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Dialysis: Do's and Don'ts

May 23 | 2:30 PM

In India, the increasing burden of CKD puts a strain on existing health policies due to a lack of financial resources, educated staff, and infrastructure. Dialysis maintenance is a well-known treatment option for people with end-stage renal failure. Unfortunately, the quality of dialysis provided to patients in our country varies from centre to centre. The quality could range from low to excellent, depending on the location. This is due to the lack of clearly defined maintenance dialysis care standards. Dr. Ravindra Prabhu, Professor and Head of the Department of Nephrology at Kasturba Medical College in Manipal, will discuss the key do's and don'ts of treating CKD patients on dialysis.

[Music] good evening everyone this is dr vishali from medplex and i welcome you all for this session on dialysis do's and don'ts today we have with us dr ravindra prabhu he is the professor nephrology medical college manipal after doing his mbbs in md he finished his dm and dnb nephrology and he has over 22 years of experience in academics so i hope you all are going to get to learn a lot about dialysis it's a commonly seen i wouldn't say a disease it's a commonly seen much needed treatment nowadays so i am sure you all are looking forward to listen to sir i'll just start the presentation so over to you good evening and at the outset i would like to thank dr rishali and the netflix team for this opportunity and i also welcome and thank the audience for coming in at this time in the night to listen to me i will be speaking on the do's and don'ts of dialysis as she told this is a fairly commonly available treatment for unfortunate chronic kidney disease patients and as healthcare practitioners and as doctors we really need to know something about this and that's what i am going to give a broad overview of the dialysis what we should be doing and what we should avoid so before this i would like to just briefly go through what is what we mean by a normal kidney function so basically during the day-to-day metabolism of the body the waste products that are produced are you due to the chemical reactions would be carbon dioxide water which can which are excreted through the lungs and as sweat whereas the nitrogenous waste products which are mainly due to the protein metabolism uh necessarily have to be excreted in the form of a fluid form and this is one of the main functions of the kidney to excrete nitrogenous waste products in the form of urine some of the lesser known functions of the kidney would be an individual regulation of fluid individual regulation of all the electrolytes and also to excrete the extra acid which is produced during the daily metabolism which is approximately about one mil equivalent um per kg per day and so this acid needs to be excreted so as to maintain the normal internal milieu apart from this the kidney has some endocrine functions that is it secretes certain very necessary hormones first of which is the active form of vitamin d3 so the vitamin d which is ingested in the diet or which is gets converted by the by the exposure to sunlight is not the active form the enzyme necessary for converting it to the active form is c is present only in the proximal tubule of the kidney and that is one of the important endocrine functions of required for the bone metabolism second is the secretion of the hormone renin which is necessary for maintaining the blood pressure especially during states of hypovolemia and third is the production of the hemoglobin producing hormone that is the erythrocytin which stimulates the bone marrow to increase the red blood cell mass and other less well-known functions are that kidney produces is a produce producer of glucose and it metabolizes hormones such as the insulin so when we say that the kidney has failed or the kidneys are not working what it essentially means is that the nitrogenous waste products are not getting excreted and therefore there is accumulation of nitrogenous waste products in the blood which is evident by the rise in the urea and create in which we measure as part of testing for kidney function apart from this the regulation of fluid goes haywire so the patient may become edematous electrolyte imbalance will be there especially in the form of low sodium in the blood high potassium in the blood apart from calcium phosphorus and magnesium abnormalities the patient goes into an acid retaining state so he gets into metabolic acidosis and over a period of time the endocrine functions also become have go into a problem so that the more metabolism will be will be problematic there will be slightly low to low normal calcium there will be higher phosphorus and high blood pressure the lack of erythropoietin will result in anemia and of course the glucose is not being produced insulin is not getting metabolized so these patients are more likely to get hypoglycemic or their insulin requirement may come down if they are diabetic but what i want to emphasize here is that when we say dialysis is replacing the kidney function it is mainly doing only the first part that is the removal of the nitrogenous waste products to some extent the second part that is the fluid electrolyte and acid based balance the endocrine and metabolic functions cannot be replaced by a machine which is the dialysis machine so in a patient who is requiring dialysis there are some goals which we need to follow the immediate goals will be of course to improve or bring to normal the fluid and acid-base abnormality second would be to bring about hemodynamic stability third is to support the patient or to as the life-saving measure till his kidney recovers and this we do in patients who have acute kidney injury or what is what is previously called as acute renal failure in the stage 3 of the acute kidney injury a patient may require dialysis till his own kidneys start working and then there are some ongoing goals in the form of the removal of the extra fluid taking the patient off the vasopressor requirement by improving his acid-base balance supporting the organ function again by providing by removing the fluid providing replacement fluid and also uh providing nutrition uh preventing further renal insult and promoting renal recovery so these are the goals of the renal replacement therapy so what are the types of renal replacement therapy available the three main types are one is