Q.560. What are the possible outcomes associated with nocturnal HDX?

 

HEMODIALYSIS

Q.560. What are the possible outcomes associated with nocturnal H.DX?

A. NHDX is ass. é marked benefits compared to conventional HDX. Some benefits  hav been clearly shown, while others require further analysis. Clearance of urea, Po4 & beta2-microglobulin are markedly enhanced é NHDX. Limited data sugg.:“quality of life” may be improved. Excellent B.P. control is achieved, with almost all ptn.s no longer requiring anti-H.T. dreugs. Incr. evidence also sugg.: NHDX   regression of LVH. Sleep disturbance is minimal during NHDX & sleep architecture appears to improve. NHDX also signif. liberates dietary intake of DX. ptn. Ptn.s are kept on a free diet incl.: unrestricted intake of salt, water, K, PO4 & protein.       😊         

No signif. conclusions appear concerning effect of NHDX on survival. Depending upon consumable/personnel cost ratio in different centers, NHDX cn be less or more expensive than in-center conventional HDX. Enthusiastic acceptance by ptn. & favorable financial profile, NHDX shd be cons-idered for ptn. who’re willing & capable of performing home DX. Current obsta-cles to adoption of NHDX are unfamiliarity é home HDX & financial impact of high frequency of DX.

Q561. Compare the outcomes of intensive home hemodialysis with in-center three times weekly HDX. .?

A. No randomized controlled trials hv directly studied the effect of daily HDX. on survival. Two large observational studies hv now shown improved survival ass. é intensive home HDX. compared é in-center three times weekly HDX..

Q.562. What is the role of A/V fistula (AVF) on precipitating heart failure?  💔

A. Creation of AVF hs signif. effects on both systolic & diastolic function. It is ass. é incr. bld flow, P.H. & C.O. Although us. clinically insignif., incr. C.O. & bld flow may be so great at times tht they result in overt H.F.. This is esp. true if ptn. hs underlying heart dis. and/or the access has flows  👉> 2000 mL/min. Ptn. CVS sta-tus shd influence decisions about type of DX modality & DX access. Monitoring/ surveillance should be performed in ptn. at incr. risk [= ptn of advanced age and/or those é P.H. of heart dis. and/or an upper arm access. We recmm.: access mon-itoring (physical examination) be done weekly & that surveillance be performed on a regular (monthly) basis. If a C.P. of H.F. is evident or emerges over time, ptn. shd also be eval. by determining the ratio of flow betw. access (Qa) & (C.O.).  A Qa : CO ratio > 0.3 ➤🠉risk for high-out-put H.F.  Iry indication for ttt is intractable H.F. If fluid control & pharmacological management is not effective, then approach to 🠟🠟 in cardiac work load presented by the access. In attempt to pre-serve DX access, 1^st approach to ttt of this complication shd be a flow reduction procedure. If this’s not successful, then access closure should be considered.

Q.563. What are the immune abnormalities developed in CKD/ESRD?

A. Abnormal in immune function in CKD patient developed as a result of:

(1) Direct effect of uremic toxins on immune cell function.

(2) Underlying renal condition.

(3) Therapy of underlying R. condition.

(4) Effect of proteinuria.

Q.564. What is the effect of uremia on immune system in CKD patients?

A. Uremia is ass. é hypermethylation of a No. of genes ass. é inflmm., ath-eroscl. & aging Ø changes in gene expression & cell function. Uremia  cn affect:      👌               

1)   T-cell maturation.               

2)   T-helper (CD4) cell function.

3)   T-cell activation thr. defective costimulatory signaling.

      Neutrophil function inhibition can occur thr. a No. of peptides tht’re detected in HDX. U.F. & P.D. effluent, wch. incl.:      

1)   Granulocyte inhibitory proteins. (GIP)  &

2)   Degranulation inhibitory proteins (DIP).

      These proteins inhibits all stages of neutrophlic response incl.:  👌

1.    Chemotaxis.

2.    Phagocytosis.

3.    Degranulation.

      This inhibition ➤ incr. susceptibility to bacterial infections in CKD & ESRD.

      Monocyte/Macrophage: Uremia ➤ Changes in cell surface expression of a No. of costimulatory molecules necessary for effective Ag presentation & T-cell activation ➤ defective phagocytosis.

      Monocyte activation➤ MIA. synd. (Malnutrition, Inflmm., Atherosclerosis) .

Q.565 What is the effect of proteinuria on the immune function?

A. Nephrotic ptn loose proteins in urine é non-selective proteinuria esp. Ig (Ig. G. mainly) & complement components. So, NRP➤ impaired both: i. Innate (complement).  &    ii. Adaptive (IgG) immune system, which➤ 🠉 risk of infection esp. é encapsulated bacteria e.g. pneumococcus sp.. Risk of infc. incr. if there’s breakdown † in “skin integrity”, that may develop in severe edema.