Q.550. What are the strategies to minimize dialysis-induced hypotension in the elderly?
HEAMODIALYSIS
Q.550. What
are the strategies to minimize dialysis-induced hypotension in the elderly?
1) Frequent
assessment of D.W.
2) Avoid
excessive inter-dialytic Wt. gain (<5 %
body Wt.)
3) Avoid
anti-H.T. drugs prior to DX or altogether.
4) Reduce
intake of narcotic analgesics & sedative hypnotics
5) No heavy meals on, or just prior to DX.
6) Increased
hematocrit to 33%
7) Evaluate
for silent pericardial effusion
8) Use
Dzt sod. of >140 meq/L
9) High
Dzt calcium.
10)
Use bicarbonate DX. (esp.
é high QB)
11)
Prox. O2,
esp. é cardiac or respiratory dis. & preDX PaO2 of
<80mmHg
12)
Use biocompatible membrane
13)
In selected ptn, use a cool Dzt (34°C!!).
14)
Use DX machines é UF controls
15)
Use sequential UF-DX; occasionally needed when high UF rates are
retired.
16)
Ameliorate risk f.s for LVH (anemia, hyperpara., aluminum
overload)
17)Improve
nutritional status & hypoalbuminemia if present .
Q.551. What
is the chance for women on dialysis to be pregnant?
A. Only 0.5 % of women in childbearing
period can conceive each year, from which 30 % ⮞ Surviving
infants. Infants us. premature & small for gestational age. Infertility is
the role in women with ESRD, but if pregnancy occur⮞ increased the dose of DX. (daily
dialysis).
Q.552. What
is the importance of nutritional status assessment as an indicator for RRT?
A. According to recent K/DOQI
guidelines, RRT should be initiated é evidence of
malnutrition in advanced CKD. Ptn develops anorexia &
decreased protein intake despite efforts to improve his nutritional status.
If malnutrition develops before RRT start Decreasd long-term
survival & potential for rehabilitation.
Q.553. What markers
commonly used for detection of malnutrition in advanced CKD?
A. Markers commonly used for
detection of malnutrition in advanced CKD:
(1) Anorexia, nausea & vomiting & Wt. loss.
(2) Subjective global assessment.
(3) Low albumin & pre-albumin: Albumin: Correlate
well é protein stores.
Pre-albumin⮞ shorter ½ life & change rapidly
é nutritional changes. (🠟 13 mg/dl
= malnutrition).
(4) Decreased dietary “protein” intake< 0.8 g./kg. or nPNA< 0.8 g/kg/d.= Malnutrition.
(5) Abn. “anthrobometric”
measurements: rapid & reproducible method for evaluation
of body fat & msc. mass (referred
to standard for healthy adults).
(6) Abnormally low pl. Cr.: pl. Cr. reflects muscle mass. Pl.
Cr.<10 mg/dl. at the start of DX.=
malnourished (USRDS, U.S. Renal Data
Association).
(7) Other markers: Cholesterol,
transferrin & Somatomedin C.
Malnutrition shoudld
be 👉 Strong Indicator
for start of DX. in CKD. 👆
Q.554.What
are the applied measures to reduce B2 -micro-globulinemia
in ESRD?
A. K/DOQI (2003) for management of B2 –microglobuli
amyloidosis (A.B2M):
1) Screening
for B2.M, incl. measuring of s. level of B2.M, is
NOT recommended.
2) Ptn.
with/at risk for AB2.M, non-cuprophane
high flux Dzer.s
should be used.
3) No currently available ttt.
(except R.TX.)🠞 Stop
dis. progression or Sm.tic relief.
4) R.Tx.: should be considered to stop
dis. progression/Sm.tic relief. in ptn. é B2M.
UK Renal association(2007):
1. Ultrapure water ☜ shd be regarded as standard.
2. High flux synthetic &
modified cellulose dzer,
justified for cost/benefit ratio.
3. Currently:No
available evid. to support routine use of H.F. &
HDF in ESRD.
4. Balance of evidence: Use DX. regimen promoting removal of middle molecule in ch. DX.(> 3.7 y) or predicted to be ch. ptn.