the hemodialysis which is practic which is the most commonly used type of renal replacement therapy as of now almost 70 percent of patients then second is the peritoneal dialysis which is less commonly used because the patient himself or herself has to do this and it is relatively costlier than the hemodialysis at least in our country and then of course the definitive form of renal replacement therapy which we practice in a patient who has who has irreversible kidney failure that is end stage kidney disease would be kidney transplantation if a suitable donor is available and that that takes place in about 10 to 15 percent of patients and this is the best form of therapy if it is possible to do that then coming to the indications for dialysis now does all do all patients of kidney failure require dialysis this is not so there there is a group of patients who would definitely require dialysis and that forms the indications so mainly we go by the uremic syndrome so if a patient of kidney failure has the uremic syndrome which is characterized by nausea and vomiting and it is not recovering with the medical treatment we would start dialysis secondly if the neurological system is involved that is the patient has encephalopathy how do we know encephalopathy is there that is by if you ask the patient to stretch his hand he has the characteristic metabolic flap also called as the astrixis he is not able to voluntarily hold the hand up if the patient has myoclonus or seizures with renal failure mental changes in the form of personality changes judgmental problems development of neuropathies or myopathies and something which is less commonly seen nowadays is an inflammation of the pericardium pericarditis or due to the uremia and the uremic bleeding diathesis that is the prolongation of the bleeding time and easy bruising the other indications are the electrolyte abnormalities in the form of very high sodium or a low sodium which is again not recovering with the medical therapy refractory anemia now anemia which is not require which is not recovering with the use of erythropoietin which means that there are uremic substances which are inhibiting the action of the available erythropoietin refractory hyperphosphatemia unexplained decreased functioning unexplained decrease in well-being weight loss and nutritional problems so when the patient is in uri premia this patient will have less appetite is not going to again in an acute situation for example in an acute renal failure we would do start dialysis if the patient has not passed urine for 12 hours that is the urine output is less than 200 ml over 12 hours if the there is a high potassium there is a ecg change due to high potassium and this is not recovering with medical therapy or by itself the potassium is more than 6.5 with renal failure we start dialysis severe acidemia that is a ph less than 7.1 blood ph less than 7.1 or a serum bicarbonate less than 15 or there is a low blood pressure because of the acidosis it is an indication to start dialysis then if there is a refractory or progressive fluid overload or the patient is start is having pulmonary edema especially if it is not responding to a single dose of higher dose of frucamide and that's an indication for starting dialysis and then by itself i have kept the azotemia to the last because by itself these are not the indications to start the dialysis we need some complication at least two complications when we start the dialysis the reason being that dialysis by itself has its own cons and it is not an entirely safe therapy and therefore we would give the dialysis to patients who really require it and that is at urea more than 180 milligram per deciliter creatinine more than 10 milligram per deciliter again if the patient has complications before this we would definitely start dialysis if there are no complications we would wait for this urea and creatinine to become like this to start the dialysis now some of the non-kidney indications for dialysis would be if the patient has b has intoxication due to a dialyzable a classical one would be and then if the patient has been exposed to extreme cold analyzing against normally normal temperature dielystate and bring up the temperature hyper extreme hyperthermia hypercalcemia so especially in malignancies where the calcium goes very high and is not being able treatment we could use this hyper usually as you would see syndrome metabolic alkalosis and uh to some extent nowadays in the intensive care unit the dialysis is for a non-renal support what is called as controlling fluid balancer uh cerebral protection to bring down the cerebral edema and also blood detoxification and liver support and these are highly specialized therapies which require different types of filters and their specialty by itself and practice mostly in the hemodynamic unstable patients in the intensive care units now coming to the mechanism of solute transport in a dialysis and mainly the we we know that the blood is a fluid and it contains the water and the electrolytes and in a patient with kidney failure the there is an abnormality in both the fluid and electrolytes in accumulation of nitrogenous wastes so these can be removed by three main techniques uh either diffusion convection or adsorption and mainly in dialysis we use the diffusion and to some extent the convection whereas in poisoning cases we may use some or in the sepsis situation we may use the third one that is the absorption and basically what is being done in a dialysis dialyzer in the dialysis is there is a filter which has a semi permeable membrane as you can see in the center and on one side of the membrane the blood is done in a counter current fashion so that the concentration difference between dialysis is throughout maintaining throughout the pathway of this uh toxins will depend upon to some extent on how much blood is being dialysate is made to flow through that filter and how efficient the dialyzer is so it is as simple as that so if you are able to make a higher blood flow a higher dielectric flow up to a certain limit and have a better dialyzer you can get better and better dialysis being done and based on these three things and based on the timing the there is different nomenclature being given to the dialysis and basically based on the timing we say that the dialysis could be either intermittent or continuous so intermittent means anything below six hours so normally in a patient who is on