Manual of Clinical Dialysis (eBook)

Foreword (For First Edition) 6
Acknowledgements 8
Contents 11
Abbreviations 18
Chapter 1 21
Brief History of Clinical Dialysis: The Seattle Experience 21
1.1 Definition of Dialysis 23
1.2 Mechanisms Involved in Molecular Movement 23
1.2.1 Diffusion 24
1.2.2 Ultrafiltration 24
1.2.3 Osmosis 25
1.2.4 Convection 25
1.3 Clearance 25
1.3.1 Blood vs Plasma Clearance 26
1.3.2 Clinical Factors Influencing Dialysis Urea Clearance 26
Reference 26
Chapter 2 27
Hemodialysis Technique 27
2.1 Blood Flow Rate 27
2.2 Dialysate Flow Rate 27
2.3 Dialyzer Efficiency and Mass Transfer Area Coefficient (KoA) 28
2.4 Different Hemodialysis Techniques 28
2.4.1 Traditional Hemodialysis 28
2.4.2 Hemofiltration 29
2.4.3 Hemodiafiltration 30
2.4.4 Slow Low Efficiency Dialysis (SLED) 30
2.4.5 Ultrafiltration 30
2.5 Hemodialysis Setup 30
2.5.1 Blood Circuit 31
2.5.1.1 Tubing Set 31
2.5.1.2 Blood Pump 32
2.5.1.3 Hemodialyzer 33
Dialyzer Characteristics 34
Reuse of Dialyzers 38
2.5.2 Dialysate Circuit 38
2.5.2.1 Dialysate 38
2.5.2.2 Dialysate Delivery System 40
2.5.2.3 DialysisWater 43
2.5.2.4 Water Treatment System 44
References 47
Chapter 3 48
Anticoagulation 48
3.1 Heparin Anticoagulation 49
3.1.1 Systemic Standard Heparinization 50
3.1.2 Low-Dose Heparinization 50
3.1.3 Low Molecular Weight Heparin 50
3.2 Problems with Heparin Anticoagulation 51
3.3 Alternatives to Heparin 52
3.3.1 Citrate Anticoagulation 52
3.3.1.1 Citrate Dialysate (Local Citrate) Anticoagulation 52
3.3.1.2 Regional Citrate Anticoagulation 53
3.3.1.3 Heparinoids 53
3.3.1.4 Direct Thrombin Inhibitors 54
3.3.1.5 Prostacyclin and other Prostanoids 54
3.4 No Anticoagulation 54
References 55
Chapter 4 56
Vascular Access 56
4.1 Permanent Access 56
4.1.1 Preparation 56
4.1.1.1 Preferred Access Choice 57
4.1.2 Arteriovenous Fistula 57
4.1.2.1 Technique 57
4.1.2.2 Fistula Use 59
4.1.2.3 Arteriovenous Fistula Complications 59
4.1.3 Arteriovenous Graft 60
4.1.3.1 Graft Use 61
4.1.3.2 Graft Complications 61
4.1.4 Diagnosis and Management of Arteriovenous Dialysis Access 62
4.1.4.1 Clinical Indicators of Problems with Grafts and Fistulae 62
4.1.4.2 Diagnostic Tests 63
4.1.4.3 Management 64
4.1.5 Dual-Lumen Catheters with Dacron Cuff 64
4.1.5.1 Complications 65
4.1.6 Special Arteriovenous Shunts 67
4.1.6.1 Scribner Shunt 67
4.1.6.2 Thomas Shunt 68
4.2 Temporary Access 68
4.2.1 General Technique 69
4.2.1.1 Internal Jugular Access 69
4.2.1.2 Subclavian Access (Least Desirable) 70
4.2.1.3 Femoral Access 71
4.2.2 Complications of Temporary Access 71
4.2.2.1 Procedure-Related Complications of Superior Vena Cava Access (Subclavian and Internal Jugular) 73
4.2.2.2 Procedure-Related Complications of Femoral Vein Catheters 73
4.2.2.3 Late Complications 74
4.2.3 Comparison of the Three Access Sites 74
4.3 Impact of Access 74
4.3.1 Access Surveillance 75
References 77
Chapter 5 78
Complications of Hemodialysis 78
5.1 Medical Complications 78
5.1.1 Hypotension 78
5.1.1.1 Effect of Ultrafiltration 79
5.1.1.2 Prevention of Hemodynamic Instability 84
