What are the 6 indications for dialysis?
Dialysis is a life saving process. The decision to carry out dialysis may be made in the case of either chronic or acute illness. Show Acute or sudden illnessExamples of acute conditions where dialysis may be used include: Metabolic acidosis or a change of the blood pH to acidic. Usually, this condition can be treated by neutralizing the acidic blood with sodium bicarbonate. However, dialysis may be needed in cases where this is impractical or if there is a risk of fluid overload. Electrolyte imbalance such as severe hyperkalemia where the blood level of potassium is raised. Overload of fluid in the body that diuretics cannot relieve. Acute poisoning where the harmful substance can be removed by dialysis. Lithium, a drug used to treat mood disorders and the pain reliever aspirin are two examples of drugs that can be removed using dialysis Uremia - Certain complications of the condition uremia where urea and other waste material builds up in the blood. Such complications include pericarditis (inflammation of the pericardium in the heart), encephalopathy or a disease affecting brain function and gastrointestinal tract bleeding. Usual indications for RRT can be “renal” or “non-renal” – these can be summarised using the UFAKE mnemonic Renal
Non-renal (E: extras = TNT)
TIMING Starting RRT
Stopping RRT depends on multiples factors:
PATIENT SELECTION In general, patients who are critically ill are more suited to CRRT and this is the modality most widely used for RRT in Australasian intensive care. CRRT is usually more appropriate for patients with
IHD is more suited for patients who require rapid removal of dialysable substances
EARLY VERSUS DELAYED INITIATION OF RRT IN THE CRITICALLY ILL The timing of RRT initiation in critically ill patients is controversial
Rationale for early RRT
Rationale for delayed RRT
Evidence
RENAL REPLACEMENT THERAPY IN TOXICOLOGY Renal replacement therapy is clinically useful for enhanced elimination of selected toxic agents
Table from Kellum et al (2016): 123MethanolIHD RRT should be continued until the serum methanol concentration is < 25 mg/dL and the anion-gap metabolic acidosis and osmolal gap are normal. Rebound may occur up to 36 h IsopropanolIHDRRT effectively removes isopropanol and acetone, although it is usually unnecessary except in severe cases (prolonged coma, myocardial depression, renal failure)Ethylene glycolIHDRRT should be continued until the ethylene glycol level is <20 mg/dL and metabolic acidosis or other signs of systemic toxicity have been resolved bound. Rebound may occur up to 24 hours LithiumIHDCRRTIHD removes lithium faster but rebound may be a significant problem and can be addressed effectively with CRRTSalicylateIHD CRRTBoth IHD/CRRT have been reported in the management of salicylate poisoningTheophyllineIHD CRRT haemoperfusion RRT should be continued until clinical improvement and a plasma level < 20 mg/L is obtained bound may occur. Rebound may occur Valproic acidIHDCRRT haemoperfusionAt supratherapeutic drug level plasma proteins become saturated and the fraction of unbound drug increases substantially and becomes dialysable References and LinksJournal articles and textbooks
FOAM and web resources
Critical CareCompendium …more CCC Chris NicksonChris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education. He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. What are 5 indications for needing dialysis?Indications to commence dialysis are:. intractable hyperkalaemia;. acidosis;. uraemic symptoms (nausea, pruritus, malaise);. therapy-resistant fluid overload;. chronic kidney disease (CKD) stage 5.. What indicates the need for dialysis?National Kidney Foundation guidelines recommend you start dialysis when your kidney function drops to 15% or less — or if you have severe symptoms caused by your kidney disease, such as: shortness of breath, fatigue, muscle cramps, nausea or vomiting.
What is dialysis and when is it indicated?Dialysis is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned.
At what creatinine level is dialysis started?Usually, when the creatinine clearance falls to 10-12 cc/minute, the patient needs dialysis. The doctor also uses other indicators of the patient's status to decide about the need for dialysis.
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