DIALYSIS  PATIENT

 

Indications for dialysis in renal pts:

    1. Unresponsiveness to diet and worsening renal function documented by N/V, fatigue, pruritis, in BP,  in creatinine.

    2. Hyperkalemia (EKG may not detect the level  accurately since pt develops tolerance).

    3. OD on medications that are renally clear.

    4. Renal pt who has to undergo transfusion or aggressive fluid therapy.

    5. Renal pt with CHF, pulmonary  fluid overload, pericarditis (presents with  fever, PAT, Afib), AMS (uremic encephalopathy).

Complications of  Hemodialysis (HD) and Peritoneal dialysis (PD):

    1. Hypokalemia occurs during HD (see below).

    2. Hypotension  occurs during HD

    3. Dizziness and weakness are common complaints of pts on HD that occur and resolve within a few hrs. of hemodialysis. It is presumed to be 2ry to osmotic shifts between CSF and  plasma. Dx  is confirmed by documenting lower levels of BUN after dialysis.

    4. IC hemorrhage in pts with HD (see below).

    5. Vascular complications in HD (see below).

    6.  flow from  outflow PD catheter can cause abdominal distention. This can occur 2ry to fibrin formation, adhesions 2ry to surgery, constipation. Treatment is dictated by findings.

    7. Peritonitis in PD pts (see ID section). Other infections common with PD are infection of entry site and infection of  PD catheter.

    8. Hyperglycemia due to high dextrose contained in dialysate.

    9. Fever, Bacteremias.

Common  emergencies in CRF pt:

  1. Metabolic Acidosis with AG.
     
  2. Hyperkalemia - EKG changes may not reflect accurately the K serum levels. Treated in usual fashion with CCl, HCO3, D50+Insulin (see "Hyperkalemia").
     
  3. Hypokalemia occurs during HD and can cause  PVCs, Vfib.
     
  4. BP treated with diet, ACE-I, CCB. When pt presents with  BP and AMS uremic encephalopathy is the diagnosis as long as other cause are excluded. When this occurs  BP is controlled with  Sodium Nitroprusside and dialysis.
     
  5. IC hemorrhage (usually SDH) due to platelet dysfunction, use of Heparin during HD and acute hypertension.
     
  6. GI bleed due to gastritis. Pts must not be treated with Maalox since this contains Mg that will accumulate to toxic level in renal pts. Instead pts are treated with  Phosphate binding antacids that in turn will cause constipation (another common GI complication). These pts must not be treated with Fleet Enemas since this contains Phosphate. Lactulose, GoLytely (not absorbed), Colace, Kayexalate (PO or retention enema. High sodium concentration may limit its use).
     
  7. Peritonitis is not uncommon in PD pt. Pain, fever, abdo pain are S&S.  Fluid exchange with addition of  antb into peritoneal fluid with dialysate is the treatment.
     
  8. Anemia is of chronic disease. Erythroprotein is given on chronic basis and transfusion is indicated if S&S of  anemia such as SOB, c.p., ischemic changes on EKG or Hgb <7 g/dl. Pt may need dialysis during or after transfusion.
     
  9. Vascular complications include abscess, cellulitis (treated with antb to cover Staph and Strep) and thrombi  formation (absence of  "thrill").
     
  10. Pericarditis/Pericardial effusion Xray and/or EKG are helpful in diagnosis
     
  11. Uremic lung, i.e. fluid overload. Treatment c/o dialysis.
     
  12. Pancreatitis (see GI section )

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