chronic dialysis who comes to the hospital and goes the dialysis is given for anywhere but limited dialysis the reason being it's not and it is given on alternate days it is called called as a continuous renal replacement therapy and then we have the driving force usually we use a pump which is there on the necklaces machine so the blood which is pumped out it is pumped we know venus rarely you take it from an artery and give it back to the vein that is called as arterial venous and outside of the tubes you have that dialysate which is there and what the machine is actually doing is pumping the blood through that and also pumping the dielectric through the tubes which are on the side on the right side so this is a more complex circuit diagram of the dialyzer for those of you who are interested in the technicalities of this but basic principle is the same thing on one side you have the blood being pumped and this blood pumping has to be done in a very safe way around 200 ml of blood will be there outside the patient body throughout this session of four to five hours and we have to make sure that the patient is kept safe and the dialysis machine does that and on the other side uh the pure dilute with its electro will go through this in my later slides in a brief way so basically as i told the dialysis machine has its monitors to keep it safe and the monitors are on two sides one on the blood side to keep the blood pathway free of errors and on the dielectric side to make the dielectric pathway free of error so which are the monitors which are there basically to measure the pressure on the arterial side and venous side by arterial side we mean the blood which is coming away from the patient towards the machine venous side means the blood which moves from the pump back from the machine to the patient and then we have a venous chamber wherein the blood will collect and then passes through and then finally when the blood enters the patient's body there is a air detector so that the air embolism is avoided and on the dielectric side the electrolyte composition is measured based on the electrical conductivity which is maintained within a very narrow range so that the electrical lights are the conductivity monitors as well there is any essential light to detect this blood in the dialysate and that will immediately put it in the bypass mode and stop try to stop the dialysis and then to measure the outflow pressures so that the patient is hemodynamically stable some of the other optional monitors which are there would be more sophisticated monitors which are not really necessary for the safety part but are necessary for monitoring the finer the efficiency of the dialysis so monitors for the anticoagulation for modeling of the electrolytes such as the bicarbonate sodium monitoring of how much fluid is to be removed um urea monitors temperature recirculation volume and clearance monitors can be there and some of the latest machines all have all these stuff then coming to the dialysis membrane what is this membrane as i told earlier it is mainly it is a two types hollow fiber dialyzer and the and the parallel plate dialyzer the the dialyzer is made up of usually the ordinary cellulose these were the older type of dialysis dialyzers now later ones are more more or less semi-synthetic or synthetic and mainly semi-synthetic and synthetic means they are plastics like the polysulfone or polypropylene or an-69 such kind of membranes and because these are synthetic membrane they can be manufactured in such a way that they become less clotting less thrombogenic and have better efficiency means their efficiency can be very well controlled so when we say a dialyzer efficiency we mean the how well the dialyzer removes the small solutes such as the urea and when we say the flux it is the flux of the water across the membrane and basically that will measure the large solutes larger solutes that is what is called as the middle molecules the dialysis solution mainly it is water which is which has to be pure purified water the direct municipal supply or the well water cannot be passed across this because we can to put it into perspective a person may drink about two liters of two to three liters of water every day whereas on a dialysis uh four to five hour session he could be exposed to anywhere between 100 to 120 liters of water and that is directly being exposed to his blood so necessarily this water has to be purified and i'll come to that in my little bit in my later slides and this water is then proportioned and mixed with an acid component and with the bicarb component through two commercially available cans and the final water will have a electronic composition having sodium potassium calcium magnesium chloride uh acetate as a form of bicarbonate um with or without dextrose and with the ph maintained in the now all within the normal range now all this thing that is doing of dialysis naturally requires a vascular access vascular access the vascular axis i mean that a sufficient amount of blood needs to be pumped into the dialysis cartridge so as to make the therapy effective so basically we go for the venous axis because veins are on the superfacial part of the body and they can be accessed much more easily and much more less complicated than the arteries so the veins which we use could depend upon whether we are going to put a temporary catheters the temporary catheters are basically placed in the internal jugular vein or the femoral vein and they are used in patients who are having acute kidney injury who require about 5 to 10 sessions of dialysis and their kidney improves so there we use temporary catheters then we have a group of patients whom who have to transition into chronic dialysis that is end stage kidney disease who are waiting for transplantation we use semi permanent type of accesses which are called as permacats the sides of the catheters will be same that is either in the intrajugular vein and lesser extent the femoral vein and then if a person is on for a long term dialysis we need to create an artificial connection between an artery and vein and this is you can see in the lower part of the photograph here where in either we use the radial artery with the catholic vein or the brachial artery with the cephalic vein at the elbow or brachial artery with the basilic vein in the elbow to produce an artificial artery venous fistula which matures over a period of six weeks to six months and