UHN Division of

Nephrology
DIVISION OF NEPHROLOGY

Housestaff/ACNP
Guidebook

July 2006
INTRODUCTION

Welcome to Nephrology at the University Health Network. The Division of Nephrology is one of
the largest Nephrology programs in the world, encompassing treatment of End Stage Renal
Disease (ESRD) with dialysis and transplantation, general nephrology, subspecialty clinics,
teaching and research. There are a large number of active staff nephrologists at the Toronto
General, Toronto Western and affiliated hospitals.

Dr. Ed Cole, Division Director

Dr. Judith Miller, Deputy Director
Dr. Robert Richardson, Director, Hemodialysis Program
Dr. Joanne Bargman, Director, Peritoneal Dialysis; Education Chair
Dr. Chris Chan, Director, Home Dialysis

In-patient clinical services consist of the In-patient General Nephrology Ward, and the Multiorgan
Transplant Unit. The service is always very busy, therefore requires much organization and co-
ordination. This guidebook focuses on your rotation in General Nephrology and is a guide to
management of nephrology patients utilizing accepted protocols and useful suggestions.

Outpatient clinical services consist of Hemodialysis, Home Peritoneal Dialysis, Intermittent

Peritoneal Dialysis, Outpatient Hemodialysis, Home Hemodialysis, Nocturnal Hemodialysis, Self-
Care Hemodialysis and Out patient clinics including an active Renal Management Clinic.
Additionally, we have a hemodialysis unit at Toronto Rehab Institute (TRI) on University Ave.,
which provides dialysis for patients in rehab at TRI and in chronic care at TRI’s Complex
Continuing Care (CCC) facility at Dunn Ave. Our Nephrology service covers all UHN sites as well
as consultation for Mount Sinai Hospital. The philosophy of care is toward that of Home modalities
of dialysis, PD, HD and nocturnal HD, and efforts are to be made to encourage home dialysis.

It is hoped that this Guidebook will assist you in the management of your patients and in your
learning experience. In an effort continually improve our service; we welcome feedback on this
document.

Guidebook Editor:
Diane Watson, Nurse Practitioner
(416) 340-4800 ext 8238

Contributors:
Betty Kelman, Nurse Practitioner
UHN Division of Nephrology
UHN Renal Pharmacists
UHN Nephrology Allied Health

Dr. Stephen Vas

Dr. David Mendelssohn

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 TABLE OF CONTENTS

INTRODUCTION .......................................................................................................................................................... 2
IN-PATIENT NEPHROLOGY PROGRAM.......................................................................................................................... 8

In-Patient Nephrology Ward ............................................................................................................................. 8

MEDICAL COVERAGE .................................................................................................................................................... 8
Red and Blue Teams “Acute Care Teams”: ........................................................................................... 8
Green Team “In Patient Ward Team”: ..................................................................................................... 8
ROUNDS.................................................................................................................................................................................. 8
Sign-In Rounds............................................................................................................................................................. 9
Ward Rounds................................................................................................................................................................. 9
Kardex Rounds............................................................................................................................................................. 9
Teaching Rounds ........................................................................................................................................................ 9
Sign Out Rounds ....................................................................................................................................................... 10
Ambulatory Care Clinics .................................................................................................................................... 10
On Call ............................................................................................................................................................................ 10
NEPHROLOGY TEAM .................................................................................................................................................... 11
Nursing Staff ................................................................................................................................................................ 11
Renal Coordination Office ................................................................................................................................ 11
Physiotherapy ............................................................................................................................................................. 11
Renal Pharmacist..................................................................................................................................................... 11
Vascular Access Coordinator ......................................................................................................................... 12
Hemodialysis Units ................................................................................................................................................. 12
Toronto Rehab Institute (TRI)......................................................................................................................... 12
Physician Coverage for Hemodialysis...................................................................................................... 13
Peritoneal Dialysis Unit...................................................................................................................................... 13
Nutrition for Renal Patients ............................................................................................................................. 14
Renal Social Work ................................................................................................................................................... 14
Discharges .................................................................................................................................................................... 15
Renal Education Room ........................................................................................................................................ 15
Microscope Rooms.................................................................................................................................................. 15
Bloodwork ..................................................................................................................................................................... 15
Allergies .......................................................................................................................................................................... 16
Medications .................................................................................................................................................................. 16
Admissions Policy for Dialysis Patients .................................................................................................. 18
Management of Patients Referred to the Emergency Department with
Hemodialysis related Issues ............................................................................................................................. 19
Admissions from Toronto Western .............................................................................................................. 21
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 New Nephrology Patients................................................................................................................................... 21
HEMODIALYSIS ......................................................................................................................................................... 22
THE BASICS ....................................................................................................................................................................... 22
ORDERING HEMODIALYSIS: .................................................................................................................................... 22
Filling out Hemodialysis orders sheet: .................................................................................................... 22
OTHER HEMODIALYSIS ORDERS........................................................................................................................... 24
Antibiotics...................................................................................................................................................................... 24
Blood Transfusions ................................................................................................................................................. 24
IV Iron .............................................................................................................................................................................. 24
DIALYSIS IN THE ICU AND "OFF-UNIT" - CRRT....................................................................................... 26
Peritoneal Dialysis.................................................................................................................................................. 26
Continuous Veno-venous Hemodialysis (CVVHD) or Hemofiltration (CVVHF) .... 26
Sustained Low Efficiency Daily Dialysis (SLEDD)......................................................................... 26
Problems with Continual Renal Replacement Therapies............................................................ 27
CVVHD and CVVHF - Guidelines for Doctors Orders ............................................................... 27
Citrate Anticoagulation ....................................................................................................................................... 28
VASCULAR ACCESS FOR HEMODIALYSIS ...................................................................................................... 31
Internal: .......................................................................................................................................................................... 31
Central Venous Catheters: ................................................................................................................................ 31
Polysporin Triple ..................................................................................................................................................... 32
INFECTION GUIDELINES FOR VASCULAR ACCESS .................................................................................... 33
Permanent (Tunnelled) Hemodialysis Catheter Infection .......................................................... 33
Temporary Hemodialysis Catheter Infection ....................................................................................... 33
AV Graft Infection ................................................................................................................................................... 35
TABLE 2. DEFINITIONS OF CATHETER-RELATED INFECTIONS........................................................ 37
ANTIBIOTIC PROPHYLAXIS FOR HEMODIALYSIS PATIENTS ............................................................... 38
Cystoscopy /GI ........................................................................................................................................................... 38
Dental Procedures .................................................................................................................................................. 38
THROMBOSIS GUIDELINES FOR VASCULAR ACCESS .............................................................................. 39
Temporary Catheters:........................................................................................................................................... 39
Permanent Catheters: ........................................................................................................................................... 39
Accessing HD Catheters ..................................................................................................................................... 39
Cathflow (tPA) ........................................................................................................................................................... 40
Removal of Tunnelled cuffed hemodialysis catheter....................................................................... 41
Native AV Fistulae: ................................................................................................................................................ 44
AV Grafts (PTFE): .................................................................................................................................................. 44
MANAGEMENT OF INTOXICATION....................................................................................................................... 45
Methanol ........................................................................................................................................................................ 45
Ethylene Glycol ......................................................................................................................................................... 47
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 Lithium............................................................................................................................................................................. 47
Salicylates...................................................................................................................................................................... 48
PERITONEAL DIALYSIS ................................................................................................................................... 50
PERITONEAL DIALYSIS PRESCRIPTIONS .......................................................................................................... 50
CAPD (Continuous Ambulatory Peritoneal Dialysis) ................................................................. 50
CCPD (Continuous Cyclic Peritoneal Dialysis) and E-CCPD* (Enhanced CCPD)50
NIPD (Nocturnal Intermittent Peritoneal Dialysis) ...................................................................... 51
IPD (Intermittent Peritoneal Dialysis) ..................................................................................................... 52
PERITONEAL CATHETER INSERTION .................................................................................................................. 53
POST- OP CATHETER COMPLICATIONS .......................................................................................................... 56
MANAGEMENT OF PD LEAKS................................................................................................................................ 57
Exit Site Leak............................................................................................................................................................... 57
Intra-Abdominal Leak/Hernia ........................................................................................................................ 57
PERITONEAL DIALYSIS SYSTEMS AND CONNECTOLOGY..................................................................... 58
Automated Peritoneal Dialysis (APD) Systems.................................................................................. 58
Continuous Ambulatory Peritoneal Dialysis Systems ................................................................... 58
Manual System ........................................................................................................................................................... 58
PERITONEAL DIALYSIS SOLUTIONS ................................................................................................................... 59
Standard Solutions .................................................................................................................................................. 59
Specialty Solutions .................................................................................................................................................. 59
OFF-UNIT PERITONEAL DIALYSIS ...................................................................................................................... 60
INTRAPERITONEAL (IP) MEDICATIONS ........................................................................................................... 60
Heparin ........................................................................................................................................................................... 60
Erythromycin............................................................................................................................................................... 60
Maxeran (metoclopramide hydrochloride) ........................................................................................... 61
Potassium Chloride ................................................................................................................................................ 61
Xylocaine without Epinephrine ...................................................................................................................... 61
tPA (Tissue Plasminogen Activator – Alteplase® Cathflow) ..................................................... 61
Insulin Therapy in IPD ........................................................................................................................................ 62
Insulin Therapy in CAPD................................................................................................................................... 63
Insulin Therapy in CCPD .................................................................................................................................. 64
PERITONITIS GUIDELINES ......................................................................................................................................... 64
Initial Assessment..................................................................................................................................................... 65
Management ................................................................................................................................................................ 65
Refractory Peritonitis............................................................................................................................................ 70
ANTIBIOTIC PROPHYLAXIS AND PROCEDURE PREP FOR PD PATIENTS...................................... 72
Abdominal Ultrasound......................................................................................................................................... 72
Cardiac Catheterization / Angiogram -- Dye Exposure............................................................... 72
Chest X-Ray.................................................................................................................................................................. 72
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 Cholangiogram.......................................................................................................................................................... 72
Colonoscopy (Sigmoidoscopy/Proctoscopy) ........................................................................................ 72
CT Scan ........................................................................................................................................................................... 73
Cystoscopy /Upper GI .......................................................................................................................................... 73
Dental Procedures .................................................................................................................................................. 73
Echocardiogram ....................................................................................................................................................... 73
ERCP (Endoscopic Retrograde Cholangio Pancreatography).............................................. 73
Gastroscopy ................................................................................................................................................................. 74
Gynecological procedures................................................................................................................................. 74
Iliac Dopplers ............................................................................................................................................................. 74
Stress Test ...................................................................................................................................................................... 74
Wet Contamination ................................................................................................................................................. 74
OTHER PERITONEAL DIALYSIS ISSUES ............................................................................................................ 74
Hemoperitoneum ...................................................................................................................................................... 74
Assessment of Peritoneal Dialysis Prescription ................................................................................ 75
Adequest ® ..................................................................................................................................................................... 75
Peritoneal Equilibration Test (PET)......................................................................................................... 75
Iron Management in Peritoneal Dialysis................................................................................................ 76
KIDNEY BIOPSIES ................................................................................................................................................... 77
Elective Kidney Biopsy:....................................................................................................................................... 77
Post Biopsy: ................................................................................................................................................................. 78
Emergency and Transplant Biopsies: ....................................................................................................... 79
TRANSPLANT ............................................................................................................................................................... 80
Transplant Assessment ......................................................................................................................................... 80
Management of Failed Transplant .............................................................................................................. 80
RENAL PALLIATIVE CARE ...................................................................................................................... 81

RENAL FAILURE - DEFINITIONS AND APPROACH ......................................................... 82

DEFINITIONS...................................................................................................................................................................... 82
STAGES OF CHRONIC KIDNEY DISEASE (CKD)......................................................................................... 82
APPROACH TO ACUTE RENAL FAILURE (ARF) ......................................................................................... 83
URINE SEDIMENT IN DDX OF ARF ................................................................................................................... 87
CONTRAST NEPHROPATHY ...................................................................................................................................... 88
GLOMERULOPATHIES .................................................................................................................................................. 89
Focal Segmental Glomerular Sclerosis (FSGS) ................................................................................ 89
Membranous GN ...................................................................................................................................................... 90
Membranoproliferative GN (MPGN) ........................................................................................................ 92
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 IgA Nephropathy ...................................................................................................................................................... 93
PREGNANCY & HTN ................................................................................................................................................... 95
MEDICATIONS IN CKD...................................................................................................................................... 96
DOSE ADJUSTMENTS OF DRUGS FOR RENAL FAILURE............................................................................. 96
DOSE ADJUSTMENT FOR DIALYSIS ...................................................................................................................... 96
COMMON PROBLEMS IN THE ESRD POPULATION AND THEIR THERAPIES ................................ 96
Bleeding Complications ...................................................................................................................................... 96
Anemia ............................................................................................................................................................................. 97
Guidelines for Registering Renal Failure Patients for Erythropoietin or
Darbepoietin at UHN and MSH.................................................................................................................... 98
Iron ..................................................................................................................................................................................... 99
Vitamin deficiency ................................................................................................................................................... 99
Hyperphosphatemia .............................................................................................................................................100
Hypophosphatemia ...............................................................................................................................................100
Hypocalcemia/ ↑PTH .........................................................................................................................................100
Hyperkalemia............................................................................................................................................................101
Constipation...............................................................................................................................................................103
Analgesia......................................................................................................................................................................105
OPIOID ANALGESIC COMPARISON CHART ..................................................................................................105
HS Sedation................................................................................................................................................................107
Anti-seizure medications ...................................................................................................................................107
DRUG DOSING FOR HD, CAPD AND CRRT .............................................................................................108
ANTIBIOTIC DOSING GUIDELINES IN RENAL IMPAIRMENT ..............................................................118
Table 1: Dose Adjustment of Select Medications Based on Calculated Creatinine Clearance
(CrCl) ................................................................................................................................................................................118
ANTIBIOTIC DOSING GUIDELINES IN HEMODIALYSIS ..........................................................................122
Table 2: Dosing Guidelines in Hemodialysis and CVVHD ...................................................123
UHN MEDICAL DIRECTIVE MEDICATIONS - ACNP NEPHROLOGY .......128
TELEPHONE DIRECTORY.................................................................................................................................................143

TORONTO & AREA NEPHROLOGY ....................................................................................................................145

HOW TO ORDER CATHETER INSERTIONS, BIOPSY, DOPPLER, ANAESTHESIA ......................146
CALENDAR OF WEEKLY ROUNDS................................................................................................................................147

NOTES..................................................................................................................................................................................148

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IN-PATIENT NEPHROLOGY PROGRAM

In-Patient Nephrology Ward

13ES Ph 340-3860 Fax 340-4867
• Acute Nephrology beds - No in-patient Nephrology at TWH so all
Nephrology admissions to TGH

Medical Coverage
Red and Blue Teams “Acute Care Teams”:
• Acute Care Teams - acute problems, undiagnosed renal failure, or
renal pts for various other procedures e.g. biopsy, angioplasty.
• Attending Staffperson for the month - responsible for the team,
patients and ITER forms.
• Renal resident/fellow as team leader, co-ordinates the work of the
team, assists in teaching, and aware of all pts on team.
• Diane Watson, Nurse Practitioner ph 8238, pgr 790-7775 to
consult on new dialysis pts and assist with dialysis options,
focussing on Home dialysis, out pt HD spots, palliative mgmt.
• On call does consults at TGH, MSH, PMH. Covers ward issues in
evenings & weekends

Green Team “In Patient Ward Team”:

• Nurse Practitioner:
Betty Kelman ph 8501, pgr 790-7758 (PD specialist)
• NP, Renal Fellow and Attending Staffperson.
• NP is responsible for dialysis pts with uncomplicated illness,
awaiting placement, rehab, dialysis, and for vascular access
issues or PD catheter issues as well as palliative management.
• Fellow is responsible for pts with acute/complex medical issues.
• May admit from ER between 08:00 to 16:00 for non-life
threatening admissions after assessed by On Call MD.

Rounds
Refer to Calendar of Weekly Rounds at end of Guidebook

8
Sign-In Rounds
• Mon - Fri 08:00 sharp 8N-828 Conference room. To co-ordinate
patient care for each day
• review prev days admissions, consults, dialysis, elective
admissions, vascular access
• very short (1 or 2 sentence) summary of admissions, consults and
ward problems - focus on major issues and dialysis needs
• weekends and holidays, meet with the nurses in charge of ward
and HD to plan the day.
• Red and Blue teams to notify Green Team of patients potentially
needing transfer to In-Patient Nephrology unit.
• All teams to notify renal coordinator of patients starting dialysis in
order to facilitate education and choice of dialysis modality.

Ward Rounds
• Staff nephrologists will schedule In Pt rounds with 13ES staff.

Kardex Rounds
Interdisciplinary Kardex rounds are held for Green Team each
Wednesday 09:00 in the 13ES Conference Room.
To discuss pts medical/social issues and discharge plan.

Teaching Rounds
Mornings:
Mon to Thurs, 08:30-09:00, teaching rounds in the 8N-828
conference room following Sign-In. Mon - Fluid & Electrolytes
Fri 08:30-09:30, Renal Rounds in Hugh Orr Conference Room
GW1-534. In summer, each team presents a topic on a rotating
basis. During year, staff and fellows prepare renal rounds.

Afternoons:

Tues. 12:30 Dialysis Journal Club, 8N-828. Critical review of dialysis

journal article.
Tues, 16:00, 8N-828 conference room, Residents rounds -
housestaff presentation.
9
Wednesday, 14:00-15:00, Nephrology Trainee rounds. 15:00-16:00
Dialysis Curriculum. 16:00-17:00 City Wide Neph Rounds.
Thursday,16:30-17:30, Renal Biopsy rounds 10 ES classroom. It is
the responsibility of the acute team who admitted the patient for
biopsy to present the cases and lead discussion. The pathologist will
notify Dr. Bargman’s office as to which patient will be presented and
she will contact the team as early as possible.

Sign Out Rounds

• In-pts needing to be followed and consults to be signed out to the
On-Call team nightly.
• Weekend signout Friday at 16:00 in the 8N-828 conference room.
• Prepare written sign-out sheets. Shred old sign-out sheets!!!!
• Dialysis for the weekend and Monday morning should be
arranged and orders written for your own patients before you
leave on Friday.

Ambulatory Care Clinics

• Housestaff are required to attend an ambulatory care clinic in
order to see what is, in fact, the bulk of nephrology care delivery.
• Work out with attending staff which clinic you will attend.

On Call
• On-call schedule is posted on the ward and in the residents room.
• Intern or resident on first call with renal fellow on back-up call as
well as a staff nephrologist.
• New consult pts remain with the team of junior housestaff on call.
• Person on call is responsible for all in-patients and consults.
• Please date your consults, make your name legible and pager no.
• On-call room 12ES 402 – Don’t leave valuables in the room
• On call to ensure that at least 1 HD pt has orders for following
a.m. so HD nurse can start.

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Nephrology Team
Nursing Staff
Catherine Cary, RN, MBA, Nurse Manager - 3841
• There is a nurse assigned to PD for each day pgr. 715-9232

Renal Coordination Office

Evie Porter, RN, MSc, C Neph(C) Renal Coordinator - 3588
Maria Mendez, RN, MSc, C Neph (C) Renal Coordinator - 6053
Monica Martin, B.Ed.,Clerical – 3056 fax: 4291
Geraldine Karkada, MCom(PM&IR), Medical Secretary - 6389
• Coordinates and monitors all facets of care for renal patients
• Renal education program, Renal Management Clinic, enrolling
patients in home dialysis, in-centre HD, self-care HD, home PD
and dialysis placement outside of our institution.
• Booking of admissions for renal biopsies, biopsies for in-patients
and non-urgent removal and insertions of PD catheters.
• For urgent PD catheter removals or insertions, call general
surgery on call to make arrangements.

Physiotherapy
Cecelia Cosma BHSc PT pgr. 719-3903
Aaron Hewitt PT Assistant 719-3869

On In Pt ward, HD, PD units. Physios assist in rehabilitation needs

and planning for discharge.

Renal Pharmacist
Stephanie Ong, RMC,PD, In Pt: 6547 pgr 790-8466
Marisa Battistella, BSc Phm, Pharm D. Hemo: 3207 pgr 790-0793
Philip Lui: 6547 pgr 790-7790
13ES Pharmacist: 8106 pgr 790-7790

Pt counseling re meds, discharge medication education.

Resource regarding renal dosing and medication issues specific to
nephrology.

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Vascular Access Coordinator
Cyndi Bhola RN, BScN, C Neph (C) - 3518 pgr. 790-5320
Sally Franca, Medical Secretary 6993

• Notify Cyndi for vascular access issues - permanent central line

insertion/removal, permanent vascular access creation or issues.
• Housestaff to enter requests for permanent central lines in Mysis:
Under Nephrology Order set: Diagnostics → “Abd/Thoracic
Angio”. Enter comment if necessary.
• Report all insertions/removals/changes to Cyndi at AM rounds.

Hemodialysis Units
Hemo Unit EG - 4072 fax 3084 GG – 5707 fax 4892 Home HD 3736
Treva McCumber, MN (cand), Program Director - 4176
Deloris Beech, RN, BScN, C Neph (C), HD Coordinator EG 6049
Denise Williams, RN, BScN, C Neph (C), HD Coordinator EG 6305
Annellie Cristobal, RN, HD Coordinator, GG – 6908
Jean Flermont-Williams,RN, BScN, CNeph (C) HD Coord GG – 8502
Debra Appleton, RN, MSc. C Neph (C), Clinical Educator – 8726
Vanessa Godfrey, RN, MSc (cand), Clin Educator - 2051

• HD coordinator to be contacted for all pts requiring HD or any

changes for inpatients - attends AM sign-in rounds.
• Use Standing order sheet for HD orders. Orders to be written the
night before, for the weekend and Mon am, before leaving Friday.
• HD schedule for the day reviewed at morning sign-in
• Urgent HD after hours to be discussed with the renal fellow.
• HD requests from other hospitals - call staff Nephrologist on call.
• On call HD nurse for emergency dialysis after hours and Sundays
through locating (try to avoid hemodialysis on Sundays unless
urgent.) CVVHD/F should only be initiated during the day.

Toronto Rehab Institute (TRI)

Ena Harrison, HD Coord, TRI (416) 597-3422 ext. 3801
In-Pt Unit, TRI MD (416) 597-3422 ext 3018
In-Pt Unit, CCC (416) 597-3422 ext 2235
Dr. Vanita Jassal, TRI Hemo Nephrologist 3196
12
 TGH has an HD unit at TRI, which services patients getting
rehabilitation at TRI (on University Ave) as well as those who reside
at TRI-Complex Continuing Care (CCC) on Dunn Ave. Applications
for rehab at TRI or chronic care at CCC are to be made through Jean
and Social Worker.

Physician Coverage for Hemodialysis

MWF EG GG

1 Scholey Fenton

2 Pei Chan

3 Richardson Chan

TTS

1 Richardson Lok

2 Lok Oreopoulos

3 Jassal Bargman

Peritoneal Dialysis Unit

Home Peritoneal Dialysis Unit - HPDU 12ES 5672 fax 4169
Intermittent Peritoneal Dialysis - IPD 13-ES 411 4757
Sharron Izatt, Nurse Manager 13-2399 pgr 715-4380

• Peritoneal dialysis is an excellent choice for chronic dialysis, and

all patients should be assessed for ability to carry out PD, even if
they require acute dialysis. PD can be started very soon after the
PD catheter is inserted, thus can be used acutely.
• Peritoneal dialysis is available at TW, carried out by staff nurses in
each unit (see Peritoneal Dialysis section in this Guidebook).
• All patients on PD need dialysis orders. Pts usual orders may be
faxed from the HPDU, but all acute pts need assessment.
13
Nutrition for Renal Patients
Renal Dietitians
Jane Paterson, MSc (cand), RD, (Home HD, RMC) Practice Leader.
8591 pgr 719-3600
Karla Dawdy, HBSc, RD (In-Patient) 4625 pgr 719-3114
Heather Bell, RD, HD, (PD & HD GG) 6530 pgr 790-4519
Christine Nash-Leblanc, RD (PD & HD GG) 6272 pgr 790-4536
Francie Campbell, MSc, RD, (HD EG & Tx) 4103 pgr 719-3249

*Do not order “Renal Diet” or “Diabetic Renal Diet”

Order one of the following Standard Diets: Ward Clerk will enter:
Protein PO4 Na K+

ERI (Early Renal Insufficiency) 60g <40 mmol <217 mmol

ESRD Diet (no dialysis) 60g <40 mmol <217mmol <60
Hemo Diet / IPD Diet 80g <40 mmol <217mmol <60
+ 700 ml fluid
CAPD Diet 80g <40 mmol <217mmol

When ordering diets for diabetics, add “250 mg carbohydrate diabetic

diet” (equivalent to 1800 kcal).

Renal Social Work

Michael Gaglione, MSW – 3618 pgr 719-2876
Christine Smith, MSW, GG HD and HPDU – 6047 pgr 719-3731
Michelle Veridirame MSW, 3983 pgr 719-2812

• Functions include: pre-dialysis patient and family education,

counseling regarding adjustment to illness, treatment decision-
making, family concerns, locating and arranging the resources
necessary for an appropriate and timely discharge.
• All ward patients have a social worker available for consultation.

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Discharges
• It is imperative that discharges are well planned due to the
demand for nephrology beds.
• Ensure patients are ready for discharge - Homecare (CCAC)
arrangements, discharge orders and Rx’s.
• Patients must be discharged by 11:00 AM
• Complete on line Discharge Summary for all pts. (Found under
“Other” tab on Pt care screen). Notify Nephrologist who follows pt.
• Consult teams to prepare paper Discharge Summary to fax to
dialysis unit – Monica has them at morning report.

