Indications of dialysis Acute kidney injury (AKI) is an abrupt or rapid decline in renal filtration function(No universally accepteddefinition).

1. Indications of dialysisIndications of dialysis
Dr. Mohamed AbbassDr. Mohamed Abbass
NephrologistNephrologist
PGDD,CARDIFF,UKPGDD,CARDIFF,UK

3. Acute kidney injury (AKI)Acute kidney injury (AKI) is anis an
abrupt or rapid decline in renalabrupt or rapid decline in renal
filtration functionfiltration function
(No universally accepted(No universally accepted
definition).definition).

4. It is a life-threatening conditionIt is a life-threatening condition
occurring in approximatelyoccurring in approximately 5%5% ofof
all hospitalized patients and up toall hospitalized patients and up to
30%30% of the admissions toof the admissions to
intensive care units.intensive care units.

5. From the definition of AKI , theFrom the definition of AKI , the
diagnosis depend ondiagnosis depend on
1- The1- The increaseincrease in serum creatininein serum creatinine
2- The2- The decreasedecrease in the GFRin the GFR
3- The3- The decreasedecrease in the urine outputin the urine output
This is theThis is the RIFLERIFLE criteriacriteria

6. TheThe RIFLERIFLE criteriacriteria
in serum
creatinine in GFR
In
urine output
Risk 1.5fold 25%
< 0.5 mL/ kg per
hour for six hours
Injury 2fold 50% >0.5mL/ kg per hour
for 12 hours
Failure 3fold 75% >0.5mL/ kg per hour
for 24 hours or
anuria for 12 hours
Loss Complete loss of kidney function for more than four
week (need renal replacement therapy)
ESRD Complete loss of kidney function for more than
three months ( need renal replacement therapy)

7. Chronic kidney diseaseChronic kidney disease
(CKD)(CKD)

8. kidney damage for 3 or morekidney damage for 3 or more
monthsmonths
1-Structural or functional abnormalities of1-Structural or functional abnormalities of
the kidneythe kidney
2-With or without decreased GFR.2-With or without decreased GFR.
3-Manifested by either pathologic3-Manifested by either pathologic
abnormalities or markers of kidney damage.abnormalities or markers of kidney damage.

9. GFR 60 mL/minute/1.73 m2 for 3GFR 60 mL/minute/1.73 m2 for 3
or more months, with or withoutor more months, with or without
markers of kidney damage.markers of kidney damage.

10. CKD Stages according to GFRCKD Stages according to GFR
(ml/min/1.73m(ml/min/1.73m22
))
1: Stage 11: Stage 1Kidney damage withKidney damage with
normal or GFR >90normal or GFR >90
2: Stage 22: Stage 2GFR 60:89GFR 60:89
3: Stage 33: Stage 3GFR 30:59GFR 30:59
4: Stage 44: Stage 4GFR 15:29GFR 15:29
5: Stage 5 (ESRD)5: Stage 5 (ESRD) <15<15

11. Causes of AKICauses of AKI
ARF can be classified into threeARF can be classified into three
groups:groups:
@-@-Pre-renalPre-renal –– this is caused bythis is caused by
ineffective perfusion of kidneysineffective perfusion of kidneys
whichwhich
are otherwise structurally normal,are otherwise structurally normal,
eg:eg:
@-Hypovolaemia@-Hypovolaemia
@-Cardiac pump failure@-Cardiac pump failure
@-Other causes of hypotension@-Other causes of hypotension

12. RenalRenal –– results from structuralresults from structural
damage to the glomeruli and renaldamage to the glomeruli and renal
tubulestubules
@-ATN (the most common causative@-ATN (the most common causative
condition)condition)
@-Glomerulonephritis/vasculitis@-Glomerulonephritis/vasculitis
@-Tubulointerstitial nephriti@-Tubulointerstitial nephritiss

13. @-Post-renal –@-Post-renal – obstruction of theobstruction of the
urinary tracturinary tract
@-Prostatic hypertrophy/carcinoma@-Prostatic hypertrophy/carcinoma
@-Bladder tumour/gynaecological@-Bladder tumour/gynaecological
malignancymalignancy
@-Neuropathic bladder@-Neuropathic bladder

14. Specific causesSpecific causes
The most common causes of ARFThe most common causes of ARF
seen in hospital are:seen in hospital are:
Pre-renal failure.Pre-renal failure.
Acute tubular necrosis (ATN).Acute tubular necrosis (ATN).
Obstruction.Obstruction.