then can be accessed to produ to give the blood uh which is necessary for the for the dialysis so here basically the one vein is used to take the blood another vein is to return the blood so you have two two needles being put into the patient's arm here and his this thing is the dialysis is carried out so some of the complications which can be expected from the vascular axis would be because these patients are having a bleeding diagram catheter can get clotted and that can cause venous thromb then placing the catheters in the in the jugular veins of the subclavian veins could cause pneumothorax pulmonary embolism can occur hematoma formations and then long term use of catheters can cause vein stenosis and of course the infections which could spread anywhere to the heart and the other parts of the body then the anticoagulation since this therapy is an extra corporeal therapy blood remains outside the body for at least four to five hours and it is passing through the surfaces which can cause clotting we need to maintain an anticoagulation the most common anticoagulation used is the unfractionated heparin and a number of other anticoagulants are used which i will not go through due to the want of time and again the anticoagulation is associated with its own uh complications commonness and some kind of allergic reactions bone problems and hypoaldosteronism can be there i mentioned earlier that the water which is entering needs to be a pure water and there is a system to maintain the purity basically when the water enters from the outside either maybe a municipal supply or it may be the borewell water this needs to pass through the sand filter the softeners the carbon filter and the finally we have what is called as a reverse osmosis [Music] to make it it will not be completely sterile water but it makes it safe for dialysis situation we go for about three to five hours of dialysis on alternate days or three times a week most of the patients in india due to the financial aspects they are on twice a week dialysis of about four to five hours and then the blood flow the blood flow is maintained anywhere between 250 and 500 ml per minute as per the patient's axis allowance uh how how much the patient allows the the patient's access allows the blood flow and then we have we can choose the dialyzer roughly about seventy five percent of the body surface area is taken as the surface area of the dialyzer and as i told earlier the surface area can vary between point four to two ah meter square and then the solution there is not much variation which which we can do with the dielectric solution these are commercially available solution but you could vary the potassium level we could vary the bicarb level in the solution and the calcium level and then the dilystate flow is roughly about two times the blood flow so if the blood flow is kept at 300 ml dielectric flow would be 500 to 600 ml the temperature is maintained by the machine to the body temperature and then we could set in the fluid removal which we determined by how much fluid overloaded the patient is what is his weight gain in between dialysis we can set the fluid how much fluid the machine will remove in that four to five hours and then we prescribe the anticoagulation that is the unfractionated which runs continuously during the dialysis process during the dialysis itself we need to effectively monitor the patient's vital signs before he comes itself we take the temperature blood pressure and weight we examine the access site for any infection and whether the excess is patent and during the same procedure we look for symptoms and blood pressure and after that again we test the weight and once in a while that may be monthly or once in three months we could do the blood test to see whether it is uh though it's running properly the complications which are seen in about 10 to 15 percent of dialysis patients uh the commonest complication is hypotension that is a systolic blood pressure below 100 then if you as we are removing the fluid during the dialysis the patient can get muscle cramps nausea and vomiting headaches especially if the urea is suddenly removed then chest pain back pain itching and certain pyrogenic reactions like fever and chills these are seen in fortunately seen less commonly in less than 10 percent of patients other complications are disequilibrium due to rapid removal of the urea reactions to the membrane because the blood gets exposed the membrane the some of these patients can get anaphylaxis which is very rare uh then because of the disturbance in electrolytes basically we need to understand that this is an intermittent therapy so the electrolyte such as the calcium and potassium gets disturbed so the patients can get arrhythmias and the bleeding manifestations for some patients could be in the form of cardiac tamponade or the major organ bleeds there may be mechanical hemolysis air embolism and hypoxia this is all rare complications less than three percent of patients would face this a little bit about the continuous renal replacement therapy mainly practiced in hemodynamically unstable patients so the same dialysis which is done four to five hours we make the blood flow slow and the dilystate flows slow and there are specific machines available for this wherein instead of the dielystate being used we use replacement fluids and that is the continuous reblam replacement therapy mainly used in ico in unstable patients and wherein we mainly use the convective form of solute removal using slow flow and use free and post dilutional replacement fluid the other type of modality of dialysis is what is called as the peritoneal dialysis wherein the peritoneal membrane is used as a semi permeable membrane to remove the nitrogenous wastes and again the principle is the same the dilysate fluid is put into the abdomen through a catheter which is surgically placed below the umbilicus and that remains in the patient lifelong and the fluid is passed into the peritoneal cavity and it withdraws the azotemic products across it and then it is drained out and new fluid is put in and basically as per the transport characteristics of the patient uh basically this takes out the fluid or usually these patients require about three to four exchanges of these fluid per day each exchange will take about 20 minutes and after that the patient is free to do his work so he gives a kind of independence to the patient in that he is away from the