You are on page 1of 20

So When ls Dialysis Appropriate?

So When ls Dialysis Appropriate?


lndications for dialysis in CKD:


uremic symptoms, like nausea, weight loss


recent change in philosophy to "early start:
patient is started on dialysis before

getting sick


attempt to start dialysis when creatinine clearance
is < 15 ml / min


diabetics are started on dialysis sooner (cr cl < 20
ml/min) because they don't tolerate uremia well
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Treatment
Treatment
The Philosophy of "Early Start

Dialysis
Early start dialysis
Conventional start dialysis
Well-being
Exponential lncrease in #
Exponential lncrease in #
'
'
s of Dialysis
s of Dialysis
Patients: Driven by Type ll Diabetes
Patients: Driven by Type ll Diabetes
U
S
R
D
S
Projected growth of the incident & prevalent ESRD
populations, by primary cause of renal failure
Figure 2.22
1980 1990 2000 2010 2020 2030
N
u
m
b
e
r
o
f
p
a
t
i
e
n
t
s
(
i
n
t
h
o
u
s
a
n
d
s
)
0
50
100
150
200
250
300
1980 1990 2000 2010 2020 2030
0
250
500
750
1,000
1,250
1,500
Incidence Preva lence
Diabetes
Ot her
Diabet es
Other
Calculated using a discrete time non-stationary Markov model.
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Dialysis
Dialysis
Goals of Dialysis
Goals of Dialysis
1. Solute / toxin removal (blood purification)
2. Removal of salt and water (ultrafiltration)
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Dialysis
Dialysis
Peritoneal Dialysis
Peritoneal Dialysis


catheter is inserted surgically or laparoscopically into
peritoneal cavity


dialysis fluid high in glucose concentration is instilled
through catheter and allowed to dwell in the cavity


uremic toxins diffuse from ECF into the peritoneal
fluid


ultrafiltration by osmosis (glucose in fluid)
Peritoneal Dialysis Catheter
Peritoneal Dialysis Catheter
PD Catheter
PD Catheter
in situ
in situ
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Dialysis
Dialysis
Peritoneal Dialysis Peritoneal Dialysis


patient can manually exchange dialysis fluids during
the day, and leave an exchange in peritoneal cavity
overnight


cycler dialysis: fluid exchanges overnight while
patient sleeps, and leaves an exchange in peritoneal
cavity during the daytime
Peritoneal Dialysis
Peritoneal Dialysis
-
-

Complications
Complications


infection of the
peritoneal dialysis fluid
(peritonitis)


glucose diffusion from
dialysis fluid into body:
caloric load,
hyperglycemia in some,
hyperinsulinemia,
elevated triglycerides


increased intra-

abdominal pressure
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Hemodialysis
Hemodialysis


blood is removed from the body and travels to the
hemodialysis machine where it is run across a
semipermeable membrane with a physiologic solution
on the other side of the membrane


uremic toxins cross into dialysate by diffusion and
convection


ultrafiltration by a hydraulic pressure (A

P ) placed
across the dialysis membrane
Hemodialysis
Hemodialysis
Hemodialysis: Vascular Access
Hemodialysis: Vascular Access
Vascular Access in Real Patient
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Hemodialysis
Hemodialysis


usually done as an intermittent

procedure, eg
for 4 hours 3 X a week


requires a vascular access to allow for
repeated needle insertion and high blood flow
rates


construction of an arteriovenous fistula in the
forearm, or


insertion of a prosthetic vascular graft in the arm,
or


indwelling catheter into a major vein
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Hemodialysis
Hemodialysis


hemodialysis can also be done in the home:


same sort of regimen as in the hospital (4h 3X
week)
or


short (2h) daily hemodialysis
or


slow nocturnal hemodialysis (8 h overnight, 6
nights a week)
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Hemodialysis
Hemodialysis
Complications
Complications


majority are related to the vascular access


infection (bacteremia)


thrombosis


inadequate blood flows


disequilibrium syndromes related to rapid
solute and water fluxes over a short period of
time
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Dialysis
Dialysis
With either type of dialysis, correction of uremia is only
partial


typical creatinines still are about 500 -

1000 umol/L
Chronic Kidney Disease
Chronic Kidney Disease
-
-

Dialysis
Dialysis
Which form of dialysis is better? Which form of dialysis is better?


very similar outcomes in both


choice of hemodialysis vs PD is driven by


patient choice


physician choice (medical indications, prejudice or
ignorance, reimbursement)


availability of appropriate facilities
Use of Hemodialysis
Use of Hemodialysis
vs
vs
Peritoneal
Peritoneal
Dialysis by Country
Dialysis by Country
US
Chronic Kidney Disease: Summary
Chronic Kidney Disease: Summary


almost any condition that causes renal disease can
lead to CKD


often the cause is unknown


retention of "uremic

toxins and salt/water leads to
generalized organ dysfunction (CV, neuro, blood,
bone.)


dialysis maintains life by removing uremic toxins and
salt/water


there is still accelerated cardiovascular mortality with
either dialysis or transplantation due to "non-

traditional

risk factors