deformities

What are the consequences of Calciphylaxis in CKD?

- Calcification of arterioles ==> Ischemia and subcute necrosis
- Thrombotic vaso-occlusion

How are the mineral abnormalities in CKD managed?

Eliminate Phosphate from the body
- Phosphate binders
- CaCO3
- Mg, Al
Replaced Vit D (Provide activated Vit D)
Ca-sensing R analogue to counteract HyperPTH

How should calciphylaxis in CKD be managed?

Aggressive dialysis
Wound care
Avoid calcium based phosphate binders
Bisphosphonates
Normalize PTH: Cinacalet or parathyroidectomy

What is are CVD risk factors in CKD?

Increased CV risk and mortality
•Cardiovascular risk factors
-Traditional: hypertension, lipids
-Non traditional: inflammation, uremia, homocysteine

What are the indications of initiating kidney replacement therapy in CKD?

Uremic Symptoms
Pericarditis
Uncontrolled HyperKalemia or Metabolic acidosis
Uncontrolled Pulmonary edema/Volume overload
GFR<10

What are the different Kidney replacement therapy options available?

Transplantation
Hemodialysis
Peritoneal Dialysis
Conservative therapy

What is the basic principle behind hemodialysis?

-Solute Removal
◦Diffusive transport - function of concentration difference
◦Convective transport - solute drag with ultrafiltration

-Fluid Removal
◦Performed by creating hydrostatic pressure across the dialyzer membrane (TMP)

What are the basics behind peritoneal dialysis?

Solute Removal
•Diffusive transport -
•concentration gradient
•surface area and membrane characteristics of the peritoneal membrane
•molecular size of the solute
•Convective transport -
-solute drag with fluid across membrane

Fluid Removal
-Due to oncotic pressure of the dialysate within the peritoneum

What is the general approach to toxicology?

A = Airway
B = Breathing
C = Circulation
D = Decontamination
E = Eliminate

What are the contraindications and complications of urinary alkalization?

Contraindicated in Pulmonary edema, Cerebral edema, severe renal failure

Complications: Alkalosis, hypoKalemia, hypoCalcemia

HD is preferred for removal of which elements?

Preferred for: water-soluble, LMW, non-protein bound

Barbiturates
ETOH
Lithium
Salicylates (ASA)
Heavy metals
Beta-blockers

Hemoperfusion is preferred for removal of which elements?

Lipid soluble, highly protein bound and large MW

What is the mixed acid-base disorder from ASA poisoning?

Metabolic acidosis + Resp Alkalosis

What are the indications for hemodialysis in ASA overdose?

ASA level > 6 mmol/L at >6h post ingestion

Chronic overdose with altered LOC

Noncardiogenic pulmonary edema

Cerebral edema

Severe refractory metabolic acidosis

Confusion or worsening neurologic symptoms

Renal failure (since ASA excreted by kidney)

Deterioration in condition despite supportive care

How can enhanced elimination of MeOH or ethylene glycol be ensured?

Alcohol Dehydrogenase Inhibitor
- methylpyrazole inhibits conversion of methanol to toxic metabolites
- Ethanol drip: methanol eliminated by kidney and lungs slowly

Folate, Thiamine, pyridoxine

Hemodialysis
- Removes methanol AND its toxic metabolites

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