Renal Education Room

12ES – 401, adjoining the On Call Room. The W.T.W. Clark Renal
Education room is named in honor of our former colleague who was
the first Nephrologist at TGH and is supported by his friends and
Miles Canada. There are reference books and computer programs -
“Up to Date”. Computer and Printer for your use – please do NOT try
to fix if not working, let ward chief or NP know and use other printer.
• Laptop computer and data projector may be booked through Dr. J.
Miller's office (4966) for presentations.
• Digital camera may be booked through Diane Watson, 8238.

Microscope Rooms
• 12ES – 433, or 12 NU clinic. Microscope, centrifuge, slides,
sulphasalycilic acid etc to prepare and view urine. Please
DISPOSE of urine, slides and pipettes etc when finished, and
make an effort to keep this room clean for the next person.

Bloodwork
• Because Nephrology patients are anemic, order only necessary
bloodwork, and remember to cancel orders for repeated BW
• HD pts can have bloodwork drawn in HD unit unless otherwise
indicated. This should be specified on the HD Orders form.

15
 Allergies
• Please remember to document allergies on Doctors Orders forms.

Medications
• Renal pts often require alterations in dosing of medications due to
renal failure and/or dialysis. Consult renal pharmacist if there are
questions re dosing beyond described in this Guidebook
• When admitting a patient, call the appropriate Hemo Unit or
HPDU to have them fax medication and dialysis orders.
• Remember to order Eprex/Aranesp and Venofer, HD pts may not
include these as meds that they are on, as they are given in HD
• All pts to be vaccinated for Pneumococcus, Influenza, Hepatitis
and Tetanus per protocols, documented in HD and PD charts.
• See sections "Common Drugs Used in ESRD" and "Drug Dosing
for HD, CAPD and CRRT".

Ontario Drug Coverage Overview for CKD Patients

Types of Coverage:
1) Cash
2) 3rd party insurance (through employment, Blue Cross, Liberty Health)
3) Ontario Drug Benefit (ODB)

Ontario Drug Benefit (ODB)

Who is eligible?
–65 years old or older
–Receiving services from Home Care program
–Residents of long term care facilities or Homes for Special Care
–Eligible under the Trillium Drug Program
–Receiving benefits under: Ontario Works, Ontario Disability Support Program (ODSB)
or social assistance

What is covered?
–Formulary medications - Follow the Ontario Drug Benefit Formulary
–Limited Use Products - Covered when patient meets listed criteria
-Must put Limited Use code on actual prescription
–Section 8 approved meds (see below)

16
Section 8
A source of payment that can be applied for when no formulary alternative is available or
suitable
–Application requires Individual Clinical Review
–Meds that are not listed in ODB formulary or which fall under limited use criteria
–Physician is making “special request” for coverage
–Guided by DQTC and other expert medical advisers to review individual requests

What do I need to request for Section 8 review?

–Prescriber’s information
–Patient demographics including OHIP number
–Requested drug (generic name, brand name, dosage strength and drug identification
number)
–Detailed summary of condition
–If the patient has taken the drug, provide objective evidence of efficacy (lab results,
diagnostic tests, culture and sensitivity reports, etc.)
–Additional information regarding previous therapy, contraindications to formulary
medications, concomitant drug therapy
–Desired outcome with requested drug

Before I send out a Section 8 request,

–Checklist:
»Is the patient covered by ODB?
»Has the patient tried medications covered by ODB?
»Do I have all the necessary background information to support using this request? (lab
results, diagnosis, response to treatment)
- FAX: (416) 327-8123 or (416) 327-7526
- Follow up information PHONE: 416-327-8109

If in doubt, please page renal pharmacist at 416-790-7790 or HD pharmacist 416-

790-0793.

17
Admissions Policy for Dialysis Patients
Patient Destination

• These guidelines refer to patients with ESRD who are on some

form of chronic renal replacement therapy, or are pre-dialysis, and
require in-patient care. This does not refer to patients seen on
the consult service or those with renal transplantation.
• The following tables indicate what clinical problems (in the ESRD
patient) would be directed toward General Internal Medicine,
General Surgery, and Nephrology respectively:
• N.B. If there is a concern as to which service the patient
should be admitted, residents are instructed to contact the
STAFF physicians immediately and allow them to make the
decision.

General Internal General Surgery (or appropriate

Medicine sub-specialty)
• Cellulitis • Abdominal Pain – Surgical
Abdomen, peritonitis in non-PD pts
• Pneumonia • Cholecystitis
• Pulmonary • Gallstone pancreatitis
Embolus
• DVT • Bowel Obstruction
• Unstable Angina • Unstable GI bleed
• Non-Q MI • Post-operative complications
• Cardiac • Arterial thrombosis (vascular
Dysrhythmias (non service)
CCU)
• PVD & • Gangrene requiring amputation
complications (vascular service)
• TIA/CVA • Fractures (orthopedic service)
• Seizures
• GI Bleed

18
Nephrology
Dialysis Access Issues
• Creation of access (PD or HD)
• Infection
• Thrombosis
• Radiologic/Surgical Revision
• Sepsis related to Access
Peritonitis (in PD patients)
Inadequacy of Dialysis
Urgent Dialysis
• Volume Overload
• Electrolyte Emergency i.e ↑ Potassium
• Overdose
Awaiting out-patient Dialysis spot
Dialysis patients admitted to other services who are palliative,
rehabilitating, or awaiting placement to long-term care facility.

Management of Patients Referred to the Emergency

Department with Hemodialysis related Issues
This protocol was arrived at between the Departments of
Nephrology and of Emergency Medicine to expedite the
care of patients who suffer complications while
undergoing hemodialysis and are deemed to be in
need of assessment. If such a patient is identified in a
hemodialysis suite the following should occur:

1. If the patient’s condition warrants admission (eg: line

sepsis, deterioration in cardiovascular status, decreased
level of consciousness, etc), then the Staff Nephrologist
or the Fellow in the Nephrology Program will contact the
resident on-call for the appropriate service, depending on
the patient’s presenting problem (please refer to the
attached protocol), who will then arrange direct admission
to a hospital bed. This may be a Nephrology bed, in the
case of dialysis-related issues, or a General Medicine or

19
 Surgical bed, in the case of other non-renal issues. In the
absence of beds in the appropriate service the patient will
then be transported to the Emergency Department to be
admitted to the appropriate service and consulted on by
the Renal Team as needed.

2. If the patient’s condition or deterioration in the

hemodialysis suite does not immediately demonstrate the
need for admission, then it will be the expectation that the
Staff or the Fellow will verbally directly communicate with
the physician in the Emergency Department on-call for
that time period, and that individual will communicate the
reason for referral to the Emergency Department, any
pertinent past medical history, as well as the goal of the
referral. The name and MRN of the patient will be
communicated to the emergency physician or to the
nurse in charge in verbal or written form.

3. Patients referred from the Hemodialysis Unit are quite

complex with respect to their pathology. When they are
referred to the Emergency Department they often present
complex and time consuming diagnostic and therapeutic
dilemmas. It will be the expectation that the physicians in
the Emergency Department can call the resident on-call
for the Renal Service and use the Resident’s advice in the
management of this patient.

4. If a patient is accepted by the Renal service from another

institution then the Resident who has accepted the case
will communicate this and any other pertinent information
to the Charge Nurse verbally. If the department is in a bed
crisis, attempts will be made to admit the patient straight
to the floor.

Edward Cole, MD, FRCP(C) Greg A. Jakubowski, BSc, MD,

CCFP(EM) Director, Division of Nephrology Director,
Department of Emergency

20
Admissions from Toronto Western

There are no in-patient Nephrology beds at TW, thus patients coming

to TW Emerg must be assessed, and a note written by the Nephro
resident on call at TW. If the pt requires a Nephrology admission, the
TG staff/fellow is to be notified and accept the patient in transfer. If
the patient has medical issues, as outlined in the previous table, they
would be admitted to the appropriate service at TW and followed in
consult by the TW Nephrology resident on call. Hemodialysis and
Peritoneal Dialysis are available at TW.

New Nephrology Patients

Any patient "new" to Nephrology coming through Emergency should
be stabilized and upon discharge, referred to a Nephrologist in their
area.

Notify Diane Watson, NP (14-8238) of patients new to dialysis

requiring education, discussion re dialysis options, or an out pt HD
spot.

21
HEMODIALYSIS

The Basics
Eaton Ground (EG) Hemo: 4072.Gerrard Ground (GG) Hemo: 5707
• Hours 07:30-23:00 Mon-Sat, 3 “shifts” of pts each day.
• On-call nurses cover emergency HD at TG, TW, MSH and PMH
after hours and Sundays - reached through locating. Initiation of
a new hemo patient, whether acute or chronic must be in
consultation with a staff Nephrologist, with a catheter in place and
verified radiographically.

Ordering Hemodialysis:
• Use “Hemodialysis Unit - Hemodialysis Orders” Sheet. Write the
orders a day ahead if possible. Call the HD unit as soon as you
know that an inpatient will require dialysis.

Filling out Hemodialysis orders sheet:

1. “Daily” - all acute or unstable pts, evaluate pt prior to each Rx.
“Chronic" stable chronic pts.

2. Dialyzer
For acutes-order Exceltra 190. The standard for chronic HD pts is
F80 which is reused using heat reprocessing.

3. Method
"Conventional" refers to intermittent HD. HD time includes solute
removal + ultrafiltration (UF). Can also have isolated UF if pt very
volume overloaded - may permit a greater rate of fluid removal
with less hemodynamic compromise. Increase dialysis hours until
PRU (Percent Reduction of Urea) (adequacy) is >65%
PRU = Pre Urea - Post Urea x 100
Pre Urea
4. Dialysate

22
 Sodium: standard is 140 mM. May order Na+ "Ramping" for pts
with a lot of fluid to remove, - e.g. Na 145 1st hr, 140 2nd hr, 135
3rd hr, 135 4th hr, ordered in consultation with fellow or staff.

Potassium: 0, 1.0, 2.0, or 3.0 mmol/L available. Goal is

predialysis K+ 4.0 - 5.5, post dialysis K+ 3-3.5. (to guesstimate: 7
– pt’s K+ ~= dialysate K+). Standard is 2.0.

Calcium: "regular" is 1.5 mM. Also 1.25 and 1.00 mM available

for hypercalcemia and 1.75 mM available for hypocalcemia.

Bicarbonate is the standard buffer, generally use 40.

Phosphate: No PO4 in dialysate, if pt hypophosphatemic, may

add Fleet PO4 enema, 30,60,90 ml to acid bath.

5. Target weight (TW) and fluid removal.

TW = pt’s euvolemic weight at the end of dialysis - ie. no
peripheral or pulmonary edema, normal JVP, normal BP, and no
s/s ECFV depletion - cramps, dizziness, orthostatic hypotension
Stable patients: establish TW by physical exam with reference to
patient's current weight; hemo nurses determine amount of fluid
to remove using the predialysis and target weight.
Acute In patients: Inpatients are ill and are often losing flesh
weight and require frequent assessment and TW adjustment or
they may become hypertensive and volume overloaded. In pts
who cannot be weighed, you may prescribe "fluid removal goal"
in liters. Pts to be assessed pre and post dialysis to ascertain
appropriate fluid removal.

6. Heparinization
Regular heparinization = 1000u bolus and 1000u/hr.
Tight = 0 bolus, 500 u/hr
No heparin = 0 bolus, 0 infusion, N/S flushes or Bioflow - use for
patients with bleeding, coagulopathy, or pre/post surgery. The
risk of tight or no heparinization is dialyser clotting (blood loss).
Need to balance risk of bleeding to risk of clotting system.

23
 7. Blood Flow (Qb)
Standard is “Maximize at RN discretion”, up to 400 ml/min
Generally slower Qb's for first few runs to avoid dialysis
disequilibrium (e.g. 250 mL/min).

8. BP maintenance
Standard is saline; occasionally Albumin 25%. In some ICU pts
already on inotropes, dopamine may occasionally be used.

9. Bloodwork
“Monthly Routine” - only for chronic outpts; "other" includes any
blood tests to be done before or after dialysis. Blood is taken
from the dialysis access -thus saving a venipuncture. Only order
NECESSARY bloodwork, as dialysis pts are anemic.

Other Hemodialysis orders

Antibiotics
• Some IV antibiotics are to be given post dialysis, and may be
given through the dialysis machine, the HD doses are noted in
the UHN Guidelines for Antimicrobial use.

Blood Transfusions
• Blood Transfusions – C&T prior to and give during HD to allow
removal of fluid volume and K+.
• Pts must sign a consent for blood transfusion, explained by
and signed by MD, try to get consent for 1 year.

IV Iron
• Either Iron Saccharate or Iron Dextran, may be given on HD.
Dose - IV Iron Sucrose (Venofer) - 100 mg IV with HD x 10
consecutive HD's. Maintenance dose 100 mg IV q1-2 weeks.
Dose - IV Iron Dextran - Test dose 25 mg IV with HD, with MD
present. If no problems, 75 mg IV then 100 mg x next 9 HD's
Have Benadryl 50 mg, Solumedrol 100 mg and Adrenalin
1:1000 .3-.5 ml on hand.

24
University Health Network
Toronto General Toronto Western PMH

Doctor's Order Sheet

HEMODIALYSIS UNIT
HEMODIALYSIS ORDERS
Addressograph

ALLERGIES
NO KNOWN ALLERGIES
KNOWN ALLERGIES (Specify)
DATE AND TIME PHYSICIAN'S ORDER AND SIGNATURE
ORDERED Sign Action Pharmacy

1. Daily (acute/unstable in-patients) for __/__/__(d/m/y).

Chronic dialysis orders _______ times per week

2. Dialyzer: _____________________________________

3. Method: Conventional dialysis for _________hours OR

Ultrafiltration for __________ hours.
4. Dialysate:
+
Na : ___________ mmol/L OR
+ st nd rd
Na ramping: ____mmol/L 1 h ____mmol/L 2 h ____mmol/L 3 h
th th
____mmol/L 4 h,____mmol/L 5 h
K+:________mmol/L
Ca++: 1.5 mmol/L (standard) OR 1.00 mmol/L OR
1.25 mmol/L OR 1.75 mmol/L
Bicarbonate: 35 mmol/L OR 40 mmol/l OR ____mmol/L

5. Target Weight: ______Kg. Or Fluid Removal Goal:_______litres

6. Heparinization of Dialysis Circuit:

Regular: 1000 units bolus then 1000 units per hour
Tight: ______ units bolus then ______units per hour
No Heparin

7. Blood Flow: Maximum at RN discretion OR

_________mL/minute.

8. BP Maintenance: Normal Saline as needed OR

________________________

9. Out-Patient Blood Work: Monthly Routine OR

______________

(DO NOT USE THIS FORM FOR MEDICATIONS OR IN-PATIENT BLOODWORK)

________________________ ___________________
Physician's Signature Date

25
Dialysis in the ICU and "off-unit" - CRRT
• Patients in the ICU, CCU and Off unit reviewed at AM report
ICU pts often hemodynamically unstable, with large obligate fluid
inputs, on inotropes, with co-morbid conditions, which complicate
their dialysis. Conventional HD can worsen hemodynamic instability
in this setting. Consider alternative methods which are slower and
gentler than conventional HD, collectively know as CRRT -
Continuous Renal Replacement Therapy.

Peritoneal Dialysis
• In patients with intact peritoneal cavities, PD is generally excellent
for critical care setting.
• General surgery is to be contacted to implant the peritoneal
catheter. Dr. Robinette also may be contacted. 3855 – fax
referral to 4500.
• ICU nurses carry out the dialysis - CAPD.
• ICU and ER nurses are also certified to initate PD peritonitis
protocol.

Continuous Veno-venous Hemodialysis (CVVHD) or

Hemofiltration (CVVHF)
• Slow dialysis and UF with a pump - not dependent on BP
• Requires only a dual lumen catheter as access
• Requires close nephrology supervision
• Hemo nurses must set up the system and it can be monitored by
the ICU nurses.
• Frequently therapy of choice for unstable ICU patients
• Anticoagulation with heparin/Citrate

Sustained Low Efficiency Daily Dialysis (SLEDD)

• We utilize SLEDD in the MSICU, CCU and CVICU as a cost efficient
alternative for any patient who is a candidate for CRRT. One Hemo
nurse can manage 2 or 3 SLEDD pts simultaneously.
• SLEDD consists of 6 dialysis treatments per week for 8 hrs (Mon – Sat),
utilizing a conventional HD machine with standard concentrates, slow

26
 Blood pump speed (200 ml/min), slow Dialysate flow (350 ml/min), using
Exceltra 150 dialyzer.
• Heparin anticoagulation as standard, may also do flushes.
• 1 liter/hour hemofiltration with saline
Orders for SLEDD
(Sustained Low Efficiency Daily Dialysis)
STANDARD Options
Time 8h x
Blood pump speed 200 ml/min x
Dialysate flow 350 ml/min x
Anticoagulation Heparin Saline flushes
Saline hemofiltration 1 L/h x
Dialyzer Exceltra 150 x
Sodium 140 x
Potassium 3 1,2,3
Calcium 1.5 1.25,1.5,1.75
Bicarbonate 35 30,35,40
May add to dialysate if
Phosphate 0
Pi < 1.0 mM

Problems with Continual Renal Replacement Therapies

• Requires anticoagulation with heparin. Citrate anticoagulation
available (see protocol).
• Nephrology (not the ICU staff) responsible for changing dialysis
prescriptions as required.
If you have questions or problems, please contact Dr. Richardson
(340-3889 pgr.790-9663) for advice.

CVVHD and CVVHF - Guidelines for Doctors Orders

For all order changes a new CRRT Doctors Order Sheet must
be completely rewritten. Use Dr. Order sheet for “with/without
Heparin” or Dr. Order sheet for “Citrate”
All CRRT orders must be reviewed and reordered at least
once weekly by Nephrology.

1. Modality :
CVVHD (Continuous Veno-Venous Hemodialysis).
CVVHDF (Continuous Veno-Venous Hemodiafiltration).
CVVH (Continuous Veno-Venous Hemofiltration).

27
2. Initial Blood Work:
aPTT, CBC Urea, Lytes, Creatinine, Phosphate, Bicarbonate,
Lactate, Magnesium, Albumin, if not drawn in last 24 hours.
3. Anticoagulation:
Heparin – 1000 units /mL at ___ units/h.(in multiples of 500
units)(0.5 ml) usual starting rate would be 500 units/hour.
No Heparin. Citrate: See protocol below
4. Dialysate Solutions: Select one of the following:
Hemosol BO (mix 250 mL 5.88% Na Bicarb + 4.75 L Hemosol BO
to equal bicarb 32 mmol/L, KCl 0 mmol/L, Calcium 1.75 mmol/L).
(*Note: does NOT contain K+, so may need to add)
5. Dialysate Additives: Add ___mEq KCl
NB: No solutions custom made by pharmacy are allowed
6. Replacement Solutions: Normal Saline. Other
Additives: Add _____ mEq KCl/L.
7. Flow Rates:
Blood Flow Rate: 100 mL/min.(usual), or may order other rate.
Ultrafiltration Rate : ____ mL/h. (consider ALL intake excluding
replacement solution). Dialysate Flow Rate: ____ mL/hour
(Standard- 20 mL/kg/ hour). Replacement Flow Rate: ____ mL/h.
8. Additional Bloodwork to be ordered:
• aPTT 6 hours after the start of Heparin Infusion & 6 hr after any
change in Heparin Rate. Target aPTT 60-90 seconds.
• Call Nephrology if outside range.

Citrate Anticoagulation
Citrate is used to anticoagulate the extracorporeal blood circuit during
CRRT by binding with calcium, rendering it unavailable to the clotting
cascade. When the blood returns to the patient, the pts serum
calcium mixes with the blood and neutralizes the anticoagulation
effect. Calcium is administered to the pt to replete calcium stores lost
as a result of citrate binding. Citrate Anticoagulant Citrate Dextrose
Solution USP (ACD) Formula A is supplied in 500 and 1000 mL IV
bags by Stores and is ward stock on the Hemo Unit. The citrate
infusion is administered via infusion pump.
Use “CRRT with Citrate Anticoagulaton ICU” – Doctors Order Sheet

28
 Indications for Use:
Citrate is useful for the anticoagulation of an extra corporeal circuit
when bleeding is a concern and heparin is contraindicated:

• for H.I.T. (heparin-induced thrombocytopenia) patients

• recent surgery
• active bleeding
• high risk for bleeding or coagulopathies
• uremic pericarditis

Citrate Protocol
Citrate Dextrose Solution USP ACD Formula A in access port
@starting rate of 200 ml/h. Titrate per Post-filter Ionized Ca

Calcium Gluconate 24.3g in 1L D5W @ starting rate of 50 ml/h using

separate central line. Titrate per Systemic Ionized Ca

Required Bloodwork:
Upon start of treatment: baseline Ionized Ca++ post filter and
systemic; lytes, bicarb, urea, creat, PO4, Lactate, Mg, alb
During Treatment: Post filter Ionized Ca, Systemic Ionized Ca
• At 1 hour
• Q4h x12 hr then q 12h and prn (if no changes to infusion rates)
• Repeat bloodwork 4 hours after each rate change.
Write order to initiate citrate infusion and the calcium gluconate infusion
at specified rates of infusion. Daily evaluation of coagulation status
Nurses have been educated to notify MD for the following
circumstances:
++
• systemic ionized Ca < 0.85 or as specified with MD’s orders
• when citrate rate is >200 mL / hour
• if patient has gross metabolic alkalosis (HC03 > 35)

note: Replacement fluid and dialysate fluid are both

automatically removed by the machine.

29
 Sliding Scales for Citrate Anticoagulation Infusion Rates

Citrate Infusion: Adjust rates as soon as bloodwork results are available,based on normalized
Ionized Ca results (corrected to pH 7.4). (suggested starting rate at 200 mL/h)
Anticoagulation Citrate Infusion based on post-filter ionized Calcium results:
Post –filter Ionized Ca++ (mmol/L) Change Citrate Infusion Rate :
Use PRISMA Venous Port
< 0.25 ↓ present rate by 10 mL/h
0.25-0.35 (target) no change
0.36-0.45 ↑ present rate by 10 mL/h
> 0.46 ↑ present rate by 20 mL/h
notify Nephrologist when citrate rate is > 250mL/h

Central Line Infusion: Calcium Gluconate 24.3g in 1L D5W (suggested starting rate at 50 mL/h)
Systemic Ionized Calcium Change Calcium Gluconate Infusion Rate :
(Use Patient Arterial line)
< 0.75 mmol/L ↑present rate by 20 ml/h and notify Nephrologist
.75 - .94 ↑ present rate by 20 ml/h
.95-1.10 ↑ present rate by 10 ml/h
1.11 – 1.20 (target) no change to present rate
>1.20 ↓ present rate by 10 ml/h

Replacement Fluid Infusion: (0.9% Sodium Chloride usual solution for

replacement)
• Start at 0 mL/h at the beginning of treatment and change based on scale below.
• if blood gas bicarbonate is greater that 30 mmol/L
start replacement at 250 mL/h
→ after 12 hr, if bicarb still > 30 mmol/L, increase replacement ot 500 ml/h
→No further increases without Nephrology order.
• If blood gas bicarbonate is less than 24 mmol/L, stop replacement fluid.
• if serum sodium is greater than 145 mmol/L with replacement, using a Y connector, hang 1 bag of
0.9% sodium chloride and one bag of 0.45% sodium chloride to run together at equal rates for
reinfusion.

Dialysate solution: Prism0cal (= Na 140 mmol/L, bicarb 32 mmol/L, K 0

mmol/L, Ca 0 mmol/L). Prism0cal must always be used with both calcium
and citrate infusions. It must never be used alone.
Additive: Add __ mEq/L KCl to a 5 L bag for a fin al concentration of __
mEq/L

30
Vascular Access For Hemodialysis
Internal:
AV graft
• Connects artery to a vein using synthetic plastic (PTFE “Gortex”),
implanted by vascular surgeon in forearm, upper arm or thigh.
• Can be used ~ 2-4 weeks after surgery.
• Should auscultate a bruit but may not feel a thrill.

AV fistula
• Anastamosis of patients own artery to vein, created by vascular
surgeon.
• Requires ~6 weeks to “mature”.
• Should feel a thrill and auscultate a bruit.

Both of these are accessed at hemodialysis via large bore needles.

This limb should not be used for venipuncture or BP’s.

• All patients for chronic HD should have permanent vasc access

• Refer directly to vasc access coordinator (Cyndi Bhola x 3518).
• Will be seen in Vascular Access Clinic and booked for OR
• For OR, complete standing Vascular Access Orders sheet
• Vascular surgeon is responsible for assessing pt and obtaining
consent
• Assess diabetics for need for IV, and order IV in non-access arm

Central Venous Catheters:

Temporary:
• May be placed at the bedside. Used for days to weeks.
• Placed using sterile technique in Internal Jugular or femoral veins,
not into subclavian veins
• IJ’s sit in the superior vena cava, above the right atrium.
• Use 13-15 cm for IJ’s (preferably with curved tips), 20 cm for
femorals
• Site Rite portable Ultrasound (in GG Hemo Unit 5707) should be
used to assist insertion
• Heparinize with 5000 u heparin - 1cc of 1:10,000 + 2cc of N/S,
1.5 ml per port, or Citrate, volume per catheter volume.
31
• IJ’s must be sutured, with position verified by CXR and
documented before use
• Removed by housestaff, fellows and certified hemodialysis nurses
or Nurse Practitioners.
• If catheter is slipping out, never push back in. Change over a
guide wire.

