hemodialysis
Jump to navigation
Jump to search
[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37]
Indications
- uremia
- uremic pericarditis
- uremic neuropathy
- uremic seizures
- uremic encephalopathy
- bleeding from uremia-induced platelet dysfunction
- acute renal failure
- hypervolemia
- hyperkalemia
- severe acidosis
- intractable malignant hypertension
- congestive heart failure
- chronic renal failure
- acute intoxication with toxin removed by dialysis
- methanol, aspirin, ethylene glycol, lithium, sodium, mannitol, theophylline
- NOT used for tricyclic antidepressants, benzodiazepines, digoxin, dilantin, phenothiazines
Contraindications
- severe, irreversible dementia
- severe, irreversible chronic debilitating disease
Principle
- hemodialysis works by diffusion of ions & small molecular weight molecules across a semipermeable membrane
- fluid removal is accomplished through ultrafiltration
Procedure
- preparation
- avoid venipucture & intravenous catheterization above the level of the hand when GFR drops below 60 mL/min/1.73 m2
- avoid peripherally-inserted central-venous catheters (PICC lines) in patients considering dialysis
- dialysis should be initiated before symptoms of advanced uremia develop
- access
- central venous catheter (temporary)
- immediate use
- highest rate of infection, inadequate flow
- autologous AV fistula vs AV plastic graft
- AV fistula (anastomosis)
- arteriovenous graft (AV graft)
- place 1-21 days before use
- easy cannulation
- higher rate of infection & thrombosis than AV fistula
- Aggrenox may extend AV graft patency.[8]
- autologous AV fistulas cannot always be created, particularly in older patients or those with major comorbidities; plastic grafts are the alternative, but incur relatively high rates of thrombosis and infection.
- grafts vs fistulas associated with higher all-cause mortality (RR=1.18, 1.09-1.27) & fatal infection (RR=1.36, 1.17-1.58), but not risk for cardiovascular events (RR=1.07, 0.95-1.21)[27]
- bioengineered blood vessels may provide means of AV fistulas in patients for whom an AV graft would othersise be needed[29]
- central venous catheter (temporary)
- General recommendations:
- 3 times per week adequate[7]
- intermittent vs continuous hemodialysis comparable[4]
- an increase in weekly hours of dialysis from 12 to > 20 during pregnancy
- 6x vs 3x/week associated with favorable outcomes of death & change in left ventricular mass but necessitates more frequent interventions related to vascular access[26]
- increase intake of dietary protein 1.0-1.2 g/kg/day
- fluid intake should be adjusted to allow a weight gain of 2 kg between dialysis sessions
- anti-hypertensive agents may need to be reduced or held on days of hemodialysis
- medications
- ampicillin & cephalosporins are helpful in conjunction with dialysis
- AVOID: tetracyclines, nitrofurantoin, probenecid, neomycin, bacitracin, methenamine, nalidixic acid, clofibrate, lovastatin, magnesium, oral hypoglycemic agents, antiplatelet agents
- CAUTION: ACE inhibitors & other K+ sparing agents, metoclopramide, NSAIDs, acyclovir, long-acting Ca+2 channel blockers, beta-blockers
- cardioselective beta-1 adrenergic receptor antagonists may diminish risk of heart failure[5]
- management of anemia
- 3 times per week adequate[7]
Complications
- active bleeding &/or coagulopathy
- systemic anticoagulation necessary in hemodialysis
- IV DDAVP 0.3 ug/kg in 50 mL of saline every 4-8 hours
- conjugated estrogen 0.6 mg/kg/day IV for 5 days
- intranasal DDAVP 3.0 ug/kg every 4-6 hours
- fresh frozen plasma (FFP)
- dialysis disequilibrium
- pericarditis
- separate entity from uremic pericarditis
- management
- dialysis 6-7 times/week
- cardiac tamponade
- minimize anticoagulation until pericarditis resolves
- hypotension, orthostatic hypotension, syncope
- etiology
- volume depletion
- low dialysate sodium content
- anti-hypertensive agents before dialysis
- allergic reactions to the dialyzer
- intolerance to dialysate containing acetate
- bicarbonate-based dialysate is most common
- left ventricular dysfunction
- autonomic insufficiency
- myocardial infarction
- cardiac tamponade
- sepsis
- bleeding
- beta-blockers, alpha-blockers, ACE inhibitors, ARBs & diuretics associated with increased risk of intrahemodialysis hypotension relative to calcium channel blockers[37]
- management[35]
- general measures
- IV normal saline
- reduction of dialyzer blood flow
- reduction of ultrafiltration rate
- cooling of dialysate
- specific measures for specific causes
- use of bicarbonate-based dialysate for acetate-sensitive patients
- general measures
- etiology
- vascular access infection (10-25%)
- signs/symptoms
- local or systemic manifestations may be present
- may be asymptomatic
- laboratory:
- radiology: ultrasound of access site
- management
- coverage for Staphylococci (60-90%)
- continue therapy for 4 weeks
- removal of infected access
- exception: AV fistula infection NOT involving suture line
- if there is no evidence of infection of the catheter tunnel, dialysis catheters can be exchanged over a wire in asymptomatic patients on antibiotics for >= 48 hours[3]
- signs/symptoms
- vascular access thrombosis
- recanalization by balloon catheter embolectomy
