Docstoc

Hemodialysis Access and Management

Document Sample
Hemodialysis Access and Management Powered By Docstoc
					Chronic Kidney Disease and Dialysis
           Patient Care –
 What the Generalist Should Know
    Nephrology Topic Review
    Clarian Arnett Hospital
    Lafayette Medical Education Foundation

    January 18, 2011

              Stephen R. Ash, MD, FACP
                  Clarian Arnett Health
             Director of Dialysis, Wellbound
                    Director of R&D
      Ash Access Technology and HemoCleanse, Inc.
                      Lafayette, IN
Role of Primary Physicians in Treatment of
 CKD Patients and Preparing for Dialysis
• Identify patients with CKD
• Identify causes of kidney disease (diabetes,
  hypertension, obstruction, hyperuricemia, infections,
  obstruction, medications)
• Treat the primary disease and prolong renal function,
  for example using ACE/ARB in diabetics with CKD
• Refer to Nephrology at CKD Stage 3 (GFR=30-60
  ml/min/1.73M2)
• Observe for signs of uremia
• Help to determine with patient, family and
  Nephrologist whether dialysis is indicated
• Preserve arm veins for hemodialysis access
• Expect and support access procedures at stage 4-5
  (GFR<20 ml/min/1.73M2)
• Avoid damage to fistula or graft in arm
• Monitor graft and fistula function, report abnormalities
    1. Dialysis Options and How They
                   Work

•   Peritoneal dialysis
•   Hemodialysis
•   CVVHD
•   NxStage Home Dialysis Therapy
Dialysis=Diffusion
Nighttime cyclers decrease the number of daytime
exchanges needed.
The Hemodialysis Blood Side
        System
Fresenius K-Machine
NxStage Therapy System
2. Symptoms of Renal Failure (Uremia)


•   Gastritis: nausea, vomiting, gastritis, anorexia
•   Fluid Overload, CHF: shortness of breath, orthopnea
•   Encephalopathy: confusion, sleepiness, coma
•   Neuropathy: itching, weakness
•   Pericarditis: chest pain, shortness of breath
      3. Physical               Signs of Renal
                                Failure
•   Vomiting
•   Edema
•   CHF, Rales
•   Confusion, Coma
•   Bleeding
•   Decreased urine output (sometimes)
•   Hypertension
•   Diminished inflammatory response and signs of infection
4. Laboratory              Values in Renal
                         Failure
• Creatinine elevation (normal is 0.6-1.4)
• GFR decrease by MDRD or CG (normal for 70 year old of 70 kg is
  70)
• BUN increase (normal up to 22)
• Phos increase (normal up to 4.5)
• Potassium increase (normal up to 5.5)
• Hemoglobin decrease (normal lower limit 13)
• Bicarbonate decrease (normal lower limit 24)
• Hundreds of other chemical and hormonal changes
5. Medical              Therapy of Chronic
                      Renal Failure
•   Potassium (bicarbonate, glucose & insulin, saline, β-agonists, Kayexelate,
    calcium, stop various meds)
•   Phosphorus (calcium acetate, calcium carbonate, Renvela, Fosrenol)
•   Urea (diet restriction, exclude GI bleed)
•   Optimize GFR (fluid load, fluid decrease, improve blood pressure, stop
    various meds)
•   Avoid nephrotoxic meds (nsaids, ACE, iodinated contrast agents)
•   Avoid or adjust other toxic meds (MRA contrast, Reglan, Digoxin,
    Amiodarone, Lovenox, etc).
    6. When     do we start dialysis
           in CKD? Which Type?
•   Clearance
      – GFR < 15 ml/min for non-diabetics (MDRD)
      – GFR < 25 ml/min for diabetics
      – Downward trend in GFR
      – Upward trend in uremic toxins
•   Symptoms
•   Quality and length of expected life
•   Home patient potential: good patient historically, family support and partner, mobility,
    interest and capability
      – PD, especially for heart failure, diabetes, provides several years of support
      – Short daily Hemo: capability and interest
      – Overnight Hemo 8 hours every other night also possible
•   In-center patient potential
      – Must tolerate surgery or procedures for vascular access device
      – Must tolerate rapid fluid shifts and heart strain
      – Must cooperate with medical regimen
      – Transportation must be available for three treatments per week
Stages of Chronic Kidney Disease

 Stage   Description                    eGFR (ml/min/1.73m2)




