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ABIM Nep Dialysis

QuestionAnswer
Risk factors for poor outcome on HD? shorter dialysis (< 240 min) & greater weight gain (>3 kg) are independently associated with increased all-cause mortality. Shorter time causing more mortality was independent of wt.
When is infected dialysis catheter removal necessary? patients whose fevers persist >48-72 hours of appropriate systemic antibiotics (~10% to 15%), removal of the infected catheter is mandatory. Or if patient unstable.
Antibiotic catheter locks + IV atb is a reasonable strategy for what situations? most successful (~90%) with gram-neg, less successful w Staph epi (~75%), and least w S aureus (~40%). Atb lock can potentially remove the source of the infection (the biofilm), while permitting catheter salvage
Rx of catheter associated candidemia? Antifungal rx + always requires catheter exchange
T/F determination of whether a new fistula is likely to be used successfully for dialysis should be possible within 4 to 6 weeks of the initial surgery. TRUE. mean access blood flows and fistula diameters are not significantly different in 2-4 months following fistula creation.
The combination of a diameter ___ AND access flow ___ predicts a 95% success rate for AVF . diameter >4 mm AND access flow >500 mL/min
A combination of fistula diameter ____ AND access flow ___ predicts a 33% likelihood of fistula success. diameter <4 mm AND access flow <500 mL/min
T/F Patients undergoing surveillance had a higher rate of prophylactic angioplasty, but the frequency of graft thrombosis was not decreased. TRUE. Graft surveillance has not been proven to be effective in improving graft outcomes.
Results of HEMO study? no mortality difference between high vs low flux regimens.
Outcomes of HD in elderly? 6mo mortality rate in > 75 at onset of dialysis was 8%, and % rises sharply with comorbidities. US NH pts started on HD 1998-2000, half dies by 6 mo &1/4 had maintained fcn status.
IDEAL study demonstrated? there is little value to early-start dialysis and may even be harmful.
Frequent _______ dialysis has better CV outcomes than ______ dialysis home hemo better CV outcomes than PD…. but more infections w HHD!!
Predictors of survival on PD? pulse pressure (not BP control), BNP, volume status
Better survival on peritoneal dialysis seen in which group (fast or slow transporters)? neither. Previously, rapid transporters thought to do worse, No longer true.
What is desired KT/V on hemodialysis? > 1.4 is better than 1.2, Especially for smaller patients, Women for children
What is desired weekly KT/V on peritoneal dialysis? >1.7, 0.25/day
What is desired weekly KT/V on 3x/ wk hemodialysis? 1.2/rx
What is desired weekly KT/V on 4x/ wk hemodialysis? 0.75/rx
What is desired weekly KT/V on 5x/ wk hemodialysis? 0.6/rx
What is desired weekly KT/V on 6x/ wk hemodialysis? 0.5/rx
ADEMEX study showed? residual creatinine clearance most effect on survival for PD patients. Also, no difference in RR of death between high-dose and standard dose arms
HEMO Trial results? no difference in RR between low-dose versus high-dose hemodialysis or low flux versus high flux
Hi versus low flux dialysis results show? HDF has no benefit???
Secondary analysis of HEMO trial showed that for long-term patients, _____ made a difference. Flux
T/F no randomized controlled trials have shown earlier initiation of RRT improves survival, only observational studies. TRUE
HEMO Study showed that ___ UF carried higher mortality . UF greater then 13 ml/kg/hr was associated with Wall motion abnormalities and increased mortality
What is the safe rate of UF? 10 ml/kg/hr max
What is most efficient way to improve solute clearance in CVVH? increase the blood flow rate. Prefilter administration of replacement fluid is associated with lower solute clearance than postfilter replacement fluid.
Calculate filtration fraction UF rate/plasma flow rate. Ex: UF 3100 mL/hr (postfilter replacement fluid + UF rate). Plasma flow rate is 200 mL/min × 60 min/hr × (1 — hematocrit)
OSA effects on BP for ESRD pt? BP increases by 7-15 / 4-10 mm Hg. CPAP therapy show a modest reduction in BP of 1–3/0.7–2 mm Hg.
A major contraindication for the use of citrate anticoagulation is ____. Severely impaired liver function or shock with muscle hypoperfusion, both representing a risk of citrate accumulation.
RENAL and the ATN trial study showed ____. NO benefits of increasing CRRT doses in AKI patients to > effluent flows of 20-25 mL/kg/hr
Definition of peritonitis? > WBC > 100 WBCs/mm3; OR 50% Poly’s even if WBC < hundred
PD amylase > ___ suggests intra-abdominal pathology. > 50
PD cell count > ___ after 3 days of rx suggest catheter may need to be removed. 1000. 64% likelihood of treatment failure associated with cell count > 1000
Icodextrin interferes with assay of _____. amylase, By making it lower
What is usual cell type of PD fluid? macrophages, not poly’s
Recommended empiric antibiotics for PD ? Cover Gram POS (1st gene Cephalosporin or vanco) AND gram NEG (aminoglycoside, Cipro, ceftazidime, cefepime). Ex cefazolin + cefepime; Vanc + ceftaz; vanc + gent.
May add adjuvant rifampin for how long in rx peritonitis? add for 1week ONLY (and never use alone)
Peritonitis from Pseudomonas needs atb for how long? x21 d (or more) AND catheter removal
prophylax before major dental work in PD patients? w amoxicillin 2 grams po; c-scope proph IV amp 1 gr + gent (+? flagyl)
T/F There is no evidence that use of icodextrin or use of pre-sternal catheter in lieu of an abdominal exit site has any effect on peritonitis rates. TRUE
After touch contamination, how long do you rx with atb? if break in sterile technique-atb x 2 days; if contamination after such started—7 day atb
Daily application of either mupirocin or gentamicin has been shown to be effective in reducing peritonitis rates in patients treated with peritoneal dialysis. TRUE
What is considered rapid transporter, and what does it mean? . D/P creatinine > .81; pt equilibrates sooner but continue to absorb nlly. UF is less effective. Thus, higher solute clearance but drain volume may be less than the instilled volume.
RX for rapid transporters on PD? Rx of choice: multiple short dwells with standard dialysate, as with nightly intermittent peritoneal dialysis (NIPD). Also effective: hypertonic soln (but risk of hypergly & hi trig)
Higher D/Pcreat ratio on PET reflects ? less UF
Explain “slow" transporters D/P <0.5. Ultrafiltration is not a problem in this setting, since glucose is also slowly absorbed. Rx- long dwell times to adequately remove small solutes. Results in good drain vol but low clearance.
Explain Gibbs-Donnas effect. given osmotic force of proteins in plasma, effective gradient favors movement of Na from dialysate to plasma even though anticipate movement to the dialysate. Predicts isonatric dialysis will only occur if the dialysate sodium < plasma Na.
Elevated 44 hr ambulatory BP assoc w what outcome? higher mortality
Rx dialysis assoc hypotension fewer hypotensive episodes/Rx with sodium modeling, high sodium, and cool temperature protocols. However Hi Na inc thirst & H2O retention! (Usu aim Na in dialysate < blood). midodrine very helpful. UF followed by HD NOT helpful and assoc w more LowBP
Frequent hemodialysis network trial results patients randomized to 6x/wk dialysis versus 3x/wk dialysis had a 10 mm Hg lower predialysis systolic BP and lower LV mass and mortality
Study for Heart and Renal Protection (SHARP) trial showed there was decreased risk of atherosclerotic events with statin + ezetimibe but no improvement in overall survival. (included both CKD and ESRD)
Icodextrin not absorbed from peritoneum, but absorbed via lymphatic. used for longest dwell. Does not affect Na.
Osteomalacia, bone and muscle pain, iron-resistant microcytic anemia, hypercalcemia, and neurologic abnormalities? Aluminum toxicity
Which PD modality is best during peritonitis? CAPD best, but can use cycler as long as antibiotic added to each fill. Vanc/gent only added daily to long fill d/t long absorption time.
hydrothorax on PD is most common on ___ side. right > left
Rx hydrothorax temporary transfer to HD, Low volume PD, Pleurodesis
What study is most useful to demonstrate leak of PD fluid? MRI w/o contrast
Rx hemoperitoneium heparin 500 units/liter
adding providone iodine to pleural fluid shows ______ starch from icodextrin
Look for _______ in HD patient with increasing HgB off ESA with normal iron. renal cell ca
define UF failure on PD. to maintain volume status despite fluid restriction + three or more hypertonic exchanges daily. 4hr dwell of 4.25 has < 400 ml
What remove chloramines from dialysis water? Carbon filter
_____ remove endotoxins during dialysis water treatment? reverse osmosis filter
_____% of pts on dialysis have cysts after 3 yrs and ___% after 10 yrs 50% after 3 yrs and 90 % after 10 yrs
What are causes of hemolysis on dialysis? chloramine's, copper, nitrate, formaldehyde, pump or tubing issues, hi dialysate temperature, cannulation
If you suspect hemolysis, what the immediate steps are taken? take machine off line and do not use until examined, check for recalls on that blood tubing, has biomed check for water issues
Back pain, headaches, pink skin after dialysis warrants checking for? Hemolysis
Chloramine is removed by which techniques? primarily charcoal filter. Minimally removed by deionizer and RO
Negative pressure alarm on chemo dialysis prompts checking for? arterial inflow issues from kinked or defective tubing, malocclusion of pump, catheter flow issues
IDEAL study results early start of dialysis does not benefit survival
Frequent dialysis has what benefits? does not improve survival; BUT reduces LVH, improves EF & CVD surrogate endpoints
When do you start ESA and dialysis patients? hemoglobin 9–10, With goals to keep <11.5.
Incidence of sleep apnea and dialysis patients? 21-47%! >73% in those w/ S/S (AM headache, restless sleep, daytime sleepiness, personality changes). BUT Rx not shown to improve survival.
