Approach to a dialysis patient

James talks to Associate Professor Kate Wyburn about the approach to managing a dialysis patient on the wards.

Summary Writer:  George McClintock

Editor:  James Edwards

Interviewee:  Kate Wyburn

About Kate Wyburn

Associate Professor Kate Wyburn is a Senior Staff Specialist Nephrologist at Royal Prince Alfred Hospital and a Clinical Associate Professor at the Faculty of Medicine, Central Clinical School, University of Sydney. Kate Wyburn is the current Chair of the NSW Transplant Advisory Committee. She has a long-standing interest in immunology and its relationship to renal disease and undertook a PhD in Transplant Immunology at The University of Sydney. Her main clinical and research interests include highly sensitised kidney transplantation, both HLA and ABO-incompatible and B cell immunobiology.

An approach to the dialysis patient

With Dr Kate Wyburn Senior Staff Specialist at Royal Prince Alfred Hospital and Associate Professor at the Clinical School of Medicine, Sydney University, New South Wales, Australia

Introduction

Associate Professor Wyburn discusses an approach to managing a dialysis patient on the wards. A helpful topic for those interested in renal medicine and anyone covering a renal ward after hours.

  • There are two main types of dialysis:
    • Haemodialysis
      • Removing excess fluid and toxins extra-corporeally on a dialysis machine
      • Through an arterio-venous fistula or using a vas-cath central line
      • Can be done at home, in centre or at a satellite unit
      • Can be completed nocturnally
    • Peritoneal dialysis
      • Uses the peritoneal membrane as the dialyser
      • Fluid through a catheter is placed in the peritoneal cavity
      • Excess water and toxins are removed down the gradient across the membrane
      • Can be done at home, overnight or intermittently throughout the day
  • Neither one is necessarily superior to the other, the decision depends on the patient; lifestyle, preferences and contraindications.
    • Haemodialysis
      • Advantages
        • Usually only dialysing 3 times a week
      • Disadvantages
        • Using needles – infection risk
        • Occasionally difficult to access fistulas
    • Peritoneal Dialysis
      • Advantages
        • More flexible – able to be performed at home and overnight
        • No needles
      • Disadvantages
        • Glucose in the bag may cause problems especially for diabetics
        • Difficult in patients with large abdomens
  • Patients routinely dialysed tend to be more stable than those in ICU who tend to be more complex requiring inotropic support etc.
  • In ICU we are able to do peritoneal and regular haemodialysis, however often the patients do not have the cardiovascular reserve to support this and therefore require a more gentle continuous form of dialysis
    • For example
      • CVVHD: Continuous veno-venous haemodialysis – runs 24 hours a day with less dramatic fluid shift
      • CCRT: Continuous renal replacement therapy
  • The two most common underlying causes for ESRF are hypertension and diabetes.
  • Common indications are acid-base issues, fluid overload or anuria, uraemia and electrolyte imbalances especially hyperkalaemia.
  • A simple way to remember the indications for dialysis is A, E, I, O, U:
    • Acid-base balance
    • Electrolytes
    • Ingestibles ie some overdoses/ toxins
    • Overload of fluid
    • Uraemia

Case 1 – You are an intern on the wards and you get asked to review a patient receiving dialysis with low blood pressure of 80/40. What is your initial approach over the phone and when you finally go to review the patient?

  • This is quite a common scenario for patients on dialysis, however the approach is not too dissimilar to managing hypotension with any other patient.
    • Lie the patient flat or head down
    • Give small boluses of normal saline (250ml)
    • Rule out sinister causes ie. bleeding or chest pain
    • Common cause – rapid fluid removal – manage by slowing down dialysis
  • Ideal body weight – dialysis patients all know their dry weight
  • Inter-dialysis weight gain
  • Baseline blood pressure
  • Other than that – usual assessment, pulse, BP, JVP, pedal oedema and so on
  • The most common cause, as alluded to before, is removing too much fluid via dialysis or ultrafiltration.
  • Other common causes are:
    • Cardiac failure/ IHD
    • Sepsis – particular with vascular lines or fistulas
    • Diabetic autonomic neuropathy
    • Medications/ iatrogenic – may have changed recently with the addition of dialysis
  • Will often feel awful and nauseous
  • The other complication is that the patient may clot off their fistula with low perfusion, which may just be that patient’s life-line
  • Also if they have concomitant cardiac disease it may also compromise their cardiac status
  • It really depends on your differential diagnoses:
    • Sepsis – blood cultures
    • Cardiac – ECG
    • Changing the ultrafiltration rate
    • Discuss the case with the renal team
    • Renal registrars and consultants are always around and happy to discuss their patients

Case

You are asked to review a patient who has presented directly to the renal ward from home, who is having peritoneal dialysis and is complaining of “cloudy bags”.  What does this mean and what is its clinical significance?

  • Usually a sign of infection
  • Could be peritonitis and is quite often associated with abdominal pain
  • First point of call is to culture that bag and make sure the patient is clinically stable
  • Take a history from the patient and particularly ask about any previous episodes
  • Drain the bag and take a sample
  • Blood cultures
  • Commenced antibiotics – usually given intra-peritoneally (within the bag) – most hospitals have local guidelines or protocols re empirical antibiotic choices i.e. Cephazolin and Gentamycin (2 doses) at RPA for at least 2 weeks
  • Commence nystatin – orally
  • Quite often patients with recurrent infections will grow the same bug, however, it is better to start on empirical therapy and switch to less broad-spectrum therapy when a specific pathogen is detected
  • Not necessarily, if the patient is systemically well they may go home with pre-prepared bags and come back each day to receive a new dose
  • Renal terms are great to learn about lines and electrolytes
  • Never take blood or put cannula in a fistula arm
  • Know patients electrolytes post-operatively
  • Think about medications, as some renal patients require different doses

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Tags: #approach to a dialysis patient,#CCRT,#CVVHD,#diabetes,#dialysis,#ESRD,#Haemodialysis,#hypertension,#kidney disease,#Peritoneal dialysis,#peritonitis,#Renal dialysis,#renal disease,#renal medicine

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