Indications of dialysisIndications of dialysis

Dr. Mohamed AbbassDr. Mohamed AbbassNephrologistNephrologist

PGDD,CARDIFF,UKPGDD,CARDIFF,UK

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 accepteddefinition).definition).

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

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 in serum creatininecreatinine2- The 2- The decreasedecrease in the GFR in the GFR 3- The 3- The decreasedecrease in the urine in the urine output output This is theThis is the RIFLERIFLE criteria criteria

The The RIFLERIFLE criteria criteria

in serum creatinine

in GFR

In

urine output

Risk1.5 fold 25% < 0.5 mL/ kg per hour for six hours

Injury2 fold 50% <0.5 mL/ kg per hour for 12 hours

Failure3 fold 75% <0.5 mL/ kg per hour for 24 hours or anuria for 12 hours

LossComplete loss of kidney function for more than four week (need renal replacement therapy)

ESRDComplete loss of kidney function for more than three months ( need renal replacement therapy)

Chronic kidney diseaseChronic kidney disease (CKD) (CKD)

kidney damage for 3 or morekidney damage for 3 or moremonthsmonths1-Structural or functional abnormalities 1-Structural or functional abnormalities of the kidneyof the kidney2-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 abnormalities or markers of kidney damage.damage.

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

CKD Stages according to CKD Stages according to GFR (ml/min/1.73mGFR (ml/min/1.73m22) ) 1: Stage 11: Stage 1Kidney damage Kidney damage with normal or GFR >90 with normal or GFR >90 2: Stage 22: Stage 2GFR 60:89GFR 60:893: Stage 33: Stage 3GFR 30:59GFR 30:594: Stage 44: Stage 4GFR 15:29 GFR 15:29 5: Stage 5 (ESRD)5: Stage 5 (ESRD) <15 <15

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

RenalRenal – – results from results from structural damage to the structural damage to the glomeruli and renalglomeruli and renaltubulestubules@-ATN (the most common @-ATN (the most common causative condition)causative condition) @-Glomerulonephritis/vasculiti@-Glomerulonephritis/vasculitiss @-Tubulointerstitial nephriti @-Tubulointerstitial nephritiss

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

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

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

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

Diabetes mellitus Diabetes mellitus is now is now the most common the most common identifiableidentifiablecause of cause of CKDCKD , being , being present in nearly 20% of present in nearly 20% of new patientsnew patients

Indication of dialysis in Indication of dialysis in AKIAKI

1-Hyperkalaemia greater than 1-Hyperkalaemia greater than 6.5 mmol/l or 6–6.5 mmol/l with 6.5 mmol/l or 6–6.5 mmol/l with ECG changesECG changes 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)

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 urea or creatinine at which we can dialyze the patient.can dialyze the patient.

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

Indication of dialysis in CKDIndication of dialysis in CKD

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

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

@-An early start of dialysis in @-An early start of dialysis in patients with predictably patients with predictably steadily progressive renal steadily progressive renal failure (autosomal dominant failure (autosomal dominant polycystic kidney disease – polycystic kidney disease – ADPKD – or ADPKD – or glomerulonephritis) is glomerulonephritis) is practical.practical.

Those with relatively stable Those with relatively stable renal function, however , may renal function, however , may often be treated often be treated conservatively for longerconservatively for longer

Complication of HDComplication of HD

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.

Complication of vascular Complication of vascular access ( central venous access ( central venous cannulation):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 @-Injury of adjacent structure like brachial plexus or trachea. brachial plexus or trachea.

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

AKIAKIWhen 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 Significant acid –base , fluid

and electrolytes and electrolytes abnormalitiesabnormalities

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 –pericarditis , severe acid –base , fluid and electrolytes base , fluid and electrolytes

abnormalitiesabnormalities

ThanksThanks

Dr M Dr M AbbassAbbass