Dialysis Patient in Primary Health Care

Essentials

• There are two main types of dialysis: peritoneal dialysis and haemodialysis. The most common dialysis-related problems encountered in primary health care are infections.
• The first sign of peritonitis in a patient on peritoneal dialysis is usually abdominal pain or cloudy drainage fluid. If peritonitis is suspected refer the patient immediately to a nephrology unit.
• Consult a nephrologist without delay if you suspect that there is a problem either with the peritoneal dialysis catheter, for example an infection of the exit site, or with the haemodialysis access point.

Prevalence

• Globally, nearly 4 million people are living on kidney replacement therapy. Haemodialysis and peritoneal dialysis account for 69% and 9% of it, respectively http://www.nature.com/articles/s41581-022-00542-7 http://www.nature.com/articles/s41581-022-00623-7 http://www.nature.com/articles/nrneph.2016.181. There is wide variation among countries and regions http://www.bmj.com/content/367/bmj.l5873http://journals.lww.com/kidney360/pages/articleviewer.aspx?year=2021&issue=04000&article=00001&type=Fulltext.
• The most common diseases leading to dialysis treatment are diabetic nephropathy, chronic glomerulonephritis, cystic renal disease and nephrosclerosis.

Dialysis treatment

Haemodialysis

• Normally three times a week for 4-5 hours at a time
• The treatment is usually carried out at a dialysis ward of a nephrology unit or their satellite site, which the patients generally visit from home. Patients in long term institutional care are only rarely dialysed. Some patients use haemodiafiltration (HDF) which is an intensified form of regular haemodialysis.
• Some patients have a dialysing machine fitted at home with all the relevant electrical and plumbing requirements, and they carry out the dialysis themselves. Home Compared with Hospital Haemodialysis
• Treatment is intermittent and uraemic toxins and excessive fluid, which accumulate between the treatments, must be removed at frequent intervals. If urine output is low, fluid restriction is necessary in order to avoid both the need to remove large amounts of fluid and associated haemodynamic changes.
• In haemodialysis, access to blood circulation is necessary since blood is circulated throughout the treatment at the rate of 200-300 ml/min. Medical Treatment to Increase Patency of Arteriovenous Fistulae and Grafts
  • In most cases, a vascular surgeon creates an AV fistula of the wrist or forearm vessels.
  • The arm with an AV fistula needs special care; it must not be used for blood pressure readings, cannula insertions or to draw blood samples.
  • If an AV fistula cannot be created, a vascular surgeon may insert a synthetic graft into the arm.
  • In many cases, haemodialysis is carried out via a catheter inserted into a central vein. In long term use, a soft tunnelled catheter should be inserted in order to reduce the risk of infection and vein occlusion.

Peritoneal dialysis Antimicrobial Agents for Preventing Peritonitis in Peritoneal Dialysis Patients, Catheter-Related Interventions for Preventing Peritonitis in Peritoneal Dialysis

• A peritoneal dialysis catheter is inserted into the abdominal cavity by laparoscopic procedure. The patient will then connect the bags of dialysate to the catheter using a sterile procedure.
• At home, the patient infuses 2-3 litres of fluid from the bag into his/her abdominal cavity. The fluid is left in situ for several hours. The dialysate is then drained out and replaced with fresh dialysate.
  • The dialysis fluid contains salts, sugars and both lactate and bicarbonate buffers.
  • Fluid removal is based on osmosis, i.e. the hyperosmolar dialysate with high colloid osmotic pressure will absorb water from the body.
  • Uraemic toxins will diffuse into the dialysate via the peritoneum until there is a state of equilibrium between the body and the dialysis fluid.
• As the dialysate remains in the abdominal cavity most of the day, peritoneal dialysis is a more even and constant form of treatment than haemodialysis.
• There are two types of peritoneal dialysis:
  • In CAPD (continuous ambulatory peritoneal dialysis), the patient usually exchanges the fluid four times per 24 hours, at regular intervals.
  • In APD (automated peritoneal dialysis), the patient connects himself/herself to an automatic cycler at bedtime, which carries out 4-6 fluid exchanges during the night. In the morning, the cycler finishes by refilling the abdominal cavity with fresh fluid for the day.

