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

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

2 ESRD : Life with renal replacement therapy CASE: 18 month old male with HUS develops ESRD PD complicated by a hernia for 6 months Living related transplant age 2 Recurrent HUS, back on PD after hernia repair by age 3 Ultrafiltration failure, age 5, switched to HD In-center HD, severe HTN, bilateral nephrectomy age 6 Home HD age 7 via tunneled catheter

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4 ESRD: Life with renal replacement therapy CASE: continued Home HD for 6 years via tunneled catheter Age 13, Cadaveric Renal transplant Recurrent HUS, failed transplant age 14 Home HD via combined AVG-AVF age 14 Age 16, sticks himself Age 18, Graduated from High School, 2004 Age 21: computer technologist, married, wife performs every other day hemodialysis What s next?

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6 ESRD: treatment options Dialysis Transplantation Conservative care

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8 Dialysis Indications for acute dialysis in AKI or CKD: 1. Severe hyperkalemia 2. Volume overload 3. Uremic pericarditis 4. Uremic encephalopathy 5. Intractable acidosis

9 Dialysis Indications for chronic dialysis in CKD stage 5 Uremic syndrome Fluid overload Persistently abnormal labs azotemia, hyperkalemia

10 Uremic syndrome Uremic symptoms Early - loss of concentration, insomnia, malaise, morning nausea, poor appetite, weight loss Established severe fatigue, vomiting, anorexia, pericarditis

11 How to assess uremic symptoms Weight loss? Serum albumin <4? Questions to ask patient: - Are you eating 3 meals a day? - Compared with this summer, are you feeling same, better or worse? - Are you ready to start dialysis?

12 Uremic facies

13 Uremic pericarditis

14 Renal replacement therapies Hemodialysis Peritoneal Dialysis Continuous Renal Replacement Therapies (CRRT) done in ICU Continuous Veno-Venous Hemofiltration (CVVH) Sustained Low-Efficiency Dialysis (SLED)

15 Goals of dialysis Removal of uremic toxins (clearance) in order to prevent uremic syndrome Maintenance of electrolyte balance (removal of K, repletion of bicarbonate) Removal of excess fluid

16 Clearance Clearance is defined as the volume of plasma completely cleared of a given solute over unit of time [ml/min]. Clearance of urea is used to determine adequacy of dialysis Clearance of creatinine is used as a marker of GFR

17 Principles of dialysis: solute clearance

18 Glomerular filtration Solute moves along with water by ultrafiltration (solvent drag)

19 Hemofiltration Solute is removed along with water by ultrafiltration (solvent drag)

20 Hemodialysis Solute is removed by diffusion Fluid is removed by ultrafiltration

21 Dialyzer membrane

22 Hemodialysis filter ( artificial kidney )

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24 In the 60 s

25 Modern dialysis machines were created using washing machines!

26 In-center hemodialysis

27 Home Hemo

28 Home Hemo

29 New forms of HD: Short daily dialysis Nocturnal dialysis Advantages: Excellent clearance Hemodynamic stability Patients feel better Reduced need for medications

30 Vascular access: native AV fistula

31 Vascular access: AV graft

32 Vascular Access Complications Infection Bleeding Vascular steal syndrome Central vein stenosis or thrombosis

33 Steal syndrome 1 2 3

34 Central venous stenosis

35 Vascular access: tunnelled catheter

36 Complications of TC: hematoma after placement

37 Complications of TC: clotting

38 Complications of TC: extruded cuff

39 Complications of TC: tunnel infection

40 Biofilm on TC makes it hard or impossible to treat catheter infection without removing or exchanging catheter first

41 Endocarditis

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44 Intradialytic complications Hypotension (due to delayed mobilization of interstitial fluid) Hypertension (RAS activation due to volume removal) Anaphylactoid reactions to dialyzer membrane Muscle cramps Bleeding Electrolyte disturbances Air embolism

45 Intradialytic complications Dialysis dysequilibrium happens during first-time dialysis session or in patients who miss dialysis brain naturally accumulates protective organic osmoles if plasma osmolality is rapidly lowered by dialysis, water moves into hyperosmotic brain cells and cause cerebral edema

46 Peritoneal dialysis Solute is removed by diffusion Water is removed by osmosis

47 Peritoneal dialysis Dialysate: dextrose 1.5%, 2.5% or 4.25%

48 Peritoneal dialysis

49 Peritoneal dialysis

50 Peritoneal dialysis

51 PD cycler

52 Options in peritoneal dialysis Continuous Ambulatory PD (CAPD) Nocturnal Intermittent PD (NIPD) via cycler

53 PD-specific complications Exit site infection PD peritonitis Abdominal hernias Adhesions

54 Tunnel abscess

55 PD peritonitis

56 HD vs PD Circumstance Large body habitus Elderly patient Severe lung disease Abdominal surgery CHF Coagulopathy Preferred modality HD HD HD HD PD PD

57 Complications of chronic dialysis: cardiovascular disease Hypertension (volume-dependent) Congestive heart failure Accelerated CAD and PVD

58 Complications of chronic dialysis Malnutrition Secondary hyperparathyroidism with osteodystrophy and calciphylaxis Arthritis Serositis (pericarditis, dialysis ascites) Dialysis dementia

59 Dialysis outcomes Death rate 10-15% per yr 3 year survival: y.o. 90% y.o. 60% Diabetic 50%

60 Life expectancy

61 Mortality in ESRD

62 Learning objectives accomplished? Discuss the indications for acute and chronic dialysis Discuss the principles of solute and volume removal in hemodialysis and peritoneal dialysis Discuss the basic types of dialysis access Discuss the complications of dialysis