LECTURE DAY II Part 2  Uses synthetic material to connect artery to vein

(August 15, 2023 PM)  Usual type (based on location):

o Forearm loop AVG
o Upper Arm AVG
OUTLINE o Thigh AVG (external iliac and femoral)
I. CKD-MBD o Necklace AVG
II. Anemia in CKD
HEMODIALYSIS CATHETER
I. CKD-MBD
 Short-term catheters
3 key hormones: o Acute
o Temporary
1. PTH
2. Vitamin D o Non-tunneled
3. FGF-23 o Non-cuffed
o Size:
 Right IJ: 15-16cm
IDEAL PHOSPHATE BINDERS  Left IJ: 19-20cm
 Femoral 24-31 cm
 Binds phosphate efficiently  Long term catheter
 Add nothing o Chronic
 Do not bind good things o Permanent
 High adherence o Tunneled
 No adverse reactions o Cuffed
o Perm cath

ANEMIA IN CKD When to refer access creation? When EGFR is 15-

20ml/min/m2
Include the ff in the initial evaluation of patients with CKD Inspection: see lateral borders, tubular, no aneurysm
and anemia Palpation: soft compressible consistent thrill, soft as your
lips
 CBC Auscultation: low continuous murmur, loudest at
 Serum Ferritin Level (marker of stored iron) anastomosis
 Serum Transferrin Saturation (adequacy of iron
utilization for erythropoiesis Problems in AVF
o %HRC (Hypochromic RBC) Immature AVF: Management
o CHr (reticulocyte Hb c Hand Exercise
Squeeze a soft ball
USE OF IRON TO TREAT ANEMIA IN CKD IF: Touching the fingertips
Tsat is <=30, <=20% AND Stenosis
Ferritin <= 500UG/l (<=100) Increased pressure in the vein, detected by the
machine

III. VASCULAR ACCESS AND CARE Hyperpulsation

 Ideal Access: AV Fistula Does not clappses when arm is elevated
 “Right access in the right time for the right reasons”
 KDOQI: EGFR 15-20ml/min/m2 patients should EXPANDING HEMATOMA
already have ESKD life plan Apply pressure
 ESKD Life plans: aims to maximize ESKD modality
choices and utilization for a specific patient’s ANEURYSM
foreseeable lifespan How to prevent? Cannulation site rotation

AV Fistula INFECTION
Poor hygiene
 Artery-vein anastomosis What to look for?
 Increase diameter of vein
 Samples:
o Radiocephalic AV SPECIAL CONDITIONS IN PREGNANCY
o Brachiocephalic AV
o Brachiobasilic AV Topics:
 Epidemiology
AV Graft  Changes with pregnancy
 Diagnosis
  Care of HD patients who are pregnant – before,  Congenital abnormalities occur with the same
during pregnancy and after delivery frequency as in the general population
 Pregnancy on dialysis is physically and
Epidemiology emotionally demanding
From surveys:  Patients should be encouraged to dialyze as much
 Belgium: 0.3 - Women of child-bearing age will as possible, preferably daily for long hours
conceive (from a survey in Belgium on all  It is worth re-exploring options for
dialysis units) transplantation
 Saudi Arabia: 1.4%
 USA: 0.55% Changes during Pregnancy:
 Japan: 3.4%  Kidneys increase by 1 to 2 cm in length
 ANZDATA: 2.07 per 1000 patient years (1966-  Volume- ↑ 70% of normal pregnancy - increases
2008) – backed by data from registry) in both vascular and interstitial fluid
1976- 1985 – 0.54 per 1000 patient compartments
years  most striking anatomic change: dilation of the
1986-1995 -0.67 “ calyces, renal pelvis, and ureter (more prominent
1996-2008 – 3.3 “ on the right side)
 0.5%/year - Frequency of pregnancy in American  Third trimester, about 80% of women show
women evidence of hydronephrosis
1%/year (1991-2001) Diagnosis:
 2-3 times more frequently – HD > PD patients  Average gestational age at which diagnosis of
(USRDS) pregnancy is made – 16.5 weeks
 Blood-based pregnancy test (β subunit of HCG
Reasons for low rate of conception among dialysis patients: should be done prior to GI radiograph for
 Hyperprolactinemia abdominal complaints
 Anemia  Urine pregnancy tests – not reliable even if
 Polypharmacy patient is not anuric
 Psychosocial issues  Pregnancy is best determined by ultrasound
 Uremic state
*Approximately 40% menstruates – esp first few
years on HD

