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
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Peritoneal Dialysis Complications

Complications
1. Peritonitis and Catheter-Related Infections: Peritonitis is thought to occur most often by touch contamination, but may also occur in the setting of a catheter exit site or tunnel infection. Patients with peritonitis usually present with cloudy peritoneal fluid and abdominal pain. Infections due to gram-positive cocci (Staphylococcus epidermidis and Staphylococcus aureus) tend to be most common (60–70% episodes) compared to infections with gram-negative bacteria (15–25%) or fungi (2–3%). Treatment should be continued for a total of 2 weeks, while more severe infections due to S aureus, pseudomonas, or multiple gram-negative organisms should be treated for 3 weeks. Patients should be taught to perform routine exitsite care in order to prevent catheter infections. Daily cleansing with antibacterial soap and water is recommended by most centers. The daily application of mupirocin or gentamicin cream to the exit site has been shown to be effective in reducing catheter infections and related peritonitis.

2. Mechanical Complications such as hernia, scrotal or labial edema.

3. Encapsulating Peritoneal Sclerosis: a rare but serious condition characterized by extensive intraperitoneal fibrosis and encasement of bowel loops.

4. Ultrafiltration Failure

5. Metabolic Complications

Indications for peritoneal dialysis catheter removal:
1. Refractory peritonitis: failure to respond to appropriate antibiotics within 5 days

2. Fungal peritonitis

3. Relapsing peritonitis

4. Peritonitis in the setting of severe exit site or tunnel infection

5. Peritonitis due to multiple enteric organisms in the setting of a surgical abdomen

Dietary modifications:
A protein intake of at least 1.2 g/kg is recommended for PD patients.

National Kidney Foundation has great handbook. To view please Click Here
For information on nutrition and peritoneal dialysis please Click Here

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Types of Peritoneal Dialysis

Types of Peritoneal Dialysis
1. Continuous Ambulatory Peritoneal Dialysis: In CAPD dialysis solution is constantly present in the abdomen, typically being exchanged four to fives times per day, 7 days per week. The dialysis fluid is exchanged manually by the patient using the force of gravity to drain and fill the abdomen.

2. Automated Peritoneal Dialysis: In APD a cycler machine automatically exchanges fluid into and out of the abdomen for the patient. The cycler draws dialysis solution from larger bags (usually 5 L), which it warms to the desired temperature. The patient usually spends between 8 and 10 hours a night on the cycler, disconnects from the cycler in the morning after a final fill is delivered, and then is free to go about daily activities.

3. Intermittent Peritoneal Dialysis: IPD is a form of PD that is usually performed in a hospital or in a dialysis center. It is usually reserved for patients with acute renal failure or end-stage renal failure and sometimes for patients immediately after catheter placement who are uremic and need more urgent dialysis.

Not all patients' peritoneal membranes transport solute at the same rate. In clinical practice, a patient's peritoneal membrane transport characteristics can be determined by measuring the creatinine equilibration curve and the glucose absorption curve during a standardized peritoneal equilibration test (PET). Patients are classified principally into one of four transport categories: high, high-average, low-average, and low. High transporters tend to do better on regimens that have frequent, short duration dwells, such as APD, whereas low transporters tend to do better on regimens with longer duration dwells, such as CAPD. Average transporters are generally able to do well on a variety of PD regimens.


National Kidney Foundation has great handbook. To view please Click Here
For information on nutrition and peritoneal dialysis please Click Here

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Peritoneal Dialysis Indications and Contraindications

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Peritoneal dialysis (PD) PD is a form of dialysis in which a dialysis solution is instilled in the peritoneal cavity, periodically drained, and exchanged with fresh solution through a single, indwelling peritoneal catheter. It is a established form of renal replacement therapy that is used around the world. United States Renal Data System (USRDS) data from 1998 to 2002 indicate that the prevalent PD population decreased by 3.5% per year, with only 8% of prevalent dialysis patients being treated with PD in 2002. In contrast to the experience in the United States, the prevalent number of patients with end-stage renal disease receiving PD has exceeded 60% in other countries, such as in Mexico and Hong Kong. The cause for these differences is likely multifactorial and is related to access to PD, physician expertise, patient mix, and reimbursement.

Indications:
1. PD continues to be the preferred dialysis modality for infants and young children

2. Patients with severe hemodynamic instability on hemodialysis

3. Patients with difficult vascular access

Contraindications:
1. The one absolute contraindication to chronic PD is an unsuitable peritoneum due to the presence of extensive adhesions, fibrosis, or malignancy.