hospital he can do this on his own and that much freedom the patient will get as long as he is able to practice this in a sterile manner this therapy is the preferred therapy in most of the countries where this can be afforded however as i told earlier in our country at least 80 to 90 percent of the patients would be on hemodialysis simply because the peritoneal dialysis is much more two to three times more costly peritoneal dialysis fluid usually uses the principle of osmosis so it uses a hyperosmotic substance usually it is the glucose based solution and which uses convection to withdraw the we draw the toxins into it the types of pd as per their methodology we have the continuous ambulatory type which is the commonly used one wherein the patient puts the exchange fluid into the peritoneal cavity three to four times a day the same thing can be done in the night using a pd cycler so pd cycler is connected to the pd catheter in the abdomen and that exchanges the fluid which is kept on it the complications of pde we can very well understand uh the peritoneal membrane is exposed to an outside fluid so infection is a common one if it is not if the technique is not proper so infection can be mainly in the form of peritonitis or it could be due to high pressures in the abdomen which can cause hernias dilysate leaks and non-infective complications like catheter blocks a mental entrapment migration of the catheter uh failure of the this thing to work uh mainly because uh one of the main disadvantage of this therapy is that we cannot adjust the peritoneal membrane the patient is born with the membrane and some people have membranes which are not amenable to this and therefore that technique can fail in those or over a period of time there is development of some thickness in the membrane which will cause a failure so there is a raging debate about whether we should do pd or hemodialysis it's basically basically left to the judgment of the treating physician so if a patient requires a fluid removal very urgently we would go for the hemodialysis if he is hypoalbuminemic we would go for hemodialysis if the patient wants independence he wants to do the therapy himself the return dialysis is the best form of treatment and again in the ico we need efficient removal we need better efficient membranes we could go for the hemodialysis pd is better for blood pressure control and also less chances of bleeding complications with the peritoneal dialysis so basically the peritoneal dialysis is favored by people who want to be independent who want to do the therapy themselves it's very good and the survival is equal or better in pd in those situations than the hemodialysis but if the patient wants it done under a supervised condition he wants to come to the hospital hemodialysis is the one which is done so in my concluding slides what are the do's definitely this is a procedure which has its own complications uh all these all the both of them which i mentioned so informed consent the patient if he enters this procedure with full knowledge he does much better then of course definitely we need to prior to the thing we need to check the vitals the patient has to be asked to avoid urine prior if he has urine output because he is going to be tied to the machine for four to five hours pre and post dialysis weight has to be checked the bp monitoring is very important minimum every 15 minutes it has to be done and during the procedure itself the patient is once he is connected to the machine he is free to read or write or watch tv he can also sleep most of the patients would want to sleep and if he doesn't have low blood pressure he could eat also during the procedure um the healthcare worker needs to monitor the axis for its patency both pre and post dialysis the access site has to be kept very clean because blood is going to be accessed and throughout the procedure to prevent infections the excess sites could be kept very clean and there should be a close look out for the complications which i mentioned earlier so that the therapy can be stopped and the complications can be treated if you detect them early and the axis again i am mentioning the axis again and again because this is the lifeline for these patients and care of the access would improve the survival then some of the don'ts of the procedure would be the hemodialysis access is kept on one of the hands usually we use the non dominant hand that is the left hand and once the patient is in the stage 4 of the chronic kidney disease it is best to preserve the left hand veins so that that axis can develop very well once it is constructed secondly the axis should not be used for giving any other iv fluids or injections and one should avoid checking the blood pressure tying a tight watch or tight clothes on the vascular axis limb then the patient should avoid sleeping on the excess arm and undue pressure on the excess arm should be avoided before the dialysis procedure once we start removing the fluid during dialysis these patients would start may get low blood pressure so antihypertensives are avoided prior to the dialysis procedure and the patient should be told to the diet can be more liberal as come on dialysis as compared to his pre-dialysis state but of course this excess salt excess fluid and high potassium high phosphorus diets need to be avoided so to conclude here what i want to emphasize is that this is a very important therapy which we give to our unfortunate patients but it can never replace the complete kidney the only 10 to 15 percent of the kidney function is being replaced by the dialysis and that to only the filtering part of it the technique is still evolving it's a kind of engineering and better and better machines are coming into play which would make the therapy more safer and give more quality to these patients basically we should try to encourage these patients if they are in end-stage renal disease to go for a kidney transplant because that will give the complete kidney function and make him make the quality of life and survival much better if that kidney works but basically in a patient with acute kidney injury this could prove to be a life saving therapy as i told earlier we have three types hemodialysis peritoneal dialysis and transplant if the patient is an end stage in the icu we use hybrid or the continuous renal replacement therapy so with this i would conclude and i thank you again for a very patient listening and i'm open to