Dialysis manual
  • Introduction
    • The purpose of this manual is to be a guid for the internal medicine physician as well as the dialysis technician in caring for the dialysis patient
    • This manual will provide assistance in the management of the dialysis patient for most common scenarios in the absence of a nephrologist however it is not comprehensive to cover every Possibility of pathologic conditions
    • Consulting a nephrologist is still required for Difficult or uncommon cases As well as in fine-tuning the details of the common and straightforward conditions
    • The manual is divided along the major categories involved with the care of the dialysis patient
      • End stage renal disease requiring dialysis is a complex multisystem disease involving almost all major systems of the body
      • Many of the categories mentioned below are interrelated and should not be considered as existing in a vacuum but rather a multidisciplinary approach to the care of the dialysis patient covering all categories is what is required for optimal outcomes
      • There are many objective end points that should be aimed for and met to achieve optimal care
      • The objectivity of those endpoints in each category helps standardize the care for the dialysis patient thus achieving a common ground among all of the dialysis facilities in judging the care Delivered as well as guiding Improvement processes
  • Dialysis equipment
  • Access
    • Types
      • Arteriovenous fistula
        • Discription
          • Native vain connected to an Artery and undergoes enlargement due to high-pressure bloodflow
          • Usually requires 2 to 3 months for full maturity
          • May require interventional procedures to enhance maturity
          • Once mature usually becomes reliable for years
        • Types
          • It's preferable to use the distal veins prior to using the proximal veins
          • The purpose for that is to salvage the venous system as much as possible and to make it last for as long as possible
          • The three most common types are
            • Radiocephalic fistula
            • Brachiocephalic fistula
            • Brachiobasilic fistula
      • Arteriovenous graft
        • It is established by connecting conduits of special material between the artery and vein
        • The utilization of the graph is usually done when a fistula Cannot be obtained Due to small veins
        • The graph can be cannulated many times without a problem but it's lifespan is generally shorter than The fistula however it can be years
      • Tunneled dialysis catheters
        • This is an option when neither the graft or a fistula is available
        • It is similar to the temporary catheter in regards to the intravascular portion
        • The extravascular portion is tunnelled under the skin for an average distance 10 cm And exits the body usually in the high chest area
        • The purpose of the tunnel is to provide mechanical stability as the subcutaneous tissue scars around the extravascular portion of the catheter especially the cuff and holds it in place it also provides mechanical barrier against infection
        • The life span of a catheter is usually several months with an average half-life of six months
        • It is easily placed and can be used immediately after placement
        • It is the best option if immediate dialysis is required
        • The first priority is for the right internal jugular vein approach as this is anatomically the most favorable approach due to minimal curvature in the central veins
        • When this approach is unavailable due to scarring of the veins on the right side left internal jugular vein approach is considered second choice
        • The third but least favorable option is femoral vein tunneled catheter whether that is right or left side due to high risk of infection and less stability
        • It is very important to choose the right length of the catheter depending on the approach
        • Right internal jugular vein catheters are usually 19 cm to 23 cm Depending on the person's body habitus
        • Left internal jugular vein catheters are usually 23 cm
        • Femoral vein, catheters are usually at least 28 to 35 cm
        • It is very important that the tip of the catheter being in the superior vena cava right atrial junction for the upper body catheters and high inferior vena cava for the lower body catheters
        • When the catheter tip is not in the appropriate place it could precipitate arrhythmias
        • The place where the catheter enters the vein is called the venotomy site and the place where the catheter exits the body is called the exit site
        • The venotomy sit is closed during placement and the catheter remains under the skin But having a smooth curvature at that site as the catheter enters the vein is very important to avoid future dysfunction in the catheter
    • Complications
      • Thrombosis
        • This complication happens when the flow is reduced and there is stagnation in the shunt culminating in thrombosis
        • The most common type of precipitating factor is stenosis or narrowing endovenous outflow of the graph for the fistula
        • Low blood pressure can sometimes precipitate thrombosis as well due to low flow
        • Grafts usually get thrombosed far more common than fistulas
        • Catheters can develop thrombosis as well and they show up as dysfunctional catheter which means the blood flow through the catheter is low and prohibiting delivering good dialysis