2. Abdominal hernias

3. Presence of colostomy, ileostomy, nephrostomy, or ileal conduit

4. Recurrent chronic backache with preexisting disc disease

5. Severe psychological and social problems

6. Severe diverticular disease of the colon

7. Severe neurologic disease, movement disorder, or severe arthritis preventing self care. (caregivers can be trained to perform the peritoneal dialysis)

8. Severe chronic obstructive pulmonary disease

9. Malnutrition

Studies investigating differences in patient mortality between PD and hemodialysis (HD) have been conflicting. Most reports have shown no significant difference in survival between PD and non-diabetic HD patients.



National Kidney Foundation has great handbook. To view please Click Here
For information on nutrition and peritoneal dialysis please Click Here

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Contrast Induced Kidney Damage

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Multiple studies have suggested that in-hospital mortality is significantly higher in patients developing contrast induced kidney damage especially those who require hemodialysis. 

Risk Factor

1. Hx of Chronic Kidney Disease

2. Congestive heart failure

3. Older age

4. Hypotension 

5. Volume depletion

6. Concomitant use of nephrotoxins such as nonsteroidal anti-inflammatory agents also increase the risk for contrast induced kidney damage.

In the majority of patients with contrast induced kidney damage, the serum creatinine value begins to rise within 24–48 hours after contrast media exposure, peaks within 3–5 days, and returns to baseline levels within 7–10 days. The majority of patients are nonoliguric and often have low urine sodium concentration. The urinalysis in patients with contrast induced kidney damage typically demonstrates coarse granular casts, renal tubular epithelial cells, and amorphous debris, findings characteristic of acute tubular necrosis.

Most studies, although not all, suggest that exposure to larger volumes of parenteral contrast causes greater predisposition to contrast induced kidney damage. In addition, the type of contrast material (specifically its osmolality) influences the development of contrast induced kidney damage. Contrast media formulations occur in three types: High-osmolar contrast media (also termed ionic), which have an osmolality of approximately 2000 mOsm/L, low-osmolar contrast media (also termed nonionic), which have an osmolality of 600–900 mOsm/L, and iso-osmolar contrast media (also a nonionic composition), which have an osmolality of 300 mOsm/L. Multiple studies in high-risk patients with CKD have demonstrated that low-osmolar contrast media results in less contrast induced kidney damage than high-osmolar contrast media, and there is some evidence that iso-osmolar contrast media may be less nephrotoxic than low-osmolar contrast media.

Differential Diagnosis

1. Acute Tubular Necrosis

2. Renal atheroembolism

3. Allergic interstitial nephritis 

Prophylaxis

1. Begin an infusion of isotonic sodium bicarbonate at 1ml/kg/hr for 12 hours pre- and post-procedure

2. The most commonly employed dose of NAC is 600 mg by mouth twice daily the day prior to and the day of contrast administration. Initially, this finding was greeted with widespread enthusiasm and the use of NAC quickly became common in clinical practice. Subsequent studies of its efficacy have been mixed, as have meta-analyses of those studies. To date, it remains uncertain if NAC is an effective preventative measure, but it is nonetheless often used in clinical practice, based on its safety, simplicity, and low cost.

3. Although acute administration of diuretics has been shown to increase the risk of contrast-induced acute kidney injury, the discontinuation of chronic diuretic therapy has not been demonstrated to be beneficial.

4. Discontinuation of ACE Inhibitors has not been clearly shown to decrease the risk of contast induced acute kidney injury. 

Treatment

There is no specific therapy for contrast induced kidney damage once it occurs. The best strategy is one of prevention. Preemptive nephrologic consultation to ensure that optimal prophylactic strategies are provided may be of value in certain high-risk azotemic patients.

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328

Pros and Cons of Monetary Compensation in Kidney Transplantation

Demand for organs has always exceeded supply. In order to resolve the shortage of donors, some have advocated financial payments being made to donors. Despite being illegal in most countries, the trade appears to be booming in nations such as Turkey, Russia, and South Africa

In 2008, the legislative branch of the Israeli government, approved a law that provides for various benefits to living organ donors, such as:

1. Reimbursement for medical expenses and lost work up to $5,000
2. Priority on the transplant list should they require a future organ donation
3. Waived self-participation fee for any medical service resulting from the donation
4. Attainment of a "chronic patient" status, which entitles the holder to additional medical benefits. 
5. If two patients have the same medical need, priority will now go to the patient who has signed an organ donor card, or whose family members have donated an organ (though medical necessity is still takes precedence).

