ð¥ å
§ç§å°ç§èåç
Mechanistic Deep Dive
Solute Clearance
- Diffusion: concentration gradient
- Convection: pressure-driven
- Adsorption: surface binding
- Different solutes (small vs middle vs protein-bound) cleared differently
Peritoneal Transport
- Three-pore model
- Small solutes: easy transit
- Middle molecules: slower
- Large molecules: slow
- Glucose absorption affects ultrafiltration
Recent Trials & Updates
CONVINCE (2023) â HDF vs HD
- Hemodiafiltration vs high-flux HD
- â All-cause mortality 23%
- Practice-changing for Europe
Daily HD Trials
- FHN Daily: improved CV outcomes
- FHN Nocturnal: improved LV mass
- Cost + acceptability remain barriers
Wearable Artificial Kidney (WAK)
- Investigational
- Continuous wearable
- Phase 1-2 trials
- Future direction
Adsorption Cartridges
- HemaClear, MultiBic
- For uremic toxins
- Selected use
Bioartificial Kidney
- BioMedicus, others
- Combined dialysis + tubular cell function
- Trials ongoing
- Future
High-Yield Specialist Points
Dialysis Withdrawal
- For futile cases
- Multidisciplinary discussion
- Palliative + hospice care
- Withdrawal allowed (not euthanasia)
- Family + caregiver support
Conservative Management
- Not starting dialysis
- For elderly with comorbidities
- Symptom-focused care
- Improving recognition
Calciphylaxis
- Calcific uremic arteriolopathy
- Severe complication
- High mortality
- Sodium thiosulfate, wound care
- Parathyroidectomy if hyperPTH
Vasopressin V2 Antagonists in PD
- Tolvaptan
- For ADPKD progression
- Continued on PD in some
Dialysis-Resistant Patients
- Severe pruritus
- Persistent hyperphosphatemia
- Vascular calcification
- Multidisciplinary
Vaccinations in Dialysis
- Flu (yearly), pneumococcal (PCV20 + PPSV23), COVID (boosted), hepatitis B (high-dose), RSV ⥠60
- Donât give live vaccines
Infection Prevention
- Hand hygiene
- Aseptic catheter care
- Mupirocin prophylaxis (PD exit site, nasal staph)
- Screening for hepatitis B/C, HIV regularly
Cardiac Issues
- LVH common
- Pericardial effusion
- Coronary calcification
- HF (HFpEF + HFrEF)
- Sudden cardiac death (electrolytes)
Sexual + Reproductive
- Decreased libido, ED
- Anovulation (women)
- Pregnancy rare but possible
- Preconception counseling
Nutrition Issues
- Protein-energy wasting common
- Sarcopenia
- Dialyzable amino acid losses (some)
- Nutritional support
- Renal dietitian
Mental Health
- Depression 30-40%
- Anxiety common
- Cognitive decline
- Multidisciplinary
Care Coordination
- Multidisciplinary team
- Nephrologist + nurse + dietitian + social worker + pharmacist + cardiologist + others
Transplant Listing
- Pre-emptive ideal
- After RRT start common
- Listing criteria + comorbidity assessment
- Long wait times typically
Pearls
- IDEAL 2010: defer dialysis until symptomatic
- AV fistula gold standard
- CONVINCE 2023: HDF > HD for mortality
- Difelikefalin (FDA 2021): HD pruritus
- PD peritonitis: cardinal â cloudy + intraperitoneal antibiotics
- Calciphylaxis: severe, high mortality, sodium thiosulfate
- Conservative management option for elderly multimorbid
- Transplant > dialysis for survival + QoL