Principles of Dialysis
Indications & Contraindications
Hemodialysis
Hemodialysis related therapies
Peritoneal Dialysis
Other
Minitips
Indications and contraindications of dialysis

 

Indications for Dialysis -In Chronic Renal Failure

  In patients with chronic renal failure factors to be considered before initiating dialysis should include comorbid conditions and patient preference. Timing of therapy is dictated by serum chemistries and symptoms.

 A) Absolute indications

Uremic Pericarditis

Uremic Encephalopathy or Neuropathy

Pulmonary edema (unresponsive to diuretics)

Severe Hypertension

Severe hyperkalemia

Intractable acidosis

Severe Bleeding diathesis

Persistent gastrointestinal symptoms

S.Creatinine more than 12 mg/dl, BUN more than 100 mg/dl

 B) Relative indications

Mild encephalopathy or neuropathy

Severe edema (unresponsive to diuretics)

Progressive gastrointestinal symptoms

Recurrent GI “itis”: stomatitis, gastritis, dudenitis, pancreatitis

Ascitis without hepatic disease

Anemia refractor to Erythropoietin

Mild Bleeding diathesis

Pruritus

Infectious complications

Depression

 C) Early indications

Decrease ideal body weight

Decrease in muscle mass (decrease s creatinine or its clearance)

Decrease in s.albumin to less than 4 g/l

GFR less than 15 ml/min (by I iothalamate)

S. Creatinine >10 mg/dl and bun >100 mg /dl

Decrease in s.transferrin

Low total cholesterol

Growth retardation in children

 D) Specific indications for peritoneal dialysis

Patients with cardiovascular or hemodynamic instability

Hemodialysis patients with vascular access failure or can not be created (e.g. diabetic patients)

High risk of anti coagulation

Patients in the older age group (over 65) and small children

Severe hemodialysis-related symptoms or disequilibrium

Social reason

Indications for Dialysis other than chronic renal failure

1-Acute renal failure

2-Poisons and Drug intoxication

3-Hypercalcaemia

4-Hyperuricemia

5-Hypothermia

6-Metabolic alkalosis (special dialysis solution required)

 

Dialyzable drugs and Poisons (partial list)

a) Barbiturates            : Phenobarbital -Pentobarbital -Amobarbital

b) Alcohol's                 : Methanol -Ethanol -Ethylene glycol -Isopropanol

c) Analgesics               : Acetylsalicylic acid -Methylsalicylate

d) Metals                     : Calcium -Potassium -Sodium -Lithium

e) Endogenous toxins  : Uric acid -Uremic toxins -Hyperosmolar state

f) Halides                     : Bromide

e) Miscellaneous          : Theophylline -Mannitol -Radiocontrast -Thiocynate -

                                                 Boric acid -Aniline

NB   1) Dialysis for poisoning should be considered only when supportive measures are                                                                   ineffective or there is impending irreversible organ toxicity.

          2) Hemoperfusion is required in some cases

 

Factors to be considered in determine drug’s dialyzability:

 1) Dialysis related factors:

Dialyzer membrane characteristics

Surface area

Blood flow rate

Dialysate flow rate

Degree of ultrafitration

Duration of dialysis

 

 2) Drug related factors   :

Availability of the drug in the plasma

Drug pharmacokinetic characteristics

Drug molecular weight (<500 cross the membrane more readily)

Drug solubility (water soluble are dialyzable than lipid soluble)

 

Factors Determinants for Dialysis

 Factors determining the mode of chronic dialysis should include medical and non medical factors which have an impact on the treatment modality. Physicians have the responsibility to discuss the therapeutic options and offer their advice and recommendations about the choices. In general renal transplantation should be recommended as the preferred mode of renal replacement therapy in whom surgery and immunosupression is safe and feasible.

Medical Factors

  1. Age
  2. Comorbid medical illnesses    
  3. Patient survival    
  4. Patient rehabilitation      
  5. Quality of life  

Non Medical Factors

  1. Government-imposed Economic limitations
  2. Physician  and Patient bias
  3. Resource availability
  4. Social ,Religious ,Cultural mores
  5. Availability of transplantation
  6. Family support
  7. Cost , race , sex , reimbursement

 

 Contraindications of Dialysis therapy

 Principally there is no absolute contraindication to dialysis therapy. Advanced age in and of itself is not a contraindication to dialysis therapy. Many elderly are physiologically equivalent to young patients.

Relative contraindications to dialysis therapy

  1. Advanced malignancy (except multiple myeloma)
  2. Alzheimer’s disease
  3. Multi-infarct dementia
  4. Hepatorenal syndrome
  5. Advanced liver cirrhosis with encephalopathy
  6. Hypotension unresponsive to pressors
  7. Terminal illness
  8. Organic brain syndrome

 Contraindication for Peritoneal dialysis

Absolute

  1. Peritoneal fibrosis           
  2. Pleuroperitoneal leak       

Relative Major

  1. Chronic Ostomies
  2. Severe hypercatabolic state
  3. Fresh aortic prosthesis
  4. Recent Abdominal surgery
  5. Recent Thoracic surgery
  6. Extensive Abdominal adhesions
  7. Quadriplegia
  8. Blindness
  9. Physical handicaps
  10. Mental Retardation

Relative Minor

  1. Polycystic Kidney disease
  2. Diverticulosis
  3. Obesity
  4. Peripheral vascular disease
  5. Hyperlipidemia
  6. Social