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Mahesh Raj Sigdel

 Aug 29, 2014

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

CKD 4

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Definition of CKD

• Duration

 – GFR

 – Kidney damage – Abnormality in urine

 – USG renal biopsy

 – Transplant

• Stages of CKD

• KDIGO 2012: CGA

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Stages of CKD

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Signs & symptoms of CKD

Functions of CKD:

1. Excretory

2. Regulatory

3. Endocrine

4. Metabolic

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When in CKD 5, options:

1. Dialysis

• Hemodialysis

• Peritoneal dialysis

2. Transplant

3. Supportive care, only

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Availability

•

Money•Kidney

Wish of the

patient

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Other issues to consider… 

Vision

Manual dexterity

Willingness to do self careSupport available at home

Access to Hemodialysis facility

Tolerance to any of the modality

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Which modality of RRT is the best ?

• Having considered everything,

 – Kidney TX

Cheap

Prolonged life

Quality life

• Why ???

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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 foremergency hemodialysis

eGFR around 7-10; may be higher in diabeticsand selected patients

Symptomatic• Clinically

• biochemically

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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

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Water treatment plant

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Vascular access

1. Temporary

2. Permanent

AV fistulaAV graft

Central venous catheters (jugular,femoral, subclavian) – Simple (non cuffed)

 – Tunnelled (cuffed/permcath)

• Avoid subclavian catheters

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Principles of Dialysis

Diffusion

Ultrafiltration

Counter current flow

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Maintenance HD

Three times/week, life long

4 hours/each session

With adequate blood flow

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Complications of HD

Hypotension

Cramps

Nausea vomiting

Chest pain

Allergic manifestations

Infection, fever

Dialysis disequilibrium syndrome,DDS

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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)

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Complications of PD

Infection:Peritonitis

Tunnel

Exit site

Hernia Backache

Hydrothorax

Hyperglycemia

Hypertriglyceridemia/dyslipidemia Chronic encapsulating peritonitis

Ultrafiltration failure

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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

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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

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Which RRT modality will you propose

to your patient ???

• That chosen by the well informed patient

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Thank you !!!