Mahesh Raj Sigdel

Aug 29, 2014

When to think of/discuss RRT in CKD !!!

CKD 4

Definition of CKD
Duration
GFR
Kidney damage
Abnormality in urine
USG renal biopsy
Transplant

Stages of CKD
KDIGO 2012: CGA

Stages of CKD

Signs & symptoms of CKD

Functions of CKD:
1.
2.
3.
4.

Excretory
Regulatory
Endocrine
Metabolic

When in CKD 5, options:

1. Dialysis

Hemodialysis
Peritoneal dialysis

2. Transplant
3. Supportive care, only

Availability
Money
Kidney
Wish of the
patient

Other issues to consider

Vision
Manual dexterity
Willingness to do self care
Support available at home
Access to Hemodialysis facility
Tolerance to any of the modality

Which modality of RRT is the best ?

Having considered everything,
Kidney TX
Cheap
Prolonged life
Quality life

Why ???

When to initiate Dialysis in CKD ie

maintenance dialysis ???
CKD 5
A patient of CKD 5 who in absence of acute
reversible factors has indications for
emergency hemodialysis
eGFR around 7-10; may be higher in diabetics
and selected patients
Symptomatic
Clinically
biochemically

Emergency indications for HD:

1. Hyperkalemia, esp associated with
ECG changes
2. Significant metabolic acidosis
3. Medically refractory pulmonary
edema
4. Uremic encephalopathy
5. Uremic pericarditis
6. Uremic bleeding

Water treatment plant

Vascular access
1. Temporary
2. Permanent
AV fistula
AV graft
Central venous catheters (jugular,
femoral, subclavian)
Simple (non cuffed)
Tunnelled (cuffed/permcath)

Avoid subclavian catheters

Principles of Dialysis
Diffusion
Ultrafiltration

Counter current flow

Maintenance HD
Three times/week, life long
4 hours/each session
With adequate blood flow

Complications of HD
Hypotension
Cramps
Nausea vomiting
Chest pain
Allergic manifestations
Infection, fever
Dialysis disequilibrium syndrome,
DDS

Peritoneal dialysis

Different types of PD
Intermittent peritoneal dialysis (IPD)
Continuous ambulatory peritoneal dialysis
(CAPD)
Nocturnal intermittent peritoneal dialysis
(NIPD)
Continuous cyclic peritoneal dialysis (CCPD)
Automated peritoneal dialysis (APD)

Complications of PD
Infection:
Peritonitis
Tunnel
Exit site

Hernia
Backache
Hydrothorax
Hyperglycemia
Hypertriglyceridemia/dyslipidemia
Chronic encapsulating peritonitis
Ultrafiltration failure

Compare HD vs PD
Cost
Accessibility
Finding slots
Vascular access
Freedom of mobility
Hemodynamic instability
Freedom to drink water, diet, protein
Problem of anemia
Issues of peritonitis
Preservation of residual renal function

How to monitor a patient on dialysis?

Clinically ie symptoms
Fluid overload
BP
Weight: dry weight
Anemia
Serum albumin
Skin fold thickness
Ca, Phosphorus, iPTH & bone health
Frequency of infection
Patient satisfaction
Quality of life

Which RRT modality will you propose

to your patient ???
That chosen by the well informed patient

Thank you ! !