Peeing is a wonderful thing

Peeing is a wonderful thing

Acute HemodialysisAcute Hemodialysis

Jennifer Stoddard Klenzak, MDPinehurst Nephrology

Associates5/24/2011

Jennifer Stoddard Klenzak, MDPinehurst Nephrology

Associates5/24/2011

Who receives dialysis in the hospital?

Acute kidney injury

ESRD patients

different populations, different needs, different meds,different prescriptions for dialysis

Who receives dialysis in the hospital?

Acute kidney injury

ESRD patients

different populations, different needs, different meds,different prescriptions for dialysis

What is Acute Kidney Injury?

What is Acute Kidney Injury?

Decrease in GFR Relative loss of clearance

And why do we care?

Decrease in GFR Relative loss of clearance

And why do we care?

Insert image Insert image

Variables affecting creatinine besides GFR

Variables affecting creatinine besides GFR

Malnutrition Liver disease Pregnancy Body habitus Ethnicity Vegetarianism Volume status Age

Malnutrition Liver disease Pregnancy Body habitus Ethnicity Vegetarianism Volume status Age

Stage 3 CKDStage 3 CKD

7.6 million Americans Asymptomatic (the Silent Killer) Severely increased risk of

cardiovascular events and death These patients are unlikely to live

long enough to require dialysis (one in twenty will reach stage 5)

7.6 million Americans Asymptomatic (the Silent Killer) Severely increased risk of

cardiovascular events and death These patients are unlikely to live

long enough to require dialysis (one in twenty will reach stage 5)

Causes of AKICauses of AKI

Acute Tubular Necrosis Prolonged ischemic injury Contrast nephropathy SIRS “post-operative” AKI Other derangements of homeostasis

leading to toxic or ischemic injury

Acute Tubular Necrosis Prolonged ischemic injury Contrast nephropathy SIRS “post-operative” AKI Other derangements of homeostasis

leading to toxic or ischemic injury

Systemic Inflammatory Response Syndrome Release of interleukins, oxidative

metabolites Injury to renal tubular epithelial cells Decreased perfusion related to

hypotension

Systemic Inflammatory Response Syndrome Release of interleukins, oxidative

metabolites Injury to renal tubular epithelial cells Decreased perfusion related to

hypotension

Causes of AKI, cont.Causes of AKI, cont.

Rhabdomyolysis Statin-induced Heat stroke Muscle injury

“Found down”Compartment syndromeTrauma

Rhabdomyolysis Statin-induced Heat stroke Muscle injury

“Found down”Compartment syndromeTrauma

Poisoning/Toxins/Overdose Aspirin Antifreeze/Ethylene glycol Methanol

Hyperuricemia Tumor Lysis Syndrome

Poisoning/Toxins/Overdose Aspirin Antifreeze/Ethylene glycol Methanol

Hyperuricemia Tumor Lysis Syndrome

Rapidly Progressive Glomerulonephritis Anca-associated disease Lupus Nephritis Goodpasture’s Syndrome (Anti-glomerular

basement Antibody Syndrome) IgA Cryoglobulinemic Vasculitis

Myeloma Kidney Cast nephropathy

Rapidly Progressive Glomerulonephritis Anca-associated disease Lupus Nephritis Goodpasture’s Syndrome (Anti-glomerular

basement Antibody Syndrome) IgA Cryoglobulinemic Vasculitis

Myeloma Kidney Cast nephropathy

Indications for hemodialysisIndications for hemodialysis

Volume Overload Hyperkalemia Uremia Encephalopathy Pericarditis Metabolic Acidosis Toxin clearance Platelet dysfunction

Volume Overload Hyperkalemia Uremia Encephalopathy Pericarditis Metabolic Acidosis Toxin clearance Platelet dysfunction

Dialysis PrescriptionDialysis Prescription

Indication

Hemodynamic status

Chronicity of illness

Comorbidities

Indication

Hemodynamic status

Chronicity of illness

Comorbidities

Case 1Case 1

52 year old female ESRD, MWF, patient missed Friday treatment. Saturday night presents to the ED with complaints of weakness.

