Indication of dialysis

in Acute Renal
Failure

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 Indications of dialysis in ARF

 Severe fluid overload

 Refractory hypertension
 Uncontrollable hyperkalemia
 Nausea, vomiting, poor appetite,
gastritis with hemorrhage
 Lethargy, malaise, somnolence,
stupor, coma, delirium, asterixis,
tremor, seizures,
 Pericarditis (risk of hemorrhage or
tamponade)
 bleeding diathesis (epistaxis - GI
bleeding and etc..)
 Severe metabolic acidosis 2
 Indications of Dialysis in Chronic RF

 Pericarditis
 Fluid overload or pulmonary edema
refractory to diuretics
 Accelerated hypertension poorly
responsive to antihypertensives
 Progressive uremic encephalopathy
or neuropathy such as confusion,
asterixis, myoclonus, wrist or foot
drop, seizures
 Bleeding diathesis attributable to
uremia 3
 Indications of Dialysis in Chronic RF

 Persistent nausea and vomiting

 Plasma creatinine concentration
>10-12 mg/dl or BUN >100 mg/dl
 Anorexia
 Depression, decreased attentiveness
and cognitive tasking
 Severe anemia unresponsiveness to
erythropoietin
 Persistent pruritus or restless leg
syndrome
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 Drugs and dialysis patients
 Hypotension in HD:
1- 0.9 % saline >= 100 ml
2- hypertonic saline
3- hypertonic glucose
4- mannitol & albumin
5- midodrine (alfa adrenergic
agonist) 10mg orally 30 min before
HD.
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 Drugs and dialysis patients
 Muscle cramps :
1- 0.9 % saline
Prevention:
1-Vitamin E 400 IU at bedtime
2- Quinine 325 mg at bedtime
3- Carnitine
4- Oxazepam 5-10 mg 2 hours
before dialysis.

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 Drugs and dialysis patients
 Anticoagulation
1- Heparin: 2000 U bolus , 1000-1200 U/h
until 1 hour before dialysis.
Side effects of heparin: hyperlipidemia ,
thrombocytopenia , itching, hyperkalemia
2- Heparin free dialysis: with periodic saline
rinse 100-200 ml/ 30 min
3- regional citrate anticoagulation.

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 Drugs and dialysis patients
Low molecular weight heparin :as a single
dose at the beginning of dialysis.
It ameliorates hyperlipidemia.
 Vitamins : loss into the dialysate, poor
nutrition, decreased absorption .
1- Folic acid and B vitamins as supplements
2- vitamin C : 60-100 mg/day
(hyperoxalemia)
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 Drugs and dialysis patients
 Vitamin A : serum vitamin A concentration
are almost always elevated due to decreased
renal catabolism, increased concentration of
retinol binding protein and dialysis can not
remove it.
Side effects of hypervitaminosis A :anemia,
abnormalities in lipid and Ca metabolism.
Multivitamin drugs have vitamin A and
should not be used in patients with renal
failure.
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 Drugs and dialysis patients
 Vitamin D: is necessary for patients with
secondary hyperparathyroidism and used as
calcitriol or rocaltrol.
 Vitamin E: increased red cell survival.
 Vitamin K: vitamin K deficiency can occur in
patients receiving antibiotics that suppress
vitamin K production by intestinal bacteria.
In this condition 7.5 mg/wk vi.K is beneficial.

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 Drugs and dialysis patients
hemorrhage
 Desmopressin: a synthetic form of vasopressin
increases release of von Willebrand factor. a
dose of 0.3 ug/kg in the form of injection or 3
ug/kg in the form of spray.
 Cryopreciptate: high concentration of von
Willebrand factor leads to temporary
improvement in uremic platelet function.
 Conjugated Estrogen: a single dose of 25 mg
improves platelet function for 10 days.

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 Drugs and dialysis patients
Antibiotics
 Aminoglycosides and Vancomycin cause
autotoxicity and dose must be decreased.
 Nalidixic Acid, Nitrofurantoin ,Neomycin
and Methenamin mandelate should not be
used in dialysis patients.

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 Drugs and dialysis patients
hyperphosphatemia
 Aluminum hydroxide: previously used for high
phosphate, causes aluminum toxicity, anemia, bone
pain and bone fracture and CNS dysfunction,
dementia, seizures, coma and death. If serum
phosphorus is high and can not decreased with
other drugs, Aluminum used for a limited time.
 Carbonate Calcium: is widely used but in severe
hyper P causes Ca deposit in tissues and should not
be used.
 Sevelamer: a new drug for hyper P without side
effects of Aluminum and Ca, but is very expensive.
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 Drugs and dialysis patients
Antihyperglycemic agents
 Chlorpropamide and Glibenclamide : have
risk of hypoglycemia in dialysis patients,
their metabolism partly is in the kidney, and
their use should be avoided.
 Insulin :can be used in dialysis patients.
 Tolbutamide and Glipizide also can be used.

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 Drugs and dialysis patients
Analgesics
 Morphin and other opiate drugs should be
used with caution in dialysis patients and
dose must be decreased.
 Meperidine (Pethidine) metabolizes to
normeperidine and it is toxic, causes seizures.
 Acetaminophen :can be used in renal failure
patients.
 Aspirin and NSAIDs have risk of GI bleeding.

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