00:01
Hello, and welcome back.
00:02
Today we're going to be
talking about
Renal Replacement Therapy
and our Nephrology Curriculum.
00:08
So, before we get started,
I think it's really important
to look at
the prevalence of
end-stage renal disease
in patients in the United States.
00:16
So remember,
end-stage renal disease
are patients who have
stage five chronic kidney disease,
and are eligible for
renal replacement therapy.
00:23
What I want you to notice is that
on the y-axis,
we have number of patients in need
of renal replacement therapy
by the thousands.
00:30
So that top line
represents 800,000.
00:33
Whereas the x-axis represents time
starting from 1980,
all the way through 2016.
00:39
This is data taken from our USRDS,
that's the
United States Renal Data Systems
looking at dialysis patients.
00:46
And what I want you to focus on
is that red line.
00:49
These are all
end-stage renal disease patients.
00:52
And what's interesting is that
you can see in 1980
was maybe only 10s of thousands
of patients
who were in need of
renal replacement therapy.
01:00
But look at what's
happening now.
01:02
In 2016, we now have about
700,000 people
that are on
renal replacement therapy.
01:08
And that's either hemodialysis
represented by the yellow line,
peritoneal dialysis
represented by the blue line,
and transplant
represented by the green line.
01:17
Why is this so important?
In addition to causing
incredible morbidity and mortality
in these populations,
it's also a very big cost to the
healthcare system.
01:27
A dialysis patient costs about
$88,000 per year.
01:31
A transplant patient cost about
$27,000 per year.
01:35
So it's a significant issue
when it comes to both
the care of the patient,
and the cost
to the healthcare system.
01:42
So let's talk
a little bit more about
what renal replacement therapy is?
It's a life supporting therapy in
patients who have renal failure.
01:51
Their kidneys aren't working
anymore,
so we have to have something
that can do the job for them.
01:56
It can be either acute or chronic.
01:59
So when a patient has
acute kidney injury,
and they have complications
from renal failure,
it would be critical to start
renal replacement therapy
with hemodialysis.
02:08
However, if a patient has approached
chronic kidney disease,
and now has transitioned to the need
of renal replacement therapy
because they have stage 5
chronic kidney disease,
that would be
chronic renal replacement therapy.
02:20
So renal replacement therapy
involves:
removing solute,
normalization of electrolytes
and acid base status,
and removal of extracellular volume
that means salt and water.
02:31
So what are the indications
for doing renal replacement therapy
in our patients?
If patients develop
uremic syndrome.
02:39
These are symptoms and signs
that result from toxic effects
of elevated levels
of nitrogenous waste,
and other wastes in the blood.
02:46
These are things like
aliphatic amines,
uremic phenols,
guanidines,
and middle-sized molecules
like beta-2 microglobulin.
02:53
One thing I want to draw
your attention to:
Urea is not responsible
for uremia.
02:59
We talked about it quite a bit
but we only use it as a marker
for solute removal.
03:04
Having a high urea level
doesn't necessarily mean
that a patient is uremic.
03:10
So we talked about
the symptoms of uremia
as being an indication for
renal replacement therapy.
03:14
What are those?
That includes:
nausea,
vomiting,
anorexia, meaning that
our patients just aren't hungry,
dysguesia, that means patients
have an abnormal taste,
and they might describe their
food tasting metallic in quality
or like cardboard.
03:30
Pruitus, meaning that
our patients are very itchy.
03:33
And having alterations in sleep.
03:35
They might have insomnia at night,
but have daytime hypersomnolence.
03:39
And a sensation of being cold.
03:41
That's one of the
earliest manifestations people feel,
but they might be cold
when everybody else is hot.
03:46
And then finally
cognitive changes
where they just can't
think correctly.
03:50
Some of the signs of uremia
this is what we can see on
physical exam
is that patients might have
a sallow discoloration of the skin.
03:57
They might have an ammonia odor
to the breath it's very distinct.
04:00
And you will be able
to recognize that.
04:03
They could have a
pericardial friction rub
from a pericardial effusion.
04:07
So it's important to do a good
cardiopulmonary examine
on those patients.
04:11
They might have
myoclonus or seizures.
04:13
So they have muscle irritability,
and sometimes that actually
manifests with hiccups as well.
04:18
They might have foot or wrist drop
from uremic motor neuropathy.
04:22
And finally, they can have
prolongation of bleeding time
or from uremic platelet dysfunction.
04:27
So it's interesting because
there is a relationship between
the development of uremic syndrome,
and glomerular filtration rate.
04:35
So the uremic syndrome
will predictably develop
when that GFR falls
below 10 mL/minute.
04:42
Most patients will require
renal replacement therapy
once that GFR falls between
6 and 15 mL/minute.
04:47
And I do want to say, that
there is no data to suggest that
starting renal replacement therapy
early in patients
will portend a better outcome.
04:57
And in fact,
with some of the data
that we do have available
there's a signal towards harm
if you start patients
too early.
05:03
So we really wait until
a patient absolutely needs dialysis
before starting it.
05:08
And our younger healthier patients
that might be a GFR of about
6 mL/min.
05:14
So when it comes to talking about
different types of
renal replacement therapy,
there's a few choices that we have
for our patients.
05:21
This includes hemodialysis,
peritoneal dialysis, and transplant.