- urokinase under pressure
- access can be used immediately after declotting
- dialysis dementia
- etiology:
- CNS accumulation of aluminum
- aluminum-containing phosphate binders
- signs/symptoms
- management
- monitoring blood & dialysate aluminum levels
- deferoxamine may improve progression of dialysis dementia
- etiology:
- carpal tunnel syndrome & diffuse arthropathy may occur with long-term dialysis secondary to amyloid deposition of beta-2 microglobulin
- pulmonary
- pleural effusion - generally transudative
- pulmonary calcification
- chest X-ray shows soft infiltrates that mimick pulmonary edema
- diagnosis made by Tc-99 diphosphonate radionuclide scan demonstrating Tc-99 uptake
- loss of CO2 through the dialysis membrane results in compensatory hypoventilation & hypoxemia
- dialysis may increase risk of sleep apnea
- pancreatitis 0.6%, 3 fold less than peritoneal dialysis[6]
- hyperparathyroidism secondary to chronic renal failure
- calcitriol is effective in lowering PTH
- monitor serum calcium, serum phosphate, serum PTH[9]
- transmission of infectious agents
- cystic kidney disease[3]
- risk increases with duration of hemodialysis
- 30-fold increased risk in renal cell carcinoma[3]
- iron-deficiency anemia[36]
- absolute: frequent blood testing & blood lost from the procedure
- functional: transferrin saturation < 30%[36]
- increased risk of mortality
- increased risk of cardiovascular mortality[3]
- rosuvastatin lowers LDL cholesterol but not mortality[21]
- increased all-cause mortality
- digoxin associated with 28% further increase in mortality
- higher serum digoxin & lower serum potassium predialysis associated with increased mortality[12]
- increased risk of cardiovascular mortality[3]
Management
- maintain BUN < 100 mg/dL in acute renal failure
- home hemodialysis may be an option for some[15]
- elderly with multiple comorbidities are best managed medically[35]
- diabetics undergoing dialysis
- better glycemic control does not translate to lower mortality[11]
- early initiation of dialysis may be harmful[17]
- delaying dialysis has a negative impact on clinical parameters but does not affect survival once dialysis is initiated[14]
- hemodialysis generally (3X/week) on MWF
- mortality highest on Monday after 2 days without dialysis
- 50% of deaths due to cardiovascular events[18]
- mortality highest on Monday after 2 days without dialysis
- treat hypertension
- most important objective is control of volume overload
- if predialysis blood pressure > post dialysis blood pressure, attempt more aggressive dialysis (a lower post-dialysis weight)[35]
- most important objective is control of volume overload
- treat anemia of chronic renal failure[19]
- etelcalcetide (Parsabiv) FDA-approved for treatment of secondary hyperparathyroidism in adults with chronic renal failure on hemodialysis
- dialysate calcium concentration of 1.25-1.5 mmol/L[30]
- calcitriol may be of benefit[30]
- statins may be of no benefit[21]
- anticoagulation
- continue anticoagulation for atrial fibrillation with caution
- all-cause mortality, cardiovascular mortality, & bleeding requiring hospitalization are increased by use of oral anticoagulants
- CHADS2 score predicts risk of stroke in dialysis patients with atrial fibrillation patients
- GI bleeding in the past 12 months predicts major bleeding
- for patients with previous GI bleed, major bleeding exceeds stroke by at least twofold across all categoriesof CHADS2 score[22]
- anticoagulation for treatment of venous thromboembolism
- prophylaxis for venous thromboembolism
- LMW heparin & unfractionated heparin with similar risks for bleeding[23]
- apixaban safe with close monitoring in patients with ESRD[3]
- continue anticoagulation for atrial fibrillation with caution
- avoid central venous catheters including PICC lines if possible[28]
- central venous stenosis most commonly occurs from endothelial damage from central venous catheters
- use peripheral venous access if possible[3]
- use hands for venipuncture & peripheral venous access if possible[3]
- use internal jugular vein for antibiotic therapy of weeks duration[3]
- hemodialysis on the day of surgery
- longer intervals between hemodialysis & surgery associated with higher risk of postoperative mortality[33]
- advance care planning in preparation for end-of-life decisions of benefit for surrogates[24]
Notes
- treatment by nephrologists that own their own dialysis facilities is not associated with excess adverse outcomes[34]
More general terms
More specific terms
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 274
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 618, 790
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2022
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 4.0 4.1 4.2 Journal Watch 25(2):18, 2005 Augustine JJ, Sandy D, Seifert TH, Paganini EP. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis. 2004 Dec;44(6):1000-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15558520
- ↑ 5.0 5.1 Journal Watch 25(3):23, 2005 Abbott KC, Trespalacios FC, Agodoa LY, Taylor AJ, Bakris GL. beta-Blocker use in long-term dialysis patients: association with hospitalized heart failure and mortality. Arch Intern Med. 2004 Dec 13-27;164(22):2465-71.
