All patients undergoing long-term renal replacement therapy (NRT), develop accompanying metabolic or other disorders. These disorders require appropriate attention and an additional therapy. The procedure varies from patient to patient, but usually includes a change in diet and treatment of multiple metabolic abnormalities one (Chronic kidney disease: diet).
(See also overview of the renal replacement therapy.) All patients undergoing long-term renal replacement therapy (NRT), develop accompanying metabolic or other disorders. These disorders require appropriate attention and an additional therapy. The procedure varies from patient to patient, but usually includes a change in diet and treatment of multiple metabolic abnormalities one (Chronic kidney disease: diet). Diet The diet should be monitored closely. Hemodialysis patients typically prone to anorexia and should be encouraged, daily 35 kcal / kg of their ideal body weight to consume (40-70 kcal / kg / day, depending on age and activity in children). The daily intake of sodium should be at 2 g (88 mEq) of potassium to 2.3 g (60 mEq) and phosphate (PO4) can be limited to 800-1000 mg. The liquid absorption is limited to 1000-1500 ml / day and is controlled based on the measurement of weight gain between the individual treatments. Patients undergoing peritoneal dialysis need a protein intake of 1.25 to 1.5 g / kg / day (compared to 1.0-1.2 g / kg / day in hemodialysis patients) to replace peritoneal losses ( 8.4 +/- 2.2 g / day). The best survival is at (hemodialysis and peritoneal dialysis) patients who had a serum albumin maintained> 3.5 g / dl. The serum albumin is the best predictor of survival of these patients. Clinical Calculator: Ideal body weight anemia in kidney failure Anemia that occurs in renal failure should be treated with recombinant human erythropoietin and Eisensupplementation (Chronic kidney disease: anemia and bleeding disorders). Since the absorption of oral iron is limited, many patients require i.v. Iron during hemodialysis. (Ferric and sodium gluconate Eisensucrose iron dextran are preferred, which has a higher incidence of anaphylaxis.) Iron depots are judged by serum iron, total iron binding capacity and serum ferritin. Typically, iron stores prior to starting therapy with erythropoietin and judged every two months. Iron deficiency is the most common reason for Erythropoietinresistenz. Some dialysis patients who have received many blood transfusions, however, have iron overload and should get no iron replacement. Coronary heart disease risk factors for coronary heart disease must be tackled aggressively because many patients who need a NET therapy, suffer from hypertension, dyslipidemia or diabetes, smoking and eventually die of cardiovascular disease. CAPD is more effective than hemodialysis for the removal of liquid. As a result, hypertensive patients require less antihypertensive drugs. At about 80% of the hemodialysis patients hypertension is controlled but also by only filtration. The remaining 20% ??of antihypertensive drugs are required. The treatment of dyslipidemia, diabetes control and smoking cessation are important. Hyperphosphatemia A hyperphosphatemia as a result of a phosphate retention at low GFR increases the risk of Weichteilkalzifikation, especially the coronary arteries and heart valves, when Ca × PO 4> 50-55. It also promotes the development of secondary hyperparathyroidism. The initial treatment are calcium-containing antacid (calcium carbonate 1.25 g p.o. 3 times a day, calcium acetate 667-2001 mg p.o. 3 times daily with meals), which act as a phosphate binder and reduce phosphate levels. Constipation and distension are complications of long-term use. Patients should be monitored for hypercalcemia. Sevelamer hydrochloride, 800-3200 mg, or lanthanum carbonate, 250-1000 mg or Sucroferric oxyhydroxide 500mg to 1,000 mg at each meal, are an option for patients who develop hypercalcemia while taking calcium-containing phosphate binders. Some patients (eg. As those who are admitted with acute kidney injury and very high serum phosphate levels) need additional aluminum phosphate binder, but these drugs should only be used short term (eg., 1-2 weeks as needed) to an aluminum toxicity to prevent. Hypocalcemia and secondary