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Handbook of Dialysis Therapy E-Book

Handbook of Dialysis Therapy E-Book

Allen R. Nissenson | Richard E. Fine

(2016)

Additional Information

Book Details

Abstract

Providing practical, immediately useful guidelines that can be applied directly to patient care, Handbook of Dialysis Therapy is a must-have resource for all dialysis caregivers. This new edition has been updated with the latest cutting-edge technology, dialysis techniques, and complications related to various diseases for both pediatric and adult patients. In-depth yet concise, it explains complex dialysis concepts through abundant diagrams, photos, line drawings, and tables, while its readable hands-on approach allows for quick review of key information.

  • Presents the practice-proven experience of top experts in the field of dialysis treatment.
  • Offers dialysis guidance for both adult and pediatric patients in one convenient source.
  • Features a readable hands-on approach, allowing you to quickly review the complicated concepts of dialysis.
  • Includes helpful annotated bibliography lists in each section for further in-depth research on any subject.
  • Explains complex dialysis concepts through abundant diagrams, photos, line drawings, and tables.
  • Features new chapters on care delivery, patient-centric care, rehabilitation, quality of life, geriatrics, and interventional nephrology.
  • Includes information on the management of the pediatric patient undergoing dialysis.
  • Defines the quality imperatives, roles, and responsibilities of dialysis facility medical directors and attending nephrologists.
  • Updates nephrologists on the latest alternative dialysis modalities.

Table of Contents

Section Title Page Action Price
Front Cover cover
Inside Front Cover ifc1
Handbook of Dialysis Therapy i
Copyright Page iv
Dedication v
Contributors vii
Preface xxi
Table Of Contents xxiii
I Demographics 1
1 Demographics of the End-Stage Renal Disease Patient 3
Introduction 3
Growth of the ESRD Population 3
Comorbidity, Expected Survival, and Causes of Death 5
Dialysis Initiation: Predialysis Care and Modality Selection 15
Summary 18
Recommended Reading 19.e1
II Vascular Access for Hemodialysis 21
2 Vascular Access for Hemodialysis in Adults 23
Introduction 23
History of Vascular Access 24
Multidisciplinary Approach to Vascular Access 24
Strategy and Roles 24
Education 24
Planning and Choice of Vascular Access 26
Timely and Appropriate Referral 26
Patient and Vascular Access History 28
Physical Examination 28
Supportive Investigations 28
Angiogram 30
Access Site Locations 31
Upper Extremity 31
Fistulas 31
Wrist. 31
III Peritoneal Access Devices 95
9 Peritoneal Access Devices, Placement Techniques, and Maintenance 97
Acute Catheters 97
Rigid Noncuffed Catheters 97
Soft Cuffed Catheters 98
Chronic Catheters 98
Choosing a Chronic Peritoneal Catheter 101
Chronic PD Catheter Placement Procedures 105
Percutaneous Needle-Guidewire Technique 106
Open Surgical Dissection 106
Y-TEC Procedure 107
Surgical Laparoscopy 107
Special Peritoneal Access Methods 108
Extended Two-Piece Catheters 108
Catheter Embedding 108
Acute Complications of Chronic Catheter Placement 109
Catheter Placement Approaches and Best Outcomes 110
Care of the Chronic Peritoneal Catheter 110
Postoperative Catheter Immobilization and Dressings 110
Catheter Irrigation 111
Catheter Break-in Procedures 111
Nonurgent Start 111
Urgent Start 111
Long-Term Catheter and Exit-Site Care 111
Embedded Catheter Care 112
Complications of Chronic Peritoneal Catheters 112
Mechanical Complications and Management 112
Pericatheter Leaks and Hernias 112
Infusion and Drain Pain 113
Flow Failure 114
Catheter Tip Migration 115
Superficial Cuff Extrusion 116
Catheter Infection and Management 116
Exit-Site and Tunnel Infection 116
Catheter Infection-Related Peritonitis 118
PD-Related Peritonitis 118
Removal of Chronic Catheters 119
Secondary Embedding of Chronic Catheters 119
Recommended Reading 120.e1
IV Mechanical Aspects of Dialysis 121
10 Water Treatment Equipment for In-Center Hemodialysis 123
Introduction 123
Water Contaminants 124
Equipment Used for Water Purification 126
Multimedia Filter (Fig. 10.1) 126
Monitoring the Multimedia Filter 127
Water Softener/Brine Tank (Fig. 10.2) 127
Monitoring the Water Softener 130
Carbon Tanks (Fig. 10.3) 131
Monitoring the Carbon Tanks 133
Reverse Osmosis (Fig. 10.4) 134
Monitoring the RO System 135
Deionization (Fig. 10.5) 136
Monitoring the DI System 138
Ultrafilters/Cartridge Filters/Endotoxin Retentive Filters 138
Monitoring Ultrafilters 138
Ultraviolet Lights 138
Monitoring of UV Lights 139
Water Distribution Loop (Fig. 10.6) 139
Monitoring the Water Distribution Loop 139
Other Water Treatment Components 141
Monitoring for Microbiologic Contamination 141
Recommended Readings 143.e1
11 Methods and Complications of Dialyzer Reuse 144
Background and Rationale 144
Current Status of Dialyzer Reuse in the United States 145
Dialyzer Reuse Methods 145
Effects of Reprocessing on Dialyzer Performance 146
Reprocessing Using Bleach 147
Reprocessing Using Peracetic Acid 147
Reprocessing Using Heat 148
Dialyzer Reuse Versus Single-Use Comparisons 148
Summary and Conclusions 151
Recommended Reading 151.e1
12 Dialysate Composition 152
Introduction 152
Dialysate Sodium 152
Dialysate Potassium 155
Dialysate Buffer 157
Dialysate Calcium 160
Dialysate Magnesium 161
Dialysate Phosphate 161
Recommended Reading 161.e1
13 Safety Monitors in Hemodialysis 162
Definitions and Overview 162
Dialysate Solution 162
Fluid Delivery System 163
Control Panel and Monitor Display 163
Monitor Failure 164
Fail-Safe, a Misnomer 164
Dialysate Circuit 164
Why Discuss the Details of Dialysis Machinery? 165
Water Inlet Solenoid 165
Solenoid Monitoring 166
Dialysate Temperature 166
Heater and Temperature Monitoring 167
Temperatures Greater Than 106°F 167
Temperatures Less Than 98.6°F 167
Deaeration System 167
Deaeration System Monitoring 168
Mixing Device 168
Mixing Device Monitoring 168
Composition and Conductivity of Dialysate 168
Measuring Conductivity 169
Monitoring Conductivity 169
No Intradialytic Conductivity Adjustments 170
Low Conductivity 170
Low-Conductivity Monitoring 170
High Conductivity 171
High-Conductivity Monitoring 172
Acid–Base (pH) Control 172
Monitoring Acid–Base (pH) 172
Bypass System 172
Bypass System Monitoring 173
Rinse Mode 173
Dialysate Pressure Monitor 173
Blood-Leak Detector 174
Blood-Leak Detector Monitoring 175
Dialysate Flow 175
Dialysate Flow Monitoring 175
Effluent Dialysate Line 175
Electrical Safety 175
Other Areas to Monitor in the Dialysate Circuit 176
Dialysate Prescription 176
Dialysate Prescription Monitoring 176
Sterility and Impurities 176
Microbiologic Testing 177
Bacteria in Bicarbonate Concentrate 177
Test for Endotoxins 177