Permanent:
“Uldall-Cook” “U/C” “Vascath Optiflow” "ASH split catheter"
"Medcomp", "Vaxel" “CardioMed”

Contact Cyndi Bhola (x3518) should a perm catheter be req'd

• Cuffed Tunnelled catheter inserted in Angio under fluoroscopy
• Used for weeks to months.
• Tip sits in the right atrium.
• Removed by Angio or certified Nephrology fellow or Nurse
Practitioner.
• Entering requests for permanent line insertions and removals in
Mysis as follows: Under Nephrology Order set: Diagnostics →
“Abd/Thoracic Angio”. Enter comment if necessary.
• Does not need to be X-rayed prior to use (inserted under fluoro).
• Should be capped with Citrate at insertion and for first HD
treatment.

Polysporin Triple

"Polysporin Triple topical antibiotic protocol" should be ordered for all

pts with permanent catheters EXCEPT "Medcomp" brand.
Medcomp brand has the words "Hemo Flow" written on the hub.

32
Infection Guidelines for Vascular Access
Permanent (Tunnelled) Hemodialysis Catheter Infection
If a patient with a catheter develops signs and symptoms of sepsis,
always suspect a central hemodialysis catheter as a source!

Look for Redness, pain, discharge at the exit site or over catheter tunnel.
Fever (remember not all renal pts will mount a fever). Other s/s of Sepsis
(nausea, vomiting, malaise etc.)
• Swab from exit site for C&S if discharge.
• Decide on type of Catheter Infection (see Table 2).
• Advise Hemodialysis Infection Control Subcommittee via Cyndi x 3518
per algorithm below.
• Start empiric antibiotic treatment as advised.
• Ancef 2 gm IV & Tobramycin 2 mg/kg loading then 1mg/kg post each HD
until C&S known
• If allergic to Ancef, Vancomycin 1 gm post q 2nd HD
• For Nocturnal dialysis patients, Ancef 1.5 gm loading dose, then 1gm
daily, and Tobramycin, 1 mg/kg q 2nd HD.
• If drainage from exit site, or pt unstable, remove line ASAP.
• U/C line removal or change over wire arranged through Angio or by
certified renal fellow or nurse practitioner. If removal, leave catheter out for
48-72 hours before new U/C
• Arrange re-insertion by Angio, put order in computer. Under Nephrology
Order set:: Diagnostics → “Abd/Thoracic Angio”. Enter comment if
necessary.
• If stable and no pus at exit site, continue antibiotic until blood cultures
available and adjust antibiotics accordingly.

• When C&S is known adjust antibiotics accordingly, See Table 1.

Temporary Hemodialysis Catheter Infection

As above, except:
If T°< 37.5 C, and infection confined to skin exit site, change over a
guidewire, no antibiotics required.

33
 Table 1. Culture and Sensitivity Follow-up
Culture results Continue or add Discontinu Catheter
e
Coag neg staph Ancef 2 gm IV over last hr Tobramycin Leave in unless pt
of HD x 3 wks (if unstable.
organism sens to Ancef).
If resistant to Ancef, use
Vancomycin 1 g every
second dialysis for 3
weeks**.
For Nocturnal pts, Ancef
1 gm IV daily x 3 wks.
Gram negative Tobramycin 1mg/kg post Ancef If pt clinically stable, leave
HD x 3 wks. line in. If fever or other
For Nocturnal pts, 1 S/S of infection recur after
nd
mg/kg q 2 HD x 3wks 48 hours, or if recurrent
infection with the same
organism, remove and
replace line.
Staph aureus Ancef x 4 weeks. Tobra If no other source
If SBE, treat for 6 weeks. suspected, remove line.
Contact ID re ? starting
Rifampin 600 mg po od x If discharge from exit site,
4 weeks. Check LFT's remove line.
when on Rifampin
If MRSA, contact ID, start
Vancomycin 15-20 mg/kg Ancef &
every 2nd HD**. Contact Tobra
ID re Rifampin.
Enterococci Vancomycin 1 gm q 2nd Ancef & Remove line if resistance
HD** x 4 weeks or Tobra to aminoglycoside.
Ampicillin 2 gm q 12 h x 7
days, if In-Pt. (accdg to
sensitivities)
Fungus ID consult. Ancef & Remove line, replace
Fluconazole 200-400 mg Tobra after 48-72 hr
po/IV loading dose, then
100-400 mg po/IV post
34
 HD.
Or Amphotericin B 0.5-
1.0 mg/kg IV q 24h
** Vancomycin – Ask Pharmacist re dosing (ie q HD dosing option)

AV Graft Infection
Infection in an AV graft is a medical emergency.

• More common in graft than in a native AV fistula.

• Often Staph aureus - may become septic within several hours.
• Ancef 2gm IV post HD or 1gm IV q24 hr, start ASAP.
• Stat consultation to vascular surgery to arrange assessment and
removal
• Can occasionally treat gortex graft infection with prolonged
course of antibiotics, but more likely that the graft will eventually
need to be removed.
• Monitor and assess for bacterial endocarditis.

35
 Suspect Central Venous Catheter Related
Infection

1. Check definitions (Table 2)

2. Rule out other possible non-catheter related infections
e.g. infected diabetic foot or pneumonia

Patient Patient
Hemodynamically Hemodynamically
Unstable Stable

ABC’s, Stabalize, consider ICU

Blood and appropriate Blood and appropriate
cultures, check INR cultures, check INR
Blood cultures x 2 at least 1 hr Blood cultures x 2 at least 1 hr
apart before starting Abx apart before starting Abx

Weekend or after hours Weekdays

1. Empiric Antibiotics per 1. Advise Cyndi Bhola x3518 or

protocol. Melanee Eng-Chong (416) 790-
2. Advise Cyndi Bhola x 3518 9749 or Dr. Lok x 4140 (prior to
3. Inform Diane Watson x 8238 antibiotics). Infection control
or certified Renal Fellow for committee recommends
line removal. management plan.

Possible Options per Committee Recommendations

Remove line by
guidewire exchange at Remove line and Salvage line +
the same site. re-site after 48 hr. Antibiotic lock.

IV Antibiotics IV Antibiotics IV Antibiotics

+/- Antibiotic lock +/- Antibiotic lock
36
Table 2. Definitions of Catheter-Related Infections

Definition Definite Probable

Purulent discharge at exit site Erythema, tenderness, induration (2 of

Exit site or 3) at exit site without a positive culture of
infection Erythema, tenderness, induration (2 serous discharge
of 3) at exit site with a positive culture or
of serous discharge Above without discharge but lack of
alternative explanation
Purulent discharge or aspirate from a Erythema, tenderness, induration
Tunnel tunnel or pocket site not contiguous (2 of 3) at a tunnel or pocket site not
infection with exit site contiguous with exit site and serous
or discharge or aspirate from that site
Erythema, tenderness, induration (2 without a positive culture
of 3) at a tunnel or pocket site not or
contiguous with exit site with a Above without discharge but lack of
positive culture of serous discharge alternative explanation
or aspirate from that site
Confirmation of septic 2 or more positive blood cultures with no
Catheter- thrombophlebitis with a single positive evidence for source other than the
related blood culture device
bacteremia or or
Single positive blood culture and Single positive blood culture for S.
positive culture of catheter segment aureus or Candida with no evidence for
with identical organism source other than device
or or
>- 10 fold colony count difference in Single positive blood culture for
blood cultures drawn from device and coagulase negative staphylococci,
peripheral blood Bacillus, Corynebacterium jeikeium,
or Enterococcus, Trichophyton or
Single positive blood culture and Malassezia in immunocompromised or
positive culture from discharge or neutropenic host or in patient receiving
aspirate from exit site, tunnel or total parenteral nutrition with no
pocket, with identical organism evidence for source other than a
centrally placed device

Reproduced from Preventing Infections Associated with Indwelling Intravascular Access

Devices Health Canada, 1997. Minister of Public Works and Government Services Canada,
2002.

37
Antibiotic Prophylaxis for Hemodialysis Patients
Any HD patient with a central line or PTFE (gortex) graft must have
antibiotic prophylaxis prior to any invasive procedure and any dental
procedure as follows.

Cystoscopy /GI
Not generally used for upper GI procedures unless suspected liver or
gallbladder infection
Amoxicillin 2.0 gm po 1 hour pre procedure
Or
Ampicillin 2.0 gm IM or IV 30 mins pre procedure

If Allergic to Penicillin: Clindamycin 600 mg po 1 hr pre procedure or

600 mg IV 30 min pre procedure

Dental Procedures
• For all dental procedures, including cleaning.
Amoxicillin 2.0 grams po 1 hour pre procedure.
Or Ampicillin 2.0 gm IM or IV 30 mins pre procedure
If allergic to Penicillin: Clindamycin 600 mg po 1 hr pre procedure or
600 mg IV 30 min pre procedure
Or Cephalexin or cefadroxil 2.0 gm po 1 hour pre procedure
Or Azithromycin or clarithromycin 500 mg po 1 hour pre
procedure

38
Thrombosis Guidelines for Vascular Access
Temporary Catheters:
• If catheter functions poorly during HD, assess fully, including CXR
for proper placement
• Try rotating catheter within the hub. If no improvement, change
over a guide wire.
• Try pulling back a fraction of a cm, and re-suture – Never push a
catheter back in once pulled back.
• May need to insert new cath in new site
• Generally don’t use tPA on a temp cath unless the pt has a history
of difficult line insertions.

Permanent Catheters:
• If poorly functioning, check placement on CXR, if good
placement, trial of tPA is reasonable

Accessing HD Catheters
Catheters should ONLY be accessed for IV or blood sampling under
emergency circumstances, as this is the patients lifeline. Refer to
Hemodialysis Manual, under "Departments" in UHN Intranet. Policy
numbers: 18.70.001 Accessing Central Line for Hemodialysis /
18.60.010 Central Venous Line - to Attach an IV / 18.60.011 To
Disconnect a Central Catheter with Heparin/Citrate / 18.60.013
Clearing a Thrombus - Hemodialysis rtPA Protocol

To access the catheter, use aseptic technique and have patient

supine. Remove gauze, tapes and ensure the clamps are closed.
Cleanse with chlorohexidine and place on sterile field. Remove cap,
attach sterile 5 ml syringe. Open clamp and withdraw 3-5 ml blood
(to remove heparin). Clamp and remove syringe. Attach 10cc
syringe with 5 ml. normal saline, unclamp, and aspirate small amount
of blood (to remove any air at catheter tip) then flush in saline. Clamp
and remove syringe - attach to IV line.

39
If drawing blood sample, attach 20 ml syringe, draw out 20 ml blood,
set aside with tip on sterile field, attach another syringe, draw
appropriate amt of blood, then re-attach 20 ml syringe and return 20
ml of blood. (This serves to ensure that blood sample does not
contain saline or heparin). Remember to clamp before and after
each step.
Catheter should be re-flushed and anticoagulated after use, using
appropriate anticoagulant (heparin or citrate).

Cathflow (tPA)
• tPA may be instilled using aseptic technique per Protocol “To
clear an indwelling intravascular catheter with fibrinolytic agent –
Cathflow (rtPA)", Hemodialysis Policy & Procedure Manual.
• tPA provided as Cathflow, reconstitute per package, use within 8
hours (very expensive, do not waste)
• Clean catheter and ports with chlorohexidine swabs, ensure
clamps are closed, and with patient flat, attach empty 5 ml
syringe, open clamp and aspirate heparin and/or clots. Clamp
catheter and remove syringe.
• Use 1 syringe tPA for each blocked lumen. Draw up tPA to the
volume of the catheter lumen. Attach syringe, open clamp and
instill slowly and gently, using push-pull motion until total volume
instilled.
• If unable to instill entire contents, leave syringe attached, wait
several minutes and try again. This attempt can be repeated
several times
nd
• Leave tPA in for at least 1 hour. If still clotted, leave for 2 hour, if
still clotted repeat with another syringe of tPA -leave longer (max
overnight) If still no results, arrange line change.
• If patency restored, aspirate 3-6 ml blood to assure removal of all
drug and clot residue. Flush with 10 ml N/S.

40
Removal of Tunnelled cuffed hemodialysis catheter
To be carried out only by certified Renal Fellow or ACNP.

Minor tray (NOT multi purpose)

# 15 scalpel
2% Xylocaine – 10 ml
23 or 25 g needle
2 - 10 cc syringes with needles
Dressing for after (Mepore, mefix, tegaderm)
10 4x4’s
Suture (3-0)
Chlorohexadine or other appropriate skin cleaner
Gloves – 1 pair non-sterile procedure gloves, 1 pair sterile
Alcohol prep
Steri-strips
Mask

P.
Insure INR is <1.50, no ASA, coumadin etc.
Explain to pt it takes ~ 45 min, and they will have to stay lying down
for 30 min afterward.

Mask on.
Prepare tray with scalpel blade, needle, syringes, dressing*, 4x4’s**,
suture, steri-strips,
* If dressing is in sterile package, open on to tray, if not sterile
ie, mepore, cut appropriate length and put on side of table.)
** Put 2 4x4’s off to the side of your sterile tray for cleaning solution.
Pour cleaning solution on to 2 of the 4x4’s.

With procedure gloves, Remove old dressing and tape from caps.
Landmark for cuff (NB to landmark as may not feel cuff after
Xylocaine)

Scrub hands. Gown and glove.

41
Clean skin area from cuff site outwards.
Clean external catheter, catheter clamps and caps. Drape – 1under,
1 covering neck, face – have pt turn head away.
Ensure catheter lumens are clamped.
Insert needle with 10 cc syringe into rubber port on cap. Open clamp
on that lumen and draw back ~5 ml of heparin and blood. (This
removes the heparin and allows lumen to fill with blood in case of
accidental puncture of catheter during freezing, you would know you
are in the catheter.) Clamp lumen and withdraw needle.
Repeat with other lumen. Set blood filled syringe aside for disposal.

Cover external catheter with gauze to maintain sterile field.

Fill other 10cc syringe with 10cc Xylocaine using needle on syringe
then change to small 25g needle for freezing.

Re-landmark cuff. Freeze skin superficially over cuff, aspirating each

time before injecting xylocaine. Freeze superficially either side of
cuff. Change angle on needle to 90o and enter to the side of the cuff
and inject deeper and under the cuff, aspirating each time. Repeat
on other side of cuff. Should use adequate freezing, about 8 ml total.

Prepare tray while allowing freezing to “take”.

Prepare scalpel blade on handle. Prepare suture. Set aside for use
2 curved Kelly forceps, 2 probes, 1 pair scissors, scalpel, thumb
forceps.

Check that area is well frozen.

Stretch skin and make fairly shallow incision over (or just to the side
of) length of cuff plus ~ ½ cm distal and proximal to cuff. Incision is
usually ~ 2-2 ½ cm long. Be sure not to cut cuff.

With curved Kelly’s, blunt dissect tissue to the sides and below cuff,
freeing up the cuff. (Usually takes ~ 20+ min).

If you can, clamp on the cuff full thickness of the catheter to help lift it
away. Next try to remove tissue from the actual catheter, distal and
42
proximal to the cuff. Try using the gauze as an “abrasive” to remove
the fibrous tissue. May have to carefully pinch and tear with the
thumb forceps. Do NOT use scalpel when this close to the catheter.
Remember that the other end of the catheter is in the person’s right
atrium, and a small nick could cause a huge bleed, or an air
embolus.

When cuff and distal and proximal catheter is clear, clamp catheter
above cuff. Cut catheter distal to cuff and pull distal portion thru the
tunnel. Discard.

Have pt take a deep breath and bear down (modified Valsalva). At

the same time, apply pressure at IJ site and incision site with one
hand and steadily remove catheter with the other. Apply pressure for
full 5+ minutes.

Suture incision line. Steri strips over exit site. Modified pressure
dressing (roll up gauze and cover tightly with Mepore or Mefix
dressing.)

Have pt wait ~ 30 min before getting up. Advise re. shower

technique. Suture removal in 10-14 days. Tylenol pl is usually
sufficient for pain after anaesthesia wears off.

43
Native AV Fistulae:
• Usually last for several years and are by far the preferred method
of chronic vascular access.
• One drawback is that when they thrombose, there is usually no
effective treatment.
• Do not usually require admission for thrombosis. Instead, instruct
pt to come early for next HD so that a temporary catheter can be
inserted.
• Vascular Access Coordinator to be informed so pt is put on the
list for creation of a new permanent vascular access.

The key is prevention of thrombus by adequate blood flow and

avoidance of hypotension. Therefore, careful monitoring of target
weight and avoidance of hypovolemia is essential.

AV Grafts (PTFE):

• Thrombosis not uncommon, usually possible to declot if

procedure carried out early
• Not necessary to admit, but need to contact Vasc. Access Co-
ordinator or Angiography to arrange procedure.
• Radiologist will insert catheters and infuse thrombolytic agents to
open up the graft.
• If radiology back-up is not available, unsuccessful or contra-
indicated, contact vascular surgery to perform a thrombectomy.
This still needs to be followed by an angiogram and angioplasty.
Generally, Cyndi will arrange this.
• In order to obtain flow studies and Dopplers for AV grafts, call
Vascular Lab 3589 to book study and leave a message with
Cyndi Bhola to follow up.
• Cyndi must be notified of all access related problems and
procedures

44
Management of Intoxication
All poisonings should be managed with the supervision of renal
fellow and staff Nephrologist.

Hemodialysis
• For solutes that have low MW, not protein bound, water soluble
• Concurrent: renal failure, acid-base disturbance, electrolyte or volume
abnormality correctable by dialysis
• Requires vascular access (ideally 2) and anticoagulation

Methanol
• Industrrial solvent/ windshield washer fluid, antifreeze
• T1/2 variable: 12-20 hrs, minmum lethal dose 50-100 ml
• Metabolism – oxidation to 1) formaldehyde and 2) formic acid
• Clinical manifestations
Early Stage (< 6 hrs): non-specific, mild or transient:
inebriation, drowsiness
Delayed Stage (6-30 hrs): Vertigo/N/V abdo pain
• Restless, dyspneic (Kussmaul breathing)
• Blurred vision(papilledema, disc hyperemia)→ blindness
• Seizures, opisthotonus, coma → death
• Lab findings: AGMA, osmolar gap, ↑ formate level, ↑ lactate level,
↑ amylase (pancreatitis)

• Toxic levels: >10mmol/L (50 mg% or 500 mg/L)

ANY level with anion gap metabolic acidosis
• 4 ml methanol has caused blindness - 15 ml of methanol can be
lethal!!!!
• Metabolized by alcohol dehydrogenase - has lower affinity for
methanol than ethanol.
• Metabolized into formic acid - causes the large anion gap
metabolic acidosis.
• Prognosis dependant on amt of methanol metabolized and
determined by the time between ingestion and treatment, the
amount of ethanol on board, the degree of acidosis and the extent
of the visual disturbance.
45
• Diagnosis is usually made by history and biochemical landmarks.
An anion gap metabolic acidosis with an osmolar gap between
measured and calculated osmolality is classic (calculated
osmolality = Na x 2 + urea + glucose). The difference represents
the mosmoles of methanol and can be used to guess the level
until levels are available.

Management
• Hemodialysis and Ethanol
• Ethanol is given as an antidote - orally or by IV. Aim for a blood
level of 100 mg% (20-25 mmol/L). The alcohols are distributed
across total body water.
• Oral Ethanol
• loading dose of 40 gm ethanol. (Absolute or 95% ethanol has
SG of 0.8 gm/mL.) This works out to 50 mL of absolute
ethanol or 120 mL of 40% ethanol like scotch. The
maintenance dose is 12 mL of absolute or 30 mL (1 oz) of
whisky per hour with frequent measurements to ensure levels
as above.

• IV Ethanol
• Begin with IV bolus of 0.5 gm ethanol/ Kg
• Aim for plasma ethanol concentration of 20-25 mmol/L
• NOTE: Must be diluted to a 15% solution or less to be non
toxic. Mix 72 mL absolute ethanol in 500 mL D5W or NS to
give a solution of 10 gm/100 mL i.e. 100 gm/L. A 70 Kg
man gets 350 mL of this solution or 35 gm. This is followed
by a maintenance of 10 gm (100 ml) per hour. Continue
infusion even if dialysis is in progress to make up for
metabolized ethanol.

• Fomepizole
• for acute management of methanol or ethylene glycol
intoxication at peripheral hospital until pt is stable for
transport (very costly)
• Not for routine use at UHN

46
• Hemodialysis
• Hemodialysis indicated for serum methanol levels > 10
mmol/L, or even at lower levels if anion gap metabolic acidosis
is present.
• Insert 2 catheters – in separate venous sites, use F80 (lge
surface area) dialyzer and dialyze at Qb of 300 or more
• Dialysis nurse to add ethanol to dialysate 320 mL of absolute
ethanol (95%) to 5L of acid concentrate (this is to avoid blood
ethanol from being dialyzed out).
• Dialysis often needed for > 10 hours. Change dialyzer q 6 hr.
• Continue to dialyze to methanol level < 5 mmol/L. By the time
this result is back, actual level will be much lower. D/C dialysis
and send final methanol level.
• PD is less effective but may be of some use in those who
cannot be hemodialyzed. Add ethanol to the PD fluid.
• Follow the blood levels of ethanol and methanol q 3-4 hourly
with the aid of a chart.

Ethylene Glycol
• Component of antifreeze and solvents. Dialysis indicated for level
> 6 mmol/L or lower levels with anion gap met acidosis
• T 1/2 is 3 hours
• Lethal dose ~ 100 mL.
• S/S - neurological– drunkenness to coma, tachypnea, pulmonary
edema, flank pain and RF
• Classically, but not always, crystalluria (needle shaped or
envelope shaped crystals)
• Management is same as methanol intoxication, i.e. ethanol +
dialysis.

Lithium
• Therapeutic range: 0.4-1.3 mEq/L
• Toxic manifestations may appear >1.5 mEq/L
• Clinical manifestations:
• Acute intoxication: N/V, neuromuscular irritability, coarse tremor,
ataxia, slurred speech,
47
• confusion, fever, stupor, coma, CV collapse
• Chronic intoxication: polyuria & NDI, renal acidification defects,
CIN, thyromegaly
• Lab manifestations: leukocytosis; ECG: flattened T's, AV blocks,
QT prolongation

Management
• Well hemodialyzable
• Hemodialysis for 8-12 hours
Indications: Li level > 3.5 mEq/L
Li level >2.5 mEq/L if symptomatic or renal insufficiency
Goal: sustained level 1 meq/L 8 hrs post HD
• Dialyze 8-12 hours and monitor post plasma Li levels q4h for 36
hours
• Monitor for post HD rebound as slow equilibration between extra
and intracellular lithium May require repeated HD treatments

Salicylates
• Aspirin, oil of wintergreen (topically)
• Minimum lethal dose 10 g ASA; levels useful 6 hrs post ingestion
• Acute ingestion: 1 tab/kg = severe (1 tab = 325 mg)
• Metabolism – ASA hydrolyzed to salicylic acid → glycinated to
salicyluric acid in liver→ excreted via kidneys; urine pH > 7.0
enhances excretion
• Clinical manifestations
• Chronic ingesters : HA, tinnitus, ↓hearing, dizziness, weakness,
N/V, ↑RR, confusion
• Acute/severe intoxications: above + fever, seizures, coma, ARDS
• Acid base disturbances:
• Respiratory alkalosis → resp alk + AG metabolic acidosis →
metabolic acidosis

Management
• Systemic and urine alkalinzation urine: goal urine PH >7.5
• Hemodialysis
Indications: Salicylate level > 7 mmol/L
Seizures/coma
Severe metabolic acidosis, esp. with RF
Non-cardiogenic pulmonary edema
48
 Esp if elderly, smoker, acute on chronic
ingestion

Poison Control Telephone Number: (416) 813-5900

References:
AKF Nephrology Letter 10:1-20, 1993
Brady & Wilcox. Therapy in Nephrology & Hypertension, Chapter 89,
pg 675-680 Washington Manual

49
PERITONEAL DIALYSIS

Peritoneal Dialysis Prescriptions

For all PD prescriptions, volume & frequency of exchanges, additives and
Target Weight (TW) need to be ordered. Specify the TW as “full” or
“drained” weight. “Target weight (full)” includes the instilled volume of fluid.
An “exchange” includes the fill, dwell and drain time of a specified volume.
Individual patient prescriptions and documentation are available from
HPDU 12 ES (5672) daily from 0800 to 1545.

CAPD (Continuous Ambulatory Peritoneal Dialysis)

AM I___I___I___I_________ PM
• 4 – 5 exchanges/ day with long dwell overnight.
• Dwell times average 4 – 6 hours during day and 8 – 10 hours
overnight.
• TW includes the volume of the exchange.
• Patients with diabetes have the option of intraperitoneal (IP) insulin or
s.c. insulin. (see section Insulin therapy in CAPD)
• Patients with diabetes require an order for the frequency of blood
glucose monitoring. This usually coincides with PD exchanges but may
be less frequent in stable patients.