- ↑ 6.0 6.1 Quraishi ER, Goel S, Gupta M, Catanzaro A, Zasuwa G, Divine G. Acute pancreatitis in patients on chronic peritoneal dialysis: an increased risk? Am J Gastroenterol. 2005 Oct;100(10):2288-93. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16181382
- ↑ 7.0 7.1 The VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008, 359:7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18492867
- ↑ 8.0 8.1 Dixon BS et al. Effect of dipyridamole plus aspirin on hemodialysis graft patency. N Engl J Med 2009 May 21; 360:2191 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19458364
- ↑ 9.0 9.1 Elder G et al for Caring for Australasians with Renal Impairment (CARI). The CARI guidelines. Management of bone disease, calcium, phosphate and parathyroid hormone.aring for Australasians with Renal Impairment (CARI). Nephrology (Carlton). 2006 Apr;11 Suppl 1:S230-61. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16684078
- ↑ de Jager DJ et al Cardiovascular and noncardiovascular mortality among patients starting dialysis. JAMA 2009 Oct 28; 302:1782. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19861670
- ↑ 11.0 11.1 Shurraw S et al. Glycemic control and the risk of death in 1,484 patients receiving maintenance hemodialysis. Am J Kidney Dis 2010 May; 55:875. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20346561
- ↑ 12.0 12.1 Chan KE et al Digoxin Associates with Mortality in ESRD J Am Soc Nephrol. 2010 Jun 24. [Epub ahead of print] <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20576808 <Internet> http://jasn.asnjournals.org/cgi/content/abstract/ASN.2009101047v1
- ↑ Eat Right to Feel Right on Hemodialysis http://kidney.niddk.nih.gov/kudiseases/pubs/eatright/index.htm
Hemodialysis Dose and Adequacy http://kidney.niddk.nih.gov/kudiseases/pubs/hemodialysisdose/
Treatment Methods for Kidney Failure: Hemodialysis http://kidney.niddk.nih.gov/kudiseases/pubs/hemodialysis/index.htm - ↑ 14.0 14.1 Thill N et al Outcomes of Patients with Delayed Dialysis Initiation: Results from the AVENIR Study. Am J Nephrol. 2010 Dec 17;33(1):76-83. [Epub ahead of print] PMID: https://www.ncbi.nlm.nih.gov/pubmed/21178337
- ↑ 15.0 15.1 Derret S et al Older peoples' satisfaction with home-based dialysis. Nephrology (Carlton). 2010 Jun;15(4):464-70. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20609099
Li PK et al Increasing home based dialysis therapies to tackle dialysis burden around the world: A position statement on dialysis economics from the 2nd Congress of the International Society for Hemodialysis. Nephrology (Carlton). 2011 Jan;16(1):53-56 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21175978 - ↑ Kurella Tamara M, Covinsky KE, Chertow GM, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009 Oct 15; 361(16):1539-1547. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19828531
- ↑ 17.0 17.1 Rosansky SJ et al. Early start of hemodialysis may be harmful. Arch Intern Med 2011 Mar 14; 171:396. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21059968
Johansen KL. Time to rethink the timing of dialysis initiation. Arch Intern Med 2011 Mar 14; 171:382. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21059965 - ↑ 18.0 18.1 Foley RN et al. Long interdialytic interval and mortality among patients receiving hemodialysis. N Engl J Med 2011 Sep 22; 365:1099 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21992122 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1103313
- ↑ 19.0 19.1 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
- ↑ Kurella TM, Covinsky KE, Chertow GM, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009; 361:1539-1547; October 15, 2009. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19828531
- ↑ 21.0 21.1 21.2 Fellstrom BC, Jardine AG, Schmieder RE et al Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. N Engl J Med. 2009 Apr 2;360(14):1395-407. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19332456
Navaneethan SD, Nigwekar SU, Perkovic V et al HMG CoA reductase inhibitors (statins) for dialysis patients. Cochrane Database Syst Rev. 2009 Jul 8;(3) PMID: https://www.ncbi.nlm.nih.gov/pubmed/19588351 - ↑ 22.0 22.1 Sood MM et al. Major bleeding events and risk stratification of antithrombotic agents in hemodialysis: Results from the DOPPS. Kidney Int 2013 Sep; 84:600 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23677245