5.1.1.3 Clinical Manifestation of Hypotension 85
5.1.1.4 Treatment of Hypotension 85
5.1.1.5 Convective vs Diffusive Transport and Hypotension 86
5.1.2 Cardiac Arrhythmias 87
5.1.3 Intradialytic Hypertension 88
5.1.4 Muscle Cramps 88
5.1.4.1 Prevention 89
5.1.4.2 Treatment 89
5.1.5 Carnitine and Intradialytic Hypotension, Arrhythmias, and Muscle Cramps 89
5.1.6 Nausea and Vomiting 90
5.1.7 Headache 90
5.1.8 Serious, Less Common Complications 91
5.1.8.1 Dialysis Disequilibrium Syndrome 91
5.1.8.2 Dialyzer-Related Reactions 92
5.2 Machine-Related Complications 94
5.2.1 Air Embolism 94
5.2.1.1 Management 94
5.2.2 Hemolysis 95
References 95
Chapter 6 97
Dose of Hemodialysis 97
6.1 Historical Background 97
6.1.1 Dialysis Index 98
6.1.2 Urea Clearance 98
6.1.3 Urea as a Marker for Uremic Toxins 99
6.1.4 Current Methods of Measuring Dialysis Dose 99
6.1.4.1 Urea Reduction Ratio 100
6.1.4.2 Calculating Kt/V from Urea Reduction 100
6.1.4.3 Urea Kinetic Modeling 101
6.2 Potential Problems with the Calculation of Dialysis Dose 101
6.2.1 Influence of the Single-Pool Model 101
6.2.1.1 Correcting for the Two-Pool Model 103
6.2.1.2 Urea Kinetic Modeling 103
6.2.1.3 Residual Renal Function 104
6.2.1.4 Normalized Protein Catabolic Rate 106
6.3 Determining Adequate Dialysis 109
6.3.1 Acceptable Kt/V Values 110
6.3.2 Frequency of Dose Measurement 110
References 110
Chapter 7 112
Continuous Therapies 112
7.1 Overview 112
7.2 Types of Continuous Therapies 112
7.2.1 Continuous Arteriovenous Hemofiltration (CAVH) 112
7.2.2 Continuous Venovenous Hemofiltration (CVVH) 113
7.2.3 Continuous Venovenous Hemodialysis (CVVHD) 115
7.2.4 Continuous Venovenous Hemodiafiltration (CVVHDF) 116
7.2.5 Slow Low-Efficiency Diffusion Hemodialysis (SLEDD) 116
7.2.6 Slow Continuous Ultrafiltration (SCUF) 117
7.2.7 Newer Technologies 117
7.3 Components of Continuous Therapies 119
7.3.1 Vascular Access 119
7.3.2 Tubing 120
7.3.3 Filter 121
7.3.4 Replacement Fluid 121
7.3.4.1 Composition of Replacement Fluids 121
7.3.4.2 Site of Replacement Fluids 125
7.3.5 Dialysis Fluid 126
7.3.6 Machines 127
7.4 Dialysate Flow and Ultrafiltration Rates 127
7.5 Anticoagulation 129
7.5.1 Heparin 130
7.5.2 Low Molecular Weight Heparin 130
7.5.3 Citrate 130
7.5.3.1 Citrate Dialysate 131
7.5.4 Prostacyclin 131
7.5.5 Argatroban 132
7.5.6 Lepirudin 132
7.5.7 Danaparoid 132
7.5.8 Fondaparinux 133
7.5.9 Nafamostat 134
7.5.10 No Anticoagulation 134
7.6 Drug Removal During CRRT 134
7.7 Intraoperative Dialysis 135
7.8 Dose of Dialysis in Continuous Therapies 136
References 137
Chapter 8 140
Peritoneal Dialysis 140
8.1 Historical Background 140
8.2 Anatomy and Physiology 140
8.3 Kinetics of Peritoneal Transport 142
8.3.1 Diffusion 142
8.3.2 Ultrafiltration 143
8.3.2.1 Convective Solute Transport 143
8.3.2.2 Net Ultrafiltration 143
8.3.2.3 Lymphatic Absorption 144
References 144
Chapter 9 145
Technique of Peritoneal Dialysis 145
9.1 Peritoneal Dialysis Catheters 145
9.1.1 Description 145
9.1.2 Catheter Insertion Technique 147
9.1.2.1 Surgical Implantation Technique 147