Sample Prescription of CAPD:

CAPD : 2 litre volume QID, Target weight 68.0 kg (full)

CCPD (Continuous Cyclic Peritoneal Dialysis) and E-CCPD*

(Enhanced CCPD)

AM I____(I)*____I_I_I_I_I_I_ PM
• 3 – 6 exchanges/ night with long day dwell. Exchanges are delivered
overnight utilizing a machine with last fill exchange of >500 mls. The
last fill is left indwelling during the day for 12 – 16 hours. Patient

50
 reconnects to machine at night to drain and resume overnight
exchanges.
• *Enhanced CCPD is similar to CCPD except the patient does a day
time exchange(s) to interrupt the long day dwell (i.e. fluid exchanged
manually at 1400 or at most convenient time)
• Overnight exchange volume and day volume may differ. If patient has
back pain/herniae, he/she may tolerate larger exchange volume at
night with smaller volume during day.
• TW includes the volume of day exchange.
• Patients with diabetes require an order for the frequency of blood
glucose monitoring. Patients new to CCPD should check BG’s 5 x daily
(recommended at 0800,1200,1800,2200 and 0200).
• Patients with diabetes are generally managed with 2 doses of s.c.
Insulin, one prior to dialysis on the night cycler and one in the morning
post dialysis. The patient may require the larger dose at night.

Sample Prescription CCPD

Total Volume: 12 litres (5 exchanges of 2 litre volume
overnight plus last fill of 2 litres)
Therapy Time: 9 hours
Exchange volume: 2 litres
Target weight: 70 kg (full)

Sample Prescription E-CCPD *

Total Volume: 14 litres (5 exchanges of 2 litre volume
overnight plus last fill of 2 litres + midday exchange of
2 litres)
Therapy Time: 9 hours
Exchange volume: 2 litres
Target weight: 70 kg (full)

NIPD (Nocturnal Intermittent Peritoneal Dialysis)

AM ___________I_I_I_I_I_I_ PM

• Frequent exchanges/ night with <500ml day dwell.

51
 • While it is preferable to have a day dwell, the dry day may be used for
patients who do not tolerate day exchanges (i.e. back pain/herniae,
recent abd surgery or increased fluid absorption)
• Target weight is generally an empty weight unless patient has a small
day dwell.
• Patients with diabetes require an order for the frequency of blood
glucose monitoring. Patients new to NIPD should check BG’s 5 x daily
(recommended at 0800,1200,1800,2200 and 0200).
• Patients with diabetes are generally managed with 2 doses of s.c.
Insulin, one prior to dialysis on the night cycler and one in the morning
post dialysis. The patient may require the larger dose at night.

Sample Prescription NIPD

Total Volume: 10 litres (5 exchanges of 2 litre volume
overnight no last fill)
Therapy Time: 9 hours
Exchange volume: 2 litres
Target weight: 70 kg (empty)

IPD (Intermittent Peritoneal Dialysis)

AM I_I_I_I_I_I_I_I_I_I_I_I_I_I_ PM

• Rapid exchanges delivered over 12 - 20 hours 2 – 3x per week.

• Used post-op pd catheter implantation, post hernia repair and for rapid
fluid removal.
• New catheters use low volume and gradually increase over 1-2 weeks.
• Established catheters use volume tolerated by patient.
• Provides dialysis in supine position and reduces risk of leak.
• Generally weighed empty as off dialysis between treatments
• Patients with diabetes should continue oral hypoglycemic or s.c. insulin
and have IP insulin added for glucose absorbed during dialysis (see
section Insulin Therapy in IPD)
• Capillary blood glucose monitoring ordered q bag set change (usually
every 4 - 5 hours)
• Do not add insulin for the last three exchanges.
52
 Sample Prescription IPD
Total volume: 40 liters
Therapy Time: 20 hours
Exchange volume: 2.0 litres (may range from 750mL to 2.5
litres) don’t use hypertonic dialysate*
Target weight: 45 kg (empty)

*Hypertonic solution can remove more water than sodium, leaving

patient hypernatremic at end of session; however, if patients require
fluid removal, clinical judgement should be used in determining
appropriate bag selection.

Peritoneal Catheter Insertion

The Renal Coordination Office (6053) needs to be contacted whenever a
PD catheter needs to be removed and/or inserted as an outpatient, or if a
PD patient requires an urgent or elective transfer to Hemodialysis.

Dr. Todd Penner 416-603-5800 x 6220

Performs surgical PD catheter (Swan Neck) insertions, removals or re-
insertions, and hernia repairs for PD outpatients. MP 8-332, TWH.

Dr Michael Robinette 416-340-3855

Performs surgical PD catheter (Swan Neck) insertions and removals for
inpatients at Toronto General. Fax referral to office fax 340-4500.

Dr. Martin Simons 416-603-5537

Dr. Simons inserts PD catheters (double-cuffed spiral Tenchkoff) in
radiology and performs PD catheter manipulations if a catheter has
migrated and is having inflow/ outflow problems.

Elective PD catheter insertions: use standard pre and post-op orders

sheets. “Implantation of Peritoneal Dialysis Catheter” Doctors Order
sheet to be completed (found on 13ES).

Pre-Op: Hold calcium and iron for 1 week preop, as well as ASA and
anticoagulants; a vigorous bowel preparation pre-catheter insertion is
extremely important 1-litre colyte x2 days, clear fluids 24 hours before O.R.
NPO after midnight. The surgeon gives IV cefazolin or vancomycin (if
penicillin allergic) perioperatively.

53
Post-Op: Colyte comes in 4 L and is good for 30 days in fridge; therefore the
patient should take 250 ml of Colyte every day post-op until we know the
catheter works well. If the patient objects to taking Colyte, order Senokot 1
bid; if ineffective, 2 bid; if still ineffective, 3 bid.

In-patients: PD catheters are flushed (a volume instilled and immediately

drained, no dwell time) post-op at the clinical judgement of the MD or ACNP,
with 3 exch of 1 L Dianeal 1.5% with 500 u heparin/ L. Flushes are done
with patient on left side, right side and supine. If effluent remains bloody
after initial flushes, do additional flushes until the effluent clears.

Out patients: PD catheters are not normally flushed post-op, but are flushed
weekly for 3 weeks and prior to first IPD, and assessed in PDU until PD
training is commenced. Flushes are arranged by the Renal Co-ordinator.

In a well functioning catheter, a 1 L inflow should take ~ 5 minutes and

outflow should take ~10 minutes regardless of pt’s position. It is essential
that the pt planning for APD should have good outflow when lying down.

If a pt urgently requires dialysis, IPD may be started with small volume exch
750 – 1000 ml, then volume gradually increased over a 2-week period to 2 L.

Inpatients generally receive IPD 20 hours 2 x/week. Outpatient IPD is 6-10

hours 3-4 x/week depending on available spots. Pts need a minimum of 2
weeks before PD training starts, and should be instructed to refrain from
strenuous activity/lifting and from getting the catheter site wet until training.

Note: UHN has been using the Swan Neck curled 2-cuff catheter since
August 2005 for surgical insertions. Prior to Aug 2005, UHN used the TWH
peritoneal catheter with double cuffs. The double-cuffed spiral tenchkoff
catheter, used for radiological insertion, is only used in rare and exceptional
circumstances.

54
 University Health Network
Toronto General Toronto Western PMH

Doctor's Order Sheet

Implantation of Peritoneal Dialysis Catheter
Addressograph
ALLERGIES
NO KNOWN ALLERGIES
DATE AND TIME PHYSICIAN'S ORDER SIGNATURE AND
ORDERED POSITION

PRE IMPLANT PHASE

1. NPO after MN except for oral meds.

2. M.D. to assess insulin requirements for diabetic patient Yes No N/A

3.
Hold oral hypoglycemics Yes No N/A

4. Chest X-Ray Yes No

5.
ECG Yes No
6.
CBC, urea, creatinine, lytes; PT,PTT; crossmatch for 2 units packed cells
7.
Providone-iodine scrub to abdomen x 3 Yes No
(for surgical cases only)
8.
Bowel prep. a)
Colyte ___________________________________________ b)
Other, specify ______________________________________
9. Start
I.V. ____________________________________________
10. Give
_____gm. Cefazolin immediately pre-op (to be given by
anaesthetist) 11. If
patient is allergic to Cefazolin, give ______gm. Vancomycin 2 hrs preop
over 1 hour.

POST IMPLANT PHASE

1. Flush with 1L volumes of 1.5% dialysis solution in and out x 3 exchanges
or until effluent clears.
2.
Infuse ________ units heparin and cap catheter.
3.
Flat plate of abdomen.
4.
Ensure immobilizing dressing is in place.
Do not change dressing for ________ days unless heavy bleeding occurs.
5. If
Cefazolin or Vancomycin not given pre-implant, M.D. to assess antibiotic
requirements post-implant.

___________________________ __________________________
Physicians Signature Date

55
Post- Op Catheter Complications

POOR FLOW
(in or out)

IMPROVEMENT
•inflow ≥ 200 mL/min
•outflow < 180mL/min • Flush with 1 litre
•combined inflow/outflow x 3 exchanges
failure Irrigate with N/S and
heparin (nursing
procedure).
related to
NO IMPROVEMENT

? external tubing kink

? fibrin/blood clot • Flat plate
? constipation confirming
? malposition malposition
? kink in tunnel +/- constipation
? omental wrapping • Increase bowel
peristalsis with
lactulose po and
ss or tap water
enema pr

IMPROVEMENT NO IMPROVEMENT

• Reassess with catheter flushes • Consider radiological

manipulation; if not
successful, surgical
replacement

• If uremic, consider
hemodialysis

56
Management of PD Leaks

Exit Site Leak

These occasionally occur during the first weeks following catheter
implantation. For patients who are considered at risk for exit site leak in the
postoperative period (i.e. immunosuppressed, diabetic, frail, obese or very
thin), IPD should be avoided. If the patient requires dialysis, small volume
IPD (750 ml) should be administered cautiously. Staff should ensure the
patient is completely empty at the conclusion of the flushes or IPD session. If
leak does occur, Home PD should be delayed a further 2-3 weeks.
Depending on the severity of the leak, it may be necessary to hemodialyse
the patient temporarily.
Late exit site leak is less common and may be related to accidental pulling on
the catheter. Home PD may have to be interrupted and the patient scheduled
for 2 -3 weeks IPD until the problem resolves.

Intra-Abdominal Leak/Hernia
Occasionally PD fluid may leak internally and present with swelling in the
genitalia or abdominal tissues. Patients may present with evidence of hernia.
In these cases, it may be necessary to a CT Scan, and possibly have a
Surgical consult and temporarily hold Home PD.

When surgical repair is indicated, or until the leak resolves on its own, the
patient is usually maintained on IPD because intra-abdominal pressure is
lower on IPD, which decreases risk of further leak. When Home PD is
resumed, dialysis volumes are usually decreased, then very gradually
increased. Some patients on cyclers may be able to continue dialysis at
home by reducing volumes and remaining dry during the day. If patients on
CAPD undergo more than one hernia repair and develop a subsequent
hernia, it is usually recommended that the patient change to an APD regimen
with lower abdominal pressure.

57
Peritoneal Dialysis Systems and Connectology
A PD transfer set/catheter adapter remains connected to the end of the PD
catheter to allow the connection of dialysate bags and Cycler tubing. A PD
nurse changes this transfer set/catheter adaptor approximately every six
months.

The training nurse will determine the best connectology for each patient during
training – considering the patient's abilities/disabilities, comfort/discomfort with
pulsatile inflow, and individual needs.

Automated Peritoneal Dialysis (APD) Systems

Systems that utilize a cycler machine to do IPD, CCPD, E-CCPD, and NIPD.
The Home Choice® is the Baxter cycler that delivers Dianeal® solution. This
cycler has a pump with a speed of 200 ml per minute.
The FreedomCycler/Newton Cycler® is the Fresenius cycler that delivers
Delflex® solution. These cyclers work by gravity.

At UHN, the majority of our patients use the Baxter system.

Continuous Ambulatory Peritoneal Dialysis Systems

Systems that use a manual bag and gravity to do CAPD exchanges. Manual
bags are composed of a fill bag with dialysate and a drain bag incorporated in
a sterile system. At the end of the exchange the catheter is capped. For
home CAPD, our patients generally use either the Twinbag® system by Baxter
or the Premier Plus/Stay Safe® system by Fresenius, although there are a
variety of others on the market.

Manual System
A Manual system is used for inpatients, which uses a “Y” tubing with a drip
chamber. It is used to do flushes to assess inflow and outflow times and for
PD in the ICU.

58
Peritoneal Dialysis Solutions
Standard Solutions
• Glucose concentrations: 0.5%, 1.5%, 2.5% and 4.25%. Osmolality
increases with the increases in glucose concentration. Dianeal® and
Delflex® are glucose-based solutions.

• Calcium concentration: standard ("PD101" 1.75 mmol/L) and low calcium

("PD4" 1.25 mmol/L). Note: Most patients use low Ca+ concentration
bags with the Luer-lock connections. The exception is post
parathyroidectomy in which patients use standard Ca+ bags with the spike
connections. PD101 solutions can be ordered, but may take 1-2 days to
be delivered to the unit. During the interim, consider dialysing with PD4
solutions and increasing the patient's oral Ca intake.

• Volume: 1.5L, 2L, 2.5L, 3L, 5L. Not all solutions are available in all
volumes.

Specialty Solutions
®
• Nutrineal : An amino acid based solution used for patients with
malnutrition secondary to poor oral intake. Recommend for one 6-hour
exchange during the day coinciding with a meal. Consider Nutrineal®
equivalent to 1.5% dextrose solution for insulin dosing, although there is
no glucose in this solution, thus monitor insulin requirements carefully.
®
• Extraneal (Icodextrin): A glucose polymer (7.5% solution) based
solution that metabolizes to maltose, for patients with ultrafiltration
problems. Recommended for one 8 to 12-hour dwell per day. Consider
Extraneal® equivalent to 2.5% dextrose solution for insulin dosing,
although there is no glucose in this solution, therefore monitor insulin
requirements carefully***.
***NOTE: Patients with diabetes using Extraneal should check their capillary
blood glucose using ONLY a Precision® blood glucose monitor (Precision
PCX®, Precision QID® or Precision XTRA®), as there is a risk of hypoglycemia
if the blood glucose is measured using a device that does not differentiate
maltose from glucose. There is also a risk of allergic skin reactions with
Extraneal® so patients should be advised. Additionally, it should be
avoided in those allergic to corn or cornstarch.
59
 *ALERT
If using Extraneal only use "Precision QID®" "Precision
Xtra®"or "Precision PCX®“ glucose monitoring machines as
others will give false high readings
®
• Physioneal : A pH - neutral solution for patients with intractible
abdominal pain after all other options have failed (i.e. trying tidal
volume, analgesics, or adding xylocaine. For these individuals, it is
used in lieu of other solutions for all PD exchanges.
® ® ®
• Extraneal , Nutrineal and Physioneal are only available from Baxter.
If patients using another system require these solutions, they should
convert to Baxter or use a universal adaptor.

Off-Unit Peritoneal Dialysis

When patients requiring CAPD, CCPD or IPD are admitted to hospital, the
nephrology trainee should discuss with the Nurse Manager of 13ES at TGH,
or 8AF/8BF if the patient is at TWH, a strategy to offer the optimal dialysis
prescription with the available nursing resources.

Intraperitoneal (IP) Medications

Heparin
• Indicated if fibrin is present in bags, for slow drainage and for
hemoperitoneum. Heparin should be used in each exchange for 24
hours and reassessed.
• Used routinely for outpatients coming for IPD treatment
• Use in inpatients by clinical judgement
• Indicated for peritonitis management
Dose (Non-peritonitis): 500 units/L
Dose (Peritonitis): 1000 units/L until effluent clears

Erythromycin
• Indicated for gastroparesis
• 200 mg IP in one bag daily
60
Maxeran (metoclopramide hydrochloride)
• 5 mg/L IP for control of nausea or diabetic gastroparesis if oral route not
beneficial.

Potassium Chloride
• 2 - 4 mmol/L for hypokalemic patients in-hospital (this level will limit
removal of serum K, but not supplement patient)
• for severe hypokalemia, can use maximum dose of 10 mmol/L
• oral supplementation preferred for patients on home dialysis
• For inpatients, if predialysis K< 3.0 mmol/L or if dialysis is to be
prolonged (>12 hours) KCL should be added to supplement.
• IP KCl not usually added for CAPD unless in hospital and oral
supplements and diet not sufficient.
• Please note, KCl is not available as ward stock and must be ordered
each day to be dispensed from the Pharmacy. It is no longer provided
in ampoules, rather it comes in minibags 20mmol/50ml

Xylocaine without Epinephrine

• Indicated for abdominal cramps or pain only after investigations support

that the pain is related to dialysate solution. (i.e. avoid risk of masking
pain related to other causes). Not indicated if source of pain is
unknown.
Dose: 1.25 - 5.0 ml/L of 1% or 2% Xylocaine.
®
tPA (Tissue Plasminogen Activator – Alteplase Cathflow)

• tPA is a fibrinolytic agent that is used for one-way or two-way

obstruction (poor or no inflow/outflow) when it is suspected that a
thrombus is attached to or occludes the PD catheter.
• It is also used as a treatment for recurrent peritonitis. (Refer to Policy
#17.130.007 in the UHN Policy and Procedure Manual). tPA is
dispensed from Pharmacy in powdered form.
• After reconstitution, 4.6 ml is instilled, dwelled for 2 hours according to
doctor’s orders.
• Although experience is somewhat limited, results achieved for both
obstruction and peritonitis have been fair.
61
Insulin Therapy in IPD
Only Short Acting Insulin (Humulin R, Novolin R) may be used for IP admin.
Target BS 8-12mmol/L

• Generally, if pt on s/c insulin, continue the s.c. dose for both dialysis and
non-dialysis days.
• Supplemental insulin may be given IP and usually requires 3-4 sessions
to determine baseline requirements. The sliding scale may be used.
• IP insulin should be D/C’d for the last 3 exchanges to avoid post dialysis
hypoglycemia.
• Dose: I.e. of initial baseline IP dose for new patients:
1 unit insulin per litre 1.5%
2 units insulin per litre 2.5%
3 units insulin per litre 4.25%

Sliding Scale:
BS Result Change of insulin per litre
< 4 no insulin to be added, call MD
4.1 - 7 subtract 3 units per litre, call MD
7.1 - 9 no change from baseline
9.1 - 11 add 1 unit insulin per litre
11.1 - 17 add 2 units insulin per litre
17.1 - 27 add 3 units insulin per litre
> 27 add 4 units insulin per litre, call MD

Sample IPD Order with Insulin

IPD 70 litres over 20 hours

TW 70 kg (drained)
Medications:
Heparin 500 units/L
Humulin R 3 units /L 1.5%
Humulin R 5 units/L 2.5%
Humulin R 8 units/L 4.25%
Plus IPD sliding scale – need to specify in orders

62
Insulin Therapy in CAPD
Converting from s.c. insulin to intraperitoneal insulin

• One advantage of CAPD is that the pt with diabetes may receive insulin
IP rather than S/C.
• To switch from subcutaneous insulin to the IP route:
Total usual S/C dose x 2 (to account for 50% IP absorption) and divide
into 4 doses, 1 per exchange. The night exchange should have 20-30%
less insulin than the daytime exchanges.
• Insulin must be adjusted for glucose concentrations. Increase the
calculated amount by 2 units/L for a 2.5% bag and 4 units/L for a 4.25%
bag, and decrease by 2 units/L for a 0.5% bag. This calculation will
represent the basal dose requirements.
• When pt is undergoing an acute illness, may order sliding scale, and
adjust based on BS’s ordered with each exchange. The basal dose
should then be adjusted.

Sample of CAPD Orders with Intraperitoneal

Insulin (previously on 20 units insulin s.c.
daily)
Add Humulin R per 2-litre bag as follows:
Bag strength Day Bags Night Bag
0.5% 8 units 6 units
1.5% 10 units 7 units
2.5% 12 units 8 units

May order sliding scale to adjust basal dose insulin when assessing patient’s
insulin requirements on CAPD

Sliding Scale:
BS Result Change of insulin per Bag (regardless of bag volume)
<2 Drain immediately, Instill 2.5% without Insulin Call MD
2 - 3.9 subtract 4 u insulin per bag
4 - 7.9 subtract 2 u insulin per bag
8 – 13.9 No change
14 – 17.9 add 2 u insulin per bag
18 – 21.9 add 4 u insulin per bag
22 – 44 add 6 u insulin per bag. Call MD

Converting from IP Insulin to s.c. Insulin

63
 If PD is being D/C’d, need to re-assess insulin, as a glucose load is no
longer delivered by the dialysate.
To switch from IP Insulin on CAPD to s.c:
Calculate the 24 hr insulin on CAPD. Reduce by 50%. If pt able,
advocate multidose insulin dosing first, otherwise divide into 2/3 AM and
1/3 PM, then further divide each dose into 2/3 long acting and 1/3 short
acting.
Pts who were on dietary control and/or oral agent pre-CAPD may return
to pre-CAPD status.

Insulin Therapy in CCPD

• Pts on CCPD generally receive subcutaneous insulin twice daily.
• If CCPD is D/C’d, adjust dose as glucose load from dialysate no longer
received.

Peritonitis Guidelines
Peritonitis generally managed as outpatients unless severe or patients unable
to manage at home. Diagnosis requires 2 of the following 3:
• abdominal pain
• cloudy dialysate fluid
• positive culture of dialysate fluid

A PD effluent cell count with WBC >100 cells/µL or >50% neutrophils with or
without positive cultures in addition to the above symptoms is diagnostic for
PD peritonitis.

Patients are instructed to bring the first bag noted to have cloudy fluid to the
dialysis centre. If not possible, drained dialysate from patient is sent for C&S,
Gram stain, and cell count with differential.

There are other causes of abdominal pain to consider, i.e. constipation,

pancreatitis, ischemic bowel, etc.
Even if there is true peritonitis, consider “surgical causes” such as appendicitis
(abdo pain is localized rather than diffuse).

64
Initial Assessment
Clinical examination of abdomen for s/s of peritoneal inflammation and
PD catheter exit site/tunnel; send exit site swab for C&S if drainage present.
Send first dialysate effluent for C&S and gram stain and cell count with
differential. If pt does not have indwelling effluent (IPD or NIPD) fill with min
1L and allow to dwell for minimum 2 hrs before sending sample.
Gram stain can be helpful, eg. if yeast is noted, but continue empiric
antibiotics until culture results available.
Send blood for CBC, diff, lytes, Cr, urea, Ca, PO4, alb, total protein for
In-pts or ER pts.

Management
Empiric antibiotic therapy:

IF PATIENT HAS < 100 ml/day URINE

IF wt < 50 Kg, Cefazolin 1g in ONE exch/day plus Tobramycin 40 mg in ONE
exch/day plus Heparin 1000 units/L in EACH exchange. Use heparin until
effluent clear.

IF wt > 50 Kg, Cefazolin 1.5 g in ONE exch/day plus Tobramycin 60 mg in

ONE exch/day plus Heparin 1000 units/L in EACH exchange. Use heparin
until effluent clear.

IF PATIENT HAS > 100 ml/day URINE

IF wt < 50 Kg, Cefazolin 1g in ONE exch/day plus Ceftazidime 1 g in ONE
exch/day plus Heparin 1000 units/L in EACH exchange. Use heparin until
effluent clear.

IF wt > 50 Kg, Cefazolin 1.5 g in ONE exch/day plus Ceftazidime 1.5 g in ONE
exch/day plus Heparin 1000 units/L in EACH exchange. Use heparin until
effluent clear.

Note: For patients who are allergic to cefazolin, give vancomycin

If wt > 50 kg, Vancomycin 2 grams in one exch q 5 days if residual renal
function, q 7 days if no residual renal function.
If wt < 50 kg, Vancomyin 1 gram in one exch q 5 days if residual renal
function, q7days if no residual renal function.
65
If allergic to ceftazidime, give Tobramycin according to above.

Vancomycin is also to be used as initial therapy for those with known MRSA
exit site infections, previous MRSA peritonitis, or those who have recently
come from a unit with high incidence of MRSA.

Antibiotics must dwell intraperitoneally for at least 6 hours to allow

adequate absorption of the antibiotic into systemic circulation. Generally,
IP antibiotics can be given into one exchange per day, often in an overnight
exchange, as it tends to dwell for a longer period of time.

If a patient is in hospital, it is often easier to switch them to CAPD during

treatment for peritonitis, to allow ease of specimen collection and
antibiotic dosing. If the patient must remain on CCPD, antibiotics should
be instilled into the last fill and allowed to dwell during the day.

• If fungal/yeast peritonitis, catheter to be removed ASAP, start pt on

antifungal treatment and switched to HD for at least 8 weeks.
• Order additional intraperitoneal additives:
-heparin 1000 u/L until effluent clears
-individual requirements for KCl, insulin, maxeran etc.
• Order effluent for daily cell count until cell count ≤100 ( q 2 days if out-
patient). C&S q 2 days until first “no growth”; then q 4 days until total of 3
“no growths”. Note, in Mysis, Go to “All Order Screens → Nephrology→
Other Common Tests → Dialysis →choose PD Effluent C&S or PD
Effluent, cell cnt.
• Hold phosphate binders or calcium supplements and iron supplements if
peritonitis is severe (due to constipation).
• For urgent catheter removal, call General Surg on call.
• All treatment should be guided by antibiotic sensitivity of the causative
organism (see Tables 2,3,4).

Nystatin 500,000 u 5 ml swish and swallow qid for duration of peritonitis

treatment, as prophylaxis against fungal peritonitis. Continue for 1-week
post antibiotics.