One of the few countries that has legalised the sale of organs is Iran. A third-party independent association was set up to arrange contact between donors and recipients. This agency is staffed on a voluntary basis by end-stage renal failure patients. Within the first year of the establishment of this system, the number of transplants had almost doubled; nearly four fifths (80%) were from living unrelated sources. Donors receive:

1. A Payment from the government

2. Free health insurance 

3. Often payment from the recipient or a charity

The receiver of the ‘new’ kidney is provided with highly subsidized immunosuppression and charitable organizations allow those unable to pay for the transplant themselves to receive a new organ. Importantly, it is illegal for the medical and surgical teams involved or any ‘middleman’ to receive payment. A potential donor is also not allowed to contact anyone on the waiting list. Despite, this, anecdotal stories of young men touting their ‘spare’ kidney in dialysis clinics are common.

While still illegal in ‘Western’ nations, could the ‘Iranian model’ of payment for kidney donation be used in Unites States to solve the problems of kidney donor shortages? 

Pros:

1. The advocates for legalization argue that each of us has autonomy over our own body in every aspect of our health and that from this stems the right to donate a kidney to a related or non-related patient. Payment for sperm and eggs is legal in many countries, even though they arguably have greater long-term implications due to the potential to create a whole new individual. Similarly to compensation received for participation in some clinical trials, the individual also gains no immediate benefit from putting themselves at risk.

2. After the initial peri-operative risk, the donor has no long term increased risk of mortality.

3. Most importantly, in the longer term, there is no significant acceleration in decrease in glomerular filtration rate (beyond that expected due to aging) in kidney donors fifteen years after transplantation. 

4. Charitable organizations allow those unable to pay for the transplant themselves to receive a new organ

5. Advocates of the Iranian model insist that where there was once a significant waiting time in excess of the length in ‘Western’ nations, there is now no waiting time. 

6. The Iranian system is known to have ethical and legal loopholes which have been exposed and exploited. 

7. There are “no significant differences” in groups of donors and recipients when compared in terms of socioeconomic background (wealth and education level). Thus significant social exploitation is not occurring. 

8. One of the earliest problems involved patients from abroad travelling to Iran to receive a kidney donation from an Iranian. This practice was outlawed to prevent the development of true ‘transplantation tourism’ and international exploitation of Iranian donors. In addition, refugee groups (such as those from Afghanistan) are offered transplants but are not allowed to donate to people outside of their ethnic groups, further decreasing potential exploitation of vulnerable groups.

9. As ESRD continues to grow in prevalence, the problem of unregulated organ markets and brokers is likely to become more severe. It is argued that the setting up of regulated markets would ‘cut out the middleman’ and reduce the exploitation of individuals and developing nations.

10. Inferior surgical and medical practice, common on the black market, leave both the donor and recipient at greater risk whilst the broker pockets a large cut of the proceeds.

11. The end-stage renal failure population continues to increase in most countries, putting an increasingly heavy load on medical infrastructure. Using economic cost-effectiveness analyses, a figure of approximately $90,000US has been proposed, much less than the estimated cost of dialysis of up to $70,000US per annum per patient. Government intervention would also guarantee adequate post-operative care and follow-up for the donor, something which is currently limited.

Cons:

1. The downside of legalizing Kidney trade is that the majority of those selling kidneys in Iran are disproportionately poor. 

2. Opponents argue that the donation of a kidney is permanent.

3. Iranian system insist that the systemis not as perfect as it seems. 

4. There is evidence to suggest Iran’s system has not cleared its waiting list and that trading between socioeconomic classes is a substantial problem. 

5. Critics of the Iran model would argue that even this well developed system has major flaws and that a ban on payment to kidney donation should be maintained in other parts of the world.

A possible compromise

1. A non-monetary reward system. For instance, patients who have previously agreed to be on the transplant list could receive priority health care.

2. It has also been suggested that governments should control the monetary aspects of the transactions rather than payment passing directly from individual to individual. The donor would effectively sell their organ to the state which would then allocate it on the basis of clinical need. By making the process more medically transparent, it may placate to some degree those who accuse pro-monetary transplantation advocates of disregarding the exploitation of the poor by the rich. It is also likely that a ‘fair’ standard price could be set to prevent those in desperate financial need from being even further exploited. 

As the pressure of demand for organs continues to increase rapidly, the idea of financial compensation for kidney donation will continue to rise. 

References:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322914/

Griffin A. Kidneys on Demand. BMJ. 2007;334:502–505.

Ghods AJ, Savaj S. Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation. Clin J Am Soc Nephrol. 2006;1:1136–1145.

http://en.wikipedia.org/wiki/Knesset

Ardavan Mashhadian D.O.

