What is Hyperkalemia?

Hyperkalemia

Author: Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine
Coauthor(s): Rosemary Ouseph, MD, Professor of Medicine, Director of Kidney Transplant, University of Louisville School of Medicine; Vibha Nayak, MD, Assistant Professor of Nephrology, Director of Home Dialysis, Kidney Disease Program, University of Louisville; Son Dinh, MD, Nephrologist, Southland Renal Medical Group, Inc
Contributor Information and Disclosures

eMedicine from WenMD: Mar 19, 2010

Introduction

Background

Potassium homeostasis
Hyperkalemia is defined as a condition in which serum potassium greater than 5.3 mEq/L.

Potassium, the most abundant intracellular cation, is essential for the life of the organism. Potassium is obtained through the diet. Common potassium-rich foods include meats, beans, fruits, and potatoes. Gastrointestinal absorption is complete, resulting in daily excess intake of about 1 mEq/kg/d (60-100 mEq). This excess is excreted through the kidneys (90%) and the gut (10%). Potassium homeostasis is maintained predominantly through the regulation of renal excretion. The most important site of regulation is the distal nephron, including the distal convoluted tubule, the connecting tubule, and the cortical collecting tubule, where aldosterone receptors are present.

The regulation of potassium excretion at the cortical collecting tubule has been extensively studied. Sodium reabsorption through epithelial sodium channels (ENaC) located on the apical membrane of cortical collecting tubule cells, is driven by aldosterone and generates a tubular lumen negative electrical potential, driving the secretion of potassium at this site through specific potassium channels called the renal outer medullary K channels (ROMK). Studies have demonstrated, however that aldosterone also regulates sodium transport in the thick ascending limb of the loop of Henle, the distal convoluted tubule, and the connecting tubule.

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What is CRRT?

CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)

Dr. Manish Chaturvedi Nephrologist, Dr. S. N. Medical College, Jodhpur

The Indian Anaesthetists’ Forum – (www.theiaforum.org) Online ISSN 0973-0311 October 2004

It is a mode of renal replacement therapy for hemodynamically unstable, fluid overloaded, catabolic septic patients and finds its application in management of acute renal failure especially in the critical care /intensive care unit setting. The popularity of ‘slow continuous therapies’ for the treatment of critically ill patients with renal failure is increasing. The techniques most commonly used are slow continuous hemodialysis and hemodiafiltration. Slow continuous hemofiltration and slow continuous ultrafiltration also are commonly used.

ARF in the ICU setting is frequent especially secondary to multiple organ dysfunction syndrome; post surgical setting i.e after abdominal surgery; post interventional studies eg. PTCA, PTRA studies in already susceptible individuals. These patients having various co-morbid conditions are on mechanical ventilation and various life supporting modalities which do not merit the dialysis procedure to be carried out in the routine dialysis set up.

Being catabolic, they require continuous clearance of waste produced due to ongoing illnesses and an adequate potential for infusion of nutritional and inotropic agents for sustenance of vital parameters which is continuously desired in the management. CRRT has tried to meet these challenges in the ICU settings since its inception and has saved many lives across the globe including critically ill paediatric or geriatric population with renal failure as a co-existent co-morbid illness.

The outcome of therapy depends on clearance of waste products achieved with restoration of blood biochemistry; maintenance of fluid, electrolyte and acid base balance; ability to maintain hemodynamic stability during the procedure with minimum side effects during the procedure.

GOALS OF CRRT THERAPY

The aggressive management in initial hours to counter the derangements in critically ill patients is the cornerstone in the therapy. CRRT initiated for ARF in critically ill patients should serve as a renal ‘replacement’ therapy mimicking as artificial kidney support. It should enhance recovery of the native kidneys with prevention of hyperkalemia, hyper/hyponatremia, acidosis/alkalosis and rapid correction of pulmonary/peripheral edema by gradual and consistent removal of surplus fluid retained in the body. It should also diffuse the various ongoing smoldering proinflammatory mediators especially in multiple organ dysfunction syndromes.

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Vascular Access for Haemodialysis

Final Draft Version (26 October 2010) Posted on www.renal.org

Authors of this guideline were:

Dr Richard Fluck at Derby Hospitals NHS Foundation Trust and Dr Mick Kumwenda at Betsi Cadwaladr University Health

Introduction

Vascular access remains a key component of haemodialysis. The ideal vascular access should provide safe and effective therapy by enabling the removal and return of blood via an extracorporeal circuit. Vascular access should be easy to use, reliable and have minimal risk to the individual receiving haemodialysis. However, the provision of good quality access, whilst it is a fundamental aspect of the treatment of haemodialysis patients, remains difficult to achieve.

Native access, in particular arteriovenous fistulae, requires prior planning yet has a high primary failure rate. Arteriovenous grafts utilizing replacement of synthetic or biological material in conjunction with native vessels again require planning and surgical expertise yet have a high demand to maintain them and a high rate of complications. Venous catheters (both tunnelled and non-tunnelled) are in common usage both as temporary access and in a smaller number of patients as the only form of access that is available, yet offer inferior therapy. Vascular access via central venous catheters provides poorer solute clearance related to the limited achieved blood flow and also a higher rate of complications.