66
 Table 2. Culture and Sensitivity Follow-up
Culture results Continue or add Discontinue Frequency (F) and duration (D)
No growth in 2-3 days Cefazolin 1.5 g (1 g if <50 kg) Discontinue F: 1 exchange/DAY
tobra/ceftaz D: Continue for 2 weeks. Note:
If no improvement in 5 days,
consider cath removal,
continue Cefazolin 2 gm IV
qHD when cath is out. Ask lab
re. TB or yeast.
Gram Positive Coag Cefazolin 1.5 g (1g if <50 kg) Discontinue F: 1 exchange/DAY
Negative Staphylococcus tobra/ceftaz D: Continue for 2 weeks
(CoNS)
Gram Positive Methicillin Vancomycin 2g IP (1g if <50 kg) Discontinue F: 1 exchange/WEEK
Resistant Coag Negative cefazolin and D: Continue for 3 weeks.
Staphylococcus (MRSE) tobramycin/ceft NOTE: If residual renal function
azidime (RRF),(i.e. urine >100
ml/24hr) give: 1 exchange/ 5
days cont. for 3 weeks
Gram Positive Cefazolin 1.5 g (1g if <50 kg) and Discontinue F: 1 exchange/DAY
Staphylococcus aureus consider rifampin 300 mg po BID for the tobra/ceftaz D: Continue for 3 weeks
first week of therapy
Gram Positive Methicillin Vancomycin 2g IP (1 g if < 50kg) PLUS Discontinue F: 1 exchange/WEEK *
resistant Staphylococcus rifampin 300 mg po BID for the first 2 cefazolin and D: Continue for 3 weeks
aureus (MRSA) weeks of therapy. tobramycin/ *NOTE: If RRF (urine >100
ceftazidime ml/24hr) give Vanco in 1
exchange q 5 days and
continue for 3 weeks.
Enterococci Ampicillin 125 mg/L q exchange (If Discontinue F: Ampicillin EACH exchange,
ampicillin resistant, may change to cephalosporins Tobramycin 1 exchange/DAY.
Vancomycin 2 g one exch q 7 days (1g if Vancomycin 1 exch/WEEK.
<50 kg) (q 5 days if RRF) For VRE, consider quinupristin/
dalfopristin (Synercid) –
Consider gentamicin 20 mg/L IP in one Consult ID.
exchange for synergy D: Continue for 4 weeks
Streptococci (Gram +) Cefazolin 1.5 g. F: Cefazolin 1 exch/day. OR
OR Penicillin G 50,000 u /L loading dose Penicillin In each exchange
then 25,000 u/L D: Continue for 2 weeks
Gram Negative (e coli, Tobramycin 60 mg (40 mg if <50 kg) if no Discontinue F: 1 exchange/DAY
Klebsiella, proteus, RRF, OR cefazolin D: Continue for 3 weeks
serratia) Ceftazidime 1.5 g (1g if <50 kg) if RRF
Polymicrobial Tobramycin 60 mg (40 mg if <50 kg ) if no Discontinue F: Ampicillin in each exchange
RRF cefazolin Tobramycin in 1 exchange/day
OR D: Continue for 4 weeks.
Ceftazidime 1.5 g (1g if <50 kg) AND Continue 1 week post catheter
Ampicillin 125 mg/L if RRF, removal, minimum treatment 4
weeks
AND metronidazole 500 mg IV/po q8h If any organism is gram neg,
Get surgical consult consider bowel perforation.
Pseudomonas/ Tobramycin 60 mg (40 mg if < 50 kg) if no Discontinue F: 1 exchange/day
Stenotrophomonas RRF, OR cefazolin D: Continue for 4 weeks if cath
Ceftazidime 1.5 g (1.g if <50 kg) if RRF is in, or for 2 weeks following
AND Anti-pseudomonas or anti- cath removal.
stenotrophomonas (see Table 2 or 3).
Recommended to use 2 antibiotics – may
use oral quinolone plus alternate.
Fungal / Yeast While catheter is STILL IN: fluconazole Discontinue When catheter is OUT and
200 mg in 1 bag IP (dwell x 8 hr) q48h cefazolin and patient is on HD: fluconazole
OR amphotericin B 0.5-1.0 mg/kg mg IV tobramycin/ 200 mg po daily for additional 2
q24h. If >1 mg/kg needed, contact ID. ceftazidime weeks OR itraconazole 100
OR itraconazole 100 mg po q12h. mg po q12h for 2 weeks.
Arrange for urgent PD catheter removal.
Mycobacteria Rifampin (RIF) 600 mg po daily, D: Rifampicin and isoniazid 12
Isoniazid (INH) 300 mg po daily. mo.
Pyrazinamide (PZA) 1.5 g po daily. Pyrazinamide 3 mo.
Pyridoxine 100 mg po/day to avoid INH
induced neurotoxicity. Monitor LFT’s. Arrange for Catheter removal
(NOTE: Do not use ethambutol except
under unusual circumstances because of
the risk of ocular toxicity)
Consult ID re sensitivities
All organisms Nystatin 500,000 u 5 ml swish and F: qid
swallow qid for duration of peritonitis D: Continue for one week after
treatment plus one week, as prophylaxis cessation of antibiotics.
against fungal peritonitis.

69
Table 3. Antibiotics with anti-pseudomonas activity

Antibiotic Dosage/administration
Ceftazidime 125 mg/L IP IN EACH exchange
Piperacillin-Tazobactam 3.375 g IV q12h
Ciprofloxacin 500 mg po BID
Cefepime 1gm IP in 1 exchange per day

Table 4. Antibiotic with anti-stenotrophomonas activity

Antibiotic Dosage/administration
Trimethoprim / Loading dose: 320 mg/ 1600 mg (20 ml) IP
sulfamethoxazole Maintenance dose: 40 mg/ 200 mg (2.5 ml)
IP in one exchange per day

Oral Therapy for PD Peritonitis: Based on culture and sensitivity

When oral antibiotics are given, consider holding all phosphate binders (e.g.
calcium carbonate, aluminum hydroxide) and iron supplements.
NOTE: Oral therapy should NOT be considered for initial therapy

Ciprofloxacin 500 mg po BID OR Co-trimoxazole 1 DS tab po daily

OR
Cephalexin 250 mg po TID AND Rifampin 600 mg po daily

Refractory Peritonitis
• If no decrease in cell counts in 3 days or if count fell initially and
then increased, repeat culture and consider possibility of
secondary peritonitis due to ischemic bowel, cholecystitis
diverticulitis or appendicitis
• Refractory peritonitis is defined as failure to respond to
appropriate antibiotics within 5 days.
• Consider temporary discontinuation of PD - arrange for temp HD
• Consider conversion to IPD, if suspected microperforation of
bowel. IPD allows bowel to rest between treatments.
 • Catheter removal - required for virtually all fungal peritonitis, and
for serious refractory bacterial peritonitis.
Notify HD unit, and arrange U/C line for hemodialysis through
Vascular Access Co-ordinator or Angio.
• If UF failure with peritonitis (weight gain/ECFV overload), alter
regimen (ie., shorten dwells, hypertonic bags,
Icodextrin/Extraneal™ more frequent exchanges, IPD ).
• Note that Icodextrin is compatable with antibiotics, so can be put
into Icodextrin exchange.
• Stable pts may be discharged and continue therapy at home.
Consult HPDU to assess pts ability to administer meds.

For management of any complicated peritonitis, please contact

Dr. J. Bargman, pgr. 790-6317, or Dr. Oreopoulos, pgr 648-7007.

References:

Hussein, M., Mooij, J.M., Roujouleh, H. (2003). Tuberculosis and

chronic renal disease. Seminars in Dialysis, 16(1). 38-44.

Piraino, B, Bailie, G., Bernardinin, J., Boeschoten, E., Gupta, A.,

Holmes, C., Kuijper, EJ., Li, P.K, Lye, W., Mujais, S., Paterson, DL.,
Fontan, MP., Ramos, A., Schaefer, F., Uttley, L. (2005). ISPD
Guidelines/Recommendations. Peritoneal dialysis-related infections.
Recommendations: 2005 Update. Perit. Dial. Int.25(2). 107-139.

71
Antibiotic Prophylaxis and Procedure Prep for PD Patients

Abdominal Ultrasound
Patient should be drained ("empty") prior to test.

Cardiac Catheterization / Angiogram -- Dye Exposure

N Acetylcysteine (Mucomyst®) 600 mg po bid on day before and day of
procedure. Hydration is required prior to, during, and post procedure
(0.45% saline 1mL/kg).
Available in liquid form at UHN Pharmacies.
Patient should be instructed to arrive drained ("empty") for angiogram, and
CAPD exchanges to resume ASAP after procedure.
.
Chest X-Ray
Patient should be drained ("empty") prior to test.

Cholangiogram
Patient should be drained ("empty") prior to test.

Colonoscopy (Sigmoidoscopy/Proctoscopy)
Bowel prep is required for colonoscopy, sigmoidoscopy or proctoscopy.
Mag Citrate 1 bottle (600 ml) and 4 Dulcolax® (20 mg) hs pre procedure.
**Bowel prep caution: Colyte only used for pts going for initial PD cath
insertion. Once cath is in situ, Colyte may contribute to gram-neg peritonitis.
Never use regular Fleet enema because of risk of increased PO4

Antibiotic prophylaxis is not necessary for sigmoidoscopy or proctoscopy.

Antibiotic prophylaxis is necessary for colonoscopy:
• Ampicillin 1 gm IP in night bag/long dwell prior to procedure or oral
amoxicillin 2 grams 1 hour before procedure
• Tobramycin 120 mg IP in night bag/long dwell prior to procedure,
• Flagyl 500 mg po 1hour pre procedure and 500 mg po 12 hours post
procedure.

Patient should be drained ("empty") prior to procedure.

72
CT Scan
100 ml of “Visipaque” (available from Radiology) is added IP to the dialysis
solution regardless of the volume of the exchange. It is preferred the patient
hold at least 2 L as this may make the leak more visible on the scan.
Once the solution is dwelling the patient walks around (as able) for 2 hours.
Drain at end of scan and resume dialysis.

Cystoscopy /Upper GI
Bowel prep as per radiology request except do not use Colyte. (see under
Colonoscopy)
Antibiotic Prophylaxis not generally used for upper GI procedures unless
suspected liver or gallbladder infection. If infection:
Amoxicillin 2 gm po 1 hour pre procedure or Ampicillin 2 gm IM or IV 30
minutes pre procedure. If allergic to Penicillin: Clindamycin 600 mg po 1
hour pre or 600 mg IV 30 min pre procedure
Patient should be drained ("empty") prior to procedure.

Dental Procedures
Amoxicillin 2 gm po 1 hr pre or Ampicillin 2gm IM or IV 30 min pre procedure.
If allergic to Penicillin: Clindamycin 600 mg po 1hour pre or 600 mg IV 30 min
pre procedure
OR Cephalexin or cefadroxil 2.0 gm po 1 hour pre
OR Azithromycin or clarithromycin 500 mg po 1 hour pre procedure

Echocardiogram
Patient should be drained ("empty") prior to test.

ERCP (Endoscopic Retrograde Cholangio Pancreatography)

Amoxicillin 2 gm PO 1 hour pre-procedure
Patient should be drained ("empty") prior to procedure.

73
Gastroscopy
Patient should be drained ("empty") prior to procedure.

Gynecological procedures
(Invasive procedures i.e. Uterine biopsy and D&C. NOT for routine PAP)

Amoxicillin 2 gm 1 hour pre procedure.

Flagyl 500 mg 1 hour pre procedure and 500 mg 12 hours post procedure.
If allergic to penicillin, clarithromycin 500 mg 1 hour pre-procedure.

Patient should be drained ("empty") prior to procedure.

Iliac Dopplers
Patient should be drained ("empty") prior to test.

Stress Test
Patient should be drained ("empty") prior to test.

Wet Contamination
Contamination when the tubing system is open or unclamped,
potential for organisms to enter the peritoneal cavity.
For pts < 50 kg: cefazolin (Ancef®) 1 gm IP for 6 hr dwell x 1 dose.
For pts > 50 kg: cefazolin 1.5 gm IP for 6-hour dwell x 1 dose.
If allergic to Cefazolin, use Vancomycin 1 gm IP for 6 hr dwell x 1 dose.

Other Peritoneal Dialysis Issues

Hemoperitoneum
Small concentration of red blood cells which results in bloody appearance to
effluent. Causes may be benign to significant pathology. Noted post surgical
implantation of catheters, post abdominal surgery; associated with ovulation
and menstrual bleeding; warfarin use; pancreatitis; metastases; ischemic
bowel; encapsulating sclerosing peritonitis.

74
May clear with flushes as in post catheter implantation. Add heparin 500 u/L to
prevent catheter obstruction. Heparin not absorbed across peritoneal
membrane and will not have systemic effect on anticoagulation.

Assessment of Peritoneal Dialysis Prescription

Adequacy of dialysis may be assessed by Adequest® and membrane
characteristics may be assessed by PET. Doing these studies must be
arranged in advance with the Charge Nurse.
Prior to either study, the patient must be stabilized on peritoneal dialysis for 1
month and be peritonitis free for 1 month.
®
Adequest
• Involves a 24-hour collection of dialysate and urine.
• Write order for “Adequest and 24 hour urine for urea and Cr Cl”.
• Interpretation of results in consultation with PD nephrologist, primary
Home Dialysis RN or NP.

Peritoneal Equilibration Test (PET)

Determines the rapidity of solutes moving across the peritoneal membrane.
Patients with rapid transport characteristics are better managed with shorter
dwell periods (i.e. CCPD) to minimize dextrose absorption and improve
ultrafiltration. Patients with slow transport characteristics require CAPD with
longer dwell periods.

To perform PET:
• Drain overnight effluent, send sample for Cr, Urea, Glucose, volume
• instill 2.5% dialysis solution
• At 0 hours send effluent sample for Cr, Urea and Glucose
• At 2 hours send effluent and blood samples for Cr, Urea and Glucose, to
blood tests
• At 4 hrs send complete effluent for Cr, Urea, Glucose and Volume.

To calculate the transport characteristic, determine the Dialysate/Plasma

ratio and plot on graph to ascertain characteristics.

75
Iron Management in Peritoneal Dialysis
Inpatient
Iron Saccharate - No test dose, maximum 300 mg IV in 250 to 500 mL
normal saline over 2 hours

• Have Benadryl 50 mg and Solumedrol 100 mg and Adrenalin 1:1000 .3-

.5 ml on hand

• Oral iron may also be used for maintenance dose

Outpatient HPDU/PDU
Iron saccharate- No test dose required. DO NOT write “IV iron protocol”,
rather, specify the dose and # of doses.

It is generally ordered in either 2, 3 or 4 doses as follows:

IV iron saccharate 500 g x 2 doses each given over 6 hours
IV iron saccharate 300 g x 3 doses each given over 4 hours.
IV iron saccharate 250 g x 4 doses each given over 3 hours.
The objective is to receive 1g total with doses scheduled at least one
week apart.
Advise patients of the risk of allergic reactions prior to ordering IV iron
preparations.
IV iron must be booked in advance with Sharron Izatt (Nurse Manager) in
order to ensure adequate staffing.

76
KIDNEY BIOPSIES

Elective Kidney Biopsy:

Before the procedure:

• ASA should be held x 10 days, Coumadin should be held at least

4 days prior to procedure, preferably 5.
• Elective admission package from Monica at Renal Coordination
office (8NU ph 3056) -includes requisition from nephrologist, and
pt notes.
• Use Renal Biopsy standing order form for pre & post bx orders.
• Carry out pt admission, note pts BP (BP to be <160/95 or Bx may
not proceed), examine pts urine microscopically and identify
reasons for biopsy (diagnostic, prognostic or therapeutic)
• Follow instructions on biopsy standing order sheet.
• Pt to be NPO prior to procedure
• Ensure PT/INR are within (N) range (INR<1.5). If elevated,
consider administration of FFP’s. Platelets >50.
• If pt uremic, Cr > 150 umol/L chronically, order DDAVP 20 ug in
100 ml N/S IV over 20 min.
• Consult hematology for any unexplained coagulopathy
• The biopsying radiologist will cancel the biopsy if
appropriate measures to document and correct a
coagulopathy are not undertaken.
• Make sure the post biopsy standing order sheet is in the chart.
• Consent forms for Blood and Tissue are to be filled out by
housestaff and signed by pt.
• Informed consent is usually obtained by the radiologist just prior
to the biopsy.
• If pt does not speak English, arrange for a family member or
hospital interpreter to translate. If no one can translate, consent
can not be obtained and the biopsy will be cancelled
• Enter the procedure into the Mysis computer system as follows:
• Order entry →Procedure tab, type in “Biopsy” →Select “Abd
Biopsy”(goes under Interventional)→ Kidneys (5) →Left (as
approp) →Tomorrow (4) →Reason Screen: (2) see Comment
77
 Field →(8) Comment: "localization for kidney biopsy"
→OK→Accept (A). If probs, call biopsy room 8257.
• Sedatives should not be ordered routinely before a kidney biopsy
as pt cooperation is required and excessive sedation can make
the procedure impossible to do.
• If it is necessary to use sedation, discuss with biopsying
interventionist so that consent can be obtained well in advance.
• The following information is provided to assist in informing the
patient:
• A biopsy is “low risk” if kidney size is normal, BP is well
controlled, platelet count, PT, PTT and INR are normal and the
serum creatinine is < 150.
• In these circumstances, the only tangible risk is that of
bleeding.
• At our institution, the following are the risk estimates:
• the incidence of gross hematuria is approximately 5-10%,
• the incidence of significant bleeding sufficient to delay
discharge is approx 1:100. This refers to persistent
hematuria, or perinephric hematoma, which usually settles
with conservative management.
• A transfusion is occasionally necessary.
• Serious bleeding complications sufficient to warrant
interventions to stop bleeding are of the order of 1:1000.
• Kidney biopsy can be life threatening in 1:5000 – 1:10,000.

Post Biopsy:
• Pts monitored closely for complications, usually apparent in the
first few hours.
• The patient is on bed rest for 12-24 hours if admitted. Usually
D/C'd next am.
• Vital signs are done frequently and urine is observed for gross
hematuria.
• If a complication occurs, notify the biopsying radiologist.
• Most complications are managed expectantly. For a serious
complication, consult urology, and/or interventional radiology if
consideration of an ablative procedure is warranted.

78
• If the patient is stable the next morning, they are discharged and
an appointment for follow up should be made with the referring
staff nephrologist in ~ 2 weeks time to discuss dx and Rx.
• Advise pt to carry out light activities only for 48 hrs post
discharge. No heavy lifting or strenuous exercise for 2 weeks. It
takes ~ 6 weeks to heal completely, after the first 2 weeks, they
can carry out routine activity and moderate exercise.
• Prepare pts case for presentation at biopsy rounds, focussing on
indications for the biopsy.

Emergency and Transplant Biopsies:

• Much the same as for electives, except the housestaff is

responsible for completion of the requisition. Note that req needs
to be the one with barcode.
• Pts BP must be within acceptable limits (<160/95)
• Indicate clearly the tests required - usually “light only” for
transplants, “light, IF and EM” for native kidney, and if it is
“STAT”. If it is STAT, make arrangements with pathologist, Dr.
Andrew Herzenberg, 14-4560.
• For non-transplant biopsy, the completed requisition should be
brought to Monica at Renal Coordination Office (12NU) and she
will make arrangements for the biopsy.
• If unable to inform Renal Coordination Office, call EM at 14-3184
and Biopsy room 8257 to inform them of biopsy for In-Patients.

Any biopsy, elective or emergency, which is not low risk or

which has any unusual features at all, should be discussed in
detail with the biopsying interventionist.

79
TRANSPLANT

Transplant Assessment
• All pts should be screened for transplant eligibility when CrCl <30
ml/min. Include willingness, risk factors, potential living donor.
• A following is needed to initiate transplant assessment::
• the patient’s blood group.
• current medication records.
• Bloodwork: CBC, lytes, Ca, PO4, LFT's, HIV, HBsAg & Ab,
Hep C, CMV IgG & EBV.
• cardiac status: ECG, 2D Echo and Persantine Stress Test
(within the last year if available).
• the type of dialysis, date of initiation, unit, days and shift if HD
• the patient’s height and weight.
• the referring staff physician.
• a social work assessment completed within one yr of referral.
• any significant information e.g. disabilities, language barrier,
family/social support, substance abuse, nursing concerns.

Management of Failed Transplant

Patients to remain on transplant service during the admission for
failed transplant, when initiating dialysis.

Withdrawal of Immunotherapy, Septra:

Discuss with Transplant Nephrologist for management.

Withdrawal of Steroids:
• Consult Transplant Nephrology fellow or staff
• rapid reduction to 15 mg/day (if no acute problem)
2 weeks later reduce to 12.5 mg/day
2 weeks later reduce to 10 mg/day
further taper over 1/4 total duration of steroid treatment
eg. 4 years of steroids, taper over 1 year to zero
• patients on steroids > 10 years may not recover adrenal function.
Suggest maintain on 7.5 mg/day permanently or until next
transplant

80
RENAL PALLIATIVE CARE

The annual mortality in the dialysis population in Toronto is

approximately 15%. Our patients are getting older, frequently with
many co-morbidities. It is not that uncommon that individuals and
families elect to stop dialysis or for the team to initiate end of life
treatment decision-making. Dialysis patients are justifiably entitled
to excellent palliative care, which focuses on physical, emotional and
spiritual comfort.

Renal palliative care works best with a team approach. The staff
nephrologist, who knows the patient best, should be involved in the
terminal care. The renal Social Workers usually know the patients
well, and have a lot of experience with end of life care. They can
provide support to the families, and also be an excellent source of
support for house staff and nurses. Additionally, the Nurse
Practitioners, nephrology nurses come to know our patients
extremely well. Other members of the team may be involved
including, dietitians, physical and occupational therapists, dialysis
nurses, chaplains, and others.

Once a decision is made to stop dialysis, death usually follows within

7-14 days. This depends in part on the patient's co-morbidities and
on residual renal function. The "best death" occurs when there is a
sudden cardiac arrest, secondary to hyperkalemia. Fluid overload,
which may occur, can be distressing to families and patients, and
can be dealt with by providing medications to ease breathing and
secretions. Even when a decision not to provide further dialysis has
been made, it is still our responsibility to provide excellent care. This
means a plan of care including physical, emotional and spiritual
comfort. This may involve family meetings, often of a multi-
disciplinary nature and if possible, include the staff nephrologist.

Finally, we expect to see more and more patients using Advanced

Directives. We should inquire as to whether or not they exist, and
make every effort to use them to guide us in our approach to the
terminal care of the dialysis patient.

81
RENAL FAILURE - DEFINITIONS AND APPROACH

Definitions
Creatinine Clearance (CrCl) (ml/s) =
(140- Age) x Lean body wt (kg) (x.85 for females) (x60 for ml/min)
Creatinine x 50

GFR in ESRD = (Cl urea + Cl Cr)/2

CrCl = Ucr x vol

Scr x t
Anuria <50ml/d
DDX: RPGN, cortical necrosis, bilat RA occlusion (dissection)
Very severe ATN , HUS/TTP
Oliguria < 400ml/d or < 20ml/hr (minimum .4ml/kg/hr)
Nonoliguric >800ml/d
Polyuria >3L/d

Proteinuria: 1) Normal < 150 mg/d (alb 50%)

2) tubular <1g/d
3) glomerular >1g/d
4) nephrotic >3.5g/1.73 m BSA

Stages of Chronic Kidney Disease (CKD)

Chronic kidney disease is defined as either kidney damage or GFR<
60 mml/min/1.73 m2 for ≥ 3 months.
Stage 1 GFR ≥ 90 Kidney damage with normal or ↑GFR
Stage 2 GFR 60-89 Kidney damage with mild ↓ GFR

Stage 3 GFR 30-59 Moderate ↓ GFR

Stage 4 GFR 15-29 Severe ↓ GFR
Stage 5 Kidney Failure GFR <15 (or dialysis)

82
Approach to Acute Renal Failure (ARF)
PRERENAL

1) True volume depletion

• Renal losses : diuretics, osmotic diureses (eg. glucose),
hypoaldosteronism, Na wasting nephropathy, DI
• GI losses : vomiting, diarrhea, bleeding
• Skin or respiratory losses (insensible losses, sweat, burns)
N= 800ml-1L/d, 20% with each 1° C
• Third space sequestration (intestinal obstruction, crush injury/
skeletal #, pancreatitis)
2) Hypotension (shock/sepsis)
3) Edematous states (heart failure, cirrhosis, nephrosis)
4) Selective renal ischemia (hepatorenal S, NSAIDs, bilat RAS,
dissecting AA, ACEI, CSA)

Prerenal ATN (heme granular casts)

Uosmol (mosmol/L) >500 <350

Una (mEQ/L) <20 >40
FENa <1 >3
Uspec. gravity >1.015 <1.015

POST RENAL
Anatomical Functional
prostatic hypertrophy DM
cervical Ca anticholinergic meds
strictures Neurogenic bladder
tumour
external compression eg. colon ca
stones, clots, sloughed papillae
retroperitoneal tumours/fibrosis

83
 RENAL

Preglomerular (vascular), Tubular, Interstitial, Glomerular

Preglomerular
• accelerated HTN
• scleroderma
• cholesterol or atheroembolic disease
• thrombotic microangiopathy eg. HUS/TTP

Tubular
• Polycystic Kidney Disease, Multiple Myeloma

• ATN (ischemia→prerenal insuff→ATN→cortical necrosis)

UA=tubular epithelail cells, granular casts “muddy brown”,
hemegranular casts, eosinophils (NOT RBC cast = GN)

Endogenous Exogenous
Ca++ Antibx eg. AMGs, Ampho B
Uric acid Contrast dye
Hemoglobinuria ChemoRx (esp. cisplatin, MTX)
Myoglobinuria Cyclosporin A
(rhabdo) Acyclovir
NSAIDs
ACEI

Interstitial

Acute
• Idiopathic
• Drugs: • Antibx: penicillin, methicillin, amp, rifampin, sulpha, cipro,
pentamidine
• NSAIDs (and other antiinflamm other than prednisone)
• Diuretics: thiazides, lasix, bumetanide (sulpha derivatives)
• Cimetidine, dilantin, allopurinol, cyclopsorin A, tacrolimus

• Infection: Streptococcus, leptospirosis, Rocky Mtn spotted fever,

Legionnaire’s, EBV, CMV, acute pyelonephritis
84
• Systemic: lymphoma, leukemic infiltration, SLE,
• Renal transplant rejection, toxic radiation

Chronic
• Therapeutic and environmental agents, e.g. analgesics, lithium,
heavy metals (lead, cadmium)
• Immunologic conditions, e.g. sickle cell disease,
lymphoproliferative diseases
• Metabolic disorders, e.g. uric acid nephropathy, cystinosis
• Infections - systemic or local

Glomerular

• Nephrotic Syndrome: Proteinuria >3.5g/1.73 m BSA/d, ↓albumin

<30, ↑chol, peripheral edema
• Nephritic : > 5 RBC/HPF, active sediment, HTN, ↓GFR, +/-
proteinuria

NEPHROTIC NEPHRITIC

Focal Proliferative

1) Minimal change 1) IgA = Berger’s = Mesangioproliferative

• Hodgkin’s D • Advanced liver D,
• NSAID • Sprue
• Dermatitis herpetiformis
2) FSGS
2) HSP
• HIV/AIDS
• Heroin abuse 3) Alport’s (Familial nephritis)
• Reflux nephropathy
• Massive obesity 4) SLE.

