Transcript Chronic Kidney Disease

Peeing is a wonderful thing
Acute Hemodialysis
Jennifer Stoddard Klenzak, MD
Pinehurst Nephrology Associates
5/24/2011
 Who receives dialysis in the hospital?
Acute kidney injury
ESRD patients
different
different
different
different
populations,
needs,
meds,
prescriptions for dialysis
What is Acute Kidney Injury?
 Decrease in GFR
 Relative loss of clearance
 And why do we care?
 Insert image
Variables affecting creatinine
besides GFR








Malnutrition
Liver disease
Pregnancy
Body habitus
Ethnicity
Vegetarianism
Volume status
Age
Stage 3 CKD
 7.6 million Americans
 Asymptomatic (the Silent Killer)
 Severely increased risk of
cardiovascular events and death
 These patients are unlikely to live long
enough to require dialysis (one in
twenty will reach stage 5)
Causes of AKI
 Acute Tubular Necrosis
 Prolonged ischemic injury
 Contrast nephropathy
 SIRS
 “post-operative” AKI
 Other derangements of homeostasis
leading to toxic or ischemic injury
 Systemic Inflammatory Response
Syndrome
 Release of interleukins, oxidative
metabolites
 Injury to renal tubular epithelial cells
 Decreased perfusion related to hypotension
Causes of AKI, cont.
 Rhabdomyolysis
 Statin-induced
 Heat stroke
 Muscle injury
 “Found down”
 Compartment syndrome
 Trauma
 Poisoning/Toxins/Overdose
 Aspirin
 Antifreeze/Ethylene glycol
 Methanol
 Hyperuricemia
 Tumor Lysis Syndrome
 Rapidly Progressive Glomerulonephritis
 Anca-associated disease
 Lupus Nephritis
 Goodpasture’s Syndrome (Anti-glomerular
basement Antibody Syndrome)
 IgA
 Cryoglobulinemic Vasculitis
 Myeloma Kidney
 Cast nephropathy
Indications for hemodialysis








Volume Overload
Hyperkalemia
Uremia
Encephalopathy
Pericarditis
Metabolic Acidosis
Toxin clearance
Platelet dysfunction
Dialysis Prescription
 Indication
 Hemodynamic status
 Chronicity of illness
 Comorbidities
Case 1
 52 year old female ESRD, MWF, patient
missed Friday treatment. Saturday
night presents to the ED with
complaints of weakness.
 What measures could be taken to keep
the patient alive until she gets on the
machine?
 What measures could be taken to keep
the patient alive until she gets on the
machine?
 Calcium gluconate
 Albuterol
 Insulin/D50
 Kayexalate
 Lasix?
 Bicarbonate
 What is the most likely complication of
this acute dialysis treatment?
 How can the dialysis prescription
decrease the risk of this event?
 79 year old man admitted with AMI. He
has advanced chronic kidney disease at
baseline. After an emergent cardiac
cath, he develops cardiogenic shock
and becomes oliguric.
 Later that night, he is on bipap, with
worsening hypoxemia, and despite high
dose diuril and lasix, makes no urine.
 Is dialysis indicated? Why?
 What is the goal of treatment?
 What are the expected risks?
 Prescription?
 26 year old man who presents to the ED with
headache and lethargy. He has noticed
fatigue, dyspnea with exertion, chest pain,
loss of appetite, food aversion, and cold
intolerance for approximately one month.
 On exam, BP is 228/112, his skin is darkened,
conjunctivae are pale, nail beds are pale,
heart is regular and bounding, and friction
rub is present.
Labs
 BUN 278
 Creatinine 23.2
 Hgb 7.4
 Renal Ultrasound Normal
 UA 3+ protein, 1+ blood
 Is dialysis indicated? Why?
 Is there an expectation of renal recovery?
 Potential complications during dialysis?
 Prescription?
 18 year old female admitted with acute
renal failure and hemoptysis.
 She receives 1000 mg solumedrol and
undergoes renal biopsy.
 She starts plasmapheresis and dialysis the
next morning.
 Are there any special considerations for her
treatment? Potential life-threatening
complications?
 Is there an expectation of renal recovery?
 Dialysis prescription?
 62 year old woman found down at
home. Medical history of depression.
Otherwise healthy.
 Creatinine 3.2 mg/dl
 Serum CO2 4 meq/L
 Anion gap 24
 Osmolar gap 22
 Is dialysis indicated? Why?
 What other measures should be taken
here?
 Do we expect renal recovery if she
survives?
Interdisciplinary Team
Approach to AKI
 Nephrologist
 Diagnosis and management of renal disease
 Access management
 Interventional radiologists and nephrologists
 Vascular surgeons
 General surgeons
 Nurse
 Floor nurse/ICU nurse
 Hemodialysis nurse
 PD nurse
 Dietician
 Assessment of nutritional needs of patient
in acute setting
 TPN/TF
 Electrolyte replacement
 Education of patient and family
 Social Worker
 Discharge planning
 Financial concerns, Disability, Insurance
 Pharmacist
 Renal dosing, precautions
AKI: Role of the Nurse
The bedside nurse assessment
the key ingredient