any questions thank you so much sir for such an informative session uh you explained the do's and don'ts really well and i'm sure our audience has enjoyed it we have many uh super positive comments wonderful presentation excellent they've learned a lot uh so there's one question by dr gauche any comments on epo injection or derby point in alpha for management of anemia hb is eight in a ckd patient of regular dialysis so this is uh both of these are almost equal like erythropoietin or derby patent now derby pythin is there's a patient who is anyway coming to the dialysis room at least two to three times a week we could use either one of them so either the erythropoietin or the darby parting and now we have the newer ones that is the that's the oral ones that is the hypoxia inhibitors which are available orally and so with that i don't know this injectables how much it will be taken up in the future all right dr alicia has a question how can we treat intradialytic hyper now intra dialytic hypertension it is seen in about i can say about 30 to 40 percent of these patients face this and basically it seems to occur in a kind of odd way that when the when we start removing the fluid these patients start getting high blood pressure so some of the some of the ways to prevent it is would be to counsel the patient to take less salt before the dialysis avoid too much fluid gain so if you have a fluid gain more than three liters and we have to remove more than three liters on dialysis the introduction hypertension would be more and then there are some studies to show that if you use carbodylol as a antihypertensive uh that could prevent or bring down the bring down the blood pressure during the dialysis if there is this hypotension occurring and if it is symptomatic we could use um this iv levitol as as you would use in any hypertensive emergency but in most patients we just give them extra tablets of their usual antihypertensives either it is either clonidine or the calcium channel blockers to tide over that crisis uh next question by dr jaydeep if you could explain a little about urea reduction ratio and kt slash v because this is the technical part of the dialysis and it is used to look at the efficiency that is the urea is a measure of the small solute clearance so how efficient and basically to look at the efficiency of dialysis we look at the quality of life of the patient but these are the measures which are used especially by insurance companies in the u.s wherein you want to give a kind of standardized treatment across all the units so we need to maintain a urea reduction ratio of about 63 percent which would translate into a kt by v of about 1.4 that is the kt by v which is crude if and if you take a natural logarithm of this area reduction ratio you get the kt by v that is taken as 1.4 and this is about 63 percent so how you take the post dialysis urea is very important because there could be a situation where there is a recirculation of the blood within the axis and therefore we are taking the post dilution we use what is called as a slow flow method you slow down the blood flow below 100 ml for 10 seconds and then take the urea then apply the formula 3 minus post by 3 which should be at least 63 take a natural logarithm of that you get kt by v that is more than 1.4 of course the time i don't think i can go across claiming orally that thank you so much for a detailed explanation dr bhugneshwari would like to ask if a patient on dialysis has been advised dental extraction should it be done pre or post dialysis so ideally because you are going to give anticoagulation during the dialysis that is the heparin the normal action of heparin is about 45 minutes but in a patient of chronic kidney disease the action is the duration is doubled that is about two hours so to be on the safer side we should not be doing this procedure on the day of dialysis i would advise the patient to do it after on the day after the dialysis or the day before but definitely not on the same day okay okay dr murphy would like to ask that you mentioned that anemia improves when patient is on hemodialysis can you explain about it a little bit so as i told one of the functions of the kidney is to release erythropoietin which is uh which improves the rbc mass in the in the bone marrow but one more thing is because of the urine milieu itself there are a number of toxins which will again produce a resistance to the action of erythropoietin so many of these patients would have a normal level of erythropoietin but it is still not acting so there are two things to this there is a relative deficiency of erythropoietin which you could replace by giving erythropoietin and there is a resistance which you could improve by reducing the uremic toxins and that is what the dialysis is doing it is removing the uremic toxins that resistance to ether python is reduced with because of that the next question is by dr deepak when to use hemo filtration or ultra filtration now ultra filtration means you use a convection that is your as i mentioned it is a semi permeable membrane dialysis if you apply a negative pressure on the dielect's side the fluid will get pulled out from the blood so that is called as ultra filtration whereas hemofiltration is a kind of technique used in the continuous renal replacement therapy wherein instead of using the dielectric fluid you use the convection to remove the fluid and the toxins from the blood so he may not be much uremy but he is in pulmonary edema you want to remove the water fast you could use the ultra filtration and especially uh and if you use dielectric fluid filtration means you re use replacement fluid and if you use both of the things that is dielectric and filtration it is called as demo dia filtration okay great uh next question is uh by dr kaushik that apart from aeiou is there any indication for dialysis related to creatine in lab value so roughly we take as like some people said eight milligram per deciliter and some people say 10 milligram per deciliter and basically the uremia is like a slow poison and different people have different tolerance to this so roughly what we say is if the patient has a complication which is life threatening like for example high potassium is there and you are not able to bring it down with medical therapy or there is fluid overload we don't look at the level of the creatinine at all we just go for the dialysis whereas if you want to give a ball figure