15. The ‘Surgical Triad’The ‘Surgical Triad’
((post-operative volume depletion,post-operative volume depletion,
infection andinfection and
nephrotoxic drugs)nephrotoxic drugs)
is a common cause of hospital-is a common cause of hospital-
acquired ARFacquired ARF

16. Causes of CKDCauses of CKD
DiabetesDiabetes
GlomerulonephritisGlomerulonephritis
HypertensionHypertension
Autosomal dominant polycysticAutosomal dominant polycystic
kidney diseasekidney disease
Reflux nephropathyReflux nephropathy
RenovascularRenovascular

17. Diabetes mellitusDiabetes mellitus is now theis now the
most common identifiablemost common identifiable
cause ofcause of CKDCKD , being present, being present
in nearly 20% of new patientsin nearly 20% of new patients

18. Indication of dialysis in AKIIndication of dialysis in AKI

19. 1-Hyperkalaemia greater than 6.51-Hyperkalaemia greater than 6.5
mmol/l or 6–6.5 mmol/l with ECGmmol/l or 6–6.5 mmol/l with ECG
changeschanges
2-Pulmonary edema2-Pulmonary edema
3-Metabolic acidosis causing3-Metabolic acidosis causing
circulatory compromise.circulatory compromise.
(unresponsive to medical(unresponsive to medical
management)management)

20. 4-Uraemic encephalopathy,4-Uraemic encephalopathy,
pericarditis .pericarditis .
5-There is no absolute level of5-There is no absolute level of
urea or creatinine at which we canurea or creatinine at which we can
dialyze the patient.dialyze the patient.

21. 6- Poisoning with (lithium,6- Poisoning with (lithium,
methanol, ethylene glycol,methanol, ethylene glycol,
aspirin, theophylline ).aspirin, theophylline ).
7- Other metabolic disturbance7- Other metabolic disturbance
refractory to medical treatmentrefractory to medical treatment
like hypercalcemia withlike hypercalcemia with
hyperphosphatemiahyperphosphatemia

22. Indication of dialysis in CKDIndication of dialysis in CKD

23. When do you start treatment?When do you start treatment?
@-@-There is no simple answer to thisThere is no simple answer to this
question.question.
Studies (usually retrospective) ofStudies (usually retrospective) of
early versus late dialysis show noearly versus late dialysis show no
obvious gain in life expectancy as aobvious gain in life expectancy as a
result of starting treatment early .result of starting treatment early .
Advantages in terms of quality of lifeAdvantages in terms of quality of life
are another matter, howeverare another matter, however

24. @-Dialysis should be considered when@-Dialysis should be considered when
the GFR is 10–15 ml/min, depending onthe GFR is 10–15 ml/min, depending on
symptoms.symptoms.

25. @-An early start of dialysis in@-An early start of dialysis in
patients with predictably steadilypatients with predictably steadily
progressive renal failure (autosomalprogressive renal failure (autosomal
dominant polycystic kidney disease –dominant polycystic kidney disease –
ADPKD – or glomerulonephritis) isADPKD – or glomerulonephritis) is
practical.practical.
Those with relatively stable renalThose with relatively stable renal
function, however , may often befunction, however , may often be
treated conservatively for longertreated conservatively for longer

26. Complication of HDComplication of HD

27. Complications of vascularComplications of vascular
access(temporary/permanent).access(temporary/permanent).
Complications during HD.Complications during HD.
Complication of long term HD.Complication of long term HD.

28. Complication of vascular accessComplication of vascular access
( central venous cannulation):( central venous cannulation):
immediate:immediate:
@-Arterial puncture.@-Arterial puncture.
@-Pneumothorax.@-Pneumothorax.
@-Hemothorax.@-Hemothorax.
@-Arrythmias.@-Arrythmias.
@-Air embolism.@-Air embolism.
@-Venous or cardiac perforation.@-Venous or cardiac perforation.
@-Pericardial tamponade.@-Pericardial tamponade.
@-Injury of adjacent structure like brachial@-Injury of adjacent structure like brachial
plexus or trachea.plexus or trachea.

29. Delayed:Delayed:
@-Like thrombosis.@-Like thrombosis.
@-Infection( endocarditis,@-Infection( endocarditis,
osteomyelitis, thrombophlebitis).osteomyelitis, thrombophlebitis).
@-Vascular stricture.@-Vascular stricture.

30. AKIAKI
When to refer?When to refer?
Persistence of ARF for 2-4Persistence of ARF for 2-4
weeks.weeks.
When to admit?When to admit?
Significant acid –base , fluid andSignificant acid –base , fluid and
electrolytes abnormalitieselectrolytes abnormalities

31. CKDCKD
When to refer?When to refer?
When GFR 60ml/min forWhen GFR 60ml/min for
mangementmangement
When to admit?When to admit?
Congestive heart failure,Congestive heart failure,
pericarditis , severe acid –base ,pericarditis , severe acid –base ,
fluid and electrolytesfluid and electrolytes
abnormalitiesabnormalities

32. ThAnKsThAnKs
Dr M AbbassDr M Abbass