[Age, HLA Ssz, recurrent dis. etc].
v High flux membranes🠟 B2M by
diffusion/convection & adsorption.
v HDF 🠞Higher clearance
of B2.M by convective removal.
v 🠝frequency &
duration of DX. 🠞🠟B2.M.
Q.555. How
to manage
secondary hyperparathyroidism & mineral metabolism in dialysis patients? What are the
indications of parathyroidectomy (Pec.)?
A. Management of secondary hyperpara. & mineral metabolism abnormal in
DX.:
v
Maj. f.s responsible for stimulating
parathyroid gland in R.F.:† {hypocalcemia, low 1,25-dihydroxyvit. D &
hyperphosphatemia}.
v
If physiologic abnormal are uncorrected, R. bone
dis. will developed:† [weakness,
fractures, bone & msc. pain & avascular necrosis, mostly in DX.].
Along é R. osteodystrophy, 2ry hyperpara. is ass. é diso. of mineral metb., mainnly abn. in Po4
& Ca. in addition to increased risk of all-cause & CVS, M.R. é disorder of mineral mtb.
v
So, keep i.PTH (2nd generation PTH assay): 150-300 pg/mL (80-160 pg/mL é Bi-PTH assay), Po4: 3.5-5.5 mg/dL
(1.13-1.78 mmol/L) & corrected Ca:(8.4-9.5 mg/dL
(2.10-2.37 mmo
l/L).
v
Current management of 2ry hyperpara. in DX
involves: combination of Po4 binders (either Ca or non-Ca containing binders), vit. D analogues & calcimimetic.
v
Ptn. é increased i.PTH, the general strategy is to dcreased s. Po4
to normal, limit excessive
Ca. loading, avoid high dose active vit. D analogue, decreased. vit. D analog
dose in ptn. é suppressed PTH, use a calcimimetic to help lower PTH, prevent progression
of parathyroid dis., maintain bone health & prevent fractures.
v
Ptn é increased PTH.: stepped approach to management of hyperpara. & bone mineral abnormality. This
approach requires a complex balance of 4 drugs, namely {Ca-containing
binders, non-Ca binders, calcimimetics & vit. D analogues}.
Aspects of suggested approach include:
v Initial focus in managing 2ry hyperpara. is†management
of hyperphosphatemia é diet and/or Po4 binders. Sp.
interventions us. based é s. Po4 & Ca
levels.
v Next: decide whether Po4
binder is sufficient or calcimimetic/vit.D analogue should be added, based é Ca, Po4 & PTH measured during starting Po4
binder.
v Finally: adjust Po4 binders “doses”, active vit. D
& cinacalcet to target values.
A. Indications of parathyroidectomy:
I.
Sever Hyperparathyroidism:
(1) With persistent
hyperphosphatemia.
(2) Unresposive to Calcitriol
& Calcium.
(3) Renal Tx. candidates.
(4) With sev. hypercalcemia.
(5) Evidence of metastatic
calcifications.
II.
Calciphylaxis with
evidence of hyperpara.
III.
Severe pruritus, only if additional evidence
of hyperpara.
N.B. Patients é CKD 5 on Dx, s. phosphorus should be
maintained between 3.5-5.5 mg/dL bec. Sustained hyperphosphatemia † SHPT
thr. sustained low s. Ca.
PO4 binders are considered 2nd-line
therapy to control s. phosphorus and/or PTH following failure of dietary posphorus restriction.
Although PO4 binders hv bn shown to decreased s. phosphorus,
there’s no evidence tht this hs a direct effect on lowering s. iPTH in
dialysis ptns., or dcr. morbidity & M.R. associated é SHPT. Vit. D sterols are considered first-line therapy in CKD DX ptn. é sust-ained
increase s. iPTH. In addition to active vit. D sterols, calcimimetics may be used to treat high s. iPTH in CKD ptn.
on DX. who have SHPT. Pec. should be considered in ptn. who do not
achieve target s. iPTH, Ca+, PO4, or Ca+-PO4
cx. foll. trial
of cinacalcet. Pec. should also be considered é
sustained levels of iPTH > 800 pg/mL, or for é sustained levels > 470 pg/mL
in whom target levels of s. Ca+, PO4, or the Ca+-PO4 cx
hv bn achieved (Medscape).
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