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Q.535. When to start R.R.T.?




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Q.535. When to start R.R.T.?     

A. (1) GFR < 15 ml/min. + Sm. (UK-RAG).

    (2) GFR < 6 ml/min. + No Sm. (UK-RAG).

    (3) GFR < 15 ml/min. (physician evaluation) (2006 K/DOQI).

Q.536.What is the A/V fistula and why is it preferred for hemodialysis?

A. An AV fistula is surgically created by connecting an a. & v.., the vein grows larger & is able to handle more bld vol.. Us. an AV fistula is made in the arm/leg so it’s easily accessible for DX. After several weeks or m.s, fistula matures mak-ing it ready to use for HDX. In March 2005 the Centers for Medicare & Medicaid (CMS) along with other leaders in kidney care community launched the Fistula First initiative. This initiative ws started to support better health for Medicare ptns on DX & lower costs for Medicare program by incr. No. of HDX ptn.s using fistulas as their HDX access.

The A/V fistula is considered the “gold standard” access because:

1)    It is a connection of the patient’s own artery and vein so it is all natural.

2)    It allows for greater blood flow resulting in better ttt in less time.

3)    It hs a lower infection rate than (A/V) graft or central venous catheter.

4)    It hs less risk of clotting than (A/V) graft or central venous catheter (CVC).

5)    It lasts longer than arteriovenous (A/V) graft or central venous catheter.

6)    Costs associated é creating & maintaining fistulae are less thn (A/V) graft or CVC.

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Q.537. What are the recommendations for vascular access creation & follow up? 

A. Ptn.  should be referred to Nephrologist/Surgeon é  👉 stage 4 CKD (EBPG, 2007):

Permanent vascular access (in order of  👍 preference)  wrist AVF, elbow AVF, transposed brachial-basilic v. fistula, AVG of synthetic material (preferably PTFE) (K/DOQI, 2003).


Access type

Time of creation.

Effective flow.





6  m. bef. HD.(GFR<30 )

> 600 ml/min.

>one m.

>3 y.

2003 K/DOQI

AV Graft.

3-6 w. bef. HD. (GFR <30 )

>  800 ml/min.

2-3 w.

> 2 y.

2003 K/DOQI

Cuffed Catheter

At time of HD.

>  300 ml/min.


> 3 w.

2003 K/DOQI



Q.538.What are the benefits of early referral to the Nephrologist?

A. Early referral is mandatory for:

(1)                 Slowing Progression rate of CKD.

(2)                 Patient counseling & Education.

(3)                 Reduction of co-morbid load.

(4)                 Choice of dialysis modality.

(5)                 Vascular access creation.

(6)                 More compliance to treatment.

(7)                 Pre-emptive transplantation.

(8)                 Better outcome of early dialysis.

(9)                 HB.V. vaccination in pre-DX. 🠊 Good immune response.

(10)              Non-emergent initiation of DX.

(11)              Lower morbidity & improved rehabilitation.

(12)              Less frequent & shorter hospital stays.

(13)              Lower cost.

(14)              Improved survival. 

Q.539. How to prescribe acute hemodialysis?    R/

A. RRT in ARF indicated é: [volume overload refractory to diuretics, hyperkalemia, metabolic acidosis, uremia & toxic drug overdose]. Once decision of DX. is made, sp. Modality of dialytic support should be chosen: P.D. or H.D. & H.F., etc. & DX. prescription is determined. When Ac. HDX. is chosen as dialytic support, vasc. access must be established prior to ttt. Placement of venous cth.  shd be considered. Optimal choice of DX membrane in ARF, is unclear. Biocompatible membranes is suggested. If water system is of high quality, high flux biocompatible membranes shd be used. But, low flux biocompatible membranes or prefilter added to DX machine shd be used if water system is not of high quality. Dzt. sol. consists of: [K, Na, HCO3, Ca, Mg, Cl. & gluc.]. Dzt. composition in Ac. HDX is routinely altered each ttt to correct metab. abn. in ARF. There’s No fixed Dzt. K+ conc. in Ac. HDX. bec. of wide variability in s. K+ prior to start of HDX. Typical K+ in Dzt. for Ac. HDX ranges fr. 2-4 meq/L. Dzt. bath k+ is deter-mined by both absolute pre-DX. K+ & rate of rise in the interdialytic period. Rapid rate of rise of s. k may best be ttt by daily HDX rather thn lowering Dzt. K bath. HDX can 🠊 ventricular arrhythmias, due to DX-induced  K+. They’re associated é num-erous risk f. e.g. CAD, LVH, digoxin use, systolic B.P.& advanced age. It’s recomm.: cardiac ptn in Ac. HDX shd be placed on a cardiac monitor dur. DX.