Success in delivering a surviving infant:

 ≈ 60 – 70% - if the mother reaches the 2nd
trimester (excluding elective abortion)
 75 – 80 % - for women who start dialysis after
conception

Unsuccessful pregnancies are due to:

 72% - spontaneous abortion
 10% - stillbirth
 15% - neonatal death
 3% - therapeutic abortion for life-threatening
maternal problems

What dialysis patients of childbearing age should know:

 13- 45% of pregnancies result in spontaneous
miscarriage before 20 weeks’ gestation
 Outcomes of pregnancy on dialysis are improving
1980 – 23%
2010 - >70% - 90%
 Maternal morbidity (hospitalization)remains
significant but mortality is rare
 Maternal hypertension is common
 Pre-term birth (70-100% mean gestational age 32
weeks) and low birth weight (100%) are
extremely common
 Long-term outcomes of these infants are not yet
known
 Prolonged admissions to neonatal care intensive
care are common
Managing Hemodialysis during pregnancy:
PRE-PREGNANCY
 Discuss risks of pregnancy (miscarriage, fetal
death, fetal growth restriction, prematurity, pre-
eclampsia)
 Ensure all medications safe in pregnancy
 Aspirin: 75-150 mg daily
 Folic acid: 5 mg/day
DURING PREGNANCY
 DIALYSIS: 20 hrs./week in 4 or more sessions
Aim for pre-dialysis BUN<40
mg/dL
Heparin requirement may increase
(Hypercoagulability of pregnancy)
 ANEMIA: IV Iron to maintain iron stores
Dose ESA to achieve Hgb 10-12g/dL
 BICARBONATE: Adjust oral and dialysate
bicarbonate to achieve normal serum bicarb for
pregnancy (18-22 mmol/L)
CONTROL OF BP
 NUTRITION: Dietician advice to ensure
adequate protein and nutrient intake  Major risk associated with pregnancy in dialysis
 PHOSPHATE: Supplement oral and dialysate patients – severe hypotension
phosphate to maintain post-dialysis PO4  80% of pregnant dialysis patients have some degree of
in normal range hypertension (BP>140/90mmHg)
 CALCIUM: Maintain normal serum calcium  40% have severe HTN (diastolic BP>110 mmGf or
with additional oral Ca & vit D, as well as systolic BP >200mmg_
increased dialysate Ca  75% of severe HTN occurs before 3rd trimester
 Hypercalcemia occasionally  Control of maternal BP: 110-140/80-90
provoked by placental PTHrP & vit D-like  Difficult to achieve
substance
AFTER PREGNANCY
 Return to usual dialysis schedule immediately
  Readjust dry weight and antihypertensives
weekly for 6 weeks

INFECTION CONTROL IN THE HD UNIT

A.. Blood Borne Diseases

What to do after needle stick injury or exposed to

blood/body fluids?
 Wash needle stick & cuts with soap & water
 Flush splashes to the nose, mouth or skin with
water (skin- water & soap)
 Irrigate eyes with clean water, saline & sterile
irrigant (at least 30 secs)
 DO NOT squeeze or rub injury site
Hepatitis B vaccination schedule
 Report the incident to your supervisor
 Immediately seek medical treatment.

1. Hepatitis B infection
Modes of Transmission:
 mother to fetus (Horizontal), sexual intercourse,
paternal transmission
 blood Transfusion & ppercutaneous inoculation
HBV is relatively stable in the environment and
remains viable for at least 7 days
on environmental surfaces at room temperature. Blood-
contaminated surfaces
that are not routinely cleaned and disinfected represent
a reservoir for HBV
transmission.