52 year old female ESRD, MWF, patient missed Friday treatment. Saturday night presents to the ED with complaints of weakness.

What measures could be taken to keep the patient alive until she gets on the machine?

What measures could be taken to keep the patient alive until she gets on the machine?

What measures could be taken to keep the patient alive until she gets on the machine? Calcium gluconate Albuterol Insulin/D50 Kayexalate Lasix? Bicarbonate

What measures could be taken to keep the patient alive until she gets on the machine? Calcium gluconate Albuterol Insulin/D50 Kayexalate Lasix? Bicarbonate

What is the most likely complication of this acute dialysis treatment?

How can the dialysis prescription decrease the risk of this event?

What is the most likely complication of this acute dialysis treatment?

How can the dialysis prescription decrease the risk of this event?

79 year old man admitted with AMI. He has advanced chronic kidney disease at baseline. After an emergent cardiac cath, he develops cardiogenic shock and becomes oliguric.

Later that night, he is on bipap, with worsening hypoxemia, and despite high dose diuril and lasix, makes no urine.

79 year old man admitted with AMI. He has advanced chronic kidney disease at baseline. After an emergent cardiac cath, he develops cardiogenic shock and becomes oliguric.

Later that night, he is on bipap, with worsening hypoxemia, and despite high dose diuril and lasix, makes no urine.

Is dialysis indicated? Why?

What is the goal of treatment?

What are the expected risks?

Prescription?

Is dialysis indicated? Why?

What is the goal of treatment?

What are the expected risks?

Prescription?

26 year old man who presents to the ED with headache and lethargy. He has noticed fatigue, dyspnea with exertion, chest pain, loss of appetite, food aversion, and cold intolerance for approximately one month.

On exam, BP is 228/112, his skin is darkened, conjunctivae are pale, nail beds are pale, heart is regular and bounding, and friction rub is present.

26 year old man who presents to the ED with headache and lethargy. He has noticed fatigue, dyspnea with exertion, chest pain, loss of appetite, food aversion, and cold intolerance for approximately one month.

On exam, BP is 228/112, his skin is darkened, conjunctivae are pale, nail beds are pale, heart is regular and bounding, and friction rub is present.

LabsLabs

BUN 278 Creatinine 23.2 Hgb 7.4 Renal Ultrasound Normal UA 3+ protein, 1+ blood

BUN 278 Creatinine 23.2 Hgb 7.4 Renal Ultrasound Normal UA 3+ protein, 1+ blood

Is dialysis indicated? Why?

Is there an expectation of renal recovery?

Potential complications during dialysis?

Prescription?

Is dialysis indicated? Why?

Is there an expectation of renal recovery?

Potential complications during dialysis?

Prescription?

18 year old female admitted with acute renal failure and hemoptysis.

She receives 1000 mg solumedrol and undergoes renal biopsy.

18 year old female admitted with acute renal failure and hemoptysis.

She receives 1000 mg solumedrol and undergoes renal biopsy.

She starts plasmapheresis and dialysis the next morning.

Are there any special considerations for her treatment? Potential life-threatening complications?

Is there an expectation of renal recovery?

Dialysis prescription?

She starts plasmapheresis and dialysis the next morning.

Are there any special considerations for her treatment? Potential life-threatening complications?

Is there an expectation of renal recovery?

Dialysis prescription?

62 year old woman found down at home. Medical history of depression. Otherwise healthy.

Creatinine 3.2 mg/dl Serum CO2 4 meq/L Anion gap 24 Osmolar gap 22

62 year old woman found down at home. Medical history of depression. Otherwise healthy.

Creatinine 3.2 mg/dl Serum CO2 4 meq/L Anion gap 24 Osmolar gap 22

Is dialysis indicated? Why?

What other measures should be taken here?

Do we expect renal recovery if she survives?

Is dialysis indicated? Why?

What other measures should be taken here?

Do we expect renal recovery if she survives?

