1. Dialysis
(Intern’s Guide to Eckel)
Intern Boot Camp
7/6/2010

2. Why the boot camp lecture?
 Most do not get ample exposure to
patients on hemodialysis during medical
school
 Patients on hemodialysis have a different
set of medical problems that are unique to
them.
 We’ll try to make this short and simple.

3. Objectives
 - Types of Dialysis
 - Access
 - Acute Indications for Dialysis
 - What do I need to know to survive Eckel
 - Cases of common admissions and
overnight issues

4. Types of Dialysis That You Should
Be Aware of
 1. Hemodialysis
 2. Peritoneal dialysis – just be aware of it’s
existence
 3. CVVH / CVVHD / CVVHDF – mostly
seen in the ICU setting and can be
grouped into one entity

5. Hemodialysis
 Hemodialysis -Dialysis works on the principles of the
diffusion of solutes and ultrafiltration of fluid across a
semi-permeable membrane.
 Hemodialysis removes wastes and water by circulating
blood outside the body through an external filter that
contains a semipermeable membrane. The blood flows
in one direction and the dialysate flows in the opposite.
This maximizes the concentration gradient of solutes
between the blood and dialysate
 Ultrafiltration occurs by increasing the hydrostatic
pressure across the dialyzer membrane. This usually is
done by applying a negative pressure to the dialysate
compartment of the dialyzer. This pressure gradient
causes water and dissolved solutes to move from blood
to dialysate, and allows the removal of several liters of
fluid

6. Source - Wikipedia

7. Peritoneal Dialysis
Peritoneal dialysis - uses the same principles as before however
rather than extracorpeal membranes, uses patients own peritoneal
membrane to move solutes across. Place dialysate bath into
patient’s abdomen. May have a few patients on this on the Eckel
service

8. CVVH / CVVHD / CVVHDF
WHY SO MANY ACRONYMS????
 Continuous veno veno hemofiltration, continuous veno veno hemodialysis,
Continuous veno veno hemodiafiltration
 You’ll see this in the ICU setting in patients who have acute renal failure and
volume overload. This basically allows for fluid removal through
ultrafiltration and convection (high to low pressure system) as well as
dialysis for solute removal in patient’s who may not be able to tolerate
intermittent dialysis. Allows for less drastic fluid shifts and hypotension.
Goes on for 24 hours a day. Do to the high volume of ultrafiltrate that is
produced, know that fluid replacement is needed to to restore ideal fluid
balance.
 You can either just have
- hemofiltration (no dialysate, replacement fluid, moderate solute removal and
large fluid removal)
- hemodialysis (dialysate, no replacement fluid, large solute removal, less
fluid removal
- combination of both with dialysate and replacement fluid

9. An Attempted diagram to Make you
Understand
Dialysate
Replacement
Fluid
Ultrafiltrate
Pump
Dialysate Pump
Fluid Pump
Hemofilter
Blood Pump
From the Air Detector
Patient
To The Patient

10. One slide on access.
This includes AV fistulas, grafts, temporary lines or permanent central access
lines that are tunneled.
Fistulas are the preferred access type but take 3-6 months to mature. Grafts
are used when you don’t have good veins/arteries next to each other and
they don’t take as long after insertion to use. Complications of these include
thrombosis, infections and aneurisms, and outlet obstruction.
Lines are common with our patients in the hospital because the most common
admission on the eckel service is line infection or probable line infection.
KNOW THEIR ACCESS.
 FYI – When you try to order a picc line on a patient who is on dialysis, the
picc line nurse will likely say no and that you need nephrology approval.
This is because picc lines use potential areas for future access so we prefer
not putting them in. If access is really needed for a long period of time, you
can order a tunneled picc line to be put in by IR.

11. Eckel Admissions – Must Know
Mr/Ms ________ is a ____ y/o with a hx of esrd or not (CKD stage __) 2/2 ______ on
hemodialysis _______via ______ at __________
 - also know dry weight
 - inter-dialysis weight gains
 - last dialysis session
 - full session or not
 - their nephrologist’s name
 - nutritional status
 - code status
Gold Star - If their admission pertains to missed dialysis session, hypotension during
dialysis, anything to do with dialysis, you can get the flow sheets from the dialysis
center by calling them. They will fax that last few sessions to you and will document
vitals and bp during session, febrile or not, medications that were given during
dialysis.
 Know if they get any medications during dialysis such as antibiotics, epogen etc.

12. Now this is getting good. What else?
Give me more, give me more!!
 - Dosing of meds - always check renal dosing on medications or HD
dosing. These are not the same as what you usually have to
prescribe. This is important because HD patients do not clear meds
the same way as others might, must check dosing of medications.
 - ABX dosing - many abx are given as loading doses and then
dosed after dialysis. Remember common ones such as vanc and
gent which are given as loading doses and then dosed during/after
dialysis depending on vanc or gent levels. (Vanc dosing is usually
20 mg/kg loading and then 500 mg after dialysis, gent is 1.5 - 2
mg/kg loading dose, then 1 mg/kg maintenance)
 - Medications not to give to HD patients - fleet enemas, mri gad,
magnesium and phosphate, morphine!
 CHECK DOSING, CHECK DOSING, CHECK DOSING

13. Case 1
 62 y/o female with pmh of esrd (not initiated on
dialysis yet who is on the transplant list,
(baseline creatinine 7) htn, dm presents from an
osh with complaints of chest pain x 5 days,
generalized fatigue and malaise. Patient on
arrival to UH MICU was unstable with
temperature of 39.0, tachycardia into 140’s,
blood pressure into systolics of 70’s, with
respirations 24. On exam, patient is alert and
oriented, conversive, has flat neck veins, slightly
decreased breath sounds over left base, cv
exam remarkable for tachycardia and no
pericardial rub, no abdominal pain, trace pedal
edema, foley catheter with dark urine.

14.  Laboratory evaluation as below.
131 / 104 / 126 /
--------------------- < 117
WBC 10, HGB/ HCT 11.4 / 35.9, PLT 195
5.5 / 7 / 10.9
What more would you like?
- if you asked for a blood gas, ph was 7.07
- Coagulation panel showed inr of 10.2 as patient was on coumadin
What abnormalities do you see on hx, exam, and labs?
- Decreased breath sounds suggesting possible pna
- Vitals signs
- Anion Gap Metabolic Acidosis (as well as a non anion gap metabolic
acidosis)
- Upper limit of normal potassium
- Acute on Chronic Renal Failure
- Hyponatremia (likely hypovolemic hyponatremia)
- Uremia
Does this patient need Dialysis?

15. ACUTE INDICATIONS FOR
DIALYSIS
 Creatinine level is not an indication for dialysis
 Remember your vowels
 - A – Acidosis (metabolic acidosis)
 - E - Electrolyte Abnormalities (hyperkalemia)
 - I - Ingestants/Toxins (lithium)
 - O – Overload (volume overload causing respiratory
distress)
 - U – uremia (systemic effects – uremic encephalopathy,
uremic pericarditis)

16. Case 2
 Patient is a 42 y/o female with esrd 2/2 lupus nephritis
on HD mwf via left radial av fistula who presents to ED
with compalints of muscle cramps. Vitals signs are
 T 36.3 / hr 97 / bp 109/68 / r 20
 Exam is significant for 1+ edema b/l in lower extremities.
 Laboratory evaluation shows a renal function panel as
below.
132 / 109 / 36
-------------------- 142
6.3 / 22 / 7.3
- What is your next step?

18. Common Admissions
HYPERKALEMIA
Questions to ask
 - did they miss a dialysis session
 - was their dialysis session cut short - inadequate
dialysis session
 - did they eat an extra banana for breakfast - dietary
indiscretion
 - any new medications
Follow C a BIG K Drop (Calcium, B-agonist/Bicarbonate,
Insulin, Glucose, Kayexalate, Dialysis)

19. Case 3
 Mr. Jackson is a 55 y/o female with esrd 2/2
hypertensive nephrosclerosis on hd t/t/s via right
tunneled ij line who presents from his HD
session with hypotension. Patient’s session was
cut short 2/2 to blood pressure systolic drop into
70 systolic. Currently patient is without
complaints.
- What are the different causes of hypotension
during dialysis?

20. Case 3 Continued
HYPOTENSION during dialysis
 - too rapid or excessive fluid removal
removal
 - acetate in dialysate
 - heat-related vasodilation
 - underlying conditions (eg, autonomic
neuropathy, myocardial ischemia,
arrhythmias)
 - sepsis

21. Case 3 continued
Mr. Jackson was admitted to the hospital for low
blood pressures. Overnight, Odessa the
secretary on LK40 calls you stating the nurse
just took his temperature and it is 38.4.
You look at your signout and realize you don’t
have a signout on Mr. Jackson. Now what?
You now head over to LK40 to read the admission
note which states that the patient was admitted
for hypotension during dialysis, is usually
hypertensive and now has spiked a temperature.
Patient had a temperature during dialysis of
38.0 based on dialysis flowsheets in the chart.
What are you thinking?
- Could this patient be septic?
- Next steps?

22. Case 3 Continued
 You go an examine the patient and notice
vital signs of 38.3 / 110 / 90/60 / 22
 On exam of the right tunneled ij, you
noticed some erythema and tenderness at
the line site, no active drainage from the
catheter site?
 Now what?
 Labs?
 Meds?

23. Things that go bump in the
night……
FEVER
 - common things common (pneumonia, uti
(make sure they are not anuric), line infections,
diarrhea, osteomyelitis
 - Line infection – Make sure you look at the line -
exit site infection, tunnel infection, catheter
related bacteremia.
 Treatment options include catheter removal,
change catheter over guide wire, antibiotic locks
and catheter salvage. This depends on the
speciation of the organism.

24. Things that go bump in the
night……
SHORTNESS OF BREATH
Questions to ask
 - did they miss a dialysis session
 - was their dialysis session cut short - inadequate
dialysis session
 If they make urine, you can give trial of diuretic (high
dose lasix or bumex if blood pressure allows)
 If they don’t make urine, will they make it to their next
dialysis session
 - remember those things that pertain to all patients – PE,
pleural effusions, pna, pericardial effusions (htn
medications)

25. Things that go bump in the
night……
Hypertension – Stuck between a rock and a hard place.
- Treat the hypertension with prn antihypertensives,
increasing the next doses of medications that are
already given.
- Do not want the patient to go into hypertensive
emergency and flash pulmonary edema however the
patient needs adequate blood pressure for perfusion
(normal at higher blood pressures, need to perfuse
access site as well as need adequate blood pressure for
next dialysis session.)

26. Things that go bump in the
night……
Bleeding Post Dialysis
- Not much you can do about this as most
ESRD patients have thrombocytopenia
and platelet dysfunction.
- PRESSURE, PRESSURE, PRESSURE
- In the ICU setting, can consider DDAVP
however not used very often.

27. Things that go bump in the
night……
 Low Blood Counts
- You will likely get called on a patient’s morning
CBC by a nurse. This is likely not acute and if it
is, pay attention to next week’s boot camp
lecture by Dr. Tannous on GI bleed.
- Remember in most cases, DO NOT give blood
overnight. Give blood with dialysis. (general rule,
give abx during or after dialysis, give blood
during or after dialysis, get labs during or after
dialysis.

28.  Questions?
 Remember
- ALWAYS GO ASSESS THE PATIENT
- YOU ARE NEVER ALONE, IF YOU NEED
HELP, CALL YOUR SENIOR

29. THE END
bio1903.nicerweb.com/.../ch44/nephron_urine.html