Clinical manifestations:
 asymptomatic, non specific (e.g. joint pain, loss of Hepatitis B Screening and Monitoring
appetite, nausea), fever,
 jaundice, dark urine

Independent risk factors for Hepatitis B infection in

non endemic areas
1. Presence of HBsAg patient in the same HDU.
2. Non segregation with dedicated HD machine for HBsAg
patient.
3. Lower than 50% prevalence of Hep B vaccination in the
same unit.

HBV outbreaks
1. Omission of periodic HBsAg screening.
2. Sharing of multi-dose vials/ blood contact equipment.
3. Failure to reduce the susceptible pool of patients by
vaccination.
4. Preparation of injectable meds on a cart or in-patient
treatment area.
 Screening ang Monitoring of Hepatitis C

Outbreak of HCV in HDU

1. Preparation of injections in a contaminate environment
(Patient tx station)
2. Re-use of single dose medication vial for >1
patient
3. Use of mobile cart to transport supplies or meds
to patients
4. Inadequate cleaning or disinfection of shared
environmental
5. surfaces between patients
6. Failure to separate clean & contaminated areas
7. Failure to change gloves & perform hand hygiene
between tasks or patients
8. Hurried change-over process
9. Low staff to patient ratio
2. Hepatits C infection
Modes of transmission
 IV drug use, blood transfusion, sex with IV drug Prevention:
users, pierced ear or body parts, immunoglobulin - Standard precaution, proper disinfection of Hemodialysis
injection, percutenous injection. stations

Clinical manifestations 3. HIV

- asymptomatic, jaundice, fatigue, nausea, fever Clinical manifestations
muscle aches - asymptomatic, non specific signs and symptoms
( fever, headache, mse and joint pain, rash,)sore throat &
Diagnosis: painful mouth sores, swollen lymph nodes, diarrhea, weight
 anti HCV, HCV nucleic acid test(if living in high loss, fungal infections.
prevalence areas), HCV RNA
(if anti HCV positive) Modes of transmission
- blood transfusion, needle sharing injection drug use,
Interpretation of Hepatitis C Test percutenous needle stick, mucous membrane exposure to
blood, sexual intercourse

Diagnosis: anti HIV -1 & 2

Possible source of Transmission of HIV in the HD unit

1. Re-use dialyzer, blood lines, needles for different
patient.
2. Weak chemical germicide (Benzalkonium) to reprocess
needles.
3. Contaminated ports connecting HD machine to blood
lines
 4. Use of contaminated multi-dose heparin vial alt: New catheter at separate site

3 Catheter Related Bloodstream Infection (CRBSI)

HIV Screening and Monitoring Clinical manifestation
 fever + rigors, rigors during hemodialysis,
malaise, infection of the exit site (may or may not
be present) altered mental state, , hemodynamic
instability during HD .

KDOQI 2019 Diagnosis:

 Clinical Manifestation. +
 At least 1 (+) blood culture same org.
 1. peripheral source - dialysis circuit or vein
 2. from catheter segment - >15 cfu/catheter
hub/tip OR >102 cfu/catheter hub/tip
Most Sensitive, specific & accurate
- HD circuit and venous CVC hub

 No apparent source of infection

Prevention of HIV transmission  Supportive:
- Strict adherence to standard infection 1.Simultaneous quantitative cultures of blood
control. sample ratio > 3:1 (catheter
tip/hub vs peripheral)
Post exposure prophylaxis is recommended with anti 3. differential pd catheter culture vs peripheral (2h)
retroviral meds Management of CRBSI
 source is HIV positive or with risk factors for
HIV.
 Should be started ASAP, w/in 72h of exposure

B. Vascular Access Infection

1. Exit Site Infection

CVC Exit Site infection
- hyperemia, induration & or tenderness < 2c
from exit site.
- maybe associated with drainage from exit site.
+ bacteremia
Dx: gs cs (discharge)
Mgt: No discharge
-Topical antibiotic. e.g. Mupirocin,
Ketoconzole
Purulent exit site
-systemic antibiotic < 7 d.
-removal of catheter – if no improvement

