1. Renal Replacement Therapies Dr Phyo AungEmergency Medicine Registrar

2. This presentation will include Causes of renal failure Dialysis Techniques Complications of dialysis Common problems in dialysis patients Download link : will be posted in

3. Why renal failure talk? Common patients population 10th leading cause of death (2008 data) : 3224 deaths One in nine Australians over 25 years has reduced renal function Patients receiving dialysis treatment per year ( 2009)=10341 Leading cause of death in Aboriginal populations , 10 times higher than rest of populationEconomic impact of ESKD $ 800 millions per year ( All facts and numbers from Kidney Health Australia )

4. Acute renal failure defination Acute Kidney Injury Network (AKIN) www.akinnet.org criteria Abrupt reduction ( within 48 hours ) in renal function Absolute increase in serum creatinine (> or = 100 umol/L)Percentage increase in serum creatinine > or = 50% from base line ( 1.5 fold from the base line ) Reduction in urine output ( < 0.5 ml/kg per hour for more than six hours)

5. Causes of Acute Renal Failure Pre Renal ( Renal Hypo perfusion) Intravascular volume depletion ( dehydration , blood loss) Severe hypotension ( drug overdose , sepsis , shock )pump failure ( myocardial causes) Renal artery emboli Renal ATN ( Acute Tubular Necrosis from a/c pancreatitis ,burn ,sepsis , toxins including exogenous and endogenous ) Interstitial nephritis / AGN Hepatorenal syndrome Post Renal Renal vein thrombosis , Ureteric stones , Prostate , retroperitoneal f fibrosis , increased intra abdominal pressure )

6. ECG Changes

8. Hyperkalemia Treatment

9. Indications for renal dialysis Hyperkalemia ( refractory Rx , persistently > 6.5 mmol/L)Pulmonary Odema ( Refractory Rx ) Severe Acidosis ( pH < 7.1 ) Uraemic complications ( pericarditis , encephalopathy )Anuria or oliguria ( urine < 200ml in 12 hours ) Drug Overdoses Removable drugs ( Lithium , Barbiturates , Salicylates , Methanol , cephalosporins , aminoglycosides ) Non removable drugs ( Digoxin , tricyclic antidepressants , pheyntoin, benzodiazepines , beta blockers , OHAs)

10. Types of dialysis IHD ( Intermittent Haemodialysis ) : day procedure setting . 3 times per week : mostly for ESRD patients Peritoneal Dialysis : home dialysis , 4 -5 exchange times per day or overnight procedure . Less effective than HD Continuous Renal Replacement Therapy CVVH – Continuous Venovenous Hemofiltration CVVHD – Contiouous venovenous Hemodialysis CVVHDF – Continuous venovenous Hemodaifiltration

11. Different types

12. Typical dialysis machine

13. Diffusion Convection

14. CVVH

15. CVVHD

16. CVVHFD

17. VasCath for dialysis Mahurkar Double Lumen Catheter Medcomp Duo Flo IJ Catheter

18. Advantages and disadvantages Advantages Haemodynamic Stability – patients who cannot tolerate IHD are candidate for CRT Slower electrolyte and fluid shifts effective removal of larger molecules Disadvantagesneeds skills for vascular access continuous anticoagulation => risk of bleedingICU support needed

19. Complications in IHD patients Vascular Complications AV fistula = lifeline for ESRD patients 1) Bleeding common complication , from minor trauma or after HD Rx : firm gentle pressure x 10 -15 minutes topical gel foam to avoid vigorous pressure IV DDAVP or Protamine sulfate for heparin reversal 2) loss of thrill or bruit over fistula – thrombosis Rx : urgent vascular consult for clot removal Avoid : BP cuff , IV cannula , Central line over access arm 3) Infection over vascular access : common Rx : needs admission for IV anti Single loading dose of Vancomycin and loading dos e of aminoglycoside followed by cephalosporin

22. Non vascular complications in IHD patients Hypotension Most common cause = sudden reduction in circulating volume during and after HD Other important causes Acute haemorrhage from various sited due to qualitative platelet defect , Rx administration of DDAVP Occult GI Bleeding Anaphalytic reaction t o contents in dialysateSevere Hyper kalemiaPericardial tamponade due t o pericardial h’age or worsening pericardial effusion

23. Dyspnoeain ESRD Volume Overload Congestive Heart Failure 10-30% higher prevalence in dialysis patients ESRD+CHF = 83% mortality at 3 yearsOther Causes of dyspnoea Pleural Effusion Pleural Haemorrhage Air Embolism less common with newer dialysis machines more common in usage of subclavian catheters “ Mill wheel murmur “ crunching sound on auscultation Rx : clamp the catheter and stop dialysis place patient in the left lateral decubitus position if continued decompensation : aspirating air backwards

24. Altered Mental State in IHD Patients Dialysis Disequilibrium Syndrome e (DDS ) mostly occurred during or immediately after haemodialysis Symptoms included headache , nausea , vomiting , muscle cramps , confusion , seizures or coma . The syndrome is triggered by rapid movement of water into brain cells following the development of transient plasma hypoosmolality as solutes are rapidly cleared from the bloodstream during dialysis . Rx : supportive ( usually self limiting ) resolved after fluid and solutes are re distributed across cell membranes.

25. Differential Diagnosis of confusion in IHD Uremia Hypertensive EncephalopathyHypocalcaemiaHypoglycaemiaHyperkalemiaHypovolemiaIntracranial haemorrhage : high risk of spontaneous bleeding Subdural Haemorrhage are common Have a low threshold for CT scan Dialysis Dementia chronic dialysis patient . Due to aluminium or phosphate binding in brain Rx : Desfuroxamine

26. Chest Pain in CRF Pericarditis occur 6 to 10 % of ESRD pt usually those who have yet to start dialysis lacks the typical ECG changes * Rx : hemodialysis Acute Coronary Syndrome 50% of all death in ESRD due to cardiovascular disease 25 to 40 % have LV dysfunction risk factor usually present ( DM , HT , hyperlipidaemia ) Silent ischemia is also common chest pain during dialysis is ISCHEMIC until proven otherwise dialysis is like a stress test , should delay HD in patients with unstable angina for at least 24 hours.

27. Troponins Regulatory proteins found in cardiac and skeletal musclethree subunits T , I and C Genes encoding for both cardiac and skeletal isoform Tn C is identical : so not useful for TnC. Theories for elevation Tn in CRF inflammatory response to CRF uremic myopathy subclinical myocardial injury from chronic fluid overload reduced renal clearance CK MB will be elevated up t o 50% of CKD patients

28. EMCREG Recommendations Emergency Medicine Cardiac Research &Education Group Elevations of Tr T or I likely represent myocardial injury and should not be considered non specific due to CRF Patients with elevated Tr , no matter how minor , are at higher risk for cardiovascular mortality and over all mortality. Elevated Tr may not be secondary to ACS , patients with CKD are higher risk . Any elevation in Troponin should warrant further cardiac evaluation. Patient with CKD having chronic low level trop require s measuring a typical rise in Tr over a period of hours improves diagnostic accuracy . ( with serial blood and ECGs)

29. Peritoneal Dialysis Complications Peritonitis is the most common complicationPt present with abdomen pain , fever , malaise and dialysis effluent become cloudy. Peritoneal fluid sent for Gram’s stain , culture , Total and DC. Dx : > 100 WBC/mm3 with neutrophils predominant or culture positive. Rx : loading dose of Vancomycin IP +/- gentamicin IP follow ed by once daily dose IP at the time of exchange.

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