that this level will do we advise dialysis once the patient goes above 10 milligram per deciliter again i want to say that there is no advantage of starting it early early versus late early means the quality of life by a patient being tied to the machine and also the survival advantage is not there by doing it early so if you go by a gfr level it should be below 10 ml per minute for starting the estimated gfr should be less than 10 ml per minute in a diabetic you may start at below 15 ml per minute again we go by the symptoms and the complications are the exact figure of the creatine right thank you so much i think dr kaushik i hope that answered your question dr sheetal has the next question what would be the crrt dosing in icu again the crrt dosing what we say is that the survival is better the more um filter it is removed so roughly about 25 ml per kg per hour that should be the field rate and as it climbs above 30 ml per kg per hour there are studies which say that there is a survival advantage and why the survival advantage is there is mainly because we are able to remove some of the cytokines and the inflammation is reduced as you go higher and higher and again i must mention the replacement fluids are extremely costly uh if you go on removing more you have to replace more and so the cost becomes a limiting factor uh certain specialized units like for there are units in italy which remove 60 ml per kg per hour and they have shown wonderful results so the higher you remove the better but you should aim for at least 25 ml per kg per hour all right dr nisarg has a question what cardiac care should be taken during dialysis so this heart and kidney seem to go together and one of the facts we should understand is that a patient going on to dialysis has 100 times the chance of getting a heart event as compared to the general population and these heart events can occur usually more commonly occur within first three months of starting the dialysis and usually they occur during the dialysis or within plus or minus 12 hours of the dialysis so more apart from just carefully monitoring these patients for both symptoms and their vitals um we can we could prevent this by having these all these patients being seen by a specialist cardiologist to assess first all right next question is uh again one more uh i didn't mention it one more factor which apart from the traditional risk factors like atherosclerosis cholesterol and all that some of the non-traditional risk factors which we could improve to improve the heart function would be the anemia part and the calcium phosphorus abnormalities so these two things are very important you should control the calcium phosphorus and if the hemoglobin is between 11 and 12 the chances would be less for the patients to get the cardiac events great dr nisser i hope that answered your question dr harinathwarma would like to ask which are the parameters that would indicate post dialysis complications parameters which would indicate post dialysis means after the dilation yeah most dialysis complications mainly what can happen is one is the main complications which occur is related to the fluid removal during the dialysis so i told that hypotension and muscle cramps these are the two very common complications which occur and they are related to the fluid removal so any fluid removal 13 ml per kg per hour or more uh the chances of these patients going into low blood pressure so he goes out with the low blood pressure especially the blood pressure may be normal when he is sleeping during dialysis when he stands up it falls and he has a syncopal attack and the cramps which occur and the patient has a feeling of being washed out completely so this can happen a rough figure i can give is if the removal of fluid is more than three liters and we have to remember one thing this is a machine you can set it to remove even up to six liters in during the session and it's going to do that but if you remove more than three liters that is the thing which is uh going to produce the complications and the patient needs to be counseled that he should limit his fluid intake and he should remove his salt intake so that the amount of fluid removed is less and he'll be less symptomatic okay great dr joshi anthony would like to ask a question in ckd patients on medical therapy when do we start dialysis effectively as their vbg and rft will be deranged and they will be having minor symptoms most of the times so this is started once the patient goes into the ckd stage five that is the fifth stage and he has a complications so as long as the urine output is maintained above 500 ml per day and as long as his electrolytes are normal especially we look at the bicarbonate level and the potassium level and he is not having the symptoms of uremia such as the nausea and vomiting is able to retain the food so if these three things are there we would avoid the dialysis once the gfr estimated gfr there are calculators for that you put the creatinine value into the calculator you get the gfr value below 10 ml per minute patient gets symptomatic that is the time we would start dialysis one more thing i would like to mention before this it is always better to have a fistula constructed so once the patient has gone into the ckd stage four we have to start counseling him and preserve the left hand so that when he enters dialysis he goes in with the functioning av fistula as compared to which if a patient is postponing the fist law formation he will enter the dialysis with the catheter and the catheter itself has its own complications dialysis may not be as effective and there may be infections inflammation and nutritional problems if the patient enters with the catheter so main our job is to counsel the patient to go in for with an axis such as the heavy fistula and we in a dictum is that in a chronic kidney disease you try to postpone the dialysis as much as possible in an acute kidney injury wherein the chance of complication is more we need we may have to do the dialysis the index for doing dialysis may be much lower okay great next question by dr madhav desai what are the vaccines advised before recurrent dialysis so usually we give these patients the hepatitis b vaccine and the strep pneumonia vaccines so these are the two main vaccines we are getting in our children we also give the varicella vaccine because as a preparation for the transplantation otherwise it is these two hepatitis b and the