3) Membranous

• SLE, Sjogren’s Diffuse Proliferative

• Sacroid, sickle cell D.
• Ca: lung, breast, colon, 1) Post Infectious
stomach, lymphoma
85
 • Meds: Gold, Cd, • Grp A Beta hemolytic strep
Captopril, probenicid • Bacterial endocarditis
D-penicillamine • Infected ventriculoatrial shunts

4) Diabetes Mellitus 2) Membranoproliferative

n
5) Amyloidosis/MM • malaria, Hep B&C, chronic infec
• “shunt” nephritis, Sickle cell D
6) MPGN - rare • SLE, HUS/TTP, mixed cryo
• Congenital complement defic'y

3) Cryoglobulinemia

4) SLE

5) RPGNs

Rapidly Progressive Glomerular Nephritis (RPGN)

Anti-GBM Immune Mediated ANCA associated

• Anti-GBM D • MPGN • Wegener’s (C-ANCA)
• Goodpasteur’s • Post Strep GN • PAN (C & P ANCA)
• IgA (<3%) • Churg Strauss - P-ANCA
• SBE/shunt nephritis
• Cryoglobulinemia
• SLE
• Idiopathic crescenteric GN

ImmunofluorescenceDisease Rx
• lumps/bumps SLE Immunosuppressants
• linear Anti GBM Cytotoxic drugs
eg. cyclophosphamide
Goodpasteur’s Plasmapheresis
• none ANCA associated Ds. Cyclophosphamide
(pauci-immune) No plasmapheresis

86
Urine Sediment in DDX of ARF
Normal or few RBC or WBC
Prerenal azotemia
Arterial thrombosis or embolism
Preglomerular vasculitis
HUS/TTP
Scleroderma crisis
Postrenal azotemia

Granular casts
ATN (muddy casts)
Glomerulonephritis or vasculitis
Interstitial nephritis

RBC casts
GN or vasculitis
Malignant HTN
Rarely IN

WBC casts
AIN or exudative GN
Severe pyelonephritis
Marked leukemic or lymphomatous infiltration

Eosinophiluria (>5%)
Allergic IN (Antibx>NSAIDs)
Atheroembolic disease

Crystalluria
Acute urate nephropathy
Calcium oxalate (ethylene glycol toxicity)
Acyclovir
Sulfonamides
Radiocontrast agents

87
Contrast Nephropathy
Definition
Proportional rise in creatinine (25-50%) within 48-72 hrs of receiving
radiocontrast medium - other causes ruled out

Presentation
Creatinine peak 4-5 days, with return to baseline 7-10 days
Usually non-oliguric
Low FeNa
UA – mild protein; Micro – bland or granular casts

Risk Factors
• Pre-existing renal insufficiency (CRI)
• Diabetes
-No CRI risk is similar to non-diabetics
-With CRI risk = 2x CRI alone
-Often oliguric, requiring dialysis
• CHF- related ECFV↓ +/- renal vasoconstriction
• MM - related ECFV↓ +/- CRI
• Contrast agent
-High volume
-High osmotic>low osmotic medium (LOCM)

Prevention
• Avoid contrast
• Low contrast volumes
• LOCM (vs. HOCM) in CRI
• ECFV repletion/hydration

Recommendations
• Measure renal function before, 48h and 72 hrs after contrast
• Assess clinical circumstances and ensure adequate hydration
- NS 1cc/kg/hr 6-12hrs before and 12-24 hrs after
- D/C diuretics x 24 hrs
• Acetylcysteine 600 mg BID on the day before and day of procedure, along
with hydration
• Avoid nephrotoxins, e.g. NSAIDS
• Careful with renally excreted meds. E.g. Metformin
88
 References

KI 1998, vol 53, p. 230-242 AJKD 1994, vol 24, p. 713-727

NEJM 1989, vol 320, p. 143-149 NEJM 2000, vol 343 (3) p 180-184

Glomerulopathies
Focal Segmental Glomerular Sclerosis (FSGS)
Pathology
Glomerular Interstitium Variants
• Focal lesions - Tubular atrophy Classic
• Segmental scarring - Fibrosis - Tip
• Adhesions - Hypercellular
• Intracapillary foam cells - Collapsing

Natural History
• 3-15% of all biopsies 7-12% of all proteinuria
• Most common progressive type in children & black population (all ages)
• Increasing frequency in past decade
• Children M:F = 1:1
• Adults M:F = 2:1

Presentation
• Nephrotic 70% children, 50% adults
• Asymptomatic proteinuria 30-50%

Associated Findings
• Hypertension 25% children, 50% adults
• Impaired GFR 20-40%
• Microhematuria 40-60%

Course
• Spontaneous complete remission 5-8%
• Rapid progressive renal failure 10-15%
• Slowly progressive renal failure 40-60%
• Persistent proteinuria 20-30%

Prognostic Factors
89
 Good Bad
• Complete remission Interstitial fibrosis
• Steroid responsive Impaired GFR
Persistent high grade proteinuria

Treatment
• Establish diagnosis is primary
• Symptomatic Rx
• Rx of co-morbid condition e.g. hyperlipidemia
• Nephrotic patients: Prednisone 1 mg/kg/day x 3-6 mos
If no response: cyclophosphamide 1-1.5 mg/kg x 3-6 mos* or
Cyclosporine 4-6 mg/kg x 6 mos
• Subnephrotic/stable GFR: limit Rx to steroids or observation only

Recommendations
1) Initial - prednisone 0.5-1 mg/kg x 6 mos (grade C)
2) Resistant/dependent: cyclosporine 3-5 mg/kg x 4-12 mos (Grade D) or
Cyclophosphamide 2.5 mg/kg x 3 mos*

Membranous GN
Pathology
• Diffuse, uniform thickening of GBM
• Minimal mesangial cell proliferation
• “Staging” dependent on position of deposits on EM

Natural History
• 5-10% of all biopsies
• 10-20% of all proteinurias
• common cause of adult nephrotic syndrome
• rare in children (<1% under age 16 - usually d/t maligancy)
• secondary causes 20-30% of cases, malignancy ↑ with age

Presentation
• Nephrotic 60-70%
• Asymptomatic proteinuria 30-40%

90
 Associated finding
• Renal insufficiency 10%
• Hypertension 10-20%
• Microhematuria 40-60%
• Renal vein thrombosis 5-30%
0
Course (1 only)
• Spontaneous remission 20-30%
• Persistent proteinuria 30-40%
• Progressive renal failure 20-30%

Prognostic Factors
Good
• Complete remission
• Low level proteinuira (<3.5g/d)
• Female sex

Bad
• Persistent high grade proteinuria
• Renal insufficiency
• Hypertension
• Male sex

Treatment
• Low risk = chlorambucil/prednisone routine (Grade A)
• High risk = a) cyclosporine 4-5 mg/kg x 6-12 mos +/- prednisone (A/B)
b) chlorambucil/prednisone routine (A/B)
c) cyclophosphamide 2 mg/kg x 4-12 mos +/- prednisone (C/D)*
• Mod/high risk = aggressive Rx of HTN, hyperlipidemia, thrombotic risk

* Remember to follow up re. side effects of Cyclophosphamide /prednisone.

91
 Membranoproliferative GN (MPGN)
Pathology
• Glomerular
- mesangial cell proliferation
- matrix expansion (tram tracks)
• Variants
Type I - subendothelial (+/- mesangial) deposits - most common
Type II - dense deposits - abnormal material in GBM - rare
Type III - mixed - subendothelial + subepithelial - rare

Natural History
• Uncommon - 1-3% of all biopsies, 3-5% of all proteinuria
• ↓ing frequency in past 2 yrs (vs. 2ndary ↑ng, esp Hep B & C)
• Children - predominance of type II vs. adult type
• Predominantly Caucasians affected

Presentation
• Nephrotic 40-60%
• Asymptomatic 20-40%
• Acute nephritic syndrome 10-30%

Associated Findings
• Hypertension 30%
• Microhematuria 60-70%
• Impaired GFR 30-50%
• Hypocomplementemia 80-90%
• Type I - classic pathway C3↓ C4↓
• Type II (III) - alt pathway C3↓ C4N

Course
• Spontaneous remission 20-30%
• Slowly preogressive renal failure 40-50%
• Persistent proteinuria 20-30%

Prognostic Factors
Good Bad
Spontaneous remission Persistent heavy proteinuria
Interstitial fibrosis
92
 Treatment
• All ages with N GFR, subnephrotic proteinuria
no specific Rx (Grade B/C)

• Children - nephrotic +/- ↓GFR

prednisone 40mg/m2 x 6-12 mos
+ conservative measures (B/C)

• Adults - nephrotic +/- ↓GFR

ASA 325 mg +/- dipyridamole 100 mg TID x 12 mos
+ conservative measures (B/C)

IgA Nephropathy
Pathology
• Mesangium cell proliferation (focal or diffuse)
• Mesangium matrix expansion
• IgA in mesangium on IF

Natural History
• 10-25% of all biopsies
• 5-15% of all proteinuria
• Most common glomerular pathology
• Uncommon in children
• Rare in blacks
• Family history 10-20%
• Secondary causes 10-20% of cases

Presentation
• Microscopic hematuria 70-95%
• Macroscopic hematuria 15-40%
• Asymtomatic proteinuria 5-25%
• Acute renal failure 2-15%
• Nephrotic syndrome 2-10%

Associated Findings
• Hypertension 10-20%
• Renal insufficiency 10-25%
93
 Course
• Spontaneous remission 10-15%
• Progressive renal failure
Slow 10-50%
Rapid 5-10%
• Persistent microhematuria 30-50%
• Persistent proteinuria 15-30%

Prognostic Factors

Good Bad
Microhematuria alone Hypertension
Recurrent macrohematuria alone Moderate proteinuria (1-4 g/d)
Renal insufficiency
Male
Age >35

Treatment
• No adverse profile - ACEI
• Adverse profile - ACEI + a) Fish oil b) Prednisone OD x 1-2 years
• Unstable - IV IG x 3 mos and IM IG x 6 mos

94
Pregnancy & HTN

Types: 1) pre-existing i.e. present before 20 wks gestation

2) Gestational (transient) - no proteinuria
3) Pre-eclampsia/eclampsia - + proteinuria
4) Pre-existing + superimposed gestational

When to admit: When to Rx:

BP ≥ 170/110 BP ≥ 140/90 and:
- symptoms
PET suspected or diagnosed - chronic HTN
- < 28 weeks
- PET
Otherwise Rx BP > 150/95
Monitor (if outpt follow weekly):
- ↑ uric acid (↑ perinatal complications)
- CBC (↓ Plts);
- Liver enzymes
- 24 hr urine protein
- fetal monitor

Treatment: aim for reducing BP over at least 24 hrs (be careful not to let the
BP plummet, as there is no placental autoregulation)

BP >170/110 BP <170/110 C/I

Hydralazine po Methyldopa ACEI
Labetolol IV Labetolol po ATIIRI
Nifedipine SL Nifedipine

Goals:
for chronic HTN BP <170/110 (nadir at 20 wks)

Postpartum HTN - All antihypertensives safe for breastfeeding

- BP highest 3-5 days post delivery
- May last 6 mos

95
 MEDICATIONS IN CKD

Dose adjustments of drugs for renal failure

Estimate CrCl using Cockcroft-Gault equation:

CrCl (ml/s) = (140-age) x wt (kg) (x 0.85 for women)

50 x SCr (umol/l)

Commonly prescribed drugs that require dose adjustment:

• Antibiotics (penicillins, cephalosporins, quinolones, vanco, Septra)
• H2 receptor blockers
• Allopurinol
• Analgesics
• Antivirals (gancyclovir, acyclovir)

Dose adjustment for dialysis

Consider:
• Type of dialysis (HD vs. PD. vs. CRRT)
• Drug properties (MW, protein binding, water solubility, metabolism)
• Drugs that are renally cleared are usually dialyzable (except Vanco)
• Most antibiotics (penicillins & cephalosporins) are dosed after dialysis
• Dose antibiotics per UHN Guidelines for Antimicrobial Use
• Discuss with Nephrology fellow/staff or pharmacist

Common problems in the ESRD population and their therapies

Bleeding Complications
• Platelet dysfunction in the uremic environment contributes to bleeding
• Before invasive procedures, advisable to use FFP’s or DDAVP
o DDAVP dosing: 0.3 ug/kg/hr to max 20 ug
o Max 20 ug in 100 ml N/S over 20 min
• To stop bleeding, apply direct pressure for prolonged period of time.
o may require Gelfoam
o Never use Thrombostat (high incidence of anaphylaxis in HD pts)

96
 Anemia
• Decreased erythropoietin (EPO) production in renal failure contributes to
anemia
• Most patients require EPO supplementation +/- IV or po iron
• Iron should be given prior to EPO if ferritin is < 100 and/or iron sat is <20%
• Erythropoietin (Eprex™) dosing guidelines: start 100-200 U/kg 1-3x/week.
e.g. 4000 U 3x/wk. Allow 2-6 wks to see a response to EPO therapy
• Darbepoietin (Aranesp™) guidelines: 0.45 mcg/kg s.c. or IV once weekly
• For those on chronic HD at TGH, Aranesp is given Tuesdays and Fridays.
• Because of very rare pure red cell aplasia seen with some EPO recipients,
pts on HD are to receive IV Eprex, and PD/pre-dialysis patients to receive
subcutaneous Eprex only from a multi-dose vial, or Aranesp.
• The patient may experience an increase in blood pressure; therefore, BP
should be well controlled prior to initiating EPO, and monitored following.
• Goal hemoglobin: 110-120

Common causes of non-response to EPO include:

- Iron deficiency - Blood loss (active bleeding or hemolysis)
- Infection - Active inflammatory disease
- Malignancy - Hyperparathyroidism
® ®
Conversion from Eprex to Aranesp
A simple method of conversion is to multiply Eprex® dose by 4 and use 1st
2 digits as the Aranesp® dose.

A more specific method is to multiply weekly Eprex® dose by conversion

factor in table below. Aranesp® dose is the 1st 2 digits rounded off. E.g. Pt
gets Eprex® 8,000 u/week with Hgb 122 → 8,000 x 4 = 32,000, therefore
give 30 ug Aranesp®
Prefilled syringes available in 10, 20, 30, 40, 50, 60, 80,100 and 150 ug.

Aranesp® start dose: 0.45 ug/kg/wk

Give Aranesp® once per week or once per 2 weeks.
Order Aranesp® IV for HD patients and SC for all others.

97
 ® ®
Conversion Factors Eprex to Aranesp
Eprex Dose Hemoglobin
U/week <120 g/L ≥120 g/L
<15,000 5x 4x
≥15,000 4x 3x

Remember to fill out registration form for new Aranesp® therapy and
send to Dr. Richardsons office (8NU-861).

Guidelines for Registering Renal Failure Patients for

Erythropoietin or Darbepoietin at UHN and MSH
1. Complete a Ministry of Health EPO registration form (available in the HD units, PD
unit, the nephrology ward and through Dr. Richardson’s office)
• Include the patient’s MRN for identification purposes as well as name
• Fill out all spaces including MOH insurance number
• In the section “type of dialysis” check “none” if they are predialysis or transplanted
• In the section “Physician” print the name of the staff physician and your name if
different – a signature is not required
• For patients not on dialysis, indicate if they are predialysis or transplant

2. For center hemodialysis patients

• After completing the form, send it to Dr. Richardson’s office (8NU-861)
• Write an order for erythropoietin in the patient’s chart

3. For peritoneal dialysis patients

• After completing the registration form, make a photocopy of the top page
• Write a prescription for erythropoietin
• Give the patient both the prescription and the copy of the registration form to take to
TGH pharmacy. The registration form will serve as proof the patient has been
registered
• Give the registration form to the ward clerk who will send it to Dr. Richardson’s office

4. For office or clinic outpatients at TWH, TGH, MSH or PMH

• After completing the registration form, make a photocopy of the top page
• Write a prescription for erythropoietin
• Give the patient both the prescription and the copy of the registration form to take to
either TWH or TGH pharmacy. The registration form will serve as proof the patient
has been registered
• Send the registration form to Dr. Richardson’s office. There is no need to phone the
office since the copy of the registration form has been given to the patient to take to
pharmacy

5. For inpatients at TGH, TWH, MSH or PMH being registered for EPO for the first time
• After completing the registration form make a copy of the top page
98
 • Order Eprex/Aranesp in Mysis; give a copy of the registration form to the ward
pharmacist
• Send the registration form to Dr. Richardson’s office

6. For inpatients at TGH, TWH, MSH or PMH who are receiving erythropoietin at other
dialysis centers and are transferred here temporarily for care and require
erythropoietin
• Write an order for erythropoietin in the chart
• Add a statement to the effect that the patient is registered for erythropoietin at
another center
• Do NOT fill out a registration form for these patients

7. Note that if a patient comes to the outpatient pharmacy with a prescription for EPO who is
not on the registration list or who does not have a photocopy of the registration form,
the patient will be asked to return to their nephrologist’s office or clinic to be properly
registered, or if they go to an outside pharmacy, they will be charged the cost of the
meds. Revised July 2002

Iron
1) IV iron. Two forms used are iron dextran and iron saccharate. Please
refer to the sections on IV iron
2) Oral iron. The recommended oral iron therapy is 200 mg elemental iron
OD or Ferrous gluconate 600 mg TID or Ferrous fumarate 300 mg BID
Note: most patients can only tolerate ferrous gluconate 300 mg po TID
How to advise patients on how to take iron po:
• Absorbed best on empty stomach,either 1 hr before or 2 hrs after meals
• Iron and phosphate binders (calcium & aluminum) bind together so they
should be taken 1 -2 hrs apart
• Separate other drugs that interact with iron such as cipro, L-Thyroxine,
methyldopa.

Vitamin deficiency
• Replavite (or Diavite) 1 tab daily, a water soluble vitamin that contains B
vitamins, vitamin C and folic acid
• Other multivitamins may contain fat soluble vitamins which may
accumulate and cause toxicity and should not be substituted

99
 Hyperphosphatemia
• Calcium carbonate is used as a phosphate binder given with meals
• Tums Extra Strength = CaCO3 750 mg = 300 mg Ca++
• Oscal = CaC03 1250 mg = 500 mg Ca++
• For severe hyperphosphatemia with hypercalcemia, aluminum
hydoroxide can be used short term e.g. Amphogel 15-30 ml TID with
meals x 5 days then reassess
• Renagel - a Ca-free PO4 binder - useful for pts with both
hyperphosphatemia and hypercalemia - expensive and as yet not
covered by ODB - requires Section 8 form from pharmacist.

Hypophosphatemia
• May use Fleet PO4 enema in Acid concentrate of dialysate, use 30,60 or
90 ml with HD until corrected. Hold PO4 binders.

Hypocalcemia/ ↑PTH
• The kidneys' production of 1,25 dihydroxy Vitamin D3 (the active form of
vitamin D) declines in ESRD; therefore, calcium absorption from the GI
tract is also diminished leading to hypocalcemia and hyperparathyroidism
• May use Calcium carbonate between meals as calcium supplement.
• Calcitriol=Rocaltriol = the pharmacological replacement of active vit D3
which increases gut absorption of Ca++ (and PO4) and suppresses PTH
• Dose of rocaltriol ranges from 0.25 ug 3x/wk to 1.0 ug OD (may be given
po, or IV pulse with HD)
• Sensipar (Calcinet) is a new calcimimetic, which is available, however is
not covered by insurance as yet, and is very costly. Payment needs to be
determined before prescribing this medication.
• Goal PTH = 20-30 pmol/L (normal 7-8); normalization may be a risk factor
for adynamic bone disease

100
 Hyperkalemia
Initial monitoring and diagnosis
1. Perform 12-lead ECG unless pt undergoing continuous ECG monitoring
2. Hyperkalemia is not always associated with ECG changes; but no ECG
changes does not mean that potential for arrhythmia does not exist.
3. Transfer to monitored setting or arrange for telemetry if K+ > 7 mmol/L
or if ECG changes attributable to hyperkalemia present independent of
K+ level
4. Measure blood levels of creatinine, bicarbonate, calcium and
glucose. Note that with restoration of normal blood sugar the K+ may
shift back into cells
5. Discontinue K+ administration (including IP KCl) or meds contributing to
hyperkalemia (eg ramipril)

For treatment:
Shifting potassium into cells and protecting the heart:
1. Give one amp of calcium gluconate unless the patient is
hypercalcemic.
2. Give 20 units regular insulin intravenously as a bolus; if the patient is
not hyperglycemic give 50 ml intravenously of 50% glucose in water.
3. Give 2-3 puffs of albuterol (Ventolin) with MDI or inhalation treatment
by RT.
4. If the serum bicarbonate is < 20 mmol/L and the patient is not volume
overloaded, give 1-2 amps (44-88 mEq) of sodium bicarbonate.

Removing potassium from the body:

1. If the patient is hemodialysis-dependent already, arrange for urgent
hemodialysis through the HD unit. Hyperkalemia is unusual in the
peritoneal dialysis patient; however, it will respond to rapid-cycling
PD (see section on PD orders).
2. If the patient is not dialysis-dependent, determine whether it is likely
that you will be able to increase urine potassium excretion quickly. It
is unlikely if the patient is oligo-anuric and has a rapidly rising serum
creatinine due to acute tubular necrosis or if the patient has
cardiogenic shock. It is more likely if the patient has pre-renal failure
due to hypovolemia, which can be corrected or if the hyperkalemia is
in large part drug-induced such as with ACE-inhbitors, NSAIDS,
sprironolactone etc.
101
To increase urine volume and potassium excretion the following methods
may be appropriate depending on the situation:
1. Volume resuscitation with isotonic saline if the patient has prerenal
failure and is volume depleted
2. High dose furosemide if/when the patient is euvolemic or volume
overloaded (ie160-240 mg IV)
3. IV sodium bicarbonate if the patient is acidotic and hypovolemic - aim
to get serum bicarbonate to > 20 mmol/L.
4. If the patient is on an ACEi, ARB, spironolactone or NSAIDs,
consider giving 0.2 mg Florinef orally to increase aldosterone effect.
5. If the patient is obstructed, consider nephrostomy tubes and
adequate volume replacement.
It is imperative to continue to monitor the patient's serum potassium,
bicarbonate and creatinine during therapy as well as urine flow to be sure
that conservative therapy is in fact succeeding. If serum potassium is not
decreasing then dialysis should be strongly considered.

Follow up
+
• Repeat K determination within 2 hr of initial exam (unless pt on
dialysis)
• Repeat ECG if any changes on the first ECG
+
• Continue appropriate therapy and continue monitoring q 2-4 hr until K
< / = 5.5 mmol/L

Use of Potassium exchange resins

Occasionally, in chronic dialysis patients, exchange resins may be used to
treat or prevent hyperkalemia if for some reason they have to delay or
miss a dialysis e.g. due to machine breakdown at home, access problems,
weather, travel etc.
Oral: Calcium resonium 30 gm in Sorbitol 30 ml or Sodium polystyrene
(Kayexalate) 30 gm in Sorbitol 30 ml but be aware of sodium load with
Kayexalate. Takes 4-6 hr for effect. May also be given by enema (30 gm
in100 ml water) (less effective than oral).

102
 Constipation
AVOID
• Magnesium containing products (MOM, Mag citrate)
• Bulk forming laxatives in fluid restricted patients e.g. Metamucil or Prodiem
• Fleet enemas d/t high phosphate content (may use Fleet Mineral Oil)

SAFER
• Docusate sodium, Lactulose, senna
• Stimulant laxatives (bisacodyl, cascara)
• Glycerin suppositories prn
• Tap water or mineral oil enemas for severe constipation
• Colyte for bowel preps (not for PD patients) or lower dose (250-500 ml) for
very severe constipation.