This guideline updates the section on vascular access in the haemodialysis module of the 4th edition of the RA guidelines published on-line at www.renal.org in 2007. These guideline recommendations are based on a literature review from relevant publications in journals cited on MEDLINE, PubMed and UpToDate up to 1^st May 2010. The modified GRADE system has been adopted by the Renal Association Clinical Practice Guidelines Committee and has been used to grade the recommendations in all of the modules in the 5^th edition of the Renal Association guidelines. It explicitly describes both the strength of the recommendations and the quality of the underlying evidence, with the aim of maximising applicability to standard clinical practice (1-4). The modified GRADE system grades level of expert recommendation as “strong” (Grade 1) or “weak” (Grade 2) according to balance of benefits, risk, burden and cost. The quality or level of evidence is assessed as “high” (Grade A), “moderate” (Grade B), “low” (Grade C) or “very low” (D) depending on factors such as study design, directness of evidence and consistency of results (1-4).

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To All Muslim Brothers & Sisters

"Selamat Hari Raya AidilAdha"

"Sacrifice is a token of Love & Devotion"

Best Wishes & Warmest Regards

from

MalaysianKidneySPA

Portable and wearable dialysis

Portable and wearable dialysis: where are we now?

Andrew DAVENPORT¹, Claudio RONCO², Victor GURA³

Hemodialysis International, 14: S22–S26. doi: 10.1111/j.1542-4758.2010.00486.x

Abstract

Although dialysis is a life-saving treatment for patients with acute and chronic kidney disease, mortality remains high, with the survival of patients treated by regular hemodialysis similar to that of some solid organ tumors. Recent reports have suggested that a major increase in the dose of dialysis, delivered by frequent nocturnal dialysis, may improve survival. Unfortunately, only a minority of centers can offer this type of therapy, and only to a minority of their patients. Thus, to improve access to dialysis as well as increase the delivered dose of dialysis, a major change in the current paradigm of dialysis delivery is required. For many years, the “holy grail” of dialysis has been to develop a wearable or portable system, allowing patients to be treated while performing their normal activities of daily living. It is only recently with the advances in technology that such dialysis devices have been possible. Prototype devices for both hemodialysis and peritoneal dialysis have been studied with favorable results. Typically, these have been short-term studies, and longer term trials are eagerly awaited, to determine whether the current generation of wearable continuous dialysis devices cannot only remove waste products of metabolism and control volume but also maintain acid-base and electrolyte homeostasis and actually improve outcomes. In addition, a novel generation of dialysis devices based on nanotechnologies are being developed. Hopefully, these wearable continuous devices will be available as an option for routine clinical practice in the not-too-distant future.

The influence of maintenance....

The influence of maintenance quality of hemodialysis machines on hemodialysis efficiency

Ahmad Taher Azar
Department of Biomedical Engineering, Misr University for Science and Technology, 6th of October 2009, City, Egypt
Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2010 Nov 8];20:49-56

Abstract

Several studies suggest that there is a correlation between dose of dialysis and machine maintenance. However, in spite of the current practice, there are conflicting reports regarding the relationship between dose of dialysis or patient outcome, and machine maintenance.

In order to evaluate the impact of hemodialysis machine maintenance on dialysis adequacy Kt/V and session performance, data were processed on 134 patients on 3-times-per-week dialysis regimens by dividing the patients into four groups and also dividing the hemodialysis machines into four groups according to their year of installation. The equilibrated dialysis dose eq Kt/V, urea reduction ratio (URR) and the overall equipment effectiveness (OEE) were calculated in each group to show the effect hemodialysis machine efficiency on the overall session performance. The average working time per machine per month was 270 hours.

The cumulative number of hours according to the year of installation was: 26,122 hours for machines installed in 1998; 21,596 hours for machines installed in 1999, 8362 hours for those installed in 2003 and 2486 hours for those installed in 2005. The mean time between failures (MTBF) was 1.8, 2.1, 4.2 and 6 months between failures for machines installed in 1999, 1998, 2003 and 2005, respectively. Statistical analysis demonstrated that the dialysis dose eq Kt/V and URR were increased as the overall equipment effectiveness (OEE) increases with regular maintenance procedures. Maintenance has become one of the most expedient approaches to guarantee high machine dependability. The efficiency of dialysis machine is relevant in assuring a proper dialysis adequacy.

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To All Hindu Brothers & Sisters

"A Happy & Blessed Deepavali"

"May the *light* be our Strength"

Best Wishes & Warmest Regards

from

MalaysianKidneySPA

The Buttonhole Technique.....

The Buttonhole Technique: Strategies To Reduce Infections

Lynda K. Ball
Nephrology Nursing Journal, 37(5), 473-478

Submitted By Mr Jeff Chong

The buttonhole technique has been utilized in the United States for over 10 years, and it has been very effective in reducing pain associated with cannulation, empowering patients to learn to self-cannulate, and decreasing complications related to site rotation cannulation. Unfortunately, there is one aspect of this technique that may impact its use – high infection rates.

Over the course of the last 20 years, there has been very limited published literature identifying concerns or complications associated with the buttonhole technique. It has only been within the last four years that research has been published citing infection as a potential problem requiring the renal community’s attention (Doss, Schiller, & Moran, 2008; Marticorena et al., 2006, 2009; van Loon, Goovaerts, Kessels, van der Sande, &Tordoir, 2009; Verhallen, Kooistra, & Van Jaarsveld, 2007). This article discusses specific issues associated with the buttonhole technique and identifies strategies to reduce the incidence of infection.

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