MANAGEMENT OF END-STAGE RENAL DISEASE

depletion should be suspected if B P is not raised and postural hypotension tencte to occur. 4. Diuretics - Large doses of Frusemide 250 mg-2 g in 24 hours) may promote diuresis even in advanced CRF 5 Treatment of associated disorders - (a) ANEMIA - Some degree of anemia is well tolerated by most patients and it is best to leave it untreated except for correction of obvious iron deficiency. Anemia of CRF in dialysis patients as also pre-dialysis patients has greatly improved with use of recombinant human erythropoietin (r-HuEPo) Dose -25-50 g/kg I. M. 2-3 times a week. Maintenance dose, 10 g/kg 2-3 times a week Care must be taken to see that hypertension is not exacerbated in patients receiving this drug as it may lead to convulsions. (b) RENAL OSTEODYSTROPHY - results from combination of disturbed vitamin D metabolism and secondary hyperparathyroidism. A rise in serum alkaline phosphate and parathyroid hormone are the cardinal features Treatment - (i) Calcium carbonate is palatable and effective and also helps to correct metabolic acidosis. (ii) Synthetic vitamin D analogues, such as 1-hydroxycholecalciferol 0.25 g/day or vitamin D metabolite 1,25-dihydroxy-cholecalciferol 1-2 g/day Frequent monitoring of serum calcium is essential for early detection of hypercalcemia. which would further decrease renal function and cause pruritus, vomiting and occasionally, pancreatitis. (c) HYPERTENSION - Loop diuretics such as frusemide, -blockers, vasodilators such as nifedipine, ACE inhibitors (d) HYPERLIPIDEMIA - HMG and COA reductase inhibitors. (e) ALUMINIUM TOXICITY - Reverse osmosis to reduce aluminium level in the dialysate, and removal of aluminium by dialysis after infusion of desferriexamine. Oral calcium carbonate as phosphate binder. (f) SYSTEMIC ACIDOSIS -Most patients tolerate mild degree of acidosis, but when plasma bicarbonate falls to 15 mmol/litre or less, correction with sodium bicarbonate 6-12 gm b. d. or t ds is indicated - Domperidone 10 mg. t.d.s. Protein restriction. If no response dialysis should be considered. (h) PRURITUS - Correction of serum calcium and phosphate levels and use of antipruritic drugs such as chlorpheniramine maleate. (i) PERIPHERAL NEUROPATHY - If no obvious cause such as drugs (nitrofurantoin), or alcohol, dialysis is indicated CAPD is superior to hemodialysis in improving peripheral neuropathy MANAGEMENT OF END-STAGE RENAL DISEASE (ESRD) - Renal replacement therapy (RRT) -cab be provided by hemodialysis, peritoneal dialysis or kidney transplantation. Hemodialysis - Types of hemodialysis: HEMODIALYSIS - in its classical form is the most common treatment. The blood passes through an extracorporeal circulation where it is separated from the dialysis fluid by an artificial semipermeable membrane Solutes move across the membrane only by diffusion. The dialysis solution comprises water and electrolytes. By means of a controlled pressure gradient created between the blood and dialysis solution, it is possible to draw water corresponding to fluid overload Such ultrafiltration, is sometimes used alone, without diffusion to reduce fluid overload HEMOFILTRATION - Here a pump connected to the dialyser creates a negative pressure on the side of the dialyser opposite to the blood compartment This sucks the plasma fluid and the solutes dissolved in it across the dialysis membrane This process is called 'convection' No dialysis solution is used and high volumes of plasma fluid can be ultrafiltered (30-60 litres per session) HEMODIAFILTRATION - This method uses convection and diffusion Dialysis