103
 Analgesia
Opioid Analgesic Comparison Chart
Doses Equivalent Brand Name Consideration in CKD
to Morphine 10 mg IM or SC Duration of
Opioid IM or Oral Conversion Analgesia Caution Dialyzability
SC ** ** Injection to
Oral
Meperidine 75 mg 300 4 Demerol® 2 to 3 h AVOID: metabolite No (HD)
mg normeperidine can Unlikely (PD)
precipitate seizures
Codeine 120 mg 200 1.5 Codeine tablet/syrup 3 to 4h Caution: consider No data (HD)
mg Compounds (Tylenol #1, #2, #3) 3 to 4h decrease starting dose Unlikely (PD)
to 50% due to
prolonged half life
Codeine Contin CR 12 h
Morphine 10 mg 30 mg 3 Morphine tablet/syrup (MS-IR ® / 3 to 4h Metabolite morphine 6 Yes (HD)
Statex®) glucoronide has No (PD)
M- Eslon® capsule 12 h narcotic activity
MS Contin® SR tablet 12 h increase risk of side
effects
Oxycodone NA 15 mg NA Oxy-IR® 3 to 4 h Caution Yes (HD)
Oxycontin® CR 12 h No data (PD)
Percocet® (oxycodone + 3 to 4 h
acetaminophen)
Hydromorph 1.5 mg 7.5 5 Diluadid® 3 to 4 h Caution due high No data (HD)
one mg Hydromorphone Contin 12 h potency narcotic No data (PD)
Fentanyl 100 ug NA NA Duragesic® Patch 72 hours Decrease starting No (HD)
dose by 50% No data (PD)
* Opiods are in order of increasing potency

** All above dose equivalencies are compared to 10 mg of injectable morphine. For example, Codeine 120 mg IM = Morphine 10 mg IM = Hydromorphone 1.5 mg IM
Other Considerations:
• It is easier to keep pts out of pain than to get them out of pain, consider
standing analgesia with breakthrough as needed.
• Acetaminophen (Tylenol) +/- codeine – max 4 gm acetaminophen/day
• NSAIDs - remember pts are at a higher risk of GI bleed therefore,
misoprostal or a proton pump inhibitor should be added for prophylaxis
• All opioids – start at small doses and titrate up for pain relief as excessive
sedation may occur

HS Sedation
AVOID
• Chloral hydrate as the active metabolite may accumulate and cause
excessive sedation

SAFER
• Benzodiazepines such as lorazepam and oxazepam are hepatically
metabolized and safer.

Anti-seizure medications
• Carbamazepine, diazepam, phenobarbital, valproic acid are hepatically
metabolized and do not require dose adjustment
• Phenytoin dosing is unchanged but blood levels require careful
interpretation:
Corrected blood dilantin level: measured level (.48)(.9) (alb/40)
+0.1
Drug Dosing for HD, CAPD and CRRT
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Acarbose D Avoid Unknown Unknown Avoid

Acebutolol D 30-50% None None 50%
Acetazolamide I Avoid Unknown Unknown Avoid
Acetohexamide I Avoid Unknown None Avoid
Acetohydrox- D Avoid Unknown Unknown Unknown
aminic acid
Acetaminophen I Q8H None None q6h
ASA I Avoid After HD None q4-6h
Acrivastine D Unknown Unknown Unknown Unknown
Acyclovir D,I See UHN Guide See UHN Guide Dose for RF 3.5 mg/kg/d
Adenosine D 100% None None 100%
Albuterol D 50% Unknown Unknown 75%
Alcuronium D Avoid Unknown Unknown Avoid
Alfentanil D 100% Unknown Unknown 100%
Allopurinol D 25% ½ dose Unknown 50%
Alprazolam D 100% None Unknown NA
Alteplase (tPA) D 100% Unknown Unknown 100%
Altretamine D Unknown Unknown Unknown Unknown
Amantadine I q7d See UHN Guide None q48-72h
Amikacin D,I 20-30% q24-48h See UHN Guide 15-20mg/L/d 30-70% q12-18h
Amiloride D Avoid NA NA NA
Amiodarone D 100% None None 100%
Amitriptyline D 100% None Unknown NA
Amlodipine D 100% None None 100%
Amoxapine D 100% Unknown Unknown NA
Amoxicillin I See UHN Guide See UHN Guide 250mg q12h NA
Amphotericin I q24-36h See UHN Guide See UHN Guide q24h
Ampicillin I See UHN Guide See UHN Guide 250mg q12h q6-12h
Amrinone D 50-75% Unknown Unknown 100%
Anistreplase D 100% Unknown Unknown 100%
Astemizole D 100% Unknown Unknown NA
Atenolol D,I 30-50% q96h 25-50 mg None 50%q48h
Atovaquone - 100% None Unknown Unknown
Atracurium D 100% Unknown Unknown 100%
Auranofin D Avoid None None None
Azathioprine D 50% Yes Unknown 75%
Azithromycin D 100% None None None
Azlocillin I q8h Dose after HD Dose for RF q6-8h
Aztreonan D 25% 0.5g after HD Dose for RF 50-75%
Benazepril D 25-50% None None 50-75%
Bepridil - Unknown None None Unknown.
Betamethazone D 100% Unknown Unknown 100%
Betaxolol D 50% None None 100%
Bezafibrate D 25% Unknown Unknown 50%
Bisoprolol D 50% Unknown Unknown 75%
Bleomycin D 50% None Unknown 75%

108
Bopindolol D 100% None None 100%
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Bretylium D 25% None None 25-50%

Bromocriptine D 100% Unknown Unknown Unknown
Brompheniramine D 100% Unknown Unknown NA
Budesonide D 100% Unknown Unknown 100%
Bumetanide D 100% None None NA
Bupropion D 100% Unknown Unknown NA
Buspirone D 100% None Unknown NA
Busulfan D 100% Unknown Unknown 100%
Butorphanol D 50% Unknown Unknown NA
Capreomycin I q48h Dose after HD None q24h
Captopril D,I 50% q24h 25-30% None 75% q12-18h
Carbamazepine D 100% None None None
Carbidopa D 100% Unknown Unknown Unknown
Carboplatin D 25% 50% Unknown 50%
Carmustine D Unknown Unknown Unknown Unknown
Carteolol D 25% Unknown None 50%
Carvedilol D 100% None None 100%
Cefaclor D 50% 250 mg after HD 250mg q8-12h NA
Cefadroxil I q24-48h 0.5-1.0g afterHD 0.5g/d NA
Cefamandole I q12h 0.5-1.0g afterHD 0.5-1.0g q12h q6-8h
Cefazolin I See UHN Guide See UHN Guide See UHN Guide q12h
Cefepime I q24-48h 1g after HD Dose for RF Not recommend
Cefixime D 50% 300 mg after HD 200 mg/d Not recommend
Cefmenoxine D,I 0.75g q12h 0.75g after HD 0.75g q12h 0.75g q8h
Cefmetazole I q48h Dose after HD Dose for RF q24h
Cefonicid D,I 0.1g/d None None None
Cefoperazone D 100% 1g after HD None None
Ceforanide I q24-48h 0.5-1.0g afterHD None 1 g/d
Cefotaxime I See UHN Guide See UHN Guide 1g/d 1g q12h
Cefotetan D See UHN Guide See UHN Guide 1g/d 750 mg q12h
Cefoxitin I q24-48h 1g after HD 1g/d q8-12h
Cefpodoxime I q24-48h 200 mg after HD Dose for RF NA
Cefprozil D,I 250 mg q24h 250 mg after HD Dose for RF Dose for RF
Ceftazidime I See UHN Guide See UHN Guide See UHN Guide q24-48h
Cefibuten D 25% 300 mg after HD Dose for RF 50%
Ceftizoxime I q24h 1g after HD 0.5-1.0g/d q12-24h
Ceftriaxone D 100% See UHN Guide 750 mg q12h 100%
Cefuroxime axetil D See UHN Guide See UHN Guide Dose for RF NA
Cefuroxime sodium I See UHN Guide See UHN Guide Dose for RF 1g q12h
Celiprolol D 75% Unknown None 100%
Cephalexin I See UHN Guide See UHN GuideDose for RF NA
Cephalothin I q12h Dose after HD 1g q12h 1g q8h
Cephapirin I q12h Dose after HD 1g q12h 1g q8h
Cephradine D 25% Dose after HD Dose for RF NA
Cetirizine D 30% None Unknown NA
Chloral hydrate D Avoid None Unknown NA
Chlorambucil D Unknown Unknown Unknown Unknown
Chloramphenicol D 100% See UHN Guide None None
109
Chlorazepate D 100% Unknown Unknown NA
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Chlordiazepoxide D 50% None Unknown 100%

Chloroquine D 50% See UHN Guide None None
Chlorpheniramine D 100% None Unknown NA
Chlorpromazine D 100% None None 100%
Chlorpropamide D Avoid Unknown None Avoid
Chlorthalidone I Avoid NA NA NA
Cholestyramine D 100% None None 100%
Cibenzoline D,I 66% q24h None None 100% q12h
Cidofovir D Avoid Unknown Unknown Avoid
Cilastin D Avoid Avoid Avoid Avoid
Cilazapril D,I 10-25% q72h None None 50%q24-48h
Cimetidine D 25% None None 50%
Cinoxacin D Avoid Avoid Avoid Avoid
Ciprofloxacin D See UHN Guide See UHN Guide 250mg q8h (200 if IV) 200 mg IV q12h
Cisapride D 50% Unknown Unknown 50-100%
Cisplatin D 50% Yes Unknown 75%
Cladribine D Unknown Unknown Unknown Unknown
Clarithromycin D See UHN Guide See UHN Guide None None
Clavulanic acid D 50-75% Dose after HD Dose for RF 100%
Clindamycin D 100% See UHN Guide See UHN Guide None
Clodronate D Avoid Unknown Unknown Unknown
Clofazimine -- 100% None None Unknown
Clofibrate I Avoid None Unknown q12-18h
Clomipramine D Unknown Unknown Unknown NA
Clonazepam D 100% None Unknown NA
Clonidine D 100% None None 100%
Cloxacillin See UHN Guide See UHN Guide
Codeine D 50% Unknown Unknown 75%
Colchicine D 50% None Unknown 100%
Colestipol D 100% None None 100%
Cortisone D 100% None Unknown 100%
Cotrimoxazole See UHN Guide See UHN Guide
Cyclophosphamide D 75% ½ dose Unknown 100%
Cycloserine I q24h None None q12-24h
Cyclosporine D 100% None None 100%
Cytarabine D 100% Unknown Unknown 100%
Dapsone -- Unknown None Dose for RF Unknown
Daunorubicin D 100% Unknown Unknown Unknown
Delavirdine -- 100% None Unknown Unknown
Desferrioxamine D 100% Unknown Unknown 100%
Desipramine D 100% None None NA
Dexamethasone D 100% Unknown Unknown 100%
Diazepam D 100% None Unknown 100%
Diazoxine D 100% None None 100%
Diclofenac D 100% None None 100%
Dicloxacillin D 100% None None NA
Didanosine I q24-48h Yes Dose for RF Dose for RF
Diflunisal D 50% None None 50%
110
Digitoxin D 50-75% None None 100%
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Digoxin D,I 10-25% q48h None None 25-75%q36h

Dilevalol D 100% None None Unknown
Diltiazem D 100% None None 100%
Diphenhydramine D 100% None None None
Dipyridamole D 100% Unknown Unknown NA
Dirithromycin -- 100% None Unknown 100%
Disopyramide I q24-40h None None q12-24h
Dobutamine D 100% Unknown Unknown 100%
Doxacurium D 50% Unknown Unknown 50%
Doxazosin D 100% None None 100%
Doxepin D 100% None None 100%
Doxorubicin D 100% None Unknown 100%
Doxycycline D 100% See UHN Guide None 100%
Dyphilline D 25% ⅓ dose Unknown 50%
Enalapril D 50% 20-25% None 75-100%
Epirubicin D 100% None Unknown 100%
Ebastine D 50% Unknown Unknown 50%
Erythromycin D See UHN Guide See UHN Guide None None
Esmolol -- -- None None Unknown
Estazolam D 100% Unknown Unknown NA
Ethacrynic Acid I Avoid None None NA
Ethambutol I q48h See UHN Guide Dose for RF q24-36h
Ethchlorvynol D Avoid None None NA
Ethionamide D 50% None None None
Ethosuximide D 100% None Unknown Unknown
Etodolac D 100% None None 100%
Etomidate D 100% Unknown Unknown 100%
Etoposide D 50% None Unknown 75%
Famcyclovir I See UHN Guide See UHN Guide Unknown Unknown
Famotidine D 10% None None 25%
Fazadinium D 100% Unknown Unknown 100%
Felodipine D 100% None None 100%
Fenoprofen D 100% None None 100%
Fentanyl D 100% Unknown Unknown 100%
Fexofenadine I q24h Unknown Unknown q12-24h
Flecainide D 50-75% None None 100%
Fleroxacin D 50% 400 mg post HD 400 mg/d NA
Fluconazole D See UHN Guide See UHN Guide See UHN Guide 100%
Flucytosine I q24h Yes 0.5-1.0 g/d q16h
Fludarabine D 50% Unknown Unknown 75%
Flumazenil D 100% None Unknown NA
Flumarizine D 100% None None None
Fluorouracil D 100% Yes Unknown 100%
Fluoxetine D 100% Unknown Unknown NA
Flurazepam D 100% None Unknown NA
Flurbiprofen D 100% None None 100%
Flutamide D 100% Unknown Unknown Unknown
Fluvastatin D 100% Unknown Unknown 100%
111
Fluvoxamine D 100% None Unknown NA
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Foscarnet D 6 mg/kg See UHN Guide Dose for RF 15 mg/kg

Fosinopril D 75-100% None None 100%
Furosemide D 100% None None NA
Gabapentin D,I 300 mg/d Yes -- 300 mg q12-24h
Gallamine D Avoid NA NA Avoid
Ganciclovir I See UHN Guide See UHN Guide Dose for RF 2.5 mg/kg/d
Ganciclovir oral D,I 500 mg q48-96h Yes Dose for RF NA
Gemfibrozil D 100% None Unknown 100%
Gentamycin D,I 20-30% q24-48h See UHN Guide3-4 mg/L/d 30-70%q12h
Glibornuride D Unknown Unknown Unknown Avoid
Gliclazide D Unknown Unknown Unknown Avoid
Glipizide D 100% Unknown Unknown Avoid
Glyburide D Avoid None None Avoid
Gold Na thiomalate D Avoid None None Avoid
Griseofulvin D 100% None None None
Guanabenz D 100% Unknown Unknown 100%
Guanadrel I q24-48h Unknown Unknown q12-24h
Guanethidine I q24-36h Unknown Unknown Avoid
Guanfacine D 100% None None 100%
Haloperidol D 100% None None 100%
Heparin D 100% None None 100%
Hexobarbital D 100% None Unknown NA
Hydralazine I q8-16h None None q8h
Hydrocortisone D 100% Unknown Unknown 100%
Hydroxyurea D 20% Unknown Unknown 50%
Hydroxyzine D Unknown 100% 100% 100%
Ibuprofen D 100% None None 100%
Idarubicin -- Unknown Unknown Unknown Unknown
Ifosfamide D 75% Unknown Unknown 100%
Iloprost D 50% Unknown Unknown 100%
Imipenem D See UHN Guide See UHN Guide Dose for RF 50%
Imipramine D 100% None None NA
Indapamide D Avoid None None NA
Indinavir -- 100% None Dose for RF Unknown
Indobufen D 25% Unknown Unknown NA
Indomethacin D 100% None None 100%
Insulin D 50% None None 75%
Ipratropium D 100% None None 100%
Isoniazid D 50% See UHN Guide Dose for RF Dose for RF
Isosorbide D 100% 10-20 mg None 100%
Isradipine D 100% None None 100%
Itraconazole D See UHN Guide See UHN Guide See UHN Guide 100 mg q12-24h
Kandamycin D,I 20-30% q24-48h ⅔ dose after HD 15-20 mg/L/d 30-70% q12h
Ketamine D 100% Unknown Unknown 100%
Ketanserin D 100% None None 100%
Ketoconazole D 100% See UHN Guide None None
Ketoprofen D 100% None None 100%
Ketorolac D 50% None None 50%
112
Labetolol D 100% None None 100%

Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available
st
Lamivudine D,I 25 mg/d (50mg 1 dose) Yes Dose for RF 50-150 mg/d (full
st
1 dose)
Lamotrigine D 100% Unknown Unknown 100%
Lansoprazole D 100% Unknown Unknown Unknown
L-dopa D 100% Unknown Unknown 100%
Levofloxacin D See UHN Guide See UHN Guide Dose for RF 50%
Lidocaine D 100% None None 100%
Lincomycin I q12-24h None None NA
Linexolid See UHN Guide See UHN Guide
Lisinopril D 25-50% 20% None 50-75%
Lispro insulin D 50% None None None
Lithium carbonate D 25-50% Yes None 50-75%
Lomefloxacin D 50% Dose for RF Dose for RF NA
Loracarbef I q3-5d Yes Dose for RF q24h
Lorazepam D 100% None Unknown 100%
Losartan D 100% Unknown Unknown 100%
Lovastatin D 100% Unknown Unknown 100%
LMW heparin D 50% Unknown Unknown 100%
Maprotiline D 100% Unknown Unknown NA
Meclofenamic acid D 100% None None 100%
Mefenamic acid D 100% None None 100%
Mefloquine -- 100% None None Unknown
Melphalan D 50% Unknown Unknown 75%
Meperidine D 50% Avoid None Avoid
Meprobamate I q12-18h None Unknown NA
Meropenem D,I 250-500 mg q24h See UHN Guide Dose for RF 250-500 mg q12h
Metaproterenol D 100% Unknown Unknown 100%
Metformin D Avoid Unknown Unknown Avoid
Methadone D 50-75% None None NA
Methenamine D Avoid NA NA NA
mandelate
Methicillin I q8-12h None None q6-8h
Methimazole D 100% Unknown Unknown 100%
Methotrexate D Avoid None None 50%
Methyldopa I q12-24h 250 mg None q8-12h
Methyl prednisolone D 100% Yes Unknown 100%
Metoclopramide D 50% None Unknown 50-75%
Metocurine D 50% Unknown Unknown 50%
Metolazone D 100% None None NA
Metoprolol D 100% 50 mg None 100%
Metronidazole D See UHN Guide See UHN Guide See UHN Guide 100%
Mexiletine D 50-75% None None None
Mezlocillin I q8h None None q6-8h
Miconazole D 100% None None None
Midazolam D 50% NA NA NA
Midodrine -- Unknown 5mg q8h Unknown 5-10 mg q8h
Miglitol D Avoid Unknown Unknown Avoid
113
Milrinone D 50-75% Unknown Unknown 100%
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Minocycline D 100% See UHN Guide None 100%

Minoxidil D 100% None None 100%
Mitomycin C D 75% Unknown Unknown Unknown
Mitoxantrone D 100% Unknown Unknown 100%
Mivacurium D 50% Unknown Unknown Unknown
Moricizine D 100% None None 100%
Morphine D 50% None Unknown 75%
Moxalactam I q24-48h Yes Dose for RF q12-24h
Nabumetone D 100% None None 100%
N-Acetylcysteine D 75% Unknown Unknown 100%
N-Acetyl- D,I 25% q12-18h None None 50% q8-12h
Procainamide
Nadolol D 25% 40 mg None 50%
Nafcillin D 100% None None 100%
Nalidixic acid D Avoid See UHN Guide Avoid NA
Naloxone D 100% NA NA 100%
Naproxen D 100% None None 100%
Nefazodone D 100% Unknown Unknown NA
Nelfinavir -- Unknown Unknown Unknown Unknown
Neostigmine D 25% Unknown Unknown 50%
Netilmicin D,I 10-20% q24-48h ⅔ dose after HD 3-4 mg/L/d 20-60% q12h
Nevirapine D 100% None Dose for RF Unknown
Nicardipine D 100% None None 100%
Nicotinic acid D 25% Unknown Unknown 50%
Nifedipine D 100% None None 100%
Nimodipine D 100% None None 100%
Nisoldipine D 100% None None 100%
Nitrazepam D 100% Unknown Unknown NA
Nitrofurantoin D Avoid See UHN Guide NA NA
Nitroglycerine D 100% Unknown Unknown 100%
Nitroprusside D 100% None None 100%
Nitrosourea D 25-50% None Unknown Unknown
Nizatidine D 25% Unknown Unknown 50%
Norfloxacin I Avoid NA NA NA
Nortriptyline D 100% None None NA
Ofloxacin D 25-50% 100 mg bid Dose for RF 300 mg/d
Omeprazole D 100% Unknown Unknown Unknown
Ondansetron D 100% Unknown Unknown 100%
Orphenadrine D 100% Unknown Unknown NA
Ouabain I q36-48h None None q24-36h
Oxaprozin D 100% None None 100%
Oxatomide D 100% None None NA
Oxazepam D 100% None Unknown 100%
Oxcarbazepine D 100% Unknown Unknown Unknown
Paclitaxel D 100% Unknown Unknown 100%
Pancuronium D Avoid Unknown Unknown 50%
Paroxetine D 50% Unknown Unknown NA
Para-aminosalicylate D 50% Yes Dose for RF Dose for RF
114
Penbutolol D 100% None None 100%
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Penicillamine D Avoid 1/3 dose Unknown Avoid

Penicillin G D See UHN Guide See UHN Guide Dose for RF 75%
Penicillin VK D 100% See UHN Guide Dose for RF NA
Pentamidine I q48h See UHN Guide None None
Pentazocine D 50% None Unknown 75%
Pentobarbital D 100% None Unknown 100%
Pentopril D 50% Unknown Unknown 50-75%
Pentoxifylline D 100% Unknown Unknown 100%
Pefloxacin D 100% None None 100%
Perindopril D 50% 25-50% Unknown 75%
Phenelzine D 100% Unknown Unknown NA
Phenobarbital I q12-16h Yes ½ normal dose q8-12h
Phenylbutazone D 100% None None 100%
Phenytoin D 100% None None None
Pindolol D 100% None None 100%
Pipecuronium D 25% Unknown Unknown 50%
Piperacillin I See UHN Guide See UHN Guide Dose for RF q6-8h
Piretanide D 100% None None NA
Piroxicam D 100% None None 100%
Plicamycin D 50% Unknown Unknown Unknown
Pravastatin D 100% Unknown Unknown 100%
Prazepam D 100% Unknown Unknown NA
Prazosin D 100% None None 100%
Prednisolone D 100% Yes Unknown 100%
Prednisone D 100% None Unknown 100%
Primaquine -- 100% Unknown Unknown Unknown
Primidone I q12-24h ⅓ dose Unknown Unknown
Probenecid D Avoid Avoid Unknown Avoid
Probucol D 100% Unknown Unknown 100%
Procainamide I q8-24h 200 mg None q6-12h
Promethazine D 100% None None 100%
Propafenone D 100% None None 100%
Propofol D 100% Unknown Unknown 100%
Propoxyphene D Avoid None None NA
Propanolol D 100% None None 100%
Propylthiouracil D 100% Unknown Unknown 100%
Protriptyline D 100% None None NA
Pyrazinamide D Avoid See UHN Guide Avoid Avoid
Pyridostigmine D 20% Unknown Unknown 35%
Pyrimethamine D 100% None None None
Quazepam D Unknown Unknown Unknown NA
Quinapril D 75% 25% None 75-100%
Quinidine D 75% 100-200 mg None 100%
Quinine I q24h Yes Dose for RF q8-12h
Ramipril D 25-50% 20% None 50-75%
Ranitidine D 25% ½ dose None 50%
Reserpine D Avoid None None 100%
115
Ribavirin D 50% Yes Dose for RF Dose for RF

Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Rifabutin -- 100% None None Unknown

Rifampin D 50-100% See UHN Guide See UHN Guide Dose for RF
Ritonavir -- 100% None Dose for RF Unknown
Saquinavir -- 100% None Dose for RF Unknown
Secobarbital D 100% None None NA
Sertraline D 100% Unknown Unknown NA
Simvastatin D 100% Unknown Unknown 100%
Sodium valproate D 100% None None None
Sotalol D 15-30% 80 mg None 30%
Sparfloxacin D,I 50% q48h Dose for GFR<10 Unknown 50-75%
Spectinomycin D 100% None None None
Spironolactone I Avoid NA NA Avoid
Stavudine D,I 50% q24h Yes Unknown Unknown
Streptokinase D 100% NA NA 100%
Streptomycin I q72-96h See UHN Guide 20-40 mg/L/d q24-72h
Streptozotocin D 50% Unknown Unknown Unknown
Succinylcholine D 100% Unknown Unknown 100%
Sufentanil D 100% Unknown Unknown 100%
Sulbactam I q24-48h Yes 0.75-1.5 g/d 750 mg q12h
Sulfamethoxazole I q24h 1g after HD 1g/d q18h
Sulfinpyrazone D Avoid None None 100%
Sulfisoxazole I q12-24h 2g after HD 3g/d NA
Sulindac D 100% None None 100%
Sulotroban D 10% Unknown Unknown Unknown
Tamoxifen D 100% Unknown Unknown 100%
Tazobactam D See UHN Guide See UHN Guide Dose for RF 75%
Teicoplanin I q72h Dose for RF Dose for RF q48h
Temazepam D 100% None None NA
Teniposide D 100% None None 100%
Terazosin D 100% Unknown Unknown 100%
Terbutaline D Avoid Unknown Unknown 50%
Terfenadine D 100% None None NA
Tetracycline I q24h See UHN Guide None q12-24h
Theophylline D 100% ½ dose Unknown 100%
Thiazides D Avoid NA NA NA
Thiabendazole See UHN Guide
Thiopental D 75% NA NA NA
Ticarcillin D,I 1-2g q12h 3g after HD Dose for RF 1-2g q8h
Ticlopidine D 100% Unknown Unknown 100%
Timolol D 100% None None 100%
Tobramycin D,I 20-30% q24-48h See UHN Guide See UHN Guide 30-70% q12h
Tocainide D 50% 200mg None 100%
Tolazamide D 100% Unknown Unknown Avoid
Tolbutamide D 100% None None Avoid
Tolmetin D 100% None None 100%
Topiramate D 25% Unknown Unknown 50%
Topotecan D 25% Unknown Unknown 50%
116
Torsemide D 100% None None NA
Drug Method Renal Failure dose Dose after HD Dose during CAPD Dose during CRRT
D = Decrease Dose I = Prolonged Interval NA = Not Available

Tranexamic acid D 10% Unknown Unknown Unknown

Tranylcypromine D Unknown Unknown Unknown NA
Trazodone D Unknown Unknown Unknown NA
Triamcinolone D 100% Unknown Unknown Unknown
Triamterene I Avoid NA NA Avoid
Triazolam D 100% None None NA
Trihexyphenidyl D Unknown Unknown Unknown Unknown
Trimethadione I q12-24h Unknown Unknown q8-12h
Trimethoprim I q24h Yes q24h q18h
Trimetrexate D Avoid Unknown Unknown Unknown
Trimipramine D 100% None None NA
Tripelennamine D Unknown Unknown Unknown NA
Triprolidine D Unknown Unknown Unknown NA
Tubocurarine D Avoid Unknown Unknown 50%
Urokinase D Unknown Unknown Unknown Unknown
Valacyclovir D,I 0.5 g q24h Yes Dose for RF Unknown
Valganciclovir See UHN Guide See UHN Guide
Vancomycin D,I See UHN Guide See UHN Guide See UHN Guide 500 mg q24-48h
Vecuronium D 100% Unknown Unknown 100%
Venlafaxine D 50% None Unknown NA
Verapamil D 100% None None 100%
Vidarabine D 75% Yes Dose for RF 100%
Vigabatrin D 25% Unknown Unknown 50%
Vinblastine D 100% Unknown Unknown 100%
Vincristine D 100% Unknown Unknown 100%
Vinorelbine D 100% Unknown Unknown 100%
Voriconazole See UHN Guide See UHN Guide
Warfarin D 100% None None None
Zafirlukast D 100% Unknown Unknown 100%
Zalcitabine I q24h Unknown Unknown Unknown
Zidovudine D,I 100 mg q8h Dose for RF Dose for RF 100 mg q8h

Arnoff, G.R. in Manual of Nephrology, Fifth Edition, Edited by Robert W. Schriver, Lippincott
Williams & Wilkins Press 2000. ISBN 0-7817-2172-5

UHN 2003 Guidelines for Antimicrobial Use. The University Health Network, Toronto, Ont.