9.1.2.2 Percutaneous Approach 148
9.1.2.3 Insertion with Peritoneoscopy 149
9.1.2.4 Comparison of the Three Techniques 150
9.1.2.5 Postoperative Complications 150
9.2 Peritoneal Dialysis Fluid 153
9.2.1 Osmotic Agents 153
9.2.1.1 Dextrose 153
9.2.1.2 Alternative Agents 154
Amino Acid Solutions 154
Icodextrin Solution 155
9.3 Delivery Mechanism 156
9.4 Peritoneal Dialysis Techniques 156
9.4.1 Continuous Ambulatory Peritoneal Dialysis (CAPD) 156
9.4.2 Automated Peritoneal Dialysis (APD) 156
9.4.2.1 Tidal Peritoneal Dialysis (TPD) 157
9.4.2.2 Cyclers 158
References 159
Chapter 10 160
Dose of Peritoneal Dialysis 160
10.1 Weekly Creatinine Clearance 160
10.1.1 Residual Glomerular Filtration Rate 161
10.1.2 Peritoneal Creatinine Clearance 161
10.1.3 Correction for Body Surface Area 162
Total Weekly Creatinine Clearance Calculation 163
10.2 Urea Clearance Concept (Kt/Vurea) 163
10.2.1 Volume of Distribution of Urea 163
10.3 Recommended Dose of Dialysis 164
10.3.1 Potential Problem with Dose Measurements 165
10.3.2 Frequency of Dose Determination 165
10.4 Peritoneal Function Test 166
10.4.1 Traditional Peritoneal Equilibration Test 166
10.4.2 Fast Peritoneal Equilibration Test 166
10.4.3 Results of the Peritoneal Equilibration Test 167
10.5 Use of Fast Peritoneal Equilibration Test Results in Selecting a Peritoneal Dialysis Regimen 168
10.5.1 Selection of Technique 169
10.5.1.1 Empirical Approach to Deciding a Peritoneal Dialysis Regimen 169
References 170
Chapter 11 171
Complications of Peritoneal Dialysis 171
11.1 Peritonitis 171
11.1.1 Clinical Diagnosis 171
11.1.1.1 Clinical Work-Up of Suspected Peritonitis 173
11.1.2 Therapy 174
11.1.2.1 Lavages 174
11.1.2.2 Antimicrobial Therapy 174
11.1.2.3 Treatment of Fungal Peritonitis 179
11.2 Exit Site and Tunnel Infection (also see Chapter 9) 179
11.3 Under-dialysis 179
11.4 Malnutrition 180
11.5 Membrane Failure 180
11.6 Cardiovascular Complications 180
11.7 Intra-Abdominal Pressure 181
11.8 Hemoperitoneum 181
References 181
Chapter 12 183
Nutritional Issues 183
12.1 Protein Calorie and Nutritional Status of Dialysis Patients 183
12.2 Significance of Nutritional Status 184
12.2.1 Hemodialysis 184
12.2.2 Peritoneal Dialysis 184
12.3 Factors Causing Malnutrition 186
12.3.1 Uremia 186
12.3.2 Other Factors 186
12.4 Assessment of Nutritional Status 187
12.4.1 Dietary Intake 187
12.4.2 Anthropometry and Body Weights 189
12.4.3 Bioelectric Impedance Analysis 189
12.4.4 Dual Energy X-Ray Absorptiometry 189
12.4.5 Subjective Global Assessment 189
12.4.6 Biochemical Assessment 190
12.5 Nutritional Requirements 190
12.5.1 Protein 192
12.5.2 Caloric Intake 192
12.5.3 Lipids 192
12.5.4 Fatty Acids, Lipids, and Carnitine 192
12.5.5 Vitamins and Trace Elements 193
12.5.6 Additional Nutritional Support 194
12.5.7 Metabolic Acidosis 194
References 195
Chapter 13 197
Hypertension 197
13.1 Prevalence 197
13.2 Control of Hypertension 197
13.3 Significance of Hypertension Control 200
13.4 Pathogenesis 200
13.4.1 Sodium Excess 201
13.4.2 Other Factors 202
13.5 Treatment of Hypertension 202
