Elisa’s Survival Guide to Hillcrest Renal Consult

Inpatient Dialysis Unit: x36871 Door code: 1,3

Outpatient Dialysis Unit: x35646 (Useful to get pt’s dialysis prescription & meds)
On-call dialysis nurse: call operator

Who goes to which service?

Attending to Call
C Service *If pt received transplant within 1 yr Transplant
*If pt has a transplant and is NOT followed by
UCSD
A Service Everyone else Your attending
B Service Outpatient --

Call:
-2nd weekend (Friday through Sunday) -> cover A Service only and Outpatient Dialysis Unit (not Transplant)
- Wednesday night each week  A Service and Transplant Service

Most Common Things You Get Called About:

1) CRRT:
-Access pressure is too high or catheter is not working
*Give TPA 2mg and let sit for 1 hour, then retry
-Filter clotted
*Shut off machine and replace filter

2) CT with contrast in renal failure

-If pt already on hemodialysis, then it doesn’t matter -> say ok
-If pt is not on hemodialysis but CT is urgent b/c condition is life-threatening, then tell them to weight
risk vs. benefit; if not life-threatening, try to do CT without contrast

3) MRI with gadolinium

-If GFR>30, then ok
-If GFR<30, then no

4) Peritoneal dialysis patients presenting with peritonitis

-Get fluid and send for cell count, culture
-No data to support giving abx through catheter. Just give IV abx and reevaluate in AM

5) Outpatient calls (ie, transplant pt calling w/ diarrhea, fever, anything) -> tell them to go to the ED

6) Fever on dialysis (calls from Outpatient Dialysis Unit)

- If pt has fistula/graft/line -> give Vanc (1gm) & Gent (1.5mg/kg), then if they feel ok after dialysis, pt
can go home.
- If pt is not ok or unsure -> tell them to send pt to ED

7) Pt hypertensive on hemodialysis
- If pt is symptomatic, send them to ED
- If pt feels ok, can give PO clonidine and reevaluate

8) General rule for calls from Outpatient Dialysis Unit or direct calls from patients: if they don’t feel ok,
tell them to go to the ED
 9) Transplant Eval (Weekday calls only)
- Check EKG, CXR, labs
- Make sure pt has does not have signs of infection
- Recent cath? (can check in Epic for transplant note)
- coagulation disorders to require heparin intraop?
- call Transplant attending -> depending on who it is, he/she may not have you go into to see pt

How to Determine Efficiency of Dialysis:

1) Uremic Reduction Ratio = Pre BUN – Post BUN > 60%

Pre BUN

2) KT > 1.4
V
• where K is a constant based on the dialyzer, T is time on dialysis, V = volume of distribution
• Way to increase KT/V is to increase time on dialysis or change dialyzer
• Fatter people (higher volume of distribution) will have less efficient dialysis (or require more time)

Chronic Kidney Disease:

1) BP control: diuretics, b-blockers
2) Anemia: goal Hgb 11-12 -> give Epo
Fe sat goal 25% -> if below goal, give IV Venofer 100mg IV on HD x10
3) Acidosis: bicarb goal <22 -> give Sodium bicarb 650mg BID & titrate up
Bicitra (liquid) increases bicarb by 1mEq/ml
4) Ca xPO4 product <55
5) PTH (secondary hyperparathyroidism): goal is to keep PTH within normal limits by:
- Decrease PO4 -> PhosLo (Ca acetate), Renagel, Lanthanum (give when on tubefeeds, must be crushed)
- replace Vit D
- Sensipar (activates Ca-sensing receptor in various tissues/organs) if can’t give Vit D and PO4 already
low/normal

*Ca best absorbed between meals; if given with meals, acts as phos-binder
Dialysis Orders: fill out orders as below
Intermittent Hemodialysis:
The Form: Adult Acute Hemodialysis (located in closet outside of dialysis unit)
Diagnosis: AKI or ESRD
Allergies: See PCIS
Indications: Fluid management
Acid/base/electrolyte management
Duration of treatment: usually 3.5 hrs (unless new on dialysis, then do 1 hr the 1st time)
Access: check off the type of access pt has
Machine: Fresenius
Dialyzer: F160 (always)
HD Mode: UF + HD (usually)
Dialysate flow: 800ml/min unless new on dialysis, then do 500ml/min
Dialysate composition: check off Custom
Na: 140 (unless serum Na super low)
K: goal is to get serum + dialysate K = 7
Bicarb: 35
Ca: if corrected Ca normal -> 2.5
“ “ Low -> 3
“ “ High -> 2 (I’ve never given 1)