Nephrologist

1400 S Grand Ave Suite 615, Los Angeles, CA 90015

(213) 537-0328

Erectile Dysfunction in Chronic Kidney Disease Patients

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Sexual dysfunction is very common in patients with chronic kidney disease. Kidney disease can cause chemical changes in the body affecting circulation, nerve function, hormones and energy level. The condition has been found to be significantly more common in men and women with chronic kidney disease (CKD) than in the general population. Approximately 50% of male predialysis CKD patients and 80% of male dialysis patients have erectile dysfunction. Multiple factors contribute to the frequent occurrence of sexual dysfunction in CKD patients, including hormonal disturbances such as hyperprolactinemia, hypogonadism in males.

Causes of erectile dysfunction in chronic kidney disease:
1. Diabetes 
2. High Blood pressure
3. Men with renal disease may find their hormone levels changing
4. Side effect of medicines, particularly those taken to control blood pressure
5. Symptoms such as breath and body odor, weight gain or unusual facial or body hair may be present
6. A man on hemodialysis may feel self conscious about how his vascular access site looks and feels
7. Men on peritoneal dialysis may worry about the size of their abdomens
8. Some men with kidney disease are afraid sexual activity may be harmful to their condition or harmful to their partners. 
9. Anemia due to kidney disease
10. Chronic kidney disease mineral and bone disorder

Treatment must start with determining and treating the underlying causes. Honest evaluation of alcohol, tobacco, and recreational drugs is essential. Assessment of emotional life, i.e. how well the patient gets along with his partner is vital. He may benefit from a referral to a psychotherapist, or the couple may be advised to seek marriage guidance. For men in whom vascular problem appears to predominate: Doppler studies, pharmacocavernosometry, pharmacocavernosography, dynamic infusion studies, and colour Doppler response studies may be helpful. 

Once erectile dysfunction is diagnosed and psychosexual component is ruled out a review of the drugs, haemoglobulin levels and dialysis adequacy should be corrected. They should have hormonal studies, including testosterone, LH, FSH, and prolactin. Correction of these hormones may not necessarily restore libido. The use of testosterone injections have shown only a small and variable response in erectile function. Using clomiphene in uraemic males may correct the androgen deficiency and increase the sense of well‐being, libido, and potency, similarly to testosterone administration; however, its long‐term use in uraemia is inconclusive.  To treat erectile dysfunction, bromocriptine in doses of 2.5–5 mg has been shown to improve libido and potency; the mechanism, however, remains unclear and it is possible that bromocriptine may influence potency directly as a result of its dopaminergic properties.

Treatment of erectile dysfunction in chronic kidney disease:
1. Your doctor can perform blood work to determine if your lack of interest in sex is due to your changing hormone levels. He may prescribe medicine to bring your levels to a normal range.
2. Talk to your doctor about the blood pressure medications you are taking if you are experiencing impotence. 
3. Phosphodiesterase-5 inhibitors (PDE5i) such as viagra compared with placebo significantly increases sexual performance.
4. Oral zinc supplementation results in a significant increase in plasma testosterone concentration along with an increase in the potency and frequency of intercourse. 
5. Only sparse data are available for vitamin E, bromocriptine, and dihydroxycholecalciferol in CKD patients and no trials assessed intracavernous injections, transurethral injections, mechanical devices, or behavioral therapy in CKD. 

Therapies that have been used to treat sexual dysfunction include phosphodiesterase-5 inhibitors (PDE5i), intracavernosal injections, intraurethral suppositories, hormonal therapy, mechanical devices, and psychotherapy.
Studies have also identified significant associations between sexual dysfunction in chronic kidney disease patients and depression, impaired quality of life, and adverse cardiovascular outcomes. Effective treatment of sexual dysfunction in CKD patients may therefore potentially lead to improvement in these patient-level outcome. There are now many new assessment techniques and treatments. There are encouraging reports in the use of phosphodiestrase 5‐inhibitors use in patients with CKD. A greater awareness of this common problem should be encouraged so that patients and their partners do not feel embarrassed about broaching this subject with their physicians. Although renal transplant may effectively reverse many of the hormonal and psychological changes of chronic renal failure, many patients will remain on a transplant waiting list for a considerable length of time. Patients who develop significant vascular disease may still remain impotent even after a successful transplant.

Resources:
http://cjasn.asnjournals.org/content/5/6/985.abstract
http://ndt.oxfordjournals.org/content/15/10/1525.full
http://www.davita.com/kidney-disease/overview/living-with-ckd/male-sexuality-and-chronic-kidney-disease/e/4900

Ardavan Mashhadian D.O.
Nephrologist
1400 S Grand Ave Suite 615, Los Angeles, CA 90015
(213) 537-0328