Pyrogens 178
Ultrapure Dialysis Fluid 178
Cleaning and Disinfection 178
Central System Hazard 178
Routine Cleaning 179
Fluid Delivery System Disinfection 179
Heat Disinfection 179
Chemical Disinfection 179
Sodium Hypochlorite 179
Formaldehyde 180
Peracetic Acid 180
General Principles for Chemical Disinfection 181
Documentation of Dialysate Monitoring 181
The Blood Circuit 182
Arterial Pressure Monitor—Pre-Blood Pump 182
Arterial Pressure Monitoring 184
Venous Pressure Monitor 185
Venous Pressure Monitoring 185
Air-Foam Detector 186
Venous Line Clamp 187
Air-Foam Detector and Venous Line Clamp Monitoring 187
Heparin Infusion Pump 188
Heparin Infusion Pump Monitoring 188
Blood Flow Rate 188
Blood Flow Rate Monitoring 189
Blood Pump and Blood Lines 189
Narrowed Blood-Pump Tubing Segment 189
Kinked Arterial Blood Lines 189
IV Saline Infusion 189
IV Saline Infusion Monitoring 189
Conclusion 190
Recommended Reading 190.e1
14 Methods of Hemodialysis Anticoagulation 191
Introduction 191
Systemic Anticoagulation 191
Standard Heparin Anticoagulation 191
Low-Dose Heparin 193
Low-Molecular-Weight Heparins 194
Recombinant Hirudin Anticoagulation 195
Argatroban 195
Heparinoids: Danaparoid and Fondaparinux 195
Regional Anticoagulation 196
Regional Anticoagulation With Protamine Reversal 196
Regional Citrate Anticoagulation 196
Prostacyclin Regional Anticoagulation 198
Anticoagulant-Free Dialysis 198
Heparin-Free Dialysis 198
Heparin-Grafted Dialyzers 199
Citrate Dialysate 199
Anticoagulation for Continuous Renal Replacement Therapy 199
Heparin 200
Regional Citrate Anticoagulation (RCA) 200
Regional Prostacyclin and LMWHs Anticoagulation 201
Heparin-Induced Thrombocytopenia 201
Catheter Lock in Patients With HIT 204
Recommended Reading 204.e1
V Home Dialysis 205
15 Home Preparation and Installation for Home Hemodialysis 207
Introduction 207
Basis for Home Hemodialysis 207
Requirements 207
A. Legal 208
B. Water Preparation, Standards, and Plumbing 208
C. Electrical Considerations Including Backup Power Supply 209
D. Dialysis Machine Choice and Other Equipment 210
E. Space Considerations and Siting of Dialysis Machine 210
F. Hygiene and Noise 212
G. Safety 212
H. Medical Staff and Technical Support 212
I. Disposal of Waste 212
J. Storage of Medication 213
Conclusion 213
Recommended Reading 213.e1
16 Peritoneal Dialysis Cyclers and Other Mechanical Devices 214
Mechanical Aspects and Hydraulics 214
Gravity-Based Cyclers 214
Combined Gravity- and Pump-Based Cyclers 217
Pump-Based Cyclers 217
Connectology 219
Information Technology and Connectivity 219
User Interface and Ease of Use 220
Cost Considerations 221
Current and Future Developments 222
Conclusions 223
Recommended Reading 223.e1
VI Dialyzers 225
17 Selecting a Dialyzer 227
Introduction 227
Dialyzer Construction 227
Sterilization 229
Dialysis Membrane Structure and Characteristics 230
Cellulose-Based Membranes 231
Synthetic Membranes 232
Polyacrylonitrile (PAN, AN69, AN69ST) 232
Polymethylmethacrylate (PMMA) 233
Ethylenevinylalcohol Copolymer (EVAL) 233
Polyamide 234
Polysulfones 234
Polyarylethersulfones (PEPA, Arylane, DIAPES, Polyamix) 234
Clinical Implication of Membranes, Structure and Characteristics 234
Biocompatibility 236
Solute Removal 236
Dialyzer Choice and Prescription 237
Conclusions 238
Recommended Reading 238.e1
VII Adequacy of Dialysis 239
18 Uremic Toxicity 241
Uremic Toxicity: The Modern Definition of Uremia 241
Clinical Syndrome of Uremia 241
The Residual Syndrome 243
Uremic Toxins Defined 243
Source of Toxins: Nitrogen Compounds 245
Mechanisms of Toxicity 246
Role of Malnutrition 248
Role of Inflammation and Oxidative Stress 249
Role of Anemia 249
Magnitude of Toxicity 249
Classification of Uremic Toxins 250
Small Water-Soluble (Dialyzable) Solutes 251
Larger Solutes (Molecular Weight > 500 Da) 253
Protein-Bound Solutes 254
Sequestered Solutes 257
Markers of Uremic Toxicity: Role of Urea 257
Role of Salt and Water Accumulation 259
Adverse Effects of Dialysis 259
Renal Toxicity From Uremic Toxins 260
Elimination of Uremic Toxins 260
How Much Removal? 260
Removal of Poorly Dialyzed Solutes 261
Effect of Residual Kidney Function 262
Patient Variability 263
Summary and Future Directions 263
Recommended Reading 263.e1
19 Urea Kinetic Modeling for Guiding Hemodialysis Therapy in Adults 264
Blood Urea Concentration, Normalized Protein Catabolic Rate, and Fractional Clearance 264
NCDS Domains of Adequate and Inadequate Dialysis Doses 264
The HEMO Study 267
Observational and Randomized Studies 268
Volume as an Independent Predictor of Outcome 269
Role of UKM in Dialysis Therapy 269
Role of UKM in More Frequent and/or Continuous Hemodialysis Therapy and With Residual Renal Function 271
Dosing Recommendations for Adequate HD per CAPD Dosing 272
Recommended Reading 273.e1
20 The Dialysis Prescription 274
Philosophy of Dialysis Adequacy 274
Kt/V 275
Urea Reduction Ratio 276
Thresholds for spKt/V and URR 277
Equilibrated Kt/V 277
Middle Molecule Clearance 278
Fluid Removal 278
Conclusion 280
Recommended Reading 280.e1
VIII Improving Outcomes in Dialysis Patients 281
21 Improving Outcomes for End-Stage Renal Disease Patients 283
Recommended Reading 290.e1
22 Quality, Safety, Accountability, and Medical Director Responsibilities 291
Introduction 291
Quality 291
Patient Safety 295
Accountability 298
Medical Director Responsibilities 303
Recommended Reading 305.e1
23 Initiation of Dialysis Therapy 306
Historical Criteria for Dialysis Initiation 306
Evidence-Based Criteria for Dialysis Initiation 306
Preparation for Dialysis 306
Timing of Dialysis Initiation 307
Timing of Dialysis Access Placement 309
Conservative Management of End-Stage Renal Disease 310
Writing an Initial Dialysis Prescription: “Full Dose” versus “Incremental” 311
Writing an Initial Dialysis Prescription: Peritoneal Dialysis 311
Writing an Initial Dialysis Prescription: Hemodialysis 312
Conclusion 313
Recommended Reading 314.e1
IX Complications During Hemodialysis 315
24 Common Clinical Problems During Hemodialysis 317
Background 317
Intradialytic Hypotension 317
Muscle Cramps 322
Dialyzer Reactions 322
Dialysis Disequilibrium Syndrome 323
Air Embolism 323
Falls 323
Recommended Reading 323.e1
25 Arrhythmias in Hemodialysis Patients 324
Etiology and Prognosis 324
Management 325
General Considerations 325
Unstable Rhythms 325
Avoiding Arrhythmogenic Triggers 325
Treatment of Underlying Cardiac Disease 325
Specific Rhythm Disturbances 326
Ventricular Ectopy 326
Ventricular Tachycardia 326
Paroxysmal Supraventricular Tachycardia 327
Atrial Fibrillation 327
Approach to New-Onset Atrial Fibrillation in the Dialysis Unit 327
Rate Control 329
Stroke Prevention 329
Nonvalvular atrial fibrillation. 329
Valvular atrial fibrillation. 330
New non–vitamin K antagonist anticoagulants. 330
Rhythm Control Versus Rate Control 330
Bradyarrhythmias 330
Cardiac Arrest in the Dialysis Unit 331
Sudden Cardiac Death 331
Digoxin Toxicity 331
Summary 333
Recommended Reading 333.e1
26 Prevention and Therapeutic Management of Bleeding in Dialysis Patients 334
Pathogenesis of Uremic Bleeding 334
Platelet Dysfunction and Uremic Toxins 334
Anemia 336
Effects of Dialysis 336
Medications 337
Clinical and Laboratory Findings 338
Prevention of Bleeding in Dialysis Patients 340
Dialysis Prescription 340
Anemia Treatment 341
Appropriate Prescription of Antiplatelet and Anticoagulant Medications 341
Proton Pump Inhibitors 342
Preparation for Invasive Procedures 342
Treatment of Dialysis Patients With Active Bleeding 343
Desmopressin Acetate and Cryoprecipitate 343
Conjugated Estrogens 344
Tranexamic Acid 345
Recommended Readings 345.e1
X Alternative Hemodialytic Techniques 347
27 Hemofiltration and Hemodiafiltration 349
Definitions 350
Preparation of Ultrapure Replacement Fluid: Technical Issues 350
Modes of Hemodiafiltration 350
Postdilution Hemodiafiltration 350
Predilution Hemodiafiltration 351
Mixed-Dilution Hemodiafiltration 351
Mid-Dilution Hemodiafiltration 351
Principles of Hemodiafiltration Dosing 352
Quantifier of Hemodiafiltration Dose 352
Target Dose 353
Prescription of Hemodiafiltration Dose 353
Membrane Selection 353
Blood Flow Rate, Filtration Fraction, and Treatment Time 354
Anticoagulation 354
Selection of Hemodiafiltration Mode 355
Safety of Hemodiafiltration 355
Recommended Reading 355.e1
28 Continuous Renal Replacement Therapies for Acute Kidney Injury 356
Basic Principles and Operational Characteristics 356
Technical Issues 358
Vascular Access 358
Dialyzer Membranes 360
Dialysate and Replacement Solutions 361
Anticoagulation 361
Treatment Dosing 362
Factors That Impact Dialysis Dose 364
Fluid Management 365
Applications 366
Traditional and Special Indications for Treatment 368
Septic Acute Kidney Injury 369
Increased Intracranial Pressure 370
Heart Failure and Cardiorenal Syndrome 370
Correction of Severe Electrolyte Abnormalities 371
Hypo- and Hypernatremia 371
Hypo- and Hyperkalemia 372
Other Electrolytes 372
Correction of Acid–Base Abnormalities 372
Metabolic Acidosis 372
Metabolic Alkalosis 373
Respiratory Acidosis and Alkalosis 373
Removal of Poisons 373
Initiation of Treatment 375
Monitoring and Complications 376
Outcomes 378
Cost 379
Conclusion 379
Recommended Reading 379.e1
29 Anticoagulation for Continuous Renal Replacement Therapy 380
Selecting Anticoagulation Approaches for Continuous Renal Replacement Therapy 380
Specific Agents and Anticoagulation Techniques (Table 29.2) 381
Unfractionated Heparin 381
Citrate 381
Regional Unfractionated Heparin With Protamine Reversal 384
Low-Molecular-Weight Heparin 384
Thrombin Antagonists 384
Platelet-Inhibiting Agents 385
Conclusions 385
Recommended Reading 385.e1
30 Wearable and Implantable Renal Replacement Therapy 386
Limits of Conventional Hemodialysis 386
Solute Removal 387
Urea 387
Phosphorus 388
β2-Microglobulin 388
Salt and Water Removal 389
Wearable Systems 390
Peritoneal Dialysis 391
Hemodialysis 392
Fully Implantable Systems 393
Recellularization Approaches 393
Implantable Renal Assist Device 394
Implantable Filters 395
Bioreactor 395
Recommended Reading 396.e1
XI Peritoneal Dialysis: Clinical Practice 397
31 Determination of Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis Prescriptions 399
Rationale for Current Clearance Guidelines 399
Discrepancy Between Kt/V and Creatinine Clearance 400
Peritoneal Transport Characteristics 402
Other Uremic Toxins 403
Blood Pressure and Volume Control 404
Calculation of Prescribed Kt/V for Peritoneal Dialysis 404
Patient Preference for Continuous Ambulatory Peritoneal Dialysis Versus Automated Peritoneal Dialysis 406
Conclusion 407
Recommended Reading 407.e1
32 Peritoneal Dialysis Solutions 408
Electrolytes 409
Sodium 409
Potassium 409
Calcium 411
Magnesium 411
Osmotic Agents 412
Glucose 412
Icodextrin 413
Amino Acids 415
Glycerol 415
Fructose, Xylitol, and Sorbitol 415
Acid–Base Buffers 416
Nonbicarbonate Buffers 416
Bicarbonate–Lactate Combination Buffers 417
Bicarbonate Buffers 417
Recommended Reading 417.e1
33 Lymphatics, Peritoneal Fluid Losses, and Peritoneal Dialysis 418
Pathways of Fluid Absorption 418
Rate of Fluid Loss From the Peritoneal Cavity During Peritoneal Dialysis Exchanges 419
Clinical Implications 419
Summary 420
Recommended Reading 420.e1
XII Peritoneal Dialysis: Infectious Complications 421
34 Abnormalities of Host Defense Mechanisms During Peritoneal Dialysis 423
Host Defense Mechanisms of the Peritoneal Cavity 424
Is Opsonic Activity of Peritoneal Dialysate Important? 425
Phagocytosis and Intracellular Killing 426
Therapeutic Approaches 427
Immunization Strategies 427
Strategies to Enhance Cell Function 428
Peritoneal Membrane Resting 428
Peritoneal Dialysis Solution Biocompatibility 428
Summary 429
Recommended Reading 429.e1
35 Peritoneal Catheter Exit Site and Tunnel Infections 430
Definitions 430
Frequency 430
Causative Organisms 431
Risk Factors 431
Treatment and Outcomes 431
Prevention 432
Summary 434
Recommended Reading 434.e1
36 Peritonitis in Peritoneal Dialysis Patients 435
Peritonitis Rate in PD Patients 435
Risk Factors for Peritonitis 435
Pathogenesis and Causative Organisms 437
Diagnosis of Peritonitis in Peritoneal Dialysis Patients 438
Clinical Assessment 438
Collection of Peritoneal Dialysis Effluent for Cell Count and Culture 438
Management of Peritonitis 439
Antibiotic Administration 439
Adjunctive Treatment 440
Treatment of Specific Organisms 442
Gram-Positive Organism Cultured (Fig. 36.2) 442
Gram-Negative Organism Cultured (Fig. 36.3) 443
Culture-Negative Peritonitis 444
Polymicrobial Peritonitis 444
Tuberculous Peritonitis 444
Fungal Peritonitis 444
Indications for Catheter Removal 444
Relapsing, Recurrent, and Repeat Peritonitis 445
Special Considerations in Automated Peritoneal Dialysis 445
Predictors for Treatment Failure in Peritonitis 445
Impact of Peritonitis 446
Prevention of Peritonitis 446
Recommended Reading 447.e1
XIII Peritoneal Dialysis: Noninfectious Complications 449
37 Peritoneal Membrane Dysfunction 451
Solute Removal 451
Physiology of Solute Transport 451
Measurement of Dialysis Adequacy 452
Management of Underdialysis 453
Ultrafiltration Failure and Peritoneal Fibrosis 455
Clinical Significance of Ultrafiltration 455
Principles of Ultrafiltration 456
Causes of Ultrafiltration Failure 456
Impaired Ultrafiltration Caused by Fast (High) Solute Transport 456
Impaired Ultrafiltration Caused by Reduced Membrane Efficiency and Fibrosis 457
Other Factors Determining Ultrafiltration 458
Encapsulating Peritoneal Sclerosis 458
Pathologic Features 458
Clinical Features 459
Epidemiology of Encapsulating Peritoneal Sclerosis 459
Treatment of Encapsulating Peritoneal Sclerosis 460
Recommended Reading 460.e1
38 Abdominal Catastrophes, Peritoneal Eosinophilia, and Other Unusual Events in Peritoneal Dialysis 461
Abdominal Catastrophe 461
Pneumoperitoneum 463
Iatrogenic Complications of Gastrointestinal or Gynecologic Procedures 463
Pancreatitis 464
Peritoneal Eosinophilia 464
Hepatic Subcapsular Steatosis 465
Hemoperitoneum 465
Chyloperitoneum 467
Recommended Reading 467.e1
39 Metabolic Effects of Peritoneal Dialysis 468
Weight Gain 468
Metabolic Syndrome 469
New-Onset Diabetes Mellitus in Nondiabetic Patients 469
Hyperglycemia in Patients With Diabetes Mellitus 470
Lipid Abnormalities 471
Hypokalemia 471
Recommended Reading 472.e1
XIV Peritoneal Dialysis: Intra-Abdominal Pressure-Related Complications 473
40 Abdominal Hernias in Continuous Ambulatory Peritoneal Dialysis 475
Incidence and Prevalence 475
Types of Abdominal Wall Hernias 475
Risk Factors 476
Complications 477
Diagnosis and Management 477
Continuation of Continuous Ambulatory Peritoneal Dialysis After Hernioplasty 478
Prophylactic Measures 478
Recommended Reading 478.e1
41 Peritoneal Dialysate Leaks 479
Recommended Readings 482.e1
42 Hydrothorax and Peritoneal Dialysis 483
Introduction 483
Pathophysiology 483
Symptoms and Presentation 484
Diagnosis 484
Management 485
Recommended Readings 486.e1
XV Acid-Base Homeostasis 487
43 Acid–Base Homeostasis in Dialysis 489
Determinants of Serum [Total CO2] in Dialysis Patients 489
Hemodialysis 489
Peritoneal Dialysis 492
Normal Values 492
Diagnosis and Management of Acid–Base Disorders 493
The Patient With a Persistently Low Serum [Total CO2] Level 493
The Patient With a Persistently High Serum [Total CO2] Level 493
Identifying Superimposed Acid–Base Disorders 493
Rules for Identification of the Primary Disturbance in Dialysis Patients 494
Evaluation of the Secondary Response 495
Causes of Acid–Base Disorders 495
Metabolic Acidosis 495
Metabolic Alkalosis 496
Respiratory Acidosis 496
Respiratory Alkalosis 497
Mixed Acid–Base Disorders 497
Recommended Reading 497.e1
XVI Nutritional Management of Dialysis Patients 499
44 Nutritional Management of Hemodialysis Patients 501
Introduction 501
Screening and Assessment of Nutritional Status in MHD 501
Epidemiology of PEW in MHD Patients 503
Etiology and Prevention of PEW in MHD Patients 503
Dietary Nutrient Intake 503
Increased Catabolism Due to Renal Replacement Therapy 504
Chronic Inflammation 505
Metabolic Acidosis and Hormonal Derangements 506
Comorbidities in CKD 506
Treatment of PEW in MHD Patients 507
Oral and Enteral Nutritional Supplementation 507
Anabolic Hormones 509
Exercise 509
Emerging Therapies 509
Antiinflammatory Agents 509
Appetite Stimulants 510
Summary and Recommendations 510
Recommended Reading 510.e1
45 Intradialytic Parenteral Nutrition and Intraperitoneal Nutrition 511
Introduction 511
Intradialytic Parenteral Nutrition (IDPN) 511
Limitations of Clinical Trials of IDPN therapy 512
Nonrandomized Studies of IDPN 512
Randomized Prospective Controlled Trials of IDPN 519
Indications for Initiation of IDPN 521
Administration of IDPN 521
Monitoring of IDPN Therapy 521
Advantages and Disadvantages of IDPN 521
Intraperitoneal Nutrition 522
Recommended Reading 523.e1
46 Nutritional Management in Peritoneal Dialysis 524
Protein–Energy Wasting and Its Impact in Peritoneal Dialysis Patients 524
Risk Factors for PEW in PD 526
Protein Loss 527
Early Satiety/Fullness 528
Inflammatory States 528
Diagnosis of PEW in PD Patients 528
Serum Chemistry 528
Body Mass 530
Muscle Mass 530
Dietary Intake 530
nPNA (Also Known as nPCR) 530
Body Composition 531
Nutritional Assessment Scores 531
Management of Protein Energy Malnutrition in PD Patients 531
Daily Energy Intake Goal 531
Daily Protein Intake 531
Dialysis Prescription and Metabolic Acidosis 532
Intraperitoneal Nutrition 532
Appetite and Hormonal Stimulants 533
Oral Nutritional Supplementation 533
Impact of Nutritional Support on Outcome of PD Patients 533
Dietary Counseling 534
Conclusion 534
Recommended Reading 534.e1
XVII Gastrointestinal Disease 535
47 Liver Disease and Gastrointestinal Disorders in Dialysis Patients 537
Introduction 537
Hepatitis B 537
Interpretation of Diagnostic Tests 537
Natural History of HBV in the Dialysis Population 538
Epidemiology of Hepatitis B Virus in Dialysis Units 539
Strategies to Control HBV Transmission in Dialysis Units 539
Treatment of HBV-Related Liver Disease 540
Hepatitis B Vaccination 540
Hepatitis C 541
Interpretation of Diagnostic Tests 541
Natural History of HCV in Dialysis Population 541
Epidemiology of Hepatitis C Virus in Dialysis Units 542
Strategies to Control HCV Transmission in Dialysis Units 542
Therapy of HCV in the Dialysis Population 543
Nephrogenic Ascites and Other Gastrointestinal Disorders in the Dialysis Population 544
Conclusions 545
Recommended Reading 546.e1
XVIII The HIV-Infected Patient 547
48 Care of the HIV-Infected Dialysis Patient 549
Improved Survival of the HIV-Infected ESRD Patient 549
Hemodialysis and Vascular Access 550
Infection Control in Hemodialysis 550
Peritoneal Dialysis 551
Medical Management 551
Dialysis Care 551
Nutrition and Diet 552
Hepatitis C and Hepatitis B Coinfection 552
Transplantation 552
HIV Care 552
Antiretroviral Therapy (ART) 560
Recommended Reading 560.e1
XIX Anemia and Epoetin Use 561
49 Use of Erythropoiesis-Stimulating Agents in Hemodialysis Patients 563
Introduction 563
ESAs Available in the U.S. 563
Dosing and Administration Guidelines 564
Clinical Outcomes Associated With ESA Treatment in Hemodialysis Patients 567
Side Effects of ESA Therapy 567
ESA Hyporesponsiveness in Hemodialysis Patients 568
Biosimilars and Other Future ESAs 570
Summary 570
Recommended Reading 570.e1
50 Anemia in Patients With End-Stage Kidney Disease 571
Erythropoietin Deficiency 571
Iron Deficiency 572
Reduced Erythrocyte Survival 572
Inflammation 573
Infection 573
Hyperparathyroidism 573
Bleeding 574
Other Hematologic Disorders 574
Role of Red Blood Cell Transfusion in Management of Anemia of ESKD 574
Recommended Reading 575.e1
51 Iron Use in End-Stage Renal Disease 576
Epidemiology of Iron Deficiency in CKD 576
Pathophysiology 576
Systemic Iron Homeostasis 576
Pathophysiology of Iron Deficiency in Renal Anemia 580
Diagnosis of Iron Deficiency in CKD Patients 580
Emerging Markers of Iron Status 581
Iron Use in CKD Patients 581
Oral Iron Therapy in CKD 582
Intravenous Iron 584
Dialysate Iron Delivery 584
Future Directions for Iron-Restricted Erythropoiesis 584
Independent Benefits of Iron Unrelated to Correction of Anemia 585
Potential Long-Term Concerns of Harm With IV Iron Use 585
Recommended Reading 587.e1
52 Resistance to Erythropoiesis-Stimulating Agent (ESA) Treatment 588
Historical Background and Current Definitions 588
Disorders Inducing Resistance to Treatment 590
Iron and Other Cofactor Needs 591
Tools for Diagnosis 591
Differential Diagnosis 592
Functional Iron Deficiency 592
Treatment of Iron Deficiency 593
Identifying Clinical Problems in Iron Consumption and Bioavailability 594
Underlying Inflammatory Disease 595
Other Disorders Inducing Resistance to Treatment 596
Aluminum Intoxication 596
Secondary Hyperparathyroidism 596
Hematologic Disorders 597
Angiotensin-Converting Enzyme Inhibitors and Receptor Blockers 597
Carnitine Deficiency 597
Adequacy of Dialysis 598
Hemoglobin Cycling and Variability 598
Pure Red Cell Aplasia 599
Future Developments 599
Recommended Reading 600.e1
XX Cardiovascular Disease 601
53 The Challenges of Blood Pressure Control in Dialysis Patients 603
Challenges Defining Hypertension and in Establishing Goal Blood Pressure in Dialysis Patients 603
Challenges of Blood Pressure Measurements in Dialysis Patients 604
Importance of 24-Hour Blood Pressure Recording in Dialysis Patients 604
Pulse Pressure and Outcomes in Dialysis Patients 605
Blood Pressure Variability and Cardiovascular Outcome in Dialysis Patients 605
Pathogenesis of Hypertension in End-Stage Renal Disease Patients 606
Management of Hypertension in Dialysis Patients 606
Lifestyle Modifications 606
Control of Fluid and Volume Status With Dialysis 607
Dialysate Sodium Prescription and Blood Pressure Among Hemodialysis Patients 607
Therapy With Antihypertensive Drugs 608
Patient Demographics 608
Coexisting Disease 608
Effects of Dialysis on Antihypertensive Drugs in End-Stage Renal Disease Patients 613
Antihypertensive Drugs in End-Stage Renal Disease Patients 613
Inhibitors of the Renin–Angiotensin–Aldosterone System 613
Angiotensin-Converting Enzyme Inhibitors 613
Sulfhydryl Agents 613
Carboxyl Agents 613
Phosphoryl Agents 613
Side Effects of Angiotensin-Converting Enzyme Inhibitors 614
Angiotensin II Receptor Antagonists 614
Direct Renin Inhibitors 615
Side Effects 615
Mineralocorticoid Receptor Antagonists 615
Potential Beneficial Effect of Drugs That Inhibit the Renin–Angiotensin–Aldosterone System on Cardiovascular Diseases Independent of Blood Pressure 616
Anti-Adrenergic Drugs 616
β-Adrenergic Blocking Agents 616
Lipid Solubility 617
Cardioselectivity 617
Intrinsic Sympathomimetic Activity 617
Side Effects of Beta-Blockers 618
Centrally Acting Antiadrenergic Agents 618
α-Methyldopa 618
Clonidine 619
Guanabenz and Guanfacine 619
Rilmenidine and Moxonidine 620
Peripherally Acting α1-Adrenergic Receptor Blocking Agents 620
Prazosin 620
Terazosin 620
Doxazosin 620
Urapidil 621
Reserpine 621
Guanethidine 621
Guanadrel 621
Direct Vasodilators 621
Calcium Channel Antagonists 622
Sodium Nitroprusside 623
Nitrates 623
Diazoxide 623
Hydralazine 624
Minoxidil 624
Resistant Hypertension in Dialysis Patients 625
Effect of Frequent Hemodialysis on Blood Pressure Control in End-Stage Renal Disease Patients With Refractory Hypertension 625
Intradialytic Hypertension 625
Recommended Reading 626.e1
54 Management of Ischemic Heart Disease, Heart Failure, and Pericarditis in Hemodialysis Patients 627
Introduction 627
Ischemic Heart Disease 627
Clinical Presentation 627
Diagnosis 628
Cardiac Troponins 630
Noninvasive Stress Testing 630
Coronary Angiography 631
Medical Management 631
Aspirin 631
Antihypertensive Medications 631
Lipid-Lowering Medications 632
Bone and Mineral Metabolism 633
Anemia 634
Coronary Revascularization 634
Hemodialysis-Related Interventions 635
Lifestyle Modification 635
Heart Failure 635
Diagnosis 636
Management 636
Volume Control 636
Antihypertensive Medications 637
Digoxin 638
Uremic Pericarditis 638
Clinical Presentation and Diagnosis 638
Management 639
Recommended Reading 639.e1
55 Avoidance and Treatment of Cardiovascular Disease in Dialysis 640
Introduction 640
Presentation and Diagnostic Tests for Coronary Arterial Disease 640
Diagnostics 640
Cardiac Enzymes 641
Electrocardiography 641
Exercise Stress Testing 641
Isotope Stress Testing 641
Coronary Angiography 642
Treatment Challenges 642
Antiplatelet Therapy 642
Revascularization Therapy 643
Pharmacologic Management 643
Statins 643
Hypertension 643
Treatment Interactions 644
Peripheral Vasculature 645
Vascular Calcification 645
Inflammation and Oxidative Stress 645
Diagnostics 646
Pulse-Wave Velocity 646
Quantifying Vascular Calcification 646
Treatment Approach 647
Hypertension 647
Vascular Calcification 647
Oxidative Stress 647
Inflammation 648
Peripheral Arterial Disease 648
Diagnostics 648
Special Considerations 648
Other Critical Organ Systems Requiring Protection 649
The Gut 649
Vascular Brain Injury 649
Leukoaraiosis 650
Kidney and Residual Renal Function 650
Conclusion 651
Recommended Reading 651.e1
XXI Metabolic Abnormalities 653
56 Management of Dyslipidemia in Long-Term Dialysis Patients 655
Diet and Exercise 655
Lipid-Lowering Drugs 656
Other Lipid-Lowering Strategies 658
Summary 658
Recommended Reading 659.e1
57 Abnormalities of Thyroid Function in Chronic Dialysis Patients 660
Introduction 660
Prevalence of Hypothyroidism 660
Factors Contributing to Thyroid Functional Disease in Kidney Disease 662
Normal Thyroid Hormone Physiology 662
Thyroid Functional Disease Leading to Kidney Disease 662
Kidney Disease Leading to Thyroid Functional Disease 663
Effects of Dialysis on Thyroid Functional Tests 664
Thyroid Functional Test Alterations in Dialysis Patients 666
Low Triiodothyronine (Low T3 Syndrome) 666
Reverse Triiodothyronine 667
Low Thyroxine 667
Elevated Thyrotropin 667
Thyroid Functional Disease and Outcomes in Dialysis Patients 668
Low Triiodothyronine and Outcomes 668
Thyrotropin Elevation and Outcomes 669
Treatment Considerations 670
Exogenous T3 Replacement 671
Exogenous T4 Replacement 672
Recommended Reading 673.e1
58 Metabolic Abnormalities 674
Introduction 674
Sexual Dysfunction in Uremic Men 674
Evaluation of Sexual Dysfunction in the Uremic Man 675
Treatment of Sexual Dysfunction in the Uremic Man 677
Sexual Dysfunction in Uremic Women 679
Treatment of Sexual Dysfunction in Uremic Women 679
Recommended Readings 681.e1
XXII Uremic Osteodystrophy 683
59 Chronic Kidney Disease–Mineral and Bone Disorder 685
Pathophysiology of CKD-MBD 685
Review of PTH, Vitamin D, and Fibroblast Growth Factor-23 685
Development of Secondary Hyperparathyroidism in CKD 686
Epidemiology of Disordered Mineral Metabolism 687
Bone Disease 689
Bone Disease in CKD 689
Patients With CKD Have More Hip Fractures 690
Diagnosing Bone Disease 690
Vascular Calcification 691
Vascular Calcification and Cardiovascular Mortality 691
Diagnosing Vascular Calcification 693
Bone-Vascular Axis 693
Treatment 693
Treatment Targets 694
Dietary Phosphate 694
Medical Management 695
Optimal Dialysis Prescription 697
Conclusion 697
Recommended Reading 697.e1
60 Phosphate Management in Patients With End-Stage Renal Disease 698
Introduction 698
Phosphate Physiology 698
Phosphate Binder Therapy 699
Heavy Metal Compounds 700
Calcium-Based Compounds 700
Nonabsorbable Polymers 701
Magnesium-Based Binders 702
Iron-Based Therapy 702
Future Therapies 703
Dialytic Control of Hyperphosphatemia 703
Skeletal Health and Phosphate 704
Conclusion 704
Recommended Reading 705.e1
61 Use of Vitamin D Sterols and Calcimimetics in Patients With End-Stage Renal Disease 706
Role of Vitamin D Sterol Therapy 707
Role of Calcimimetic Therapy 708
Recommended Reading 708.e1
62 Parathyroidectomy 709
Indications for Parathyroidectomy (Table 62.1) 709
Preoperative Considerations 711
Preoperative Localization of Parathyroid Glands 711
Parathyroidectomy Options 712
Preoperative Medical Management 713
Operative Procedure 713
Postoperative Management 714
Other Postparathyroidectomy Complications 717
Recommended Readings 718.e1
XXIII Acquired Cystic Kidney Disease 719
63 Acquired Cystic Kidney Disease 721
Epidemiology 721
Pathophysiology 721
Clinical Course and Complications 722
Diagnosis and Screening 722
Treatment 724
Recommended Reading 724.e1
XXIV Diabetes 725
64 End-Stage Renal Failure in the Diabetic Patient 727
The Diabetic ESRD Population 727
Predialysis Care/Dialysis Initiation 727
Dysglycemia 728
Prediabetes 729
Assessing Glycemic Control in ESRD 729
Achieving Glycemic Control in ESRD 729
Diabetic Ketoacidosis/Hyperosmolar Coma 730
Hypoglycemia 731
Medications 731
Oral Hypoglycemic Agents 731
Insulin 734
Hemodialysis Access 734
Nutrition/Protein–Energy Wasting 735
Hypertension 736
Dialysis-Associated Hypotension 736
Cardiovascular Disease 737
Infection 737
Peripheral Arterial Disease/Foot Ulcers 738
Neuropathy 739
Gastroparesis 739
Ophthalmologic Complications 740
Home Hemodialysis 740
Peritoneal Dialysis 740
Kidney Transplantation 742
Outcomes 742
Quality of Life 743
Recommended Reading 744.e1
XXV Drug Use in Uremia 745
65 Principles of Drug Usage in Dialysis Patients 747
Pharmacologic Principles and Alterations in Uremia 747
Drug Administration 749
Renal Function Assessment 749
Effects of Dialysis on Drugs 752
Dosing Tables 753
Recommended Reading 805.e1
66 Medication Management 806
Medication-Related Problems in Dialysis Patients 807
Identifying and Resolving Medication-Related Problems in Dialysis Patients 809
Medication Reconciliation 809
Medication Review 811
Economic Impact 814
Conclusion 816
Recommended Reading 816.e1
XXVI Rehabilitation and Psychosocial Issues 817
67 Physical Activity, Function, and Exercise-Based Rehabilitation for Dialysis Patients 819
Definitions 819
Physical Activity and Function 820
Exercise Rehabilitation 820
Physical Function Assessment for People With Chronic Kidney Disease 821
Intradialytic Cycling: A Pragmatic Approach to Encourage Exercise Training 822
Patient Suitability for Starting an Exercise Program 824
Staffing 825
Equipment 825
Pragmatic Exercise Prescription 825
Goal Setting 826
Competence 826
Potential Barriers and Solutions to the Provision of Intradialytic Exercise Programs 827
Exercising on Nondialysis Days 827
The Way Forward: Translational Rehabilitation 828
Recommended Reading 828.e1
68 Physical, Psychosocial, and Vocational Rehabilitation of Adult Dialysis Patients 829
Background 829
Redefining Rehabilitation 830
Prerequisites to Effective Rehabilitation 833
Adequate Dialysis and Anemia Control 833
Comorbid Conditions and High-Risk Lifestyles 833
Family Participation 834
Implementing Renal Rehabilitation 834
Evaluation of Outcomes 835
Conclusions 836
Recommended Reading 836.e1
69 Ethical Considerations in the Care of Dialysis Patients 837
Who Should and Should Not Receive Dialysis? 837
On What Basis Should Decisions About Renal Replacement Therapy and Modality Be Made? 839
When Should a Time-Limited Trial of Dialysis Be Used? 840
When Should Stopping Dialysis Be Considered? 841
How Should a Nephrologist Respond to a Patient’s Request to Stop Dialysis? 841
How Should a Patient Who Stops Dialysis Be Treated? 842
Recommended Reading 843.e1
70 Psychosocial Issues in Dialysis Patients 844
Psychopathology 844
Depression 844
Treatment 845
Pharmacologic Treatment 845
Nonpharmacologic Treatment 845
Cognitive Behavioral Therapy 845
Exercise Therapy 845
Anxiety 846
Psychosocial Issues 846
Quality of Life 846
Social Support 846
Sleep Disorders 847
Insomnia 847
Restless Legs Syndrome and Periodic Limb Movement Disorder 848
Sleep Apnea 848
Hemodialysis Treatment Adherence 849
Types of Nonadherence 850
Fluid and Dietary Nonadherence 850
Medication Nonadherence 850
Dialysis Prescription Nonadherence 850
Factors Affecting Hemodialysis Nonadherence 851
Patient Characteristics and Nonadherence 851
Psychosocial Factors and Nonadherence 851
Social Support and Nonadherence 851
Health Beliefs and Nonadherence 851
Depression and Nonadherence 852
Illness and Treatment Perceptions and Nonadherence 852
Dialysis Environment and Nonadherence 852
Patient–Physician Dyad and Nonadherence 852
Health Literacy and Nonadherence 852
Hemodialysis-Specific Knowledge and Nonadherence 853
Addressing Hemodialysis Nonadherence 853
Conclusion 854
Recommended Reading 854.e1
71 The Care of Elderly Dialysis and End-Stage Renal Disease Patients 855
Cognitive Impairment and Dementia 855
Executive Dysfunction 855
Screening 856
Management 856
Behavioral and Psychological Symptoms of Dementia 857
Depression 857
Presentation 857
Screening 857
Management 858
Instability and Falls 858
Screening 859
Dialysis-Related Risk Factors 859
Postural Hypotension 859
Vitamin D Supplementation 859
Biochemical Abnormalities 859
Environmental Risks Within the Dialysis Unit 860
Polypharmacy 860
Visual Impairment 860
Multifactorial Management 860
Patients With Cognitive Impairment 860
Immobility and Rehabilitation 860
Geriatric Rehabilitation 861
Exercise Training 861
Polypharmacy and Safe Prescribing 861
Advance Care Planning 862
Prognostic Tools 863
Substitute Decision Makers 863
Nondialytic Management 863
Conclusion 864
Recommended Reading 864.e1
XXVII Pediatric Dialysis 865
72 Vascular Access in Children 867
Arteriovenous Fistulas 867
Preparation 868
Location 868
Preoperative Planning 869
Surgical Considerations 869
Postoperative Care and Maturation 870
Cannulation 870
Complications 870
Long-Term Care and Monitoring of Arteriovenous Fistulas 871
Arteriovenous Graft 871
Comparison With Arteriovenous Fistula 873
Composition 873
Complications 873
Central Venous Catheters 874
Characteristics 874
Location and Placement 874
Infants and Small Children 875
Long-Term Care 875
Complications 876
Recommended Reading 876.e1
73 Infant Hemodialysis 877
Vascular Access 877
Equipment/Preparation 878
Dialysis Prescription for the Infant: Special Considerations 879
Chronic Hemodialysis 881
Recommended Reading 881.e1
74 Urea Kinetic Modeling for Hemodialysis Prescription in Children 882
Chronic Hemodialysis in Children 882
The Dialysis Prescription in Children 883
Principles of Urea Kinetic Modeling in Children 884
Data Collection 885
Common Errors in Calculations 885
Application of Urea Kinetic Modeling 886
National Kidney Foundation Kidney Disease Outcomes Quality Initiative Pediatric Recommendations for Dialysis Adequacy 887
Recommended Reading 888.e1
75 Hemodiafiltration in Children 889
Dialysis: Diffusion, Convection, and Combination Therapy 889
Optimizing the Determined Convective Volume: Pre-, Post-, or Mixed-Dilution Hemodiafiltration 892
Internal Hemodiafiltration Versus Online Hemodiafiltration 893
Safety and Quality Control in Hemodiafiltration 894
The Impact of Hemodiafiltration on Solute Removal 895
Requirements for Hemodiafiltration in Children 896
Writing a Hemodiafiltration Prescription for Children 896
Advantages of Hemodiafiltration Over Conventional Hemodialysis: Pediatric Studies 897
Conclusions 898
Recommended Readings 898.e1
76 Home Hemodialysis in Children 899
What Is the Optimal Dialysis Dose? 899
Adult Home Hemodialysis Experience 899
Pediatric Home Hemodialysis Experience 900
Infrastructure 900
Finances 901
Staffing and Around-the-Clock Support 901
Training and Education 901
Dialysis Equipment 902
Dialysis Systems Requiring Home Water Conversions 902
Mobile Hemodialysis System: NxStage 902
Patient Selection 903
Prescriptions 904
Dialysis Adequacy 905
Conclusion 905
Recommended Reading 905.e1
77 Anticoagulation in Children Undergoing Hemodialysis 906
General Considerations 906
Unfractionated Heparin 907
Low-Molecular-Weight Heparins 908
Systemic Anticoagulants as Alternatives to Heparins 909
Regional Anticoagulation With Citrate 910
Other Regional Anticoagulants 913
Central Venous Line Locks and Treatment of Clotted Catheters 913
Recommended Reading 913.e1
78 Peritoneal Dialysis Catheter Placement in Children 914
Types of Peritoneal Catheters 914
Preoperative Surgical Considerations 916
Omentectomy and Fibrin Sealants 917
Surgical Techniques 917
Open Technique 918
Laparoscopic Technique 919
Postimplantation Care 920
Timing of Catheter Use 920
Mechanical Complications 921
Exit-Site Infection, Tunnel Infection, and Peritonitis 922
Complications With Peritoneal Dialysis Catheter Removal 922
Recommended Reading 923.e1
79 Prescribing Peritoneal Dialysis in Children 924
Initiation of Dialysis in Children 924
Factors to Consider in Modality Choice in Children 925
Prescription Components 927
Prevalence of Peritoneal Dialysis Use in Children 929
Recommended Reading 930.e1
80 Nutritional Management of Children Undergoing Peritoneal Dialysis 931
Assessment of Growth and Nutritional Status 931
Growth Parameters 931
Dietary Intake 932
Physical Examination 933
Adequacy of Dialysis 933
Dietary Prescription 933
Energy 933
Lipids 935
Fiber 935
Protein 935
Calcium and Vitamin D 936
Phosphate 936
Micronutrients: Vitamins and Trace Elements 937
Fluids and Electrolytes 938
Fluid 938
Sodium 938
Potassium 938
Carnitine 939
Delivery of Nutrition 939
Use of Recombinant Human Growth Hormone Therapy 939
Summary 940
Recommended Reading 940.e1
81 Peritoneal Dialysis in Neonates and Infants 941
Introduction 941
Peritoneal Dialysis as a Renal Replacement Modality for AKI 941
Peritoneal Dialysis Access in AKI 942
Prescription Considerations for AKI 942
The Chronic Setting: ESRD 943
Peritoneal Dialysis as a Renal Replacement Modality for ESRD 943
Peritoneal Dialysis Access for ESRD 944
Prescription Considerations in ESRD 945
Outcome in ESRD 947
Conclusion 947
Recommended Reading 947.e1
82 Dialysis in Inborn Errors of Metabolism 948
Techniques of Metabolite Removal 949
Extracorporeal Blood Purification 950
Dialysis Equipment 950
Catheter 950
Dialyzer 950
Dialysis Device and Tubing 950
Anticoagulation 951
Management Guidelines 953
Peritoneal Dialysis 954
Catheter 954
Dialysis Prescription 954
Recommended Reading 954.e1
83 Neurocognitive Functioning in Children Undergoing Dialysis 955
Cognitive Function in Pediatric Chronic Kidney Disease 955
Dialysis and Its Effects on Neurocognition 956
Types of Dialysis and Their Impact on Cognition 956
Findings in Infants and Toddlers 962
Findings in Older Children and Adolescents 962
Summary and Conclusions 963
Recommended Reading 964.e1
84 Growth in Children With End-Stage Renal Disease 965
Introduction 965
Growth Patterns 967
Assessment of Growth 969
Growth Failure in CKD 969
Underlying Renal Disease 969
Protein–Energy Malnutrition 970
Metabolic Acidosis 970
CKD–Mineral Bone Disorder 971
Anemia 971
Endocrine Dysfunction 971
Treatment 973
General Measures 973
Dialysis and Intensified Dialysis 974
Transplant 974
Growth Hormone Therapy 974
Summary 978
Recommended Reading 978.e1
85 Adequacy of Peritoneal Dialysis/Assessing Peritoneal Function in Pediatric Patients 979
Adequate versus Optimal Dose of Dialysis 979
Prescription of Peritoneal Dialysis 980
Choice of Peritoneal Dialysis Modality 980
Initial Dialysis Prescription 980
Peritoneal Equilibration Test 981
Personal Dialysis Capacity Test 982
Mass Transfer Area Coefficient (MTAC) 982
Measurement of Peritoneal Dialysis Dose 983
Adequacy Recommendations 988
Solute Clearance 988
Maintenance of Euvolemia 989
Timing and Frequency of Solute Clearance and Ultrafiltration Measurement 989
Adjusting the Dialysis Prescription by Computer Modeling 990
Summary 990
Recommended Reading 992.e1
86 Continuous Renal Replacement Therapy in Pediatric Patients 993
Introduction 993
Indication and Timing of Initiation 994
Mechanism of Clearance and Options for Therapy 996
Access 999
Prescription 1001
Solutions 1002
Anticoagulation 1003
Membrane and Filter 1006
Nutrition 1006
Inborn Errors of Metabolism 1007
Extracorporeal Membrane Oxygenation 1007
Intoxications 1007
Conclusion 1008
Recommended Reading 1008.e1
87 Prevention and Treatment of Bone Disease in Pediatric Dialysis Patients 1009
Pathogenesis of Abnormal Mineral Metabolism in CKD 1009
Role of Fibroblast Growth Factor 23 1009
Role of 1,25(OH)2D 1009
Role of 25(OH)D 1010
Role of Phosphorus 1010
Alterations in the Parathyroid Gland Calcium Sensing Receptor Expression 1010
Role of Skeletal Resistance to Parathyroid Hormone 1011
Renal Osteodystrophy 1012
Abnormalities in Bone Turnover, Mineralization, and Volume 1012
Turnover 1012
Mineralization 1013
Volume 1014
Cardiovascular Disease 1014
Clinical Signs and Symptoms 1015
Growth Retardation 1015
Skeletal Deformities and Pain 1015
Myopathy 1016
Prevention and Treatment of CKD-MBD 1016
Dietary Manipulation of Calcium and Phosphorus 1016
Phosphate-Binding Agents 1017
Vitamin D Therapy 1019
Assessment and Treatment of 25(OH)D Deficiency 1019
Treatment With Active Vitamin D Sterols 1020
Calcimimetics 1020
Parathyroidectomy 1021
Growth Hormone Therapy 1021
Summary 1022
Recommended Reading 1022.e1
88 Management of Anemia in Children Undergoing Dialysis 1023
Introduction 1023
Definition of Anemia 1023
Prevalence of Anemia in Chronic Kidney Disease 1024
The Effects of Anemia 1024