2. Tunnel Infection
Tenderness, hyperemia, and or induration that
extends along the SQ tunnel (IDSA- > 2cm from
exit site) + bacteremia

Dx: gs cs
Management:
Broad spectrum antibiotic -10-14d w/o CRBSI
(+) CRBSI –duration determined by mgt
CRBSI Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access
No response to antibiotic Guideline Work Group. KDOQI clinical practice guideline
- CVC exchange with new SQ tunnel and for vascular access: 2019 update. AJKD. 2020;75(4)(suppl
exit site 2):S1-S164
  Gentamicin(4-27 mg/ml) - risk of resistance,
Immediate removal with delayed CVC placement:  : 0.32 to1.7 -mg/ml no report of
 Clinically & hemodynamically unstable resistance
 Persistent fever 48-720 after initiation of systemic Recommended dose: 0.32 mg/ml
antibiotic
 Metastatic complications (suppurative C. Pulmonary Infections
thrombophlebitis, endocarditis)
 Infections due to S.aureus, P.aeruginosa, fungi or
Mycobacteria 1. Pneumonia
 Presence of Tunnel site infection Clinical manifestation
 fever, cough, difficulty of breathing
Diagnosis
Prevention:  sputum gs/cs, Chest X-ray
1. Enforce scrub the hub protocol Prevention
2. Use of face mask by the patient and health worker 1. Droplet precaution
3. Apply antimicrobial ointment to exit site e.g - single patient room, spatial separation > 3 feet,
Bacitracin + Gramicidin + Polymyxin B, Povidone draw curtain between
iodine ointment. patient bed, mask for health care worker.
Chlorhexidine patch 2. Vaccination – PCV 13 followed by Pneumo 23
Mupirocin- risk of resistance, no coverage for g(-)
organism Guidelines For Vaccinating Kidney Dialysis Patients and
4. Antibiotic lock solution – if with frequent infection Patients with CKD. CDC Advisory Committee on
despite strict aseptic technique Immunization Practices. 2013
KDOQI: ALS -only in facilities with very HIGH
baseline risk CRBSI despite implementation of best
CVC care & and Infection control practices

2.Pulmonary Tuberculosis
Symptoms suggestive of TB
a. at least 2 wks of unintentional and significant wt
loss, fever, hemoptysis, chest
or back pain (not due to musculoskeletal d/o),
5. Citrate or Citrate + antibiotic lock easy fatigability/malaise, night sweats, SOB/DOB
6. Catheter hub devices -clear guard HD, Tego and b. Unexplained cough of any duration
Curos
Mode of Transmission- airborne

Antibiotic Lock Solution

Screening and Diagnosis of Active TB
with unknown HIV status
 INFECTION CONTROL

Infection: 3rd leading cause of death in HD patients

Reasons for increased risk:

 Related to HD treatment itself

 Endogenous to the patient and uremic mileu
o Immune disorder

STANDARD PRECAUTION

 Universal masking
 Early recognition and isolation
 Patient placement
 PPE
Latent TB infection in HIV (-) , > 5 y/o  Cleaning and Disinfection

Droplet Precaution

 Single patient room

 Spatial separation >= 3 feet
 Draw curtain between patient bed
 Mask for HCW

Airborne Precaution

 AIR (Airv

HAND HYGIENE

Handwashing: single most important factor in prevention

infection in HD unit

PERSONAL PROTECTIVE EQUIPMENT2

Selection of TB Preventive Regimens

Prevention of transmission of PTB in the HD unit

1. Ensure prompt detection
2. Airborne precaution (respiratory protection
program, respiratory hygiene and cough
etiquette)
3. Environmental control
control source of droplet local exhaust e.g. hoods
dilute or remove contaminated air (general
ventilation)
clean air (high efficiency particle air (HEPA)
filter
1. Treat patient suspected or confirmed TB