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Saturday, March 9, 2013

Dialysis Access

Dialysis patients have many comorbidities. This ranges from heart disease all the way to vision problems. One of the biggest comorbidites with dialysis patients is the management of dialysis access. Unfotunately, I see a lot of hospital admissions for acute dialysis. Due to lack of access, hospital doctors are forced to place a central-line in the neck or groin and start dialysis as soon as possible. The central line placement and management is much more difficult than managing AV fistula. In additon, it exposes the patients to higher risk of infection, bacteremia, and infective endocarditis.

Chronic kidney patients need to stablish care with a caring nephrologist and start being prepared for dialysis in stage 4-5. A close follow up is required to make sure volume status and electrolytes are monitored. This prevents such patients present to emergency room in need of acute dialysis with no prepration.

The best dialysis access is AV fistula which takes 4-6 months before it is ready to be used. Unfortunately many patients start dialysis with temporarly access line in hospital, and then switched to tunneled cath dialysis access. Finally if they have good followup, the AV fistula access is placed. And even then, some the fistulas fail before they are ready to be used or take 6 months to mature.

As you see, the process gets longer and longer and meanwhile patient is exposed to high risk of blood borne infections. In fact, it is not uncommon to find some patients to be dependent on these central-lines for a longtime before they present to hospital for severe infection.

The treatment of temporarly dialysis central line is a nightmare. Why? Because most of the times, the treatment requires the removal of these lines and leave patient with no access for dialysis. Even worse is when the temporarly dialysis line has been in the body for such a long time that blood clots have formed around it.

The management of line infection in dialysis patients requires close cordination between nephrologist, cardiologists, hopital physicians, surgeons, and Interventional radiologist. As you see, the process becomes more and more difficult. Prolong hospitalization of such patients exposes them to more infections and complications.

It is very important to stablish care with nephrologist early in the process. This way, many complications can be avoided. AV fistula placement before need of acute dialysis decreases morbidity and mortality.

What access did you or your loved one used for dialysis for the first time?

Ardavan Mashhadian D.O.
Nephrologist
1127 Wilshire Blvd Suite 510
Los Angeles CA 90017
(213) 537-0328


Tuesday, March 5, 2013

Liver Dialysis


Liver failure is the cause of death for over 30,000 patients each year in the United States. When this process occurs in healthy individuals with normal livers, it is termed acute liver failure (ALF). Loss of liver function that complicates chronic liver disease is termed acute-on-chronic liver failure.

Liver transplantation is curative for ALF and acute-on chronic liver failure. Over the years, survival after transplantation has improved with advances in both patient management and surgical techniques, but the procedure is not always available in a timely fashion, prompting new surgical approaches such as split-liver transplantation, procurement from living donors, and auxiliary liver transplantation.


Liver Function
1. Synthetic
2. Metabolic
3. Detoxification (phase I and II pathways)
4. Biliary excretion

Problems:
1. Organ shortage
2. Predicting the outcome of liver failure

Main cellular approaches that are currently being investigated:
1. Isolated cell transplantation
2. Tissue engineering of implantable constructs
3. Transgenic xenotransplantation
4. Extracorporeal bioartificial liver devices

When to use temporary systems:
1. To expedite recovery from acute decompensation
2. Facilitate regeneration in ALF
3. Serve as a bridge to liver transplantation

Nonbiological approaches:
- Limited success, presumably because of the role of the synthetic and metabolic functions of the liver that are inadequately replaced in these systems.
1. Hemodialysis
2. Hemoperfusion over charcoal or resins or immobilized enzymes
3. Plasmapheresis
4. Plasma exchange have all been explored.

Biological approaches:
- Have been difficult to implement in the clinical setting
1. Liver transplantation
2. Whole organ perfusion
3. Perfusion of liver slices
4. Cross hemodialysis

Artificial detoxification devices currently under clinical evaluation include the Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and the Prometheus system. 



In addition, cell-based therapies are gaining attention as promising treatments for liver failure. Currently, several extracorporeal bioartificial liver devices are undergoing clinical evaluation. Xenogenic primary cells are available in large quantities, but immunologic and infectious concerns may necessitate the use of human cells or human-derived cells.





resources:
1. JARED W. ALLEN,TAREK HASSANEIN, SANGEETA N. BHATIA1. Advances in Bioartificial Liver Devices http://web.mit.edu/lmrt/publications/2001/Allen2001_Hepat.pdf

2. http://en.wikipedia.org/wiki/Liver_dialysis

Ardavan Mashhadian D.O.
Nephrologist
1127 Wilshire Blvd Suite 510
Los Angeles CA 90017
(213) 537-0328