Unending Kidney Disease and Dialysis Patient Care

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Incessant 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. Fiery debris, MD, FACP Clarian Arnett Health Director of Dialysis, Wellbound Director of R&D Ash Access Technology and HemoCleanse, Inc. Lafayette, IN

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Role of Primary Physicians in Treatment of CKD Patients and Preparing for Dialysis Identify patients with CKD Identify reasons for kidney sickness (diabetes, hypertension, obstacle, hyperuricemia, contaminations, hindrance, prescriptions) Treat the essential infection and drag out renal capacity, for instance utilizing ACE/ARB in diabetics with CKD Refer to Nephrology at CKD Stage 3 (GFR=30-60 ml/min/1.73M2) Observe for indications of uremia Help to decide with patient, family and Nephrologist whether dialysis is shown Preserve arm veins for hemodialysis get to Expect and bolster get to methods at stage 4-5 (GFR<20 ml/min/1.73M 2 ) Avoid harm to fistula or unite in arm Monitor join and fistula work, report variations from the norm

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1. Dialysis Options and How They Work Peritoneal dialysis Hemodialysis CVVHD NxStage Home Dialysis Therapy

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Dialysis=Diffusion

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Nighttime cyclers diminish the quantity of daytime trades required.

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The Hemodialysis Blood Side System

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Fresenius K-Machine

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NxStage Therapy System

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2. Manifestations of Renal Failure (Uremia) Gastritis: queasiness, regurgitating, gastritis, anorexia Fluid Overload, CHF: shortness of breath, orthopnea Encephalopathy: perplexity, lethargy, unconsciousness Neuropathy: tingling, shortcoming Pericarditis: mid-section torment, shortness of breath

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3. Physical Signs of Renal Failure Vomiting Edema CHF, Rales Confusion, Coma Bleeding Decreased pee yield (at times) Hypertension Diminished fiery reaction and indications of disease

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4. Research facility Values in Renal Failure Creatinine height (typical is 0.6-1.4) GFR diminish by MDRD or CG (typical for 70 year old of 70 kg is 70) BUN increment (ordinary up to 22) Phos increment (ordinary up to 4.5) Potassium increment (typical up to 5.5) Hemoglobin diminish (typical lower restrain 13) Bicarbonate diminish (typical lower constrain 24) Hundreds of other synthetic and hormonal changes

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5. Therapeutic Therapy of Chronic Renal Failure Potassium (bicarbonate, glucose & insulin, saline, β - agonists, Kayexelate, calcium, stop different meds) Phosphorus (calcium acetic acid derivation, calcium carbonate, Renvela, Fosrenol) Urea (consume less calories confinement, bar GI drain) Optimize GFR (liquid load, liquid reduction, enhance circulatory strain, stop different meds) Avoid nephrotoxic meds (nsaids, ACE, iodinated differentiation specialists) Avoid or change other dangerous meds (MRA differentiate, Reglan, Digoxin, Amiodarone, Lovenox, and so forth).

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6. At the point when do we begin dialysis in CKD? Which Type? Freedom GFR < 15 ml/min for non-diabetics (MDRD) GFR < 25 ml/min for diabetics Downward pattern in GFR Upward pattern in uremic poisons Symptoms Quality and length of expected life Home patient potential: great patient verifiably, family support and accomplice, portability, intrigue and ability PD, particularly for heart disappointment, diabetes, gives quite a long while of bolster Short day by day Hemo: capacity and intrigue Overnight Hemo 8 hours each other night additionally conceivable In-focus persistent potential Must endure surgery or techniques for vascular get to gadget Must endure fast liquid movements and heart strain Must collaborate with medicinal regimen Transportation must be accessible for three medications for every week

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Stages of Chronic Kidney Disease

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7. Prerequisites for Hemodialysis Access Blood stream rate of 400 ml/min for 4 hours treatment, without blockage Blood stream rate in region of get to (like catheter or needle) must be no less than 800 ml/min Minimal disease chance Low danger of draining No tubes through the skin if conceivable Longevity in years, not months

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Types of Hemodialysis Access AV Fistula AV Graft Tunneled Internal Jugular dialysis Catheter

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Scribner Shunt-1960

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Short History of Hemodialysis Access after Scribner Shunt:

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AV Fistula

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Original Cimino-Brescia Fistula; next to each other

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Other sorts of fistulas

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Finding Veins-Sometimes Easy, Sometimes Hard

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Vein Mapping to Find Suitable Veins and Arteries

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Fistula Problems-Stenosis Note expansion of outspread supply route to give a liter for every moment blood stream

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Signs of Venous Stenosis in Vascular Access

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Physical Exam..Detects Inflow Problems and Outflow Problems

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Aneurysms are Weakened Areas, not Able to Receive More Needlesticks

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But rather, 30-half of fistulas don't work in any case… .

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AV Grafts

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ArterioVenous Grafts Can Teflon be a Blood Vessel?

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Grafts Become Covered by Body Tissues, Sometimes Too Much Tissue

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And Stenosis Near the Connection of the Graft and Vein

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Infection is Rare, Redness is Common

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Pseudoaneurysms are Near Blowouts

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Tunneled Permanent Central Venous Catheters for Dialysis The Third Choice

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But as CMS Reports: We have a Continuing Dependence on CVCs…

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BFRs w/Vascular Accesses

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Dacron Cuff is under the skin Tips are at the passage to the heart

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Wardrobe Requirements Natalie Cole, 2009

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Did you see this first?

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Exact situation is some of the time troublesome…

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Vein section is with Ultrasound

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Problems Include Clotting

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And Fibrous Sheathing

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Catheter Sheaths create at purpose of contact to vein or atrial divider…

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L IJ CVC Fibro-Epithelial Sheath SVC RA Fibro-Epithelial (Fibrin) Sheath Courtesy, Arif Asif

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KDOQI 2007 Risky! Trade? Expand sheath? Brush? 30 minutes? Overnight?

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Can catheter results be moved forward? For sheathing, new catheter outlines may help… Centros Tips shape a level plane; ports are held in center of vein

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Centros TM : Preferred Placement in SVC craftsmanship workmanship ven The catheter tips are situated in the lower third of the SVC as opposed to in the chamber…

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Centros™: A Self Centering Catheter tip Pacemaker drives The ports are held amidst the SVC and far from the vein divider. These CT's were performed following 4 months of catheter utilize.

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Centros TM : Preliminary Study Results Flow rate of the Centros TM Catheters was 400 ml/min, consistent after some time (7 weeks) and higher than with current Dual Lumen burrowed dialysis catheters.

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Infection in Tunneled CVC for Dialysis Incidence of 1-5/1000 patient days, or 3-15% of patients for each month (higher in non-burrowed catheters) Serious outcomes, systemic and metastatic diseases Highly exorbitant Requires long haul systemic anti-microbials and generally antibacterial catheter bolt to determine For Staph Aureus or Pseudomonas living beings catheter must be evacuated/supplanted Prophylactic anti-microbial or germ-free bolts can lessen rate yet have their own particular issues

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