LONG-TERM HEMODIALYSIS

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1 LONG-TERM HEMODIALYSIS

2 LONG-TERM HEMODIAL YSIS N.K. Man H6pital Ncckcr. Dcpartement ele Ncphrologie. Paris. Francc.J. Zingraff H6pital Necker. Dcparlcmenl de Nephrologie. Paris. France and P. Jungers H6pital Necker, Departement de Ncphrologie, Paris. France lllustrated by Martine Netter Springer-Science+Business Media, B.V.

3 Library of Congress Cataloging-in-Publicatioll Data Man. N. K. Long-term hemodialysis I by N.-K.'Man. and J. Zingraff. and P. Jungers. p. cm. Inc 1 udes index. ISBN ISBN (ebook) DOI / Hemodialysis. 2. Hemodialysis--Compllcations. 1. Zingraff. Johanna. II. Jungers. P. III. Title. [ONLM: 1. Hemodlalysis. 2. Hemodlalysls--adverse effects. 3. Kidnel' Failure. Chronic--therapy. 4. Long-Term Care. WJ 378 M266L 1995J RC901.7.H45M ' dc20 ONLM/OLC for Llbrary of Congress ISBN Printed on acid-ji'ee paper AII Rights Reserved 1995 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 1995 Softcover reprint ofthe hardcover Ist edition N o part of the material protected by this copyright notice may be reproduced or utilized in any form Of by any means, electronic or mechanical, inci ud ing photocopying, recording. Of by any information storage and retrieval system, without written permission from the copyright owners.

4 TABLE OF CONTENTS Preface Xl 1. Causes and consequences of end-stage renal failure Epidemiology of chronic renal failure Types of renal disease leading to ESRD Incidence of renal diseases leading to ESRD Changing pattern of epidemiology The uremic syndrome Accumulation of low-molecular weight waste products Accumulation of middle molecular weight toxins Loss of hydroelectrolytic regulation Loss of hormonal functions Indications for initiating dialysis therapy Criteria for initiation of dialysis Preparation of the patient for regular dialysis treatment 2. Basic principles of hemodialysis Transport mechanisms Diffusion (or conduction) Convection (or ultrafiltration) Adsorption Modalities of solute transport Solute transport in hemodialysis Solute transport in hemofiltration Solute transport in hemodiafiltration Evaluation of dialyzer performances Clearance

5 VI TABLE OF CONTENTS Dialysance Ultrafiltration Contribution of convection to the overall solute transport Assessment of solute mass removal 3. Blood access Standard arteriovenous fistula Alternative methods Autogenous vein grafts Other graft material Occasional devices Complications and long-term management of arteriovenous devices Stenosis and clotting Bacterial infections Excessive flow rate Temporary access methods 4. Dialysis equipment Dialyzers Flat plate dialyzers Hollow-fiber dialyzers Large surface area dialyzers and high flux dialyzers Residual blood volume Dialyzer thrombogenicity Reuse of dialyzers Dialysis membranes Chemical structure Permeability characteristics Dialysate delivery system Dialysate preparation Monitoring Hemodiafiltration monitor Computerized monitoring Disinfection of dialysate delivery system Dialysate composition Water treatment 5. Biocompatibility Activation of blood components Complement activation Clinical consequences of complement activation

6 TABLE OF CONTENTS VB Activation of blood coagulation 45 Acute anaphylactoid reactions 45 Long-term consequences of bioincompatibility Adequacy of hemodialyis, nutrition, and dialysis prescription 49 Quantification of dialysis efficacy 49 Urea kinetic modeling: the KtN concept 49 Correlations between KtiV (urea) and outcome 51 Nutritional parameters of dialysis adequacy 52 Assessment of nutritional status: the PCR concept 52 Correlations between nutritional parameters and outcome 53 Interrelationship between URR and PCR 53 Choice of adequate dialysis duration 54 K tn -based calculation of dialysis duration 54 Adequate dialysis prescription 56 Dietary prescription to the hemodialysis patient 57 Calorie-protein requirements 57 Sodium and water intake 58 N utri tional prescription 58 Integrated dialysis prescription Management of the dialysis patient 61 First hemodialysis session 61 Monitoring of later sessions 62 Vascular connexion 62 Heparinization 62 Fluid removal by ultrafiltration 63 Patient's activity and meals during hemodialysis 63 End of dialysis and blood restitution 64 Clinical surveillance of the dialysis session 64 Technical hazards during hemodialysis sessions 64 Hemodialysis-related hypotension 65 Other intradialytic complications 66 Interdialytic complications 67 Modalities of hemodialysis treatment 67 Long-term surveillance of the dialysis patient Cardiovascular and neurological problems 69 Hypertension 70 Cardiac dysfunction in uremia 71 Mechanisms of cardiac dysfunction 71 Clinical consequences and management 72

