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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