Testing for Anemia 1025
Testing for Iron Deficiency 1025
Vitamin and Mineral Deficiency 1027
Erythrocyte-Stimulating Agents 1027
Lack of Response to ESA 1029
Risk of Adverse Outcomes 1029
Iron Therapy 1029
Oral Iron Supplementation 1029
Intravenous Iron Supplementation 1030
Intradialytic Iron Supplementation 1032
Iron Safety 1032
Recommended Reading 1033.e1
89 Assessing Quality of Life in Pediatric Patients Undergoing Dialysis 1034
Introduction 1034
Factors Impacting HRQOL Functioning 1034
Evolution of HRQOL Assessment 1035
Best Practice Considerations and Caveats 1036
Broadening the Scope to Include Intervention Planning 1037
Future Directions 1038
Recommended Reading 1038.e1
90 Immunization in Children Undergoing Dialysis 1039
Vaccine Schedule: Current American Academy of Pediatrics Recommendations 1039
Summary of Recommendations From 2015 Red Book for Children With End Stage Kidney Disease, Including Transplant Candidates 1039
Hepatitis B 1040
Influenza Vaccine 1040
Pneumococcal Vaccine 1041
Special Situations 1041
Household Vaccination 1042
Live Organ Donor Vaccination 1042
Preparing for Transplantation in the Dialysis Patient 1042
Live Vaccines 1042
Varicella Vaccine 1042
Measles, Mumps, Rubella Vaccine 1042
Rotavirus 1043
Recombinant and Inactivated (“Killed”) Vaccines 1043
DTap, Tdap, and dT Vaccines 1043
Poliovirus Vaccine 1043
Haemophilus influenzae Type B Vaccine 1043
Pneumococcus Vaccine 1043
Hepatitis A Vaccine 1044
Hepatitis B Vaccine 1044
Influenza Vaccine 1044
Meningococcal Vaccine 1044
Human Papillomavirus 1045
Updating Immunizations for Dialysis Patients Awaiting Transplant 1045
Vaccine Response in the Dialysis Population: What Is the Evidence? 1045
Summary 1046
Recommended Reading 1047.e1
91 Prevention and Treatment of Cardiovascular Complications in Children Undergoing Dialysis 1048
Cardiovascular Mortality in Children on Maintenance Dialysis 1048
Development of Cardiovascular Disease in Children With Chronic Kidney Disease 1049
Evaluation and Treatment Recommendations 1050
Echocardiographic Evaluation 1050
Hypertension 1050
Dyslipidemia 1051
Abnormal Calcium–Phosphorus Metabolism 1052
Anemia 1053
Malnutrition and Inflammation 1053
Dialysis Adequacy 1054
Recommended Readings 1054.e1
92 Surgery in Children With End-Stage Renal Disease 1055
Preoperative Surgical Evaluation 1055
Perioperative Management 1057
Fluid Therapy 1057
Electrolyte Management 1058
Hypertension 1059
Infectious Complications 1060
Bleeding Complications 1060
Anemia 1060
Pain Control 1061
Surgical Considerations 1061
Summary 1063
Recommended Reading 1063.e1
93 Infectious Complications in Children Undergoing Dialysis 1064
Peritoneal Dialysis 1064
Epidemiology 1064
Microbiology 1064
Preventive Strategies 1066
Diagnosis of Peritonitis 1067
Management of Peritonitis 1067
Adjunctive Therapies 1071
Refractory and Relapsing Peritonitis 1072
Catheter-Related Infections 1072
Postperitonitis 1073
Hemodialysis 1073
Epidemiology and Risk Factors 1073
Preventive Measures 1073
Treatment of Infection 1074
Future Steps 1075
Recommended Reading 1075.e1
94 Adherence and Transition in the Pediatric Dialysis Patient 1076
Overview of Adherence 1076
Evaluating Nonadherence 1076
Variables Associated With Nonadherence 1077
Addressing Adherence 1078
Overview of Transition 1079
Transitional Procedures for Pediatric Dialysis Patients 1080
Evidence-Based Strategies for Transfer 1080
Functional Outcomes 1082
Conclusions 1082
Recommended Reading 1082.e1
XXVIII The Pregnant Patient 1083
95 Pregnancy in Dialysis Patients 1085
Frequency of Pregnancy in Dialysis Patients 1085
Contraception 1086
Diagnosis of Pregnancy in Dialysis Patients 1087
Outcome of Pregnancy in Dialysis Patients 1087
Maternal Complications 1088
Hypertension 1088
Drug Therapy 1088
Anemia 1089
Peritonitis 1089
Dialysis Regimen 1089
Dialysis Modality 1089
Hemodialysis 1090
Peritoneal Dialysis 1090
Diet 1091
Obstetric Considerations 1091
Premature Labor 1091
Conclusions 1092
Recommended Reading 1092.e1
XXIX Miscellaneous Areas of Clinical Importance 1093
96 Treatment of Poisoning With Extracorporeal Methods 1095
General Overview of the Treatment of the Poisoned Patient 1095
Background 1095
Initial Treatment 1095
Risk Assessment 1096
Decontamination 1096
Antidotes 1096
Enhanced Elimination 1096
Characteristics of a Potentially Dialyzable Toxin 1097
Physicochemical 1097
Pharmacokinetics 1097
Choice of Extracorporeal Treatment 1098
Hemodialysis 1098
Hemoperfusion 1098
Hemofiltration 1100
Continuous Renal Replacement Therapy 1100
Peritoneal Dialysis 1101
Therapeutic Plasma Exchange 1101
Exchange Transfusion 1101
Liver Support Devices (Albumin Dialysis) 1101
Technical Considerations 1102
General Principles Regarding the Use of Extracorporeal Treatment in the Treatment of Poisoning 1102
Specific Indications for Poisons That Are Currently Considered Dialyzable 1104
Recommending Reading 1106.e1
97 Preventive Care in End-Stage Renal Disease 1107
Immunizations 1107
Hepatitis B Vaccine 1107
Influenza and H1N1 Vaccine 1108
Tetanus, Pneumococcal, Human Papillomavirus, and Varicella Zoster Vaccines 1108
Infection Prevention 1109
Diabetic Foot Care 1109
Dental Care 1109
Endocarditis Prophylaxis 1109
Tuberculosis Screening 1110
Screening 1110
Cancer Screening 1110
Falls and Frailty 1112
Falls 1112
Osteoporosis and Bone Mineral Density 1113
Frailty 1113
Abdominal Aortic Aneurysm 1113
Alcohol Abuse 1113
Cognitive Impairment 1113
Depression 1114
Vision 1115
Hearing 1115
Health Care Counseling 1115
Exercise 1115
Obesity and Weight Loss 1116
Tobacco Use and Cessation 1116
Contraception and Sexual Dysfunction 1116
Advance Care Planning and Palliative or Supportive Care 1116
Advance Care Planning 1116
Supportive (Palliative) Kidney Care 1117
Monitoring: Lipids, Glucose, Anemia, and Bone and Mineral Disorders 1118
Recommended Readings 1118.e1
98 Application of Telemedicine to Patients With End-Stage Renal Disease 1119
Telemedicine in End-Stage Renal Disease: Overview of the Opportunity and Issues 1119
The Health Care System in the United States Presents Particular Challenges 1120
A Framework for Implementation of a Teledialysis Program 1120
Routine Nonemergent Nephrologist Rounding Use Case 1121
Emergent Use Case 1122
Home and Peritoneal Dialysis: Remote Monitoring Use Case 1123
Other Miscellaneous Use Cases 1123
Integrated Kidney Care (Global Capitation) Use Case 1123
Teledialysis Technology Requirements 1124
Bandwidth, Resolution, and Frame Rate Requirements: 1124
Information Technology Security Requirements 1124
Hardware and Video Requirements 1125
Hardware and Functionality 1125
Video 1125
Other 1125
Index 1129
A 1129
B 1132
C 1134
D 1140
E 1144
F 1147
G 1147
H 1148
I 1151
J 1153
K 1153
L 1154
M 1155
N 1157
O 1158
P 1159
Q 1163
R 1163
S 1165
T 1167
U 1169
V 1170
W 1171
X 1171
Y 1171
Z 1171
Inside Back Cover ibc1