Interdisciplinary Team Approach to AKI

Interdisciplinary Team Approach to AKI

Nephrologist Diagnosis and management of renal disease

Access management Interventional radiologists and nephrologists Vascular surgeons General surgeons

Nurse Floor nurse/ICU nurse Hemodialysis nurse PD nurse

Nephrologist Diagnosis and management of renal disease

Access management Interventional radiologists and nephrologists Vascular surgeons General surgeons

Nurse Floor nurse/ICU nurse Hemodialysis nurse PD nurse

Dietician Assessment of nutritional needs of

patient in acute setting TPN/TF Electrolyte replacement Education of patient and family

Social Worker Discharge planning Financial concerns, Disability,

Insurance Pharmacist

Renal dosing, precautions

Dietician Assessment of nutritional needs of

patient in acute setting TPN/TF Electrolyte replacement Education of patient and family

Social Worker Discharge planning Financial concerns, Disability,

Insurance Pharmacist

Renal dosing, precautions

AKI: Role of the NurseAKI: Role of the Nurse

The bedside nurse assessment

the key ingredient

The bedside nurse assessment

the key ingredient Blood Pressure Pulse rate Orthostasis Strength Mental Status Fever Oxygen requirements Access Bleeding Vomiting, diarrhea, constipation Cramping

Blood Pressure Pulse rate Orthostasis Strength Mental Status Fever Oxygen requirements Access Bleeding Vomiting, diarrhea, constipation Cramping

Ongoing assessments are the integral data

How do the bedside assessments affect the management of the patient?

The dialysis prescription?

Access plans?

Ongoing assessments are the integral data

How do the bedside assessments affect the management of the patient?

The dialysis prescription?

Access plans?

Dialysis Nursing Assessments: with the patient during the riskiest time Bleeding Hypotension Tachyarrhythmias Seizure Loss of consciousness Cramping Pain Access assessment

Dialysis Nursing Assessments: with the patient during the riskiest time Bleeding Hypotension Tachyarrhythmias Seizure Loss of consciousness Cramping Pain Access assessment

AKI Dialysis Nursing Interventions

AKI Dialysis Nursing Interventions

Fluids Medications Changes in Qb Lytic instillation for catheters Removing catheters Stopping treatment

Returning blood

Fluids Medications Changes in Qb Lytic instillation for catheters Removing catheters Stopping treatment

Returning blood

AKI PharmacologyAKI Pharmacology

“Nephrotoxic Agents” NSAIDS Iodinated Contrast Dye Gentamicin IV acyclovir

“Nephrotoxic Agents” NSAIDS Iodinated Contrast Dye Gentamicin IV acyclovir

Drugs to avoid in the patient with AKI

DemerolGadoliniumFleetsMetformin/glucophage

Drugs to avoid in the patient with AKI

DemerolGadoliniumFleetsMetformin/glucophage

Proceed with cautionAce inhibitors, ARBS, DRIsSpironolactoneK supplementationOral acyclovirLMWHCoumadin

Proceed with cautionAce inhibitors, ARBS, DRIsSpironolactoneK supplementationOral acyclovirLMWHCoumadin

Acute Kidney Injury Immunosuppressants

Solumedrol/PrednisoneMycophenylateCyclophosphamideRituximab

DosingSide effectsToxicityIndications

Acute Kidney Injury Immunosuppressants

Solumedrol/PrednisoneMycophenylateCyclophosphamideRituximab

DosingSide effectsToxicityIndications

IVF When to give?

Compositions Bicarbonate based solutions

Rhabdomyolysis Tumor Lysis Syndrome Metabolic acidosis

Diuretics Loop diuretics Thiazides Acetozolamide

Antihypertensives

Others Rasburicase Fomepizole

IVF When to give?