pneumonia and the pneumonia is the two vaccines are available that is the priviner and the remover and these are given at least six weeks apart starting with the premium hepatitis b again one more thing which we should know is that the response the antibody response to the hepatitis b vaccine is lower than the general population so we have to give that in a double dose that is one cc to each arm and that is four doses are given zero one two and six months as compared to the general population where we give single dose each time for three doses here we give four doses double dose each time okay uh next question by dr sanjeev khanna how are hbv and htv patients managed it can be counted on the fingers because of the take-up of the hepatitis b vaccine so those patients who have hepatitis b they need to be we need to test the hpv dna level the levels are high we put these patients on the usual therapy that is the end take away and one thing i would like to mention these patients require very less doses maybe once a week or tablet of antigovery may be enough hepatitis c therapy earlier again the hepatitis c is a very slow disease and many patients are asymptomatic but if the patient is elderly he has a higher chance of having the problems with that elderly means about 55 years there are more chances of getting the liver complications so again it's a preventive thing we need to avoid blood transfusions so our index for giving blood transfusion should be very low so in my unit i usually give blood transfusion only if the hp is below 6 grams per deciliter simply because the chances of getting hcv are increased as the number of transfusions increases and then how do we avoid blood transfusion we have to give the erythropoietin so these patients should be an erythropoietin and now it is very cheaply available so we can give that regularly and avoid the blood transfusions treatment of hcv earlier was with the interferon which was not very effective but now we have direct acting antivirals a number of them are available and three months therapy with these would almost have a 1995 percent effect of eradicating the virus okay dr parlov mishra is having can tpn and blood be transfused by a dialysis machine tuberculosis hello can ppn hello ppn and blood be transfused via dialysis machine yes blood transfusion we can give during this blood transfusion definitely can be given and most of our people who require blood transfusion it is given through the through the dielectric line itself now tpn has to be given much more slowly and there is a chance of fat embolism and all so i think i would not recommend using the dialysis access for giving dpn it requires a separate line and should be given more slowly all right uh next question by dr nisarg the etiology of caesars in a patient post dialysis if you could elaborate on it a little uh the seizures again it could be but especially in the patient who is just starting off dialysis so we have what is called as a dialysis disequilibrium wherein his body has got used to a high urea level and when we suddenly remove the urea and bring it down suddenly over a period of four to five hours there will be a disequilibrium where cerebral edema occurs and seizures can occur apart from that if there are some problems with the sodium that is low sodium hyponatremia uh hypocalcemia these two things can cause seizures and as part of hypoxia that is if there is a hypotension that can cause the seizures other rarer causes of seizures are there if there is a intracranial bleed or a thrombus occurring that also can cause seizures but most commonly we see seizures as a part of a dialysis disequilibrium or a hyponatremia or a hypocalcemia and this is occurs more commonly at the extremes of age you become less efficient right next question right after colgate is that what emergency procedures are to be followed if we counter dialysis this equilibrium syndrome again as i told compulsorily the dialysis should be this is a syndrome which can be only prevented treatment is symptomatic for that so the prevention of this is as i told you give a less efficient dialysis for the first three dialysis and then you go for the regular dialysis the treatment of this is a symptomatic treatment if there is a seizure we give the anti-epileptic medications and after the dialysis you could use an osmotic substance so that the osmolarity of the blood increases and the cerebral edema is avoided so he uses the mandible the last question for the evening i would say is by dr mithel uh what is one non-renal absolute indication for dialysis and then what like especially like uremic encephalopathy and what would be the dialysis dose so uremic in caphalopathy is a renal indication only and dialysis knows for a patient of chronic dialysis we have to give three times a week and we aim for that kt by way of more than one point four going very high kt by v has no real advantage we try to maintain one point more than one point four again i must say in india it is based on cost many of these patients cannot afford we go for a wire media of twice a week dialysis many patients do okay with that and now there is a concept of what is called as incremental dialysis patient has good output and is not that much uremic we start with once a week we can go to twice a week and over a period of time when urine output goes down we go for a thrice away non-renal indications usually what we see in our practice is the poisonings so the common poisonings like the barbiturate overdose or adulterated alcohol that is methyl alcohol um or salicylate poisoning or patients of hypercalcemia or tumor lysis syndrome these are some of the common non-renal conditions where we would do the dialysis great thank you so much sir that was amazing i think those were the questions we have very uh good positive comments thank you so much prabhu it was an excellent session and as i said we can see in the comments we've got some amazing comments we our doctors have learnt a lot so thank you so much on behalf of netflix and i would also like to thank all the audience for attending the session you

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dr. Ravindra Prabhu

Dr. Ravindra Prabhu

Professor, Nephrology | Kasturba Medical College, Manipal

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dr. Ravindra Prabhu

Dr. Ravindra Prabhu

Professor, Nephrology | Kasturba Medical Coll...

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