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106 Cards in this Set
- Front
- Back
A progressive loss of renal function over months to years
(replacing normal kidney tissue with fibrotic tissue) |
Chronic Kidney Disease
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Chronic Kidney Disease
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presence of structural kidney damage and/or GFR <90mL/min for 3 months or more
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what is the proposed mechanism or chain of events in CKD
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1. Loss of nephron mass
2. Glomerular capillary HTN 3. Proteinuria |
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three major risk factors for development of CKD
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1. Diabetes mellitus
2. HTN 3. Glomerulonephritis |
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What is the most common risk factor of CKD
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Diabetes Mellitus
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accumulation of glycated products leads to loss of intraglomerular pressure, resulting in scarring of glomerular capillaries
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Diabetes mellitus(most common risk factor for CKD)
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higher BP in glomerular capillaries lead to damage to vessels, lose intraglomerular pressure, resulting in nephroschlerosis
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HTN(risk factor of CKD)
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Helpful in identifying CKD at risk- patients
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increased age, racial minority, low birth weight, genetics, hyperlipidemia
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These factors hasten the functional decline and increase risk of ESRD one damage has been done
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uncontrolled hyperglycemia and HTN, proteinuria, obesity, smoking, hyperlipidemia
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Amount of protein on dipstick or in 24hr collection that quantifies for proteinuria
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300mg/day
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Stage 3 CKD
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GFR = 30-59ml/min
(moderately decreased) |
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Stage 2 CKD
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GFR = 60-89ml/min
(mildly reduced) |
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Stage 4 CKD
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GFR = 15-29ml/min
(severely decreased) |
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Stage 5 CKD
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GFR = <15ml/min (or on dialysis)
(ESRD or kidney failure) |
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Do you use Cockrault Gault equation when patient is on dialysis?
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No. GFR is automatically <10ml/min
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common symptoms of CKD
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fatigue, cold intolerance, shortness of breath, palpitations, muscle cramps, depression
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Signs of CKD
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elevated BUN and SCr, electrolyte problems, HYPER(Mg, PO4, Ca), anemia, decreased OU, decreased Vit D, Acidosis, Edema
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how do ACEIs/ARBs help with CKD
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reduce blood pressure, lower proteinuria
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Goal Blood Pressure
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<130/80mmHg
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2 major adverse events when patient with CKD is taking ACEIs/ARBs
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acute worsening of renal function and hyperkalemia
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lisinopril(Zestril)
captopril(Capoten) ramipril(Altace) enalapril(Vasotec) |
Angiotensin Converting Enzyme Inhibitors (ACEIs)
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irbesartan(Avapro)
candesartan(Atacand) losartan(Cozaar) valsartan(Diovan) |
Angiotensin Receptor Blocker (ARB)
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Issues when Uremic Waste accumulates
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1. coronary artery disease
2. pericarditis 3. uremic bleeding 4.uremic encephalopathy 5. pruritis |
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circulating toxins cause chronic inflammation. Inflammation increases risks of plaque rupture, clot formation, MI
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Coronary artery disease(uremic waste accumulation)
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inflammation of pericardial sac. If severe, restrict movement of heart, reducing stroke volume
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Pericarditis (uremic waste accumulation)
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clotting function impaired because toxins coat platelets.
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Uremic Bleeding (uremic waste accumulation)
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toxins in CNS interfere with neuronal activity, displace neurotransmitters
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Uremic Encephalopathy
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Toxin enter the skin
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Pruritis
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Signs and Symptoms of Uremic Waste Accumulation
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fatigue, weakness, shortness of breath, mental confusion, bleeding
increased BUN/SCr, EKG changes, bleeding on the brain |
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how do you treat uremic waste accumulation
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remove the waste with dialysis or transplant
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Main issue with RAAS activation
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HTN
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Signs and Symptoms of RAAS activation (HTN)
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usually asymptomatic
blurred vision or confusion(HTN emergency) BP > 130/80mmHG |
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how many drugs are commonly used to treat HTN
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3-4 medications
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what is the treatment of HTN
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1. sodium restriction to 2-3g/day
2. ACEIs/ARBS (preferred) |
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If blood pressure is greater than 130/80, what is the first step taken according to JNC-7
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Starting ACEI or ARB
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If ACEI or ARB doesnt lower blood pressure, according JNC-7 what is the step 2
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adding a diuretic
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According to JNC-7, if CrCl is greater than or equal to 30 use...
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thiazide diuretic
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According to JNC-7, if CrCl is less than 30 use...
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loop diuretic
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Left ventricular hypertrophy, pulmonary edema, and GI edema are associated with what?
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Fluid overload
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What is Left Ventricular Hypertrophy?
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harder for heart to circulate blood, pumps harder and begins to hypertrophy, enlarge heart requires more oxygen. early steps of heart failure
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fluid gets into lungs, enters alveoli, cannot perform gas exchange
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pulmonary edema
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absorption of nutrients and meds reduced because of edematous mucosa
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GI edema
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Signs and Symptoms of Fluid Overload
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weight gain, fatigue, shortness of breath, metallic taste
edema, changes in UO, foaming of urine, ab distension |
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Can you use sodium and water restriction in the treatment of fluid overload?
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yes
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What are the four different types of diuretics?
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1. Thiazides
2. Loops 3. Carbonic Anhydrase Inhibitors 4. Potassium-Sparing |
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are thiazide diuretics effective at CrCl <30ml/min
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No
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HCTZ, metolazone
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thiazides
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using dosing of furosemide which is a loop diuretic
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40-80mg PO/IV
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which diuretic can cause metabolic acidosis
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carbonic anhydrase inhibitors
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acetazolamide is what kind of diuretic
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carbonic anhydrase inhibitors
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spironolactone, eplerenone, triamterene, amiloride are what kind of diuretic? and can cause what?
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potassium-sparing ; hyperkalemia
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What are signs and symptoms of hyperkalemia
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dissiness, restless leg syndrome, cramps
EKG changes |
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PTH and Calcium have what kind of relationship
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Inverse: as PTH increases, calcium decreases
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PTH and Phosphorous have what kind of relationship
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Direct: as PTH increases so does phosphorous
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signs and symptoms of bone metabolism disorder and hyperparathyroidism
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decrease range of motion, gritty sensation in eyes, redness, inflammation
increased HR and BP, bone pain, Increase PO4, increase Ca-PO4, decreased vit D |
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stimulated PTH (increased excretion of PO4)
inactive Vit D (limited absorbed calcium) |
Bone metabolism disorder and hyperparathyroidism
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When you do you treat bone metabolism disorder and hyperparathyroidism
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PTH > 300pg/ml
Ca-PO4 product > 55 |
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Does the value Ca-PO4 product of <55 stay the same or change through Stage 3, 4, 5?
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Stays the same.
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Calcium Carbonate
(Tums) |
1st line calcium salt
binds dietary phosphate inexpensive ADR: constipation, hypercalcemia |
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Calcium Acetate
(Phoslo) |
1st line calcium salt
binds dietary phosphate ADR: constipation, hypercalcemia Inexpensive |
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Expensive 2nd line phosphate binders
Used when calcium salts are ineffective |
Sevelamer (Renvela/Renagel)
Lanthanum (Fosrenol) |
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Last line phosphate binders
Acute use do to potential of accumulation |
Aluminum Hydroxide
Magnesium Hydroxide(Milk of Magnesia) |
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When is a Vitamin D precursor recommended?
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serum vitamin D levels <30ng/ml
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Active Vitamin D products are used when?
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Stage 5 CKD
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vitamin D precursors
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ergocalciferol (Vitamin D2)
cholcalciferol (Vitamin D3) |
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Active Vitamin D
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Calcitriol (Rocaltrol - Oral, Calcijex - IV)
Paricalcitol (Zemplar - Oral/IV) Doxercalciferol (Hectorol - Oral/IV) |
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What calcimimetic increases sensitivity of calcium-sensing receptor of parathyroid gland which then decreases PTH release
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Cinacalcet (Sensipar)
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The normal dosing for cinacalcet (Sensipar) is?
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30mg Po daily, increase by 30mg daily to a max of 180mg/day
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When do you not use Cinacalcet (Sensipar)
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if corrected Ca < 8.4mg/dL
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what happens in kidney failure because of a decrease in erythropoietin?
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Anemia
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What drugs are used to treat anemia in CKD
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Epoetin - synthetic erythropoietic agent
Iron supplement (TSTAT% must be 20%) |
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patients with CKD are at a high risk for developing this major cause of mortality
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atherosclerotic cardiovascular disease
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Kidneys are unable to excrete Hydrogen and Anion Gap is present
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Metabolic Acidosis
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Treatment of Biocarb Oral Therapy of 650mg or bicarb in IV fluids
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Metabolic Acidosis
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When do you use renal replacement therapy in CKD
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CrCl ~10-15ml/min (earlier in diabetics), uncontrolled BP or heart failure, neurologic deficits
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When do you use renal replacement therapy in AKI
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A: acid-base abnormalities
E: electrolyte imbalances I: intoxications (lithium, methanol, ethylene glycol O: fluid Overload U: Uremia |
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What are the 2 leading causes of mortality in relation to renal replacement therapy?
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Cardiovascular events
Peritonitis |
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3 types of renal replacement therapy (RRT)
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1. Hemodialysis (HD)
2. Peritoneal Dialysis (PD) 3. Kidney transplant |
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Advantages: intermittent, technique failure rate low, closer monitoring, better efficacy
Disadvantages: multiple visits/week, hypotension, muscle cramps, high risk of infection |
Hemodialysis
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Advantages: more hemodynamically stable, better preservation of renal function, ambulatory, convenient route
Disadvantage: reduced appetite, risk of peritonitis, technique failure rate high, non-compliance, catheter malfunction |
Peritoneal Dialysis
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Blood is taken from the arterial system and pumped through a dialyzer
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Hemodialysis
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Arteriovenous fistula (AVF)
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surgical connection of artery to vein
1st choice Permanent, 2 months to heal |
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Arteriovenous Graft (AVG)
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surgical placement of plastic tube between artery and vein
2nd choice heals 2-3 weeks, higher rates of infection and thrombosis |
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Venous catheter
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temporary use waiting for AVF or AVG
Greater risk of thrombosis and infections |
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3x/week for 4 hours
blood circulated 300-500mL/min |
In-center dialysis
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6days/week for 2-3 hours
training is required |
Home dialysis
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6 days/week for 6-8 hours
less adverse effects |
Nocturnal dialysis
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high efficiency and high flux membrane filters allow for shorter or longer dialysis times?
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Shorter times
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Goals of hemodialysis (HD)
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achieve dry weight
target post-dialysis weight free of edema removal of endogenous waste products |
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Peritoneal dialysis
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peritoneum acts as dialyzer membrane
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is continuous ambulatory peritoneal dialysis or automated peritoneal dialysis more common?
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continuous ambulatory peritoneal dialysis (CAPD)
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CAPD
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dialysate instilled by gravity
1-3L exchanges during day every 4-6 hrs |
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APD
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dialysate instilled by cycler machine
Overnight |
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Most common complications of hemodialysis (HD)
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hypotension, muscle cramps, thrombosis at access site, infections
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alpha adrenergic agonist given before dialysis if hypotension occurs
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midodrine
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criteria for hypotension in hemodialysis
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drop of >30mmHg in systolic pressure
<90mmHg during a session |
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two medications used to help with thrombosis of access site in HD
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alteplase and reteplase
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Gram + infections that are treated aggressively that occur in hemodialysis
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AV fistula infections
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What do you treat AV fistula infections with?
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Vancomycin and aminoglycoside(diabetes, HIV, etc)
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treated with antibiotic coverage for Gram +, Gram -, and enterococcus in HD
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AV graft infections
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what type of dialyzer reactions are common?
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anaphylactic, complement activation
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Common complications in peritoneal dialysis
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mechanical problems(kinking and catheter migration)
diabetes(glucose load) Cardiovascular disease peritonitis exit site & tunnel infections |
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sign of possible peritonitis
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cloudy effluent(dialysis bag) and abdominal pain
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If patient is on dialysis, is dosing based on CrCl or GFR? if no, what do you use? if yes, explain
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No. Use resources (bennetts and DI handbook)
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drug characteristics that determine removal by dialysis
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molecular weight
protein binding volume of distribution |
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What are the 6 steps to adjust drug dosages in patients with renal impairment
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1. obtain history, demographics
2. estimate CrCl (Cockcroft-Gault) 3. review medications 4. individualize treatment 5. monitor 6. revise as needed |