Dzt Na+🠊 significant impact on ptn. vol. & hemodynamic status. Dzt HCo3 shd vary é acid-base status. Us. Dzt HCo3 in ch. HDX = 33-35 meq/L. High conc. HCo3 shd be used é moderate metabolic acidosis . Severe acidosis🠊conc. maximized (eg, 40 meq/L)& extended duration of HDX may be necessary. Ac DX ptn cn also be alkalotic. Severity of alkalosis & process generating alkalosis Ømain issues to help determine optimal Dzt HCo3. It’s recommended adjusting Dzt Ca+ to avoid hyperCa+ or clinical hypo-Ca+. DX. QB of 400 mL /minute. If lower QB is required due to hemodynamic instability, best modality is unclear, slower solute removal é 6-12 h. (SLED/CCRT), is suggested. U.F. goals in ARF can be challenging. Target intravascular vol. will guide U.F. goals for I.HDX. U.F. can  intradialytic Hpt, ttt by 🠋UF rate by 🠝frequency of ttt and/or  during of ttts, as well as Na/UF. profiling & using cool °C Dzt. I.HDX provided at least 3-times/w. é monitoring of delivered dose of DX to ensure Kt/V of at least 1.2/ttt . However, more frequent DX may be needed for: intractable hyperk+, vol. overload, or sev. Hpt.

Q.540.What are the general considerations of vascular access in chronic H.DX.?

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A. Three  👌 main forms: native A/V fistulas, synth. Grafts & double-lumen tunneled cuffed cth.. AV fistulas: constructed é end-to-side v.-to-a. anastomosis between a. & v. Synth. grafts: constructed by anastomosing synth. conduit betw. a. & v..  Tunneled cuffed cth.: dual lumen, composed of silicone or polyurethane composites. Fistulas & grafts differ é failure rates, time to use, patency, complications & perioperative morbidity. Fistulas: more likely to hv. Iry failure never provided reliable access for H.DX. Despite this, long-term patency of mature fistulas is superior to grafts. Common comp.: fistulas & grafts including: thrombosis, infection, steal, aneurysms, venous H.T, seroma, H.F.& local bleeding. Thrombosis, infc. & seromas occ. more freq. é grafts . Iry adv. of tunneled cth. immediate access for all ptn.s, but main disadv.: risk of infc., malfunction & C.V. stenosis. H.DX. AV fistulas: generally associated  é  🠋 M.R. compared to grafts & tunneled cth., while HDX. cth. the worst survival rates.    

A.V fistulas: preferred over all other forms of V. acc, due to many benefits. They’re ass. 🠋M.R. & comp. to grafts & cth.. After fistulae, grafts are next preferred. Tunneled cth.🠊 least desirable access & shd be primarily used as intermediate-duration vasccular access to allow maturation of fistulas or grafts. To achieve a well-functioning fistula é initiation of DX., timely referral  for surgery is important. Minimum time for fistula maturation is one m., but may require up to 6 m. If neither radiocephalic nor brachiocephalic fistula is possible, a transposed brachiobasilic shd be considered. If fistula is not possible, a graft shd be considered. It’s debatable whether a transposed brachiobasilic fistula shd be offered before a lower forearm graft. HDX cth.: the least preferred form 😌 of chronic access.  

Revise please the abbreviation list on: