ABSTRACT
Descripción del caso: Paciente con enfermedad renal crónica terminal en tratamiento de hemodiálisis desde hace 1 año. Acude a sesión de hemodiálisis refiriendo lesiones cutáneas muy dolorosas con aspecto necrótico de 2 semanas de evolu-ción en extremidades inferiores distales sugestivas de calcifi-laxis. Dados los antecedentes clínicos de fibrilación auricular paroxística, anticoagulada con acenocumarol y los factores de riesgo que presenta, se inician medidas inmediatas dado el mal pronóstico de dicha enfermedad. Descripción/evaluación del plan de cuidados: Se suspende tratamiento con acenocumarol iniciando anticoagulación con heparina de bajo peso molecular, también se suspenden los suplementos de vitamina D. Se inicia administración de bifos-fonatos como inhibidores del calcio, de tiosulfato de sodio como vasodilatador y quelante del fósforo. Se instaura pauta de analgesia siendo uno de los objetivos más importantes del plan de cuidados, el control del dolor, con la administración de opiáceos, antiinflamatorios no esteroideos o mórficos. Aunque fue de difícil manejo, el papel de enfermería ha sido fundamental para procurar el máximo confort. También fue muy importante la vigilancia y el cuidado de las lesiones para prevenir infecciones y controlar la enfermedad observándose una adversa y rápida evolución a pesar de las terapias coad-yuvantes, puesto que cuando se diagnosticó ya presentaba lesiones necróticas. Conclusiones: La calcifilaxis es una complicación poco fre-cuente pero grave que suele observarse en pacientes con enfermedad renal crónica, sobre todo en hemodiálisis. Eltratamiento es multidisciplinar y es importante identificar precozmente a estos pacientes. Desgraciadamente, como en nuestro caso, los resultados no son siempre favorables.(AU)
Case description: Patient with end-stage renal disease undergoing hemodialysis treatment for 1 year. The patient presents to the hemodialysis session with extremely painful necrotic-looking skin lesions on the distal lower extremities, suggestive of calciphylaxis, which have been present for 2 weeks. Given the patients medical history of paroxysmal atrial fibrillation and anticoagulation with acenocoumarol, along with the risk factors present, immediate measures are initiated due to the poor prognosis of this condition. Description/evaluation of the care plan: Acenocoumarol treatment is discontinued, and anticoagulation with low molecular weight heparin is initiated. Vitamin D supplements are also discontinued. Bisphosphonates are started as calcium inhibitors, sodium thiosulfate is administered as a vasodilator, and phosphate binder. An analgesic regimen is established, with pain control being one of the most important goals of he care plan. This includes the administration of opioids, nonsteroidal anti-inflammatory drugs, or morphine. Although challenging, the nursing role has been crucial in providing maximum comfort. Close monitoring and wound care are also important to prevent infections and control the disease, although an adverse and rapid progression was observed despite the adjunctive therapies, as necrotic lesions were already present at the time of diagnosis. Conclusions: Calciphylaxis is a rare but serious complication often observed in patients with chronic kidney disease, especially in those undergoing hemodialysis. Treatment is multidisciplinary, and early identification of these patients is important. Unfortunately, as in our case, the outcomes are not always favorable.(AU)
Subject(s)
Humans , Female , Aged , Renal Dialysis , Renal Insufficiency, Chronic/complications , Renal Insufficiency, Chronic/drug therapy , Renal Insufficiency, Chronic/mortality , Calciphylaxis , Nursing Care , Patient Care Planning , Nephrology , Kidney Diseases , Inpatients , Physical ExaminationABSTRACT
BACKGROUND: Kt/V is an important index of adequacy of dialysis in patients undergoing hemodialysis (HD). However, it is difficult to prolong dialysis time in practice because of its economic impact and poor patient compliance. This study was performed to investigate the effect of increasing dialysis needle size on dialysis adequacy in HD patients. METHODS: This study enrolled 70 patients who received HD thrice weekly for more than 3 months using arteriovenous fistula or graft. The patients were divided into three groups according to the blood flow rate (200, 250, 300 mL/min). We first performed HD using 16 gauge needle. And then we increased needle size up to 15 gauge without change of any other dialysis conditions such as blood and dialysate flow rates, dialysis time, distance between needle insertion sites. RESULTS: Mean Kt/V at HD method using 15 gauge needle was increased, compared with HD method using 16 gauge needle (1.31+/-0.18 vs. 1.23+/-0.18, p<0.001). When comparing Kt/V according to the blood flow rate, increasing needle size from 16 gauge to 15 gauge significantly increased Kt/V at 250 mL/min and 300 mL/min. But there was no difference in Kt/V at 200 mL/min of blood flow rate. VDP at HD method using 15 gauge needle was decreased, compared with HD method using 16 gauge needle (88+/-23 mmHg vs. 118+/-28 mmHg, p<0.001). CONCLUSION: This study suggests that increasing dialysis needle size is safe and effective method in improving dialysis adequacy without increasing blood flow rate or dialysis time.