7 Vlll T ABLE OF CONTENTS Atherosclerosis and coronaropathy 73 Factors of accelerated atherosclerosis 73 Clinical expression and diagnostic procedures 73 Therapeutic management 74 Pericarditis 74 Valvular heart disease 75 Uremic neurological involvement 76 Uremic encephalopathy 76 Uremic polyneuropathy 76 Iatrogenic manifestations 76 Aluminum encephalopathy 77 Cerebrovascular accidents Immunologic and hematologic disorders 78 Immune system dysregulation 78 Immunodeficiency 79 Immunoactivation 79 Bacterial infections 81 Staphylococcal infections 81 Gram-negative organisms 81 Unusual infections 82 Viral hepatitis 82 Hepatitis B 83 Hepatitis C 83 Anemia and erythropoetin therapy 84 Mechanisms and consequences of anemia 84 Treatment of anemia 85 Management of EPO therapy 86 Hemostasis disorders 87 Platelet dysfunction in uremics 87 Bleeding tendency Bone and joint problems Secondary hyperparathyroidism Pathogenesis Clinical presentation Prophylactic treatment Treatment of overt secondary hyperparathyroidism Aluminum-related osteomalacia Pathophysiology and diagnosis Treatment of Aluminum accumulation Adynamic bone disease

8 TABLE OF CONTENTS Beta 2-microglobulin amyloidosis Clinical manifestations Pathogenesis and risk factors Other osteoarticular problems Soft tissue calcifications Secondary gout Osteoporosis and bone fluorosis Destructive spondylarthropathy 11. Other clinical problems Endocrine disorders Metabolic disorders Dermatological problems Uremic pruritus Bullous dermatoses Gastrointestinal complications Functional disorders GI bleeding Other digestive complications Complications in thc diseased kidneys Acquired cystic kidney disease Kidney stones Psychological problems Dialysis in children Technical problems Metabolic problems Dialysis in the elderly Dialysis in the diabetic patient Growing incidence of diabetic ESRF Management of the diabetic dialysis patient 12. Outcome and economics Results of maintenance hemodialysis Survival of patients on hemodialysis Quality of life and rehabilitation Economics of dialysis therapy Increasing needs of dialysis therapy The cost of dialysis therapy Literature for further reading Subject index IX III

9 PREFACE Major advances in both the technology and the medical knowledge of maintenance hemodialysis have been made since the early stages of such treatment in the 60s. Hemodialysis is now an established therapeutic method. and the time has come to present an up-to-date approach to all its technical and medical aspects. We adopted a simple and concise style with a clear design and a large number of tables and illustrations. so that not only health professionals but patients themselves can easily understand the essentials of hemodialysis. In addition to the most recent technical developments of hemodialysis. particular attention is given to biocompatibility. adequacy of dialysis and patient nutrition. The many clinical problems encountered in the dialysis patient have been especially emphasized. since proper management may prevent most uremia-related complications. Indeed. chronic hemodialysis consists not only of providing the patient with safe and well-tolerated dialysis sessions but also of maintaining good general condition, adequate nutritional status and well-being in the long term. All of us have worked in the field of nephrology and hemodialysis at Necker Hospital for more than 25 years, and several of our very first patients are still enjoying life thanks to hemodialysis. We hope that our experience will be of help to nephrologists. renal nurses and technicians in training so that they can offer their patients, through optimal dialysis, long survival with the best possible quality of life and rehabilitation. N.K. Man, MD J. Zingraff. MD P. Jungers, MD

End-Stage Renal Disease. Anna Vinnikova, M.D. Associate Professor of Medicine Division of Nephrology

End-Stage Renal Disease. Anna Vinnikova, M.D. Associate Professor of Medicine Division of Nephrology End-Stage Renal Disease Anna Vinnikova, M.D. Associate Professor of Medicine Division of Nephrology ESRD : Life with renal replacement therapy CASE: 18 month old male with HUS develops ESRD PD complicated