13.5.1 Sodium and Volume Control 202
13.5.2 Ultrafiltration 204
13.5.2.1 Hypertensive Response to Ultrafiltration 205
13.5.3 Pharmacological Agents 206
13.5.3.1 Calcium Channel Blockers 206
13.5.3.2 Angiotensin-Converting Enzyme Inhibitors 209
13.5.3.3 Angiotensin II Antagonists 209
13.5.3.4 Beta-Blockers 210
13.5.3.5 Vasodilators 210
13.5.3.6 Central Sympatholytics 211
13.5.3.7 Alpha-blockers 211
13.6 Conclusions 211
References 211
Chapter 14 213
Anemia 213
14.1 Pathogenesis 213
14.1.1 Erythropoietin 213
14.1.2 Uremic Factors 214
14.1.3 Other Factors 215
14.2 Treatment of Anemia 215
14.2.1 Erythropoietin-Stimulating Agents (ESA) and Administration 215
14.2.1.1 Route of Administration of Erythropoietin 216
14.2.1.2 Lack of Response to Erythropoietin 216
14.2.1.3 Adverse Effects of Erythropoietin 217
14.3 Iron Status 219
14.3.1 Tests to Evaluate Iron Status 219
14.3.1.1 Ferritin 219
14.3.1.2 Transferrin Saturation 219
14.3.1.3 Other Tests 220
14.3.2 Iron Supplementation 220
14.4 Carnitine 221
14.5 Other Measures to Improve Hematocrit Response 222
References 222
Chapter 15 224
Renal Osteodystrophy 224
15.1 Pathophysiology of Renal Osteodystrophy 224
15.1.1 Vitamin D Metabolism 224
15.1.2 Phosphorus Retention 225
15.1.3 Parathyroid Hormone 225
15.2 Histological Classification of Renal Osteodystrophy 227
15.2.1 High-Turnover Bone Disease 228
15.2.2 Low-Turnover Bone Disease 228
15.2.3 Mixed (Uremic) Bone Disease 229
15.3 Clinical Manifestation of Renal Osteodystrophy 229
15.4 Metastatic Calcification 230
15.5 Laboratory Findings and Management of ROD 231
15.5.1 Laboratory Findings 231
15.5.1.1 Parathyroid Hormone 231
15.5.1.2 Phosphorus 231
15.5.1.3 Calcium 232
15.5.1.4 Alkaline Phosphatase 232
15.5.1.5 Aluminum 233
15.5.1.6 Osteocalcin and Other Markers 233
15.5.1.7 Bone Biopsy 234
15.5.2 High Turnover Disease 234
15.5.2.1 Parathyroid Hormone Control 234
15.5.2.2 Phosphorus Control 235
15.5.2.3 Calcium Supplementation 236
15.5.2.4 Parathyroidectomy 236
15.6 Low-Turnover Disease 237
15.6.1 Aluminum Control 237
15.6.2 Low Parathyroid Hormone 237
15.6.3 Other Therapies 237
15.6.4 Prevention 238
References 238
Chapter 16 240
Atypical Dialysis Circumstances 240
16.1 Pregnancy 240
16.1.1 Dialysis 240
16.1.1.1 Hemodialysis 241
16.1.1.2 Peritoneal Dialysis 241
16.1.2 Associated Conditions 242
16.1.2.1 Hypertension 242
16.1.2.2 Anemia 242
16.1.2.3 Dietary Modifications 242
16.2 Drug Removal in Overdose Situations 242
16.2.1 Peritoneal Dialysis 243
16.2.2 Hemodialysis 243
16.2.3 Hemoperfusion 243
16.2.3.1 The Circuit 243
16.2.3.2 Complications 244
16.2.4 Specific Examples 244
Reference 245
Chapter 17 246
The Future 246
17.1 Increasing Financial Pressure 246
17.2 Changing Population 246
17.3 Patient Outcome Measures 246
17.4 Limited Transplantation Options 247
17.5 Low Rates of Rehabilitation 247
17.6 Ideal Renal Replacement Therapy 247
17.7 Simpler Machines and Daily Dialysis 248
17.7.1 Diffusion vs Convection 248
17.8 Mechanical Artificial Kidney 248
17.8.1 Implantable Mechanical, Artificial Kidney 249
Reference 250
Index 251