   I     “Normal” Renal function        >90


  II     “Mild” Renal Dysfunction       60-89


  III    “Moderate” Renal Dysfunction   30-59


  IV     “Severe” Renal Dysfunction     15-29


  V      “End-Stage” Renal Disease      <15
 7. Requirements for Hemodialysis
             Access

• Blood flow rate of 400 ml/min for 4 hours treatment,
  without blockage
• Blood flow rate in vicinity of access (like catheter or
  needle) must be at least 800 ml/min
• Minimal infection risk
• Low risk of bleeding
• No tubes through the skin if possible
• Longevity in years, not months
Types of Hemodialysis Access


• AV Fistula
• AV Graft
• Tunneled Internal Jugular dialysis
  Catheter
Scribner Shunt-1960
Short History of Hemodialysis Access after
Scribner Shunt:
AV Fistula
Original Cimino-Brescia Fistula; side-by-side
Other types of fistulas
Finding Veins-Sometimes Easy,
       Sometimes Hard
Vein Mapping to Find Suitable
     Veins and Arteries
Fistula Problems-Stenosis




  Note enlargement of radial artery-to provide a liter per
  minute blood flow
Signs of Venous Stenosis in
     Vascular Access
 Physical Exam..Detects Inflow
Problems and Outflow Problems
Aneurysms are Weakened Areas, not Able
     to Receive More Needlesticks
But, 30-50% of fistulas don’t work in the first
place….
AV Grafts
    ArterioVenous Grafts
Can Teflon be a Blood Vessel?
Grafts Become Covered by Body Tissues,
      Sometimes Too Much Tissue
And Stenosis Near the Connection
      of the Graft and Vein
Infection is Rare, Redness is
           Common
Pseudoaneurysms are Near
       Blowouts
Tunneled Permanent Central Venous
       Catheters for Dialysis
         The Third Choice
 But as CMS Reports: We have a
Continuing Dependence on CVCs…
BFRs w/ Vascular Accesses
                                     Dacron Cuff is under the skin




Tips are at the entry to the heart
     Wardrobe Requirements




Natalie Cole, 2009
Did you notice this first?
Exact placement is sometimes
          difficult…
Vein entry is with Ultrasound
Problems Include Clotting
And Fibrous Sheathing
Catheter Sheaths
develop at point of
contact to vein or
atrial wall…
Fibro-Epithelial (Fibrin) Sheath


                                   L IJ
                Fibro-             CVC
                Epithelial
                Sheath
                             SVC




                   RA


 Courtesy, Arif Asif
                                  KDOQI
                                  2007




Risky!



         Exchange?
         Balloon sheath?   30 minutes?
         Brush?            Overnight?
  Can catheter outcomes be improved? For
sheathing, new catheter designs might help…




                                      Centros
                                     Tips form
                                       a flat
                                       plane;
                                     ports are
                                      held in
                                     middle of
                                        vein
CentrosTM: Preferred Placement in SVC




art

                                                  art
ven
                                                  ven




      The catheter tips are positioned in the lower third of the SVC rather
                              than in the atrium…
   Centros™: A Self Centering Catheter

                            tip




                                         tip


Pacemaker
leads

   The ports are held in the middle of the SVC and away from the vein
    wall. These CT’s were performed after 4 months of catheter use.
    CentrosTM: Preliminary Study Results

                      Average Flow at -200 Arterial Pressure, Centros(TM) Catheters
                                          (+/- Standard Deviation)


            500

            400

            300
   ml/min




            200

            100

             0
                  0      1        2        3            4   5        6        7
                                               w eeks                             Standard Catheters
                                                                                    P < 0.05 (n=120)



   Flow rate of the CentrosTM Catheters was 400 ml/min, constant over time
(7 weeks) and higher than with current Dual Lumen tunneled dialysis catheters.
      Infection in Tunneled CVC for
                  Dialysis

•   Incidence of 1-5/1000 patient days, or 3-15% of patients per month (higher
    in non-tunneled catheters)
•   Serious consequences, systemic and metastatic infections
•   Highly costly
•   Requires long-term systemic antibiotics and usually antibacterial catheter
    lock to resolve
•   For Staph Aureus or Pseudomonas organisms catheter must be
    removed/replaced
•   Prophylactic antibiotic or antiseptic locks can diminish incidence but have
    their own problems

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:25
posted:8/8/2012
language:English
pages:67