hyperparathyroidism These complications often coexist as a result of impaired renal production of vitamin D. Treatment of hypocalcemia consists of the administration of calcitriol either orally (0.25-1.0 ug p.o 1 times daily) or iv (Per dialysis 1-3 micrograms in adults and 0.01 to 0.05 micrograms / kg in children). The treatment can increase serum phosphate levels and should be stopped to avoid Weichgewebekalzifikationen until the levels have returned to normal. The dosage is titrated to the parathyroid hormone (PTH) to press normally 150-300 pg / ml (PTH reflects bone metabolism better resist as serum calcium). Oversuppression decreased bone metabolism and results in adynamic bone disease, which involves the risk of fractures with it. The vitamin D analogues doxercalciferol and paricalcitol have less effect on calcium and phosphate absorption in the duodenum, but suppress PTH equally good. The first evidence that these drugs can reduce the mortality compared with calcitriol, are still subject to confirmation. Cinacalcet, a calcimimetic, increases the sensitivity of the calcium-sensitive receptors of the parathyroid compared with calcium, and may be also displayed in a hyperaldosteronism, but the role in everyday practice is not yet defined. Its ability to reduce PTH levels by up to 75% can reduce the need for parathyroidectomy in these patients. Aluminum toxicity The toxicity is the risk in hemodialysis, the dialysate aluminiumkontaminiertem and phosphate binders are (unusual now) exposed based on aluminum. Manifestations are osteomalacia, microcytic anemia (iron-resistant) and probably a dialysis dementia (a constellation of memory loss, dyspraxia, hallucinations, Grimacing, myoclonus, seizures, and a typical EEG). Aluminum toxicity for patients who are receiving NET, and develop osteomalacia, iron resistant microcytic anemia or neurological manifestations such as memory loss, dyspraxia, hallucinations, grimaces, myoclonus or seizures, should be considered. Diagnosis is by measuring the plasma aluminum levels before and two days after i.v. Infusion of deferoxamine, 5 mg / kg, provided. Deferoxamine “chelates” Aluminum, it triggers of tissues and increases the blood levels in patients with aluminum toxicity. An increase of the aluminum level to ? 50 g / l speaks of intoxication. Osteomalacia caused by aluminum can also be diagnosed by a bone needle biopsy that requires a special stain on aluminum. The treatment is to avoid aluminum-containing phosphate binders plus i.v. or intraperitoneal administration of deferoxamine. Tips and risks An aluminum toxicity should be considered in RRT patients with osteomalacia, iron resistant microcytic anemia or neurological symptoms into consideration. Bone disease renal osteodystrophy is an abnormal bone mineralization. This has several causes, including vitamin D deficiency, increased serum phosphate, secondary hyperparathyroidism, chronic metabolic acidosis and aluminum toxicity. treating the cause. Vitamin deficiency vitamin deficiencies resulting from the dialysis-related loss of water-soluble vitamins (z. B. Vitamin B, C, folate), and can be compensated by daily administration of multivitamin preparations. Calciphylaxis calciphylaxis is a rare disorder of systemic arterial calcification, ischemia and necrosis caused in localized areas of the fat and the skin of the fuselage, the buttocks and lower extremities. The cause is unknown. But one thinks of a serious hypoparathyroidism, vitamin D supplementation and increased calcium and phosphate (PO 4) levels. It manifests itself with painful, violet-purple, itchy plaques and nodules that ulcerate, form crusts and inflamed. It is often fatal. Treatment is generally supportive. It has been reported by several cases in which sodium i.v. was given at the end of dialysis 3 times / week, along with aggressive efforts to reduce the serum calcium x PO4 product, which has led to a significant improvement. Constipation Constipation is a rather smaller but annoying consequence of long-NET, as a result of abdominal overstretching but can interfere with the catheter drainage in peritoneal dialysis. Many patients require osmotic laxatives (eg., Sorbitol) or laxatives with swelling effect. Magnesium or phosphate-containing laxatives should be avoided.