Anticoagulation: tight heparin unless pt can’t get heparin for any reason (recent bleed, etc)
If can’t get heparin, use saline flush

Maintain blood flow: write “max” unless new on dialysis, then ask fellow
Ultrafiltrate goal: usually 2.0 – 3.0 L
Notify MD if DBP>110 or SBP<90
For BP support, give: check off 0.9% NaCl and Albumin 5% IV 50ml x2 doses
Transfusions: if blood products to be given w/ HD, check off the type
Medications: if abx to be given w/ HD, write it in
Epo: If Hgb <10, give 10000 units IV
10-11, give 4000 units IV
11 or above, no Epo
Catheter lock solution: sodium citrate (0.14M) 4% only if pt has a tunneled catheter/line
If fistula/graft, no need for catheter lock

Lab work: always get postdialysis BUN/Cre

Special orders: ie Blood cultures, other labs

CRRT orders:
The Form: Adult CRRT Protocol – make sure to use the Citrate one (NOT heparin)
Diagnosis: AKI or ESRD etc
Indications: Fluid management
Acid/base/electrolyte management
Access: check off pt’s access
Modality: CVVHDF (always)
Machine: PrismaFlex (always)
Filter: PrismaFlex Set HF1000 (always)
Blood flow: 100ml/min
Dialysate:
NaCl: should add up to 40 w/ NaHCO3
NaHCO3:
K: 5, 6, or 7 (usually start off at 5, then ask nurse if lots of K had to be given, can increase if lots of
replacement had to be given.)
Mg Sulfate: 3
Dextrose: 0.1% (can increase to as high as 0.5% if pt is hypoglycemic)

Flow rates: circle the numbers under “Standard”

Post filter: normal saline
Pre filter: normal saline

Replacement fluid: (use either pH or bicarb scale)

Solution pH scale Serum Bicarb (Bicarb scale)
Normal saline >7.35 >22
0.45% normal saline + 75mEq bicarb 7.3 – 7.35 18-22
Sterile water + 150mEq bicarb <7.3 <18

Replacement fluid flow rates:

- Net negative -> if pt is fluid overloaded
- Keep even -> if sepsis & team can give additional fluid boluses
- Net positive -> pancreatitis, burn patients

Anticoagulant:
Citrate: 140ml/hr (if pt has liver dz, start at 120ml/hr since they won’t be able to metabolize citrate as well)
Do not increase citrate rate below 120ml/hr
Do not increase citrate rate above 200ml/hr

Calcium choride: start at 40ml/hr

Do not increase calcium chloride rate above 100ml/hr (if gets above 100ml/hr, cut back both Ca and
citrate rate by 30%)

Renal MD pager # 6500

Intraoperative SLED (sustained low efficiency dialysis)

*Certain liver transplant surgeons like to use dialysis during surgery -> use SLED in this case
*Flow of SLED is slower than hemodialysis but faster than CVVHD

Fill out form like you do for Hemodialysis except for the following changes:
Maintain blood flow of 200ml/min
Dialysate composition: check off Standard
Ultrafiltration goal: determined by Anesthesia (leave blank)
Catheter lock solution: 4% citrate

Plasmapheresis:
Calculate plasma volume:
Plasma volume = 0.07 x weight x (1 – Hct)
Each unit FFP = 250cc
Machine: Centrifugal – Cobe Spectra
Blood flow: 70-80cc/hr
Anticoagulation: citrate 1:14
CaCl (2gm of 10% CaCl solution in 250cc normal saline): 80cc/hr

For TTP:
-use all FFP

For others (ie Myasthenia gravis):

-use 2/3 plasma volume of 5% albumin and 1/3 plasma volume of normal saline
-Check fibrinogen at the end and if low, give 2 units FFP