Depression in dialysis 10-66% incidence, assoc w/ increased CV risk (1.7-4.5x) and mortality
Which maybe best narcotic for chronic pain in dialysis? Methadone. Codiene accumulates. Tramadol needs dose reduction.
Best antidepressants for ESRD? sertraline (Zoloft). Recall SSRIs worsen RLS
T/F IDPN improves survival. FALSE. No difference in mortality, hospitalization, or nutritional status at two years.
T/F Megestrol is helpful in dialysis/CKD patients with Anorexia and malnutrition. falls. Associated with increased death, fluid gains, diarrhea
What are problems of buttonhole cannulation ? increased incidence of AVF infection and a bacteremia. Suspected from infected scab not being removed. if use, wash with chlorhexidine before and after scab removed
What is best agent to clean skin and reduce infections of dialysis access? Chlorhexidine superior to Betadine
Bacterial biofilm develops ___ hours after placement catheter. within 24 hours.
Fever and rigors and a dialysis patient with catheter 60-75% likelihood of bacteremia, 40% GNR. RX: ceftaz/gent AND vanco. MRSA seen in >50%
If Catheter is not removed after treatment of catheter infection, infection will revcur in ____% of cases. section will recur in 75%
Antibiotic catheter lock is useful ______. for uncomplicated bacteremia from GNR or Staph epi.
Preoperative vein mapping helps improve _____, but _____ still a problem. it improves fistula placement, but failure to mature still persists.
What predict success the AV fistula? diameter greater than 4 mm and flow> 500
Benefit of clopidrogel on fistula thrombosis? clopidrogel reduces AVF thrombosis but does not improve fistula suitability for HD
Leading cause of craft thrombosis? at Venus anastomosis, draining vein, or Central vein
Monitoring for prevention of access thrombosis has what effects? surveillance does not reduce thrombosis.
Stent grafts help AVG ____. they prevent re-stenosis BUT do not prevent thrombosis
Catheter malfunction after first use is ____ problem. technical
Catheter malfunction after previous use is ____ problem. luminal thrombosis. tPA may help short term.
___ BPs are useful to diagnose hypertension in dialysis patients . Home BP monitoring is accurate 90% of time diagnosed HTN. There's poor correlation between dialysis unit & home BPs
What is daytime BP target for dialysis patients? < 135/85.
What is pre-dialysis BP target for dialysis patients? < 140/90.
What is post-dialysis BP target for dialysis patients? < 130/80.
Options to treat large intra-dialytic weight gains? 2 gram Na. lower dialysate Na (should be < serum Na),
HD 6x/week versus 3x/week benefits? lower of pre-dialysis VP, lower LV mass, but more likelihood to undergo interventions R/T dialysis access. NOT clear if it improves survival.
T/F carnitine improves BP in hypotensive dialysis pts. FALSE
Use of statins in dialysis pts showed _____. reduced LDLc, no higher SAEs (myopathy, hepatitis), BUT did not improve all cause CV mortality… did lower CVA events in some studies
“brown” tumors are assoc with what biochemical parameters? hi Ca, hi Phos, hi PTH
Causes of hemolysis on dialysis? chloramine, chloride, overheated dialysate, defective tubing, lines/catheter kinking
What does fluoride toxicity on dialysis cause? G.I., cardiac and anticholinergic symptoms, but not hemolysis
Dialysate bath prone to grow bacteria bicarbonate
Chloramine is removed by Carbon filter
Water softener in dialysis water treatment removes? Calcium and magnesium
What does reverse osmosis in dialysis water treatment remove? dissolved solutes, bacteria, endotoxins
Multiple hemodialysis patient with fever and chills at same time? Think bacterial or toxin contamination
In a dialysis unit, what are actionable bacterial and Endotoxin counts? 50 CFU AND 0.25
During dialysis, what causes shortness of breath, Flushing, itching, hypotension. Usually within 10 minutes of starting therapy? Dialyzer reaction. Treatment: stop blood pump, clamp tubing, do not return blood.
Hemolysis on dialysis? Hypotonic or overheated dialysate, high chloramine level, high copper or nitrates, residual disinfectants such as bleach or formeldahyde, kinked tubing or malfunctioning pump. RX: stop pump, clamp lines
Chelation w deferroxamine carries risk of? fungal infection
How does Air embolism present? If sitting, will see neurologic toxicity, recumbent patients who have chest pain and SOB. Arterial alarm sounds with negative pressure.
What does a venous pressure alarm suggest? Venous port disconnected
PET test done after how much time on PD? Wait one month, because minimal changes occur after starting dialysis R/T inflammation.
Rule of fours during PET test? 4.25%, greater than 400 mL of UF, 4hrs, check Na sieving. 4.25 is used when evaluating PD failure, otherwise use 2.5.
Guidewire exchange of catheter with IV atb for treating catheter-related bacteremia is recommended for___. Stable pts. They do well w/ guide wire exchange; however, catheter removal is indicated in patients who are unstable.
Pre-dialysis bicarbonate of ______ is associated with higher risk of death? Greater than 27. Look for non-bicarbonate alkali such as Acetate or citrate.
Created by: ka1usg