Subject(s)
Humans , Arteriovenous Fistula , Dialysis , Needles , Patient Compliance , Renal Dialysis , TransplantsABSTRACT
When the middle molecule (MM) hypothesis was formulated in 1975, no MM had yet been identified as a uremic toxin. Meanwhile, the birth and implementation of the Kt/Vurea concept gained wide acceptance and has remained the world standard for assessing dialysis adequacy. However, over the past 20 years, accumulating evidence has made it clear that MM's are important uremic toxins, and that the dose of dialysis based on removal of small molecular substances does not protect against excessive hemodialysis mortality, morbidity, or the presence of uremic signs and symptoms. These poor results are, in one way or another, linked to the accumulation of MM's and other substances behaving like MM's, such as phosphate. Dialysis schedules yielding the best clinical results, such as longer dialysis and more frequent dialysis, favor increased removal of middle molecular substances. The observation that short daily dialysis is giving results similar to long nocturnal quotidian dialysis supports early observations that the volume from which middle molecular substances are extracted mainly by hemodialysis is small (about as large as the extracellular volume), and that transfer of MM's from cells to extracellular fluid is very slow. This behavior of MM's is markedly different from that of small molecular substances, which are more rapidly transferred from intracellular to extracellular compartments and are more readily extracted from total body water during hemodialysis. In order to achieve even minimum adequate dialysis, it is now scientifically validated that toxic MM's must be removed in larger amounts than currently attained. This can only be accomplished by long dialysis sessions with a 3-times per week schedule or more frequent dialyses. Five hours 3 times per week represents the absolute minimum treatment. Dialy sis 6 to 7 times per week is the ideal schedule for patients who are willing to commit the time and effort in exchange for maximum well-being and long survival.
ABSTRACT
10 years) groups.The form and function of ventricle were measured.And the blood pressure,hemoglobin,plasma albumin,pre-albumin,lipid,C responsive protein,calcium,phosphate and parathyroid hormone before dialysis were determined.Results The cardiac output(CO) of 1～2 years group was the highest.The left ventricular end-systolic and end-diastolic dimension(LVEDd/s)and left ventricular mass index(LVMI)of ≤1 year group were the lowest.With the increase of the dialysis ages,the blood pressure and the proportion of diabetes patients and those with LVH decreased,but the hemoglobin,plasma albumin,pre-albumin,calcium,phosphate and parathyroid hormone increased,while the CRP decreased.Conclusion With the increase of the dialysis ages,the left ventricular function of the uremic hemodialysis patients improves,which is probably associated with the improvement of anemia,malnutrition and inflammation.
ABSTRACT
When compared to intermittent dialysis, the theoretical advantages of continuous dialysis may be less important than its practical disadvantage: the inability to accurately quantify dialysis. With intermittent dialysis the change in blood urea nitrogen over the course of the treatment allows the ratio of K (urea clearance) to V (volume of distribution of urea or total body water) to be determined, hence an accurate Kt/V. In continuous dialysis this approach cannot be used due to the steady-state nature of blood urea levels. Instead, V is estimated, generally from the Watson equations. This estimate has sufficient inaccuracy to result in substantial unrecognized underdialysis in many patients.