        • Treatment for thrombosis of graft or fistula is thrombectomy which is removal of the clock in the graft or the fistula usually through interventional means coupled with fixing the underlying problem such as the stenosis in the venous outflow
        • Treatment of the dysfunctional tunnel catheter is usually with exchange
        • The application of aspirin Plavix or Coumadin to prevent or reduce the risk of thrombosis is sometimes used however not proven
        • There is a possibility that fish oil can help along those lines as well
      • Infection
        • Tunnelled dialysis catheters
          • The most likely access to get infected is the tunnel dialysis catheter
          • The treatment generally relies with giving antibiotics to the patient is afebrile for 24 to 48 hours
          • After achieving afebrile states catheters must be exchanged as sterilizing the catheter is never achieved with antibiotics
          • Sometimes if the patient is hemodynamically unstable catheters must be removed immediately prior to achieving afebrile states
          • other such conditions requiring immediate removal of the catheter is tunnel infection or sepsis with fungemia
          • Persistent fever or bacteremia after removal of the catheter and the administration of antibiotics is usually a sign of a more serious complications such as metastatic infections and abscess formation in the body
          • Vancomycin gentamicin combination is good as an initial treatment to achieve afebrile state pending the sensitivity profile of the blood cultures
        • Grafts
          • Grab can sometimes get infected however the management is far more complicated compared to a catheter
          • If an infection in the graft is clinically suspected along with positive blood cultures the only management is removal of the graft
          • Antibiotics are certainly used first to achieve afebrile state unless the patient is hemodynamically unstable in which case the graph must be immediately removed
          • Persistent bacteremia after antibiotics is another indication to remove the graft
          • Sometimes if the infection is mild and Negative blood cultures are achieved easily without any relapse in bacteremia the decision on removing the graph may be postponed
          • Vancomycin gentamicin combination is usually good in the setting as well after which fine-tuning the management to the sensitivity profile of the blood cultures is preferred
        • Fistula
          • Infection in fistula is a rear events as this native tissue has far more stronger immunity than prosthetic devices
          • Having said that infections can happen and they have to be diagnosed with clinical suspicion as well as positive blood cultures
          • Treatment is usually with antibiotics and surgery is really indicated
          • Sometimes aneurysmal dilation can be a harbor for persistent infections in which case surgical excision is indicated
      • Vein damage
        • The longer veins are use the more the scar and Develop stenosis
        • The most advanced form of this entity is central venous stenosis a condition that manifests with loss of the central Venus vasculature
        • Peripheral narrowing of things can be treated with balloons and possibly stands as well
        • Central stenosis can sometimes be treated with balloons and possibly stenting as well however more advanced forms of central stenosis may not be amenable to interventional treatment
        • Surgical treatment of central stenosis is doable however requires extreme experience on the operator side
      • Flow
        • Fistula's and drafts can have high flow states or low flow states that can manifest in pathologic conditions
        • Limb swelling
          • This complication usually happens if there is insufficient outflow to drain all the venous return from the arm including the shunt and this is usually a sign of central venous stenosis problem
          • Limb swelling can occasionally happen without a central venous problem from purely the high flow state
          • Treatment is done with the reducing the flow of the fistula by narrowing the fistula with external banding for partial ligation if the venous outflow cannot be optimized
          • Optimization of venous outflow is the best treatment by treating the central stenosis with balloons and or stenting
          • If optimization of venous outflow is unachievable reducing the flow of the fistula or possibly even complete ligation maybe indicates it to restore edema free state
        • Limb ischemia
          • This complication happens when the fistula takes most of the arterial supply of the arm and not enough arterial blood supply is delivered to the rest of the arm
          • It is usually a sign of extremely high flow fistula or an indigenous vascular problem in the arterial vasculature of the arm
          • Treatment is usually done by optimizing arterial vascular inflow such as treating any preferable vascular disease
          • Many times partial ligation or banding of the fistula is indicated to reduce the flow to balance that with the distal perfusion of the arm
        • High output
          • There is a rare complication of heart failure from the high flow state of the fistula
          • The diagnosis must be accurately made and this must include a cardiologist and the treatment is ligation of the fistula or reducing the flow
    • Temporary dialysis catheter
      • Indication
        • When Dialysis is indicated on emergency basis And other options for access not available
