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End of Module Survey A 46-year-old man with hypertension, diabetes, prior CVA with right residual weakness, visual impairment, heart failure with reduced ejection fraction (EF 35%), and CKD stage 5 presents for follow up with his wife who is very much involved in his care. Various renal replacement therapy options are discussed. He is currently on disability but his wife works full time. Over the last year, he has had three admissions for heart failure exacerbation because of dietary and medication non-adherence despite multiple counseling sessions.
Which of the following poses the highest risk for home hemodialysis treatment failure?
A 58-year-old female with a medical history of hypertension, diabetes, coronary artery disease, and ESRD was recently started on home HD. She is well read and curious to know her risk of hospitalization as compared with in-center HD. Which of the following statement is correct regarding hospitalization for home hemodialysis patient compared to in center HD?
A 76 year old male with ESKD secondary to ANCA vasculitis has started training for home hemodialysis. He is currently undergoing in-center HD for last 1 months and now in transition care unit. He had 1+ peripheral edema and pre dialysis BP in range 130-140/70-80. His medications include carvedilol 25 mg BID, hydralazine 50 mg TID, aspirin 81 mg OD, atorvastatin 80 mg OD, sevelamer 800 mg TIDWM. He develops severe intradialytic hypotension on Day 4 of training with systolic in 80s. He was asymptomatic during this event. Which of the following factors have contributed to severe intradialytic hypotension?
Yes. This is Correct.
It is very important to adjust antihypertensive medications for patients on short daily hemodialysis. Before decreasing EDW for these patients, antihypertensive medications should be reduced to avoid intradialytic hypotension unless they have uncontrolled hypertension.
Answer A is incorrect because although it is possible to have dialyzer reaction, he is not having any other symptoms which would just dialyzer reaction
Answer B is incorrect as myocardial stunning is less common in short daily hemodialysis patients.
Answer C is incorrect as patient does not have other symptom of tamponade and is less likely compared to option D.
Answer E is incorrect because, although dialysate potassium is 1.0 mEq/L (Nxstage dialyzer), dialysate volume is much less than in-center and therefore lower potassium removal per treatment.
Reference
Susantitaphong P, Koulouridis I, Balk EM, Madias NE, Jaber BL. Effect of frequent or extended hemodialysis on cardiovascular parameters: a meta-analysis. American Journal of Kidney Diseases. 2012 May 1;59(5):689-99.
A 66-year-old man with HTN, ESKD is currently on home HD (HHD) for last 6 months. He has left forearm fistula with good thrill and bruit, last angioplasty was 3 month back. He appears euvolemic but has lost 6 lbs in last 3 months. His dialysis prescription is spKT/V per week 2, dry weight 67 kg, treatment time of 3.5 hours for 5 days per week with total weekly UF volume of 7 L. Laboratory testing is below.
| Lab | Predialysis | Postdialysis |
|---|---|---|
| Na meq/L | 138 | 139 |
| K meq/L | 5.1 | 3.8 |
| Cl meq/L | 99 | 98 |
| CO2 meq/L | 24 | 20 |
| Anion gap | 13 | 17 |
Your medical student rotating with you is worried that patient has lower bicarbonate post dialysis. What will be your answer?
Yes. This is Correct.
The NxStage System One uses lactate as a buffer instead of bicarbonate. Dialysate lactate concentration is either 40 or 45 mEq/L. Using dialysate with higher lactate concentrations, may result in lower postdialysis bicarbonate.
Reference
Leypoldt JK, Kraus MA, Collins AJ. Optimizing serum total carbon dioxide concentration during short and nocturnal frequent hemodialysis using lactate as dialysate buffer base. Hemodialysis International. 2020 Oct;24(4):470-9.
For a 100-kg male (assume TBW = 50 L), please provide dialysate volume needed for six treatments per week home hemodialysis to achieve a target stdKt/V of 2.0? Consider blood flow (Qb) is 400 mL/min and there is negligible ultrafiltration during treatment.
Yes. This is Correct.
Kt/V weekly is 2, so Kt/V per session for 6 session/wk is ~ 0.5
Kt/V (urea) per treatment= [D/P (urea)] x [Dialysate volume] / TBW
TBW = 50 L
Kt/V = 0.5
0.5 x 50= [D/P (urea)] x [Dialysate volume]
25 = [D/P (urea)] x [Dialysate volume]
Usual approach is to use FF 40%, which achieves dialysate saturation of about 90%. D/P (urea)= 0.9
FF 50%, which achieves dialysate saturation of about 85%. D/P (urea)= 0.85
Lets check:
Answer A: 0.85 x 20 = 17 which is not equal to 30, incorrect
Answer B: 0.9 x 30 = 27 is the closest and is correct
Answer C: 0.9 x 40 = 36
Answer D: 0.85 x 25 = 21.25
Answer E: 0.9 x 25 = 22.5
Reference
Clark WR, Turk JE Jr: The NxStage System One. Semin Dial 17(2): 167-170, 2004
Gotch FA. The current place of urea kinetic modelling with respect to different dialysis modalities. Nephrology, dialysis, transplantation. 1998 Jan 1;13(suppl_6):10-4.