General problems of dialysis

• Hypotension
  • Usually associated with excessive fluid removal and dehydration
• Fluid overload
  • Symptoms may include oedema, dyspnoea and congestion in a chest x-ray or only hypertension.
  • Fluid overload is managed by dialysis and, in haemodialysis patients in particular, active fluid restriction may also be indicated (e.g. 800 ml of fluids + urine volume).
  • In patients with residual diuresis, large doses of furosemide may have some effect (removal of fluid and salt).
• Cramps
  • Often occur during haemodialysis towards the end of treatment. Worsened by excessive fluid overload.
• Increased risk of infections
  • Associated with uraemia
  • It must be borne in mind that in a dialysis patient the dialysis route introduces an extra infection pathway. In haemodialysis patients, the dialysis fistula or catheter may become infected. In peritoneal dialysis patients, the dialysis catheter may provoke peritonitis or an infection at its exit site. Treatment for Peritoneal Dialysis-Associated Peritonitis

The management of a dialysis patient in primary health care

• All dialysis patients remain under the continuous care of a nephrology unit.
  • Patients receiving haemodialysis in a hospital will visit their treatment unit three times a week and any problems will be attended to.
  • Patients on self-care dialysis will have check-ups at less frequent intervals, usually every 4-8 weeks.
• When special problems emerge, the patient should be referred to a unit with nephrology expertise.
• Septicaemia should always be primarily suspected in a febrile patient.
• If you suspect peritonitis in a patient on peritoneal dialysis, refer the patient immediately to a nephrology unit. The first signs of peritonitis will usually be abdominal pain and cloudy drainage fluid.
• Consult a nephrologist immediately if you suspect a problem associated either with the peritoneal dialysis catheter, for example infection at the exit site or development of an abdominal hernia, or with the haemodialysis access point, for example an infection of the dialysis fistula or catheter.
• Patients on dialysis naturally also have all kinds of common illnesses that are well suited for treatment in primary care. The management guidelines of e.g. driver's license-related matters, musculoskeletal disorders and mild upper respiratory tract infections usually do not differ from those applied to other patients in primary care.
• Proper management of oral and dental health is important. Before dental calculus removal or other more extensive dental procedures, antibiotic prophylaxis with e.g. amoxicillin 2 g orally is recommended one hour before the intervention.
• When prescribing medication bear in mind that, in addition to concurrent medication, renal insufficiency will also affect the dose.
  • Choose the dose given in the worst category of renal insufficiency, because the serum creatinine value of a dialysis patient will not reflect the level of renal function.
  • Certain drugs should be completely avoided, e.g. metformin and nitrofurantoin.
• If rehydration is indicated, note that the patient may be at risk of overhydration due to poor or totally absent diuresis. If problems with electrolyte and fluid balance are anticipated refer the patient readily to the nephrology unit in a hospital.
  • A patient with fluid overload may only exhibit a weak or no response to a diuretic.
  • Under normal circumstances, the fluid requirement for a haemodialysis patient is usually 800 ml + urine output / 24 hours.
  • In a patient receiving peritoneal dialysis, fluid balance in the basic state is controlled by the combined action of fluid removal caused by the PD dialysis fluid and of diuresis. Many PD patients are thus able to use fluids more freely than patients receiving haemodialysis.
  • Fluid balance in a dialysis patient is monitored by e.g. blood pressure, changes in body weight compared to the basic state, clinical signs of dehydration, possible oedema, dyspnoea and chest x-ray findings.
  • When administering parenteral fluids, potassium-containing fluids should usually be avoided because hyperkalaemia is common, particularly in haemodialysis patients, and e.g. physiological saline is used, with 5% glucose supplement if required.
  • The most effective treatment form in hyperkalaemia is dialysis, but potassium restriction is often also indicated as is potassium-binding Resonium^® powder.
• A dialysis patient may ask a primary care physician to issue various certificates, e.g. for a driving licence or relating to the ability to work.
  • Dialysis treatment as such is not a reason not to drive, and the decisive factor should be the patient's general health.
  • Many forms of employment are available for a dialysis patient, but dialysis-induced problems relating to timetables and restriction to the amounts the patient is allowed to lift may mean retirement from working life. About 25% of dialysis patients hope to receive a kidney transplant after which their ability to work will be reassessed.