      • Placement
        • Femoral approach is very common and acceptable as long as the catheter is only needed for a few days
        • These catheters may stay for several weeks however the risk of infection increases tremendously
        • Upper body approach is not recommended as these catheters are usually stiffer than there tunneled counterparts thus creating more scarring in the veins that makes these veins unsuitable for future placement of tunnel catheters or disrupting the outflow for fistulas or grafts
        • Subclavian approach is never indicated as the risk of scarring is almost hundred percent
      • Complications
        • The most common complication is infection
        • It is quite dependent on time the longer the catheter is in the higher the chance of getting an infection
        • Treatment is to remove the catheter immediately as sterilizing the catheter with antibiotics is never successful
        • Dysfunction in these catheters is sometimes a problem and the treatment is removal of the catheter as well
      • Removal
        • When they need for the catheter is satisfied or when the complication develops
        • Pressure must be applied for at least 20 minutes to the site of venipuncture to obtain homeostasis as the puncture in the van is usually 11.5 French
  • Clearance
    • Concept
      • Clearance is the measurement of the "dose of dialysis"
      • It is used to optimize the dialysis prescription and guaranteed deliverance of dialysis With acceptable quality to the patient
    • Measurements
      • Urea reduction ratio
        • It is calculated by dividing the difference between the pre-and post dialysis urea over the pre-analysis urea multiplying by a hundred
        • (Upre-Upos)/Upre*100
      • KT/V
        • Is also a numerical calculation however more complicated than your URR but more accurate also
        • There are two main types
          • single pool KT / V or sKT/V
          • equilibrated KT/V or eKT/V which is more accurate
    • Target
      • URR>70%
      • sKT/V >=1.4
      • eKT/V >=1.2
    • Low clearance
      • Generally low clearance needs a comprehensive approach with the assistance of a nephrologist to appropriately address however there are simple things that can be done to improve low clearance as well
      • Increasing the time on dialysis
      • Improving the pump blood flow rate Generally referred to as QB
      • Improving the Dialysate flow rate Referred to as QD , however the yield plateaus significantly after 1.5 times the blood flow rate
      • Analyzing the access
        • A catheter usually has lower clearance compare to a fistula or a graft
        • low flow through a fistula or a graft can be the source of the problem
  • Blood pressure
    • Pathology
      • Hypertension is a major contributor to kidney disease and is almost a unanimous finding in dialysis patients
      • It is a cause of kidney disease and eventually becomes a consequence of kidney disease as well in a vicious cycle
      • Many times we see extremely elevated numbers in the range of 200+for the systolic
    • High blood pressure
      • Hi blood pressure must be aggressively treated in a dialysis patient just the same as a non-dialysis patient as the risk of cerebrovascular accident is the same if not higher
      • The target for the treatment of high blood pressure may be slightly different than the general population as a target for systolic blood pressure 140 to 160 is generally acceptable
      • Excess volume must always be treated as well because it is a major contributor to elevated blood pressure in the Dialysis population
        • Trading high blood pressure with excess volumes will only mask that excess volume
          • Generally speaking excess volume must be removed first prior to adjusting antihypertensive management unless the numbers are extremely elevated
          • If blood pressure is extremely high and there is excess volume treatment of the blood pressure is okay along with removal of excess volume
          • when the numbers become in a safe and acceptable range we must back off antihypertensive management allow for the full Removal of the excess volume
      • Choice of medications is not as important as the achievement of Target Control
        • Obtaining numbers with in target regardless of the choices of medications is what is important
    • Low blood pressure
      • The concept of dry weight is very important in a dialysis patient
        • It is the weight where the Fluids of the patient are just right not in excess nor deficient
        • This weight is a moving target depending on the solid wt such as the fat or the muscle weight that may go up and down as the patient gains weight or loses weight
      • Low blood pressure in a dialysis patient may mean that the patient is below his dry weight
        • If the patient has excess fluid and he is certainly above his dry weight low blood pressure on Dialysis may mean the ultrafiltration is too fast for this particular patient
        • If the patient is above his dry weight and has low blood pressure on and off dialysis this may mean that the patient has a weak heart or a compromised cardiovascular system
        • It is extremely important to rule out infection or sepsis as the cause of the low blood pressure especially in patients with a catheter
        • Anemia is not a usual cause of low blood pressure
  • Volume
  • Potassium
  • Acid-base balance
  • Anemia
  • Calcium and phosphorus
  • Vitamin D
  • Secondary HPT
  • Nutrition
  • Executive summary