Compositions Bicarbonate based solutions

Rhabdomyolysis Tumor Lysis Syndrome Metabolic acidosis

Diuretics Loop diuretics Thiazides Acetozolamide

Antihypertensives

Others Rasburicase Fomepizole

Acute Dialysis: AntibioticsAcute Dialysis: Antibiotics

Antibiotics dosed with dialysis Vancomycin Cubicin Gentamicin Ceftazidime Cefazolin

Antibiotics dosed with dialysis Vancomycin Cubicin Gentamicin Ceftazidime Cefazolin

Acute Dialysis: ESAsAcute Dialysis: ESAs

Epogen, Aranesp, Procrit

Iron Supplementation Oral vs. IV

To give or not to give in the acute setting?

Pressure from outpatient units to “keep hgb in goal range” at discharge

Epogen, Aranesp, Procrit

Iron Supplementation Oral vs. IV

To give or not to give in the acute setting?

Pressure from outpatient units to “keep hgb in goal range” at discharge

Bone and Mineral Metabolism

Bone and Mineral Metabolism

Vitamin D3 Activated Vitamin D Binders

Calcium-based vs. calcium-free Calcimimetics (Sensipar) Calciphylaxis

Thiosulfate Bisphosphanates

Vitamin D3 Activated Vitamin D Binders

Calcium-based vs. calcium-free Calcimimetics (Sensipar) Calciphylaxis

Thiosulfate Bisphosphanates

Transition to Chronic Setting

Transition to Chronic Setting Communication between Acute Dialysis

Nurse and Outpatient Dialysis Nurse Crucial for success

What was patient’s diagnosis during hospitalization?

For the outpatient nurse: How will the hospitalization affect the

outpatient dialysis prescription?

If the patient is actively listed for transplant, how does this event affect his/her candidacy?

Communication between Acute Dialysis Nurse and Outpatient Dialysis Nurse Crucial for success

What was patient’s diagnosis during hospitalization?

For the outpatient nurse: How will the hospitalization affect the

outpatient dialysis prescription?

If the patient is actively listed for transplant, how does this event affect his/her candidacy?

Was the hospitalization related to a complication of outpatient dialysis?Syncope or strokeHypoglycemiaArrhythmiasSteal syndromesInfections related to bacteremia

OsteomyelitisBacterial endocarditisOther invasive infections

Was the hospitalization related to a complication of outpatient dialysis?Syncope or strokeHypoglycemiaArrhythmiasSteal syndromesInfections related to bacteremia

OsteomyelitisBacterial endocarditisOther invasive infections

Was the hospitalization related to the way the patient’s outpatient treatments have been going?

No showsSigning off earlyFailure to UF

Intradialytic hypotensionCramping

Excessive weight gainsInadequate adjustments in edwTransportation

Was the hospitalization related to the way the patient’s outpatient treatments have been going?

No showsSigning off earlyFailure to UF

Intradialytic hypotensionCramping

Excessive weight gainsInadequate adjustments in edwTransportation

Invasive procedures and potential complications at dialysis Renal biopsy Cardiac cath Debridement/treatment of lower

extremity wounds Fistulagrams Loss of access New cancer diagnosis? Other high risk invasive procedures:

lumbar puncture, bronchial biopsies, major surgeries

Invasive procedures and potential complications at dialysis Renal biopsy Cardiac cath Debridement/treatment of lower

extremity wounds Fistulagrams Loss of access New cancer diagnosis? Other high risk invasive procedures:

lumbar puncture, bronchial biopsies, major surgeries

Discharge medsDischarge meds

Antibiotic orders?

Antihypertensive medication changes?

New anticoagulants?

Immunosuppressants?

Antibiotic orders?

Antihypertensive medication changes?

New anticoagulants?

Immunosuppressants?

SummarySummary

Acute hemodialysis creates specific needs related to optimal patient outcome and patient safety Protection of renal function and chances

of recovery High risk medications and procedures Transition to outpatient setting Short and long term outcomes

perspective

Acute hemodialysis creates specific needs related to optimal patient outcome and patient safety Protection of renal function and chances

of recovery High risk medications and procedures Transition to outpatient setting Short and long term outcomes

perspective

GO HEELS!!!!GO HEELS!!!!