Haemodialysis, CAPD, and the role of GPs in the treatment of CRF: Dr. Umesh Khanna

M3 India Newsdesk Aug 11, 2019

In the Sunday Series today we bring to you an article from the archives where a noted expert, Dr. Umesh Khanna provides tips for general practitioners for the treatment of Chronic Renal Failure, construction of an AV fistula, Haemodialysis, and CAPD for CKD patients.



Treatment of complications of Chronic Renal Failure (CRF)

Anaemia correction

  • Injection Erythropoietin available as 2000, 3000, 4000, 5000 & 10,000 units given as subcutaneous injection thrice a week (approximately 100 units/kg)
  • Iron sucrose available as IV infusion to be given as slow IV bolus, found to be extremely safe with no anaphylactic reaction, given once a week if serum ferritin or transferrin saturation is low
  • B12 injection and folic acid as per the cause of anaemia

Altered calcium-phosphorous product

If phosphorous is high & calcium is low, use phosphate binders such as

  • Calcium carbonate (Shelcal)
  • Calcium acetate (Lowphos or Hypophos)

If both phosphorous and calcium are high, use phosphate binders such as Sevelamar (Renagel, Phoseal, Acutrol) 400 to 800 mg three times a day along with meals so as to remove phosphorous obtained from the diet.

Correction of volume overload

  • Salt restriction to <2 g/day
  • Fluid restriction to <750 ml/day
  • Diuretics except potassium-sparing diuretics such as Spironolactone, Amiloride

Handling electrolyte imbalance, most dangerous being hyperkalemia

  • Avoiding fruits/juices/coconut water
  • Potassium-binding resins such as K-bind or P-bind
  • Diuretics such as Frusemide or Torsemide

Check for drugs which increase potassium, such as, spironolactone, ACE inhibitors & ARBs, ß-blockers, NSAIDs, etc.


Vaccination for CKD patients

  • Hepatitis B vaccine for all CKD patients, usually double dose is given i.e. 2 ml (1 ml on each deltoid) at 0, 1, 2, and 6 months
  • Influenza and pneumococcal vaccines for all elderly patients as they are prone to respiratory infections

Construction of Arteriovenous (AV) Fistula

Once the serum creatinine reaches 5 to 6 mg%, an AV fistula must be constructed by a small surgery generally done on the forearm under local anaesthesia. It is a day care surgery requiring surgical skills but does not carry much risk and the patient should be encouraged to do it in advance so as to prevent the need for emergency jugular catheterisation for initiation of dialysis.

The AV fistula generally takes 4 weeks to mature and hence has to be done in advance. It is generally a life-long, lifeline for patients.

For the GP: BP should not be measured in the hand with the fistula, nor should injections be given on that arm or blood be collected from it. However, the patient can use the hand for all other normal activities.


Haemodialysis

  1. It is generally done 2 to 3 times per week, each session lasting for 4 to 5 hours. This timetable should be rigidly followed by the patient.
  2. 2 long fistula needles are inserted into the large veins (of the forearm or the arm) which develops 1 to 2 months after the construction of AV fistula.
  3. These needles are connected via blood tubings to an artificial dialyser mounted on a machine which monitors safe dialysis.

Continuous ambulatory peritoneal dialysis (CAPD)

  1. In this procedure, a thin silastic catheter is inserted under LA into the peritoneal cavity.
  2. The patient uses it to empty 2 liters of fluid from a special CAPD bag mounted on an IV stand into the cavity.
  3. In 10 minutes the fluid enters in and the bag is disconnected. The patient is then free to do his work and after 46 hours, empties the peritoneal cavity, only to put in a new bag full of fluid.
  4. The CAPD patient does 3 to 4 such exchanges in a day, 365 days a year and can be fully ambulatory anywhere in the world.


Kidney transplant

This is the best form of renal replacement therapy and should be advocated unless contraindicated. The present law permits only live-related kidney transplant and cadaveric kidney transplant.

For using organs from a cadaveric donor, one has to declare a patient brain-dead after a series of tests which are meticulously laid down by the law. Brain death is certified by a neurologist/neurosurgeon and an intensivist who is not connected with the transplant team. One cadaver donor can source organs for the following:

  • 2 Kidney transplants
  • 1 Liver transplant
  • Cardiac transplant
  • Pancreas transplant
  • Lung transplant

Thus as a GP, one must encourage cadaveric transplantation and people should be encouraged to pledge their organs for donation after death. Mumbai Kidney Foundation has a donor card which the patient can fill up and keep with him/her permanently.

In the previous article, Dr. Umesh Khanna offers useful pointers for GPs treating and managing CKD. Click Role of family physician in prevention and management of different stages of CKD: Dr. Umesh Khanna

This article was originaly published on 14. 11.18

 

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

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