Spotlight on indication of dialysis

Indications of dialysis
Acute kidney injury (AKI) is an abrupt or rapid decline in renal filtration function���(No universally accepted�definition).

1. Indications of dialysisIndications of dialysis
Dr. Mohamed AbbassDr. Mohamed Abbass
NephrologistNephrologist
PGDD,CARDIFF,UKPGDD,CARDIFF,UK

3. Acute kidney injury (AKI) Acute kidney injury (AKI) is an is an
abrupt or rapid decline in renal abrupt or rapid decline in renal
filtration functionfiltration function
(No universally accepted(No universally accepted
definition).definition).

4. It is a life-threatening condition It is a life-threatening condition
occurring in approximately occurring in approximately 5%5% of of
all hospitalized patients and up to all hospitalized patients and up to
30%30% of the admissions to of the admissions to
intensive care units.intensive care units.

5. From the definition of AKI , the From the definition of AKI , the
diagnosis depend on diagnosis depend on
1- The 1- The increaseincrease in serum creatinine in serum creatinine
2- The 2- The decreasedecrease in the GFR in the GFR
3- The 3- The decreasedecrease in the urine output in the urine output
This is theThis is the RIFLERIFLE criteria criteria

6. The The RIFLERIFLE criteria criteria

in serum
creatinine


in GFR

In
urine output
Risk 1.5 fold 25%
< 0.5 mL/ kg per
hour for six hours
Injury 2 fold 50% > 0.5 mL/ kg per hour
for 12 hours
Failure 3 fold 75% > 0.5 mL/ kg per hour
for 24 hours or
anuria for 12 hours
Loss Complete loss of kidney function for more than four
week (need renal replacement therapy)
ESRD Complete loss of kidney function for more than
three months ( need renal replacement therapy)

7. Chronic kidney diseaseChronic kidney disease
(CKD) (CKD)

8. kidney damage for 3 or morekidney damage for 3 or more
monthsmonths
1-Structural or functional abnormalities of 1-Structural or functional abnormalities of
the kidneythe kidney
2-With or without decreased GFR.2-With or without decreased GFR.
3-Manifested by either pathologic 3-Manifested by either pathologic
abnormalities or markers of kidney damage.abnormalities or markers of kidney damage.

9. GFR 60 mL/minute/1.73 m2 for 3 GFR 60 mL/minute/1.73 m2 for 3
or more months, with or without or more months, with or without
markers of kidney damage.markers of kidney damage.

10. CKD Stages according to GFR CKD Stages according to GFR
(ml/min/1.73m(ml/min/1.73m
22
) )
1: Stage 11: Stage 1Kidney damage with Kidney damage with
normal or GFR >90 normal or GFR >90
2: Stage 22: Stage 2GFR 60:89GFR 60:89
3: Stage 33: Stage 3GFR 30:59GFR 30:59
4: Stage 44: Stage 4GFR 15:29 GFR 15:29
5: Stage 5 (ESRD)5: Stage 5 (ESRD) <15 <15

11. Causes of AKICauses of AKI
ARF can be classified into three ARF can be classified into three
groups:groups:
@- @-Pre-renal Pre-renal – – this is caused by this is caused by
ineffective perfusion of kidneys ineffective perfusion of kidneys
whichwhich
are otherwise structurally normal, are otherwise structurally normal,
eg:eg:
@-Hypovolaemia @-Hypovolaemia
@-Cardiac pump failure @-Cardiac pump failure
@-Other causes of hypotension @-Other causes of hypotension

12. RenalRenal – – results from structural results from structural
damage to the glomeruli and renaldamage to the glomeruli and renal
tubulestubules
@-ATN (the most common causative @-ATN (the most common causative
condition)condition)
@-Glomerulonephritis/vasculitis @-Glomerulonephritis/vasculitis
@-Tubulointerstitial nephriti @-Tubulointerstitial nephritiss

13. @-Post-renal –@-Post-renal – obstruction of the obstruction of the
urinary tract urinary tract
@-Prostatic hypertrophy/carcinoma @-Prostatic hypertrophy/carcinoma
@-Bladder tumour/gynaecological @-Bladder tumour/gynaecological
malignancymalignancy
@-Neuropathic bladder @-Neuropathic bladder

14. Specific causesSpecific causes
The most common causes of ARF The most common causes of ARF
seen in hospital are:seen in hospital are:
Pre-renal failure. Pre-renal failure.
Acute tubular necrosis (ATN).Acute tubular necrosis (ATN).
Obstruction.Obstruction.

15. The ‘Surgical Triad’ The ‘Surgical Triad’
((post-operative volume depletion, post-operative volume depletion,
infection and infection and
nephrotoxic drugs) nephrotoxic drugs)
is a common cause of hospital-is a common cause of hospital-
acquired ARFacquired ARF

16. Causes of CKD Causes of CKD
Diabetes Diabetes
Glomerulonephritis Glomerulonephritis
Hypertension Hypertension
Autosomal dominant polycystic Autosomal dominant polycystic
kidney disease kidney disease
Reflux nephropathy Reflux nephropathy
Renovascular Renovascular

17. Diabetes mellitus Diabetes mellitus is now the is now the
most common identifiablemost common identifiable
cause of cause of CKDCKD , being present , being present
in nearly 20% of new patientsin nearly 20% of new patients

18. Indication of dialysis in AKIIndication of dialysis in AKI

19. 1-Hyperkalaemia greater than 6.5 1-Hyperkalaemia greater than 6.5
mmol/l or 6–6.5 mmol/l with ECG mmol/l or 6–6.5 mmol/l with ECG
changeschanges
2-Pulmonary edema 2-Pulmonary edema
3-Metabolic acidosis causing 3-Metabolic acidosis causing
circulatory compromise.circulatory compromise.
(unresponsive to medical (unresponsive to medical
management)management)

20. 4-Uraemic encephalopathy, 4-Uraemic encephalopathy,
pericarditis .pericarditis .
5-There is no absolute level of 5-There is no absolute level of
urea or creatinine at which we can urea or creatinine at which we can
dialyze the patient.dialyze the patient.

21. 6- Poisoning with (lithium, 6- Poisoning with (lithium,
methanol, ethylene glycol, methanol, ethylene glycol,
aspirin, theophylline ). aspirin, theophylline ).
7- Other metabolic disturbance 7- Other metabolic disturbance
refractory to medical treatment refractory to medical treatment
like hypercalcemia with like hypercalcemia with
hyperphosphatemiahyperphosphatemia

22. Indication of dialysis in CKDIndication of dialysis in CKD

23. When do you start treatment?When do you start treatment?
@-@-There is no simple answer to this There is no simple answer to this
question. question.
Studies (usually retrospective) of Studies (usually retrospective) of
early versus late dialysis show no early versus late dialysis show no
obvious gain in life expectancy as a obvious gain in life expectancy as a
result of starting treatment early . result of starting treatment early .
Advantages in terms of quality of life Advantages in terms of quality of life
are another matter, howeverare another matter, however

24. @-Dialysis should be considered when @-Dialysis should be considered when
the GFR is 10–15 ml/min, depending on the GFR is 10–15 ml/min, depending on
symptoms.symptoms.

25. @-An early start of dialysis in @-An early start of dialysis in
patients with predictably steadily patients with predictably steadily
progressive renal failure (autosomal progressive renal failure (autosomal
dominant polycystic kidney disease – dominant polycystic kidney disease –
ADPKD – or glomerulonephritis) is ADPKD – or glomerulonephritis) is
practical.practical.
Those with relatively stable renal Those with relatively stable renal
function, however , may often be function, however , may often be
treated conservatively for longertreated conservatively for longer

26. Complication of HDComplication of HD

27. Complications of vascular Complications of vascular
access(temporary/permanent).access(temporary/permanent).
Complications during HD.Complications during HD.
Complication of long term HD.Complication of long term HD.

28. Complication of vascular access Complication of vascular access
( central venous cannulation): ( central venous cannulation):
immediate: immediate:
@-Arterial puncture.@-Arterial puncture.
@-Pneumothorax.@-Pneumothorax.
@-Hemothorax.@-Hemothorax.
@-Arrythmias.@-Arrythmias.
@-Air embolism.@-Air embolism.
@-Venous or cardiac perforation.@-Venous or cardiac perforation.
@-Pericardial tamponade.@-Pericardial tamponade.
@-Injury of adjacent structure like brachial @-Injury of adjacent structure like brachial
plexus or trachea. plexus or trachea.

29. Delayed:Delayed:
@-Like thrombosis.@-Like thrombosis.
@-Infection( endocarditis, @-Infection( endocarditis,
osteomyelitis, thrombophlebitis).osteomyelitis, thrombophlebitis).
@-Vascular stricture.@-Vascular stricture.

30. AKIAKI
When to refer?When to refer?
Persistence of ARF for 2-4 Persistence of ARF for 2-4
weeks.weeks.
When to admit?When to admit?
Significant acid –base , fluid and Significant acid –base , fluid and
electrolytes abnormalitieselectrolytes abnormalities

31. CKD CKD
When to refer?When to refer?
When GFR 60ml/min for When GFR 60ml/min for
mangementmangement
When to admit?When to admit?
Congestive heart failure, Congestive heart failure,
pericarditis , severe acid –base , pericarditis , severe acid –base ,
fluid and electrolytes fluid and electrolytes
abnormalitiesabnormalities

32. ThAnKsThAnKs
Dr M AbbassDr M Abbass