Blood Pressure
Pulse rate
Orthostasis
Strength
Mental Status
Fever
Oxygen requirements
Access
Bleeding
Vomiting, diarrhea, constipation
Cramping
 Ongoing assessments are the integral data
 How do the bedside assessments affect the
management of the patient?
 The dialysis prescription?
 Access plans?
 Dialysis Nursing Assessments: with the
patient during the riskiest time








Bleeding
Hypotension
Tachyarrhythmias
Seizure
Loss of consciousness
Cramping
Pain
Access assessment
AKI Dialysis Nursing
Interventions






Fluids
Medications
Changes in Qb
Lytic instillation for catheters
Removing catheters
Stopping treatment
 Returning blood
AKI Pharmacology
 “Nephrotoxic Agents”
 NSAIDS
 Iodinated Contrast Dye
 Gentamicin
 IV acyclovir
 Drugs to avoid in the patient with AKI
 Demerol
 Gadolinium
 Fleets
 Metformin/glucophage
Proceed with caution
Ace inhibitors, ARBS, DRIs
Spironolactone
K supplementation
Oral acyclovir
LMWH
Coumadin
 Acute Kidney Injury
 Immunosuppressants
Solumedrol/Prednisone
Mycophenylate
Cyclophosphamide
Rituximab
Dosing
Side effects
Toxicity
Indications
 IVF
 When to give?
 Compositions
 Bicarbonate based solutions
 Rhabdomyolysis
 Tumor Lysis Syndrome
 Metabolic acidosis
 Diuretics
 Loop diuretics
 Thiazides
 Acetozolamide
 Antihypertensives
 Others
 Rasburicase
 Fomepizole
Acute Dialysis: Antibiotics
 Antibiotics dosed with dialysis
 Vancomycin
 Cubicin
 Gentamicin
 Ceftazidime
 Cefazolin
Acute Dialysis: ESAs
 Epogen, Aranesp, Procrit
 Iron Supplementation
 Oral vs. IV
 To give or not to give in the acute setting?
 Pressure from outpatient units to “keep hgb
in goal range” at discharge
Bone and Mineral Metabolism
 Vitamin D3
 Activated Vitamin D
 Binders
 Calcium-based vs. calcium-free
 Calcimimetics (Sensipar)
 Calciphylaxis
 Thiosulfate
 Bisphosphanates
Transition to Chronic Setting
 Communication between Acute Dialysis Nurse
and Outpatient Dialysis Nurse
 Crucial for success
 What was patient’s diagnosis during
hospitalization?
 For the outpatient nurse:
 How will the hospitalization affect the outpatient
dialysis prescription?
 If the patient is actively listed for transplant, how
does this event affect his/her candidacy?
Was the hospitalization related to a
complication of outpatient dialysis?
Syncope or stroke
Hypoglycemia
Arrhythmias
Steal syndromes
Infections related to bacteremia
Osteomyelitis
Bacterial endocarditis
Other invasive infections
 Was the hospitalization related to the
way the patient’s outpatient
treatments have been going?
No shows
Signing off early
Failure to UF
Intradialytic hypotension
Cramping
Excessive weight gains
Inadequate adjustments in edw
Transportation
 Invasive procedures and potential
complications at dialysis
 Renal biopsy
 Cardiac cath
 Debridement/treatment of lower extremity
wounds
 Fistulagrams
 Loss of access
 New cancer diagnosis?
 Other high risk invasive procedures:
lumbar puncture, bronchial biopsies, major
surgeries
Discharge meds
 Antibiotic orders?
 Antihypertensive medication changes?
 New anticoagulants?
 Immunosuppressants?
Summary
 Acute hemodialysis creates specific
needs related to optimal patient
outcome and patient safety
 Protection of renal function and chances of
recovery
 High risk medications and procedures
 Transition to outpatient setting
 Short and long term outcomes perspective
GO HEELS!!!!