117
 Antibiotic Dosing Guidelines in Renal Impairment
Table 1: Dose Adjustment of Select Medications Based on Calculated
Creatinine Clearance (CrCl)

Creatinine Clearance (CrCl) in mL/min

Drug > 50 25-49 10-24 < 10
(Note: The following dosage recommendations are not intended for endocarditis or meningitis treatment)
acyclovir (IV) 5-10 mg/kg q8h 5-10 mg/kg q12h 5-10 mg/kg 50% dose q24h
q24h
acyclovir (PO)
genital herpes 400 mg tid 400 mg tid 400 mg tid 200 mg q12h
varicella zoster 800 mg 5x/day 800 mg 5x/day 800 mg tid 800 mg q12h
amikacin CrCl > 60 CrCl 40-59 CrCl 20-39 CrCl < 20
(initial dosing, 15mg/kg q24h 15 mg/kg q36h 15 mg/kg Not recommendedg
once daily q48h
dosing)
amikacin CrCl > 50 CrCl 15-49 < 15
(initial dosing, 5-7.5 mg/kg load 5-7.5 mg/kg load then 2-3mg/kg IV
traditional then 5-7.5mg/kg load q24h
dosing) 4-5mg/kg IV q8h then
3-5 mg/kg IV
q12h
amoxicillin/ 250-500 mg q12h 250-500 mg q12h 250-500 250-500 mg q24h
clavulanate mg q12h
amphotericin B 5 mg/kg IV q24h 5 mg/kg IV q24-36h
lipid complex
(ABELCET)
amphotericin B 3-6 mg/kg IV q24h 3-6 mg/kg IV
liposome q24-36h
(AMBISOME)
ampicillin 1-2 g q4-6h 1-2 g q6-12h 1-2 g q6- 1-2 g q12-24h
12h
azithromycin
No adjustments required
caspofungin
No adjustments required
cefazolin 1-2 g q8h 1-2 g q12h 1-2 g q12h 1-2 g q24h
ceftazidime 1-2 g q8h CrCl <30** 1-2 g q24h 50% dose
1-2 g q12h q24-48h
ceftriaxone No adjustments required
cefuroxime 500 mg q12h 500 mg q12h 500 mg 500 mg q24h
axetil (PO) q12h

118
 Creatinine Clearance (CrCl) in mL/min
Drug > 50 25-49 10-24 < 10
cephalexin 250-500 mg q6h CrCl < 40** 250-500 50% dose q12-24h
250-500 mg q8- mg q8-12h
12h
ciprofloxacin 500-750 mg q12h CrCl < 30** 500-750 500-750 mg q24h
(PO) 500-750 mg q24h mg q24h
ciprofloxacin 400 mg q12h CrCl < 30** 400 mg 400 mg q24h
(IV) 400 mg q24h q24h
clarithromycin 250-500 mg q12h CrCl < 30** 50% dose 50% dose q12h
50% dose q12h q12h
clindamycin
No adjustments required
cloxacillin
No adjustments required
cotrimoxazole 8-10 mg/kg in CrCl < 30** 50% dose in 2- Not recommendedg
(IV) 2-4 divided 50% dose in 2-4 4 divided
doses daily divided doses doses daily
daily
PCP 15-20 mg/kg in CrCl < 30** 50% dose in 2- Not recommendedg
pneumonia 2-4 divided 50% dose in 2-4 4 divided
doses daily divided doses doses daily
daily
cotrimoxazole 1DS bid 1DS q24h 1DS q24h Not recommendedg
(PO)
(DS = trimethoprim
160 mg,
sulfamthoxazole 800
mg)
erythromycin 500-1000 mg 500-1000 mg q6h 500-1000 mg 50-70% dose q6h
q6h q6h
famciclovir CrCl < 40** CrCl < 20
genital herpes 250 mg q12h 125 mg q12h 125 mg daily 125 mg daily
varicella zoster CrCl > 60 CrCl < 40** CrCl < 20 500 mg q48h
500 mg tid 500 mg q24h 500 mg q48h
CrCl > 50
500 mg q12h
fluconazole 50-400 mg q24h 50% dose q24h 50% dose 25% dose q24h
q24h
ganciclovir (IV) CrCl > 70
5 mg/kg q12h
Treatment 2.5 mg/kg q24h 1.25 mg/kg
CrCl 50-69 q24h
2.5 mg/kg q12h

119
 Creatinine Clearance (CrCl) in mL/min
Drug > 50 25-49 10-24 < 10
Maintenance CrCl > 70 2.5 mg/kg q24h 0.625 mg/kg
5 mg/kg q24h q24h
CrCl 50-69
2.5 mg/kg q24h
gentamicin CrCl > 60 CrCl 40-59 CrCl 20-39 CrCl < 20
(initial dosing, 5 mg/kg q24h 5 mg/kg q36h 5 mg/kg q48h Not recommendedg
once daily
dosing)
gentamicin CrCl > 50 CrCl 15-49 CrCl < 15
(initial dosing, 1.5-2 mg/kg 1.5-2 mg/kg
traditional load, then 1.5-2 mg/kg load, then
dosing) 1.25 mg/kg IV load, then 0.5-1 mg/kg IV
q8h 1 mg/kg IV q12h q24h
imipenem/cilista 500 mg q6h CrCl < 30 500 mg q12h 500 mg q12h
tin 500 mg q8-12h (<1 g/day);
CrCl < 5
Not recommended
unless on
hemodialysisg
intraconazole No adjustments required
ketoconazole No adjustments required
linezolid No adjustments required
metronidazole No adjustments required
moxifloxacin No adjustments required
penicillin G 1-4 MU q4-6h 1-4 MU q8-12h 1-4 MU q8-12h 1-4 MU q12h
piperacillin/ 4.5 g q8h CrCl < 40 CrCl < 20: 3.375 g q12h
tazobactam 3.375 g q8h 3.375 g q12h
tobramycin CrCl > 60 CrCl 40-59 CrCl 20-39 CrCl < 20
(initial dosing, 5 mg/kg q24h 5 mg/kg q36h 5 mg/kg q48h Not recommendedg
once daily
dosing)
tobramycin 1.5-2 mg/kg CrCl 15-49 < 15
(initial dosing, load, then 1.25 1.5-2 mg/kg load, 1.5-2 mg/kg load, then
traditional mg/kg IV q8h then 1 mg/kg IV q12h 0.5-1 mg/kg IV q24h
dosing)
valganciclovir 450 mg q12hr 450 mg q24h 450 mg Not recommendedg
Induction every 2 days
Maintenance 450 mg q24h 450 mg every 2 450 mg Not recommendedg
days 2x/week

120
 Creatinine Clearance (CrCl) in mL/min
Drug > 50 25-49 10-24 < 10
vancomycin CrCl ≥ 65 CrCl 21-34 CrCl ≤ 20
1 g q12h or 1 g q48h 15-20 mg/kg loading
15 mg/kg q12h dose
CrCl 50-64
1 g q24h
Adjust dose based on serum drug levels
voriconazole 6 mg/kg q12h x Not recommended due to diluentg
(IV) 24h, then
4 mg/kg IV q12h
voriconazole No adjustments required
(PO)
** Discuss dosing with Pharmacist.
g
Pharmacist to discuss therapeutic alternatives with physician

References
1. McEvoy GK, ed. AHFS Drug Information. Bethesda, MD; American Society of Health-
System Pharmacists, Inc. 2002.

2. Aronoff GR, Bennett WB, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing
Guidelines for Adults, Fourth Edition. Philadelphia, PA; American College of
Physicians. 2002.

3. Welbanks L, ed. Compendium of Pharmaceuticals and Specialties, 37th Ed. Ottawa,

ON; Canadian Pharmacists Association 2002.

4. MICROMEDEX(R) Healthcare Series Vol. 123, expires 3/2005.

Updated by: Carmen Ma, BScPhm, Staff Pharmacist, Nephrology – October, 2002
Revised by: Michael Wong - 2005

121
Antibiotic Dosing Guidelines in Hemodialysis
When making a dosage schedule for patients on hemodialysis, the dose
adjustment for the degree of renal function must be determined first, and
then the effect of dialysis on the total body clearance of the drug must be
taken into account.

For practical purposes, it is most convenient to separate antibiotics into four

groups:
1. HEMODIALYZABLE with a LONG t1⁄2
A dose of these drugs should be given immediately after hemodialysis
(e.g., the order should be written: cefazolin 1 g daily give post-dialysis on
dialysis days)
2. HEMODIALYZABLE with a SHORT t1⁄2
It is difficult for hemodialysis to have a significant effect on total body
clearance for these drugs due to their intrinsically short half-life. Since
most of the drugs in this category have a high therapeutic index, it is
unnecessary to alter the dose or to supplement the dose after dialysis,
with a few exceptions.
3. NOT HEMODIALYZABLE with a LONG t1⁄2
4. NOT HEMODIALYZABLE with a SHORT t1⁄2

Note: A LONG t1⁄2 will be one which allows for a dosing interval of 24 hours
or more.

Drugs for which the recommended dosing interval is every 8 to 18 hours and
which are hemodialyzable result in the most complex dosing schedule. The
time interval from the end of dialysis when serum levels are low, until the
next dose, could be between 4 and 14 hours and would therefore be of
clinical importance. In addition, the amount of additional antibiotic needed at
the end of dialysis would be dependent on how close the previous dose was
to the start of dialysis, and this could change from day to day. Therefore, the
doses suggested have sometimes been modified from those in the literature
to avoid q8h-q18h dosage. A q6h interval with the same total daily dose may
be given. In this way, there is never more than a couple of hours with low
(subtherapeutic) serum levels.

122
 The usual recommended trough concentrations of drugs are not applicable
in patients with severe renal impairment. Because of the extended t1⁄2 of
drugs in these patients, the usual trough concentrations are not achievable
without an extended period of subtherapeutic concentrations.

The following recommendations are made assuming:

Normal hepatic function
Adult patients
Patient’s glomerular filtration rate (GFR) <10 mL/min (0.16 mL/sec)
Standard hemodialysis schedules of 3 to 6 hours of hemodialysis every 2
to 3 days

Table 2: Dosing Guidelines in Hemodialysis and CVVHD

Drug Recommended Dose for IHD Do Recommended Dose for

CVVHD
acyclovir 2.5-5 mg/kg IV q24h ys 5-10 mg/kg IV q12-24h
200 mg PO q12h (Herpes No adjustment necessary for PO
simplex)
800 mg PO q12h (Herpes
zoster)
amantadine 200 mg PO once a week neo 100 mg PO q48-72h

amikacin 5 mg/kg IV load, then yes 5-7.5mg/kg load, then

2.5 mg/kg IV post 3-4.5 mg/kg IV q12h
hemodialysis* Adjust dose based on trough
Adjust dose based on levels (see Table 3)
trough levels (see Table 3)
amoxicillin 250 mg PO q12h or yes 500 mg POq8-12h
500 mg PO q24h (liquid available)
amoxicillin/ 250 mg PO q12h or yes -
clavulanate 500 mg PO q24h
ampicillin (IV) 1-2 g IV q12-24h yes 1-2 g IV q6-12h
caspofungin 70 mg IV load, then 50 mg IV no 70 mg IV load; 50 mg IV q24h
q24h
cefazolin 1 g IV q24h or yes 1 g IV q12h
2 g IV post hemodialysis*
cefotaxime 1-2 g IV q24h yes 1 g IV q12h

123
Drug Recommended Dose for IHD Do Recommended Dose for
CVVHD
ceftazidime 1 g IV q24h or yes 1-2 g IV q12-24h
1-2 g post hemodialysis*
ceftriaxone 1-2 g IV q24h no 1-2 g IV q12-24h
cefuroxime axetil 250-500 mg PO q12h or yes 250-500 mg PO q12h
(PO) 500 mg PO q24h (liquid available)
cephalexin 250-500 mg PO q12h yes 250-500 mg PO q12h
(liquid available)
chloramphenicol 0.25-1 g IV q6h (12.5 no -
mg/kg q6h)
chloroquine 500 mg PO x 1 dose, then no -
250 mg PO weekly (malaria)

ciprofloxacin 250-500 mg PO q24h no 500 mg PO q12-24h

200-400 mg IV q24h 400 mg IV q12-24h
clarithromycin 250-500 mg PO q12h yes -
clindamycin 150-300 mg PO q6h no 150-300 mg PO q6h
300-600 mg IV q8h 300-600 mg IV q8h
cotrimoxazole 1 DS tablet PO q24h yes 1DS PO q24h
(PO) (for indications other than (liquid available)
(DS = trimethoprim PCP)
160 mg ,
sulfamethoxazole 800
mg
doxycycline 100 mg PO daily no 100 mg PO daily

erythromycin 250-500 mg IV/PO q6h no 250-500 mg IV q6h

(1 g q6h causes predictable
reversible deafness)
ethambutol Not recommended in patients N/A 15-25 mg/kg q24h
with GFR < 10 mL/ming (No dose adjustment necessary)
famciclovir 125 mg PO q24h (Herpes yes 125 mg PO q12-24h (Herpes
simplex) simplex)
500 mg PO q48h (Herpes 500 mg PO q12-24h (Herpes
zoster) zoster)
fluconazole 400 mg IV/PO loading dose, yes 100–400 mg IV/PO q24h
then 100-400 mg IV/PO daily
to q2days
foscarnet** 45-60 mg/kg post N/A -
hemodialysis

124
Drug Recommended Dose for IHD Do Recommended Dose for
CVVHD
ganciclovir (IV) Treatment: 1.25 mg/kg IV post yes 2.5 mg/kg IV q24h
hemodialysis* (treatment and maintenance)
Maintenance: 0.625 mg/kg IV
post hemodialysis*
gentamicin 2 mg/kg IV loading dose, then yes 1.5-2 mg/kg load, then
1 mg/kg IV post hemodialysis* 1 mg/kg IV q12h
Adjust dose based on Adjust dose based on trough
trough levels (see Table 3) levels (see Table 3)
Imipenem / 250-500 mg IV q12h yes 500mg IV q6-8h
cilastatin
isoniazid 300 mg PO daily yes 300 mg PO daily
itraconazole (PO) 100-200 mg PO q12h no 100-200 mg PO q12h
(Take tablets with food; take (liquid available)
solution on empty stomach)
ketoconazole 200-400 mg PO daily no 200-400 mg PO daily
linezolid 600 mg PO/IV q12h yes 600 mg PO/IV q12h
meropenem 500 mg IV q24h yes 250-500 mg IV q12h
metronidazole 500 mg IV/PO q12h yes 500 mg IV/PO q12h
C. difficile: 500 mg PO q8h C. difficile: 500 mg PO q8h
minocycline 200 mg PO x 1 dose, then no 200 mg PO x 1 dose, then
100 mg PO q12h 100 mg PO q12h
moxifloxacin 400 mg IV/PO q24h no 400 mg IV/PO q24h
No adjustment necessary No adjustment necessary
nalidixic acid Not recommended in N/A Not recommendedg
patients with GFR <10
mL/ming
(Metabolites accumulate)
nitrofurantoin Not recommended in patients N/A Not recommendedg
with GFR < 30 mL/ming
penicillin G 1 Million Units (MU) IV q8-12h yes 0.5-3 MU IV q6h
(Maximum dose = 10 MU/day)
penicillin VK 300 mg PO q6h yes 300 mg PO q6h
pentamidine 3-4 mg/kg IV q24h no 4 mg/kg IV q24h
isethionate
piperacillin/ 3.375 mg IV q12h yes 3.375 mg IV q6-8h
tazobactam
pyrazinamide 40 mg/kg PO 3x/week no 25-30 mg/kg q24h
(Give 24 hours before the
start of each hemodialysis)
rifampin 300-600 mg PO q24h no 300-600 mg PO q24h

125
Drug Recommended Dose for IHD Do Recommended Dose for
CVVHD
streptomycin 15 mg/kg IV loading dose, yes 15mg/kg q24-72h
then
9 mg/kg IV post hemodialysis*
tetracycline 250-500 mg PO q24h yes 250-500 mg q12h
(Note: doxycycline is
preferred)
tobramycin 2 mg/kg IV loading dose, then yes 1.5-2 mg/kg load, then 1 mg/kg
1 mg/kg IV post hemodialysis* IV q12h
Adjust dose based on Adjust dose based on trough
trough levels (see Table 3) levels (see Table 3)
valganciclovir Not recommended in N/A Induction: 450 mg PO q24h
hemodialysisg Maintenance: 450 mg PO q48h
vancomycin Consult renal pharmacist Consult renal pharmacist
voriconazole (IV) Not recommended in patients N/A Not recommended due to
with GFR < 50 mL/min due to vehicle for IV preparationg
g
vehicle for IV preparation
voriconazole (PO) 400 mg PO q12h x 2 days, N/A 400 mg PO q12h x 2 days, then
then 200 gm PO q12h 200 gm PO q12h
* Only give on hemodialysis days.
g
Pharmacist to discuss therapeutic alternatives with physician.
** Discuss dosing with Pharmacist.
Note: The above dosage recommendations for antimicrobials are not intended for treatment
of endocarditis or meningitis.

References
1. Aronoff GR, Bennett WB, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing
Guidelines for Adults, Fourth Edition. Philadelphia, PA; American College of Physicians.
2002.

2. Aweeka FT, Jacobson MA, Martin-Munley S, et al. Effect of renal disease and
hemodialysis on foscarnet pharmacokinetics and dosing recommendations. J Acquire
Immune Defic Syndr Hum retrovirol 1999;20:350-357.

3. McEvoy GK, ed. AHFS Drug Information 2000. Bethesda, MD; American Society of
Health-System Pharmacists, Inc. 2002.

4. Welbanks L, ed. Compendium of Pharmaceuticals and Specialties, 37th Ed. Ottawa, ON;
Canadian Pharmacists Association 2002.

5. MICROMEDEX(R) Healthcare Series Vol. 123 expires 3/2005.

Bayer Inc.
126
Hoffmann-LaRoche Limited
Janssen-Ortho Inc.
AstraZeneca Pharma Inc.
Updated by: Carmen Ma, BScPhm, Staff Pharmacist, Nephrology – October,
2002;
Revised by: Marisa Battistella - May, 2006.

127
UHN MEDICAL DIRECTIVE MEDICATIONS - ACNP NEPHROLOGY

Drug Classification Drug Name and Indications Absolute Contraindications Special Considerations
Dosage Range
(It is given that Known DZ= Dialyzable
(IP=Intraperitoneal) Allergy is an absolute
contraindication for all) PD= Peritoneal Dialysis

HD= Hemodialysis

sl=slightly mod=moderately

ACE Inhibitors Captopril 12.5 - 75 Hypertension, LVH Refractory hyperkalemia in With all ACE-I's:
mg/day p.o. b.i.d.-t.i.d. individuals with residual renal Monitor for hyperkalemia.
Enalapril 2.5 - 20 mg/d function Monitor for cough.
p.o. once or b.i.d. Monitor for post HD rise in
Lisinopril 5-30 mg/d B/P (renin).
p.o. Not used with Potassium (K+)
Ramipril 1.25-10 mg/d sparing diuretics
p.o.once-b.i.d. Mod DZ in HD, sl DZ in PD .
Alpha Blockers Prazosin 0.5 - 10 mg Hypertension - mild- Known syncopal attacks Insuff data re DZ, probably
p.o. b.i.d. mod not DZ
Monitor for postural
hypotension
Dose range represents lower
dose in CRF
Terazosin** 1 - 20 mg Hypertension - mild-
p.o. once daily mod **If used for other indication
(eg BPH) not ordered by
ACNP
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Analgesics Acetaminophen - 325 - Pain management Hepatic failure Slightly to moderately DZ in

1000 mg p.o. q4h prn HD. Not DZ in PD. Monitor
(max. 4000 mg/day) bowels if using codeine.
Acetaminophen with
Codeine (8,15, 30
mg)1-2 tabs p.o. q3-6h
prn (max 12 tabs/day)

Fentanyl 25-75 mcg/h Chronic pain i.e. Acute or post-operative pain. Dose adjusted for renal
transdermal wounds, calciphylaxis, failure.
cancer.

Analgesic/anti- Celecoxib 200 mg a Pain management Active GI bleed , active peptic No data re DZ. Highly protein
inflammatory day in divided doses particularly arthritic or of ulcers, known bronchial, bound (>97%), likely not DZ.
p.o. joint/bone origin asthmatic or anaphylactic To be avoided in pts with
reaction to ASA, other residual renal function,
NSAID's, sulphonamides. asthma.
Monitor for hyperkalemia. Not
in severe hepatic impairment.
Clarify reaction to ASA &
NSAIDS, i.e.
bronchoconstrictive asthma-
like or anaphylaxis.
Ibuprofen 200-400 mg Pain management Active GI bleed, active peptic Risk of gastric ulceration
q4-6h p.o. prn ulcers, known allergies to increases with dose. Caution
ASA, other NSAID's , hepatic in PD patients with residual
failure renal function, SLE. Not DZ.

129
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Analgesics (cont) *Morphine 2-10 mg Moderate to severe Paralytic ileus, respiratory May cause respiratory
*Note: MD’s, not p.o. /s.c./i.v. q3-4h+ pain, palliative depression depression.
ACNP’s to order breakthrough dose of management for pain
controlled 1/2 standing dose q2h control
substances.
*Hydromorphone 1-2 Moderate to severe Respiratory depression Less accumulation of
mg sub q or po q 4-6 pain, palliative metabolites. Good choice for
hours management for pain renal patients.
control

*Methotrimeprazine Pain control in palliative Restrict use to palliative care.

(Nozinan) 5-10mg management. As Useful to manage myoclonic
po/s.c/i.v q3-6h adjunct to analgesia. jerks and anxiety.
Antacids Calcium carbonate Acid indigestion Hypercalcemia. Avoid use of magnesium or
(Tums®) 1-2 tabs po Gastric-esophageal aluminum containing antacids
q.i.d. prn Reflux in renal failure.

Gaviscon liquid 10-20 Antacid of choice for renal

ml p.c. tid.& hs prn. patients
Max 80 ml/d

Gaviscon tabs 2-4 tabs

pc tid & hs prn

Aluminum hydroxide As Antacid for Maximum duration 1 day.

(Amphogel) 15-30 ml hypercalcemic patients. Avoided due to aluminum
po once-q.i.d.PRN x 1 bone disease in renal failure
day

Drug Classification Drug Name and Indications Contraindications Special Considerations

130
 Dosage Range

Anti-anemia Darbepoetin alfa* Anemia Hypertension Target Hgb 110-120g/L.

medications (Aranesp) 0.45 mcg/kg Caution in HTN Requires
s.c. or IV once weekly adequate iron stores. Patient
with hemodialysis. must be registered for
Give s.c. for peritoneal Aranesp. If ↑ in Hgb 5
dialysis patients. gm/L/mