Renal Replacement Therapy: Indication and Initiation

by Amy Sussman, MD

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    00:01 Hello, and welcome back.

    00:02 Today we're going to be talking about Renal Replacement Therapy and our Nephrology Curriculum.

    00:08 So, before we get started, I think it's really important to look at the prevalence of end-stage renal disease in patients in the United States.

    00:16 So remember, end-stage renal disease are patients who have stage five chronic kidney disease, and are eligible for renal replacement therapy.

    00:23 What I want you to notice is that on the y-axis, we have number of patients in need of renal replacement therapy by the thousands.

    00:30 So that top line represents 800,000.

    00:33 Whereas the x-axis represents time starting from 1980, all the way through 2016.

    00:39 This is data taken from our USRDS, that's the United States Renal Data Systems looking at dialysis patients.

    00:46 And what I want you to focus on is that red line.

    00:49 These are all end-stage renal disease patients.

    00:52 And what's interesting is that you can see in 1980 was maybe only 10s of thousands of patients who were in need of renal replacement therapy.

    01:00 But look at what's happening now.

    01:02 In 2016, we now have about 700,000 people that are on renal replacement therapy.

    01:08 And that's either hemodialysis represented by the yellow line, peritoneal dialysis represented by the blue line, and transplant represented by the green line.

    01:17 Why is this so important? In addition to causing incredible morbidity and mortality in these populations, it's also a very big cost to the healthcare system.

    01:27 A dialysis patient costs about $88,000 per year.

    01:31 A transplant patient cost about $27,000 per year.

    01:35 So it's a significant issue when it comes to both the care of the patient, and the cost to the healthcare system.

    01:42 So let's talk a little bit more about what renal replacement therapy is? It's a life supporting therapy in patients who have renal failure.

    01:51 Their kidneys aren't working anymore, so we have to have something that can do the job for them.

    01:56 It can be either acute or chronic.

    01:59 So when a patient has acute kidney injury, and they have complications from renal failure, it would be critical to start renal replacement therapy with hemodialysis.

    02:08 However, if a patient has approached chronic kidney disease, and now has transitioned to the need of renal replacement therapy because they have stage 5 chronic kidney disease, that would be chronic renal replacement therapy.

    02:20 So renal replacement therapy involves: removing solute, normalization of electrolytes and acid base status, and removal of extracellular volume that means salt and water.

    02:31 So what are the indications for doing renal replacement therapy in our patients? If patients develop uremic syndrome.

    02:39 These are symptoms and signs that result from toxic effects of elevated levels of nitrogenous waste, and other wastes in the blood.

    02:46 These are things like aliphatic amines, uremic phenols, guanidines, and middle-sized molecules like beta-2 microglobulin.

    02:53 One thing I want to draw your attention to: Urea is not responsible for uremia.

    02:59 We talked about it quite a bit but we only use it as a marker for solute removal.

    03:04 Having a high urea level doesn't necessarily mean that a patient is uremic.

    03:10 So we talked about the symptoms of uremia as being an indication for renal replacement therapy.

    03:14 What are those? That includes: nausea, vomiting, anorexia, meaning that our patients just aren't hungry, dysguesia, that means patients have an abnormal taste, and they might describe their food tasting metallic in quality or like cardboard.

    03:30 Pruitus, meaning that our patients are very itchy.

    03:33 And having alterations in sleep.

    03:35 They might have insomnia at night, but have daytime hypersomnolence.

    03:39 And a sensation of being cold.

    03:41 That's one of the earliest manifestations people feel, but they might be cold when everybody else is hot.

    03:46 And then finally cognitive changes where they just can't think correctly.

    03:50 Some of the signs of uremia this is what we can see on physical exam is that patients might have a sallow discoloration of the skin.

    03:57 They might have an ammonia odor to the breath it's very distinct.

    04:00 And you will be able to recognize that.

    04:03 They could have a pericardial friction rub from a pericardial effusion.

    04:07 So it's important to do a good cardiopulmonary examine on those patients.

    04:11 They might have myoclonus or seizures.

    04:13 So they have muscle irritability, and sometimes that actually manifests with hiccups as well.

    04:18 They might have foot or wrist drop from uremic motor neuropathy.

    04:22 And finally, they can have prolongation of bleeding time or from uremic platelet dysfunction.

    04:27 So it's interesting because there is a relationship between the development of uremic syndrome, and glomerular filtration rate.

    04:35 So the uremic syndrome will predictably develop when that GFR falls below 10 mL/minute.

    04:42 Most patients will require renal replacement therapy once that GFR falls between 6 and 15 mL/minute.

    04:47 And I do want to say, that there is no data to suggest that starting renal replacement therapy early in patients will portend a better outcome.

    04:57 And in fact, with some of the data that we do have available there's a signal towards harm if you start patients too early.

    05:03 So we really wait until a patient absolutely needs dialysis before starting it.

    05:08 And our younger healthier patients that might be a GFR of about 6 mL/min.

    05:14 So when it comes to talking about different types of renal replacement therapy, there's a few choices that we have for our patients.

    05:21 This includes hemodialysis, peritoneal dialysis, and transplant.

    About the Lecture

    The lecture Renal Replacement Therapy: Indication and Initiation by Amy Sussman, MD is from the course Renal Replacement Therapy.

    Included Quiz Questions

    1. It is caused by excess nitrogenous waste products in the blood.
    2. It is caused by excess bilirubin in the blood.
    3. It is expected in patients with a GFR of < 40 mL/min.
    4. Most patients will require renal replacement therapy when GFR = 25–35 mL/min.
    1. Motor neuropathy
    2. Jaundice
    3. Bleeding due to coagulation factor VII dysfunction
    4. Mineral and bone disorders
    5. Normocytic and normochromic anemia
    1. It is indicated for the normalization of acid-base status and electrolyte levels.
    2. It is contraindicated in hemodynamically unstable patients.
    3. It is indicated only for patients with end-stage renal disease.
    4. The number of patients receiving renal replacement therapy has dropped over the last 30 years.

    Author of lecture Renal Replacement Therapy: Indication and Initiation

     Amy Sussman, MD

    Amy Sussman, MD

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