- ↑ 23.0 23.1 Chan KE et al. No difference in bleeding risk between subcutaneous enoxaparin and heparin for thromboprophylaxis in end-stage renal disease. Kidney Int 2013 Sep; 84:555 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23677243 <Internet> http://www.nature.com/ki/journal/v84/n3/full/ki2013152a.html
- ↑ 24.0 24.1 Song M-K et al. Advance care planning and end-of-life decision making in dialysis: A randomized controlled trial targeting patients and their surrogates. Am J Kidney Dis 2015 Nov; 66:813 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26141307
- ↑ 25.0 25.1 CDC Health Alert Network. January 27, 2016 CDC Urging Dialysis Providers and Facilities to Assess and Improve Infection Control Practices to Stop Hepatitis C Virus Transmission in Patients Undergoing Hemodialysis. http://emergency.cdc.gov/han/han00386.asp
- ↑ 26.0 26.1 FHN Trial Group, Chertow GM, Levin NW, Beck GJ et al In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010 Dec 9;363(24):2287-300 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21091062 Free PMC Article
- ↑ 27.0 27.1 Ravani P, Palmer SC, Oliver MJ Associations between hemodialysis access type and clinical outcomes: a systematic review. J Am Soc Nephrol. 2013 Feb;24(3):465-73. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23431075 Free PMC Article
- ↑ 28.0 28.1 El Ters M, Schears GJ, Taler SJ et al Association between prior peripherally inserted central catheters and lack of functioning arteriovenous fistulas: a case-control study in hemodialysis patients. Am J Kidney Dis. 2012 Oct;60(4):601-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22704142 Free PMC Article
- ↑ 29.0 29.1 Lawson JH, Glickman MH, Ilzecki M et al Bioengineered human acellular vessels for dialysis access in patients with end-stage renal disease: two phase 2 single- arm trials. Lancet. 2016 May 14;387(10032):2026-34. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27203778
Laschke MW, Menger MD. Bioengineered vascular grafts off the shelf. Lancet. 2016 May 14;387(10032):1976-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27203754 - ↑ 30.0 30.1 30.2 Ketteler M, Block GA, Evenepoel P et al Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease - Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update. Ann Intern Med. 2018. Feb 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29459980 <Internet> http://annals.org/aim/fullarticle/2672941/diagnosis-evaluation-prevention-treatment-chronic-kidney-disease-mineral-bone-disorder
- ↑ Macdougall IC, White C, Anker SD et al Intravenous Iron in Patients Undergoing Maintenance Hemodialysis. N Engl J Med. Oct 26, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30365356 Free Article https://www.nejm.org/doi/full/10.1056/NEJMoa1810742
- ↑ McGill RL, Ruthazer R, Meyer KB, Miskulin DC, Weiner DE. Peripherally Inserted Central Catheters and Hemodialysis Outcomes. Clin J Am Soc Nephrol. 2016 Aug 8;11(8):1434-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27340280 Free PMC Article
- ↑ 33.0 33.1 Fielding-Singh V, Vanneman MW, Grogan T et al Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease. JAMA. 2022;328(18):1837-1848 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36326747 https://jamanetwork.com/journals/jama/fullarticle/2798071
Bleyer AJ Optimal Timing of Hemodialysis Before Surgery. JAMA. 2022;328(18):1816-1817. PMID: https://www.ncbi.nlm.nih.gov/pubmed/3632672 https://jamanetwork.com/journals/jama/fullarticle/2798072 - ↑ 34.0 34.1 Lin E, McCoy MS, Liu M et al. Association between nephrologist ownership of dialysis facilities and clinical outcomes. JAMA Intern Med 2022 Nov 7; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/36342723 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2797774
- ↑ 35.0 35.1 35.2 35.3 NEJM Knowledge+ Nephrology/Urology
Reeves PB, Mc Causland FR. Mechanisms, Clinical Implications, and Treatment of Intradialytic Hypotension. Clin J Am Soc Nephrol. 2018 Aug 7;13(8):1297-1303. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29483138 Free PMC article. Review. - ↑ 36.0 36.1 36.2 NEJM Knowledge+ Question of the Week. July 4, 2023 https://knowledgeplus.nejm.org/question-of-week/1077/
- ↑ 37.0 37.1 Zoccali C, Tripepi G, Carioni P et al. Antihypertensive drug treatment and the risk for intrahemodialysis hypotension. Clin J Am Soc Nephrol 2024 Oct; 19:1310-1318. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39012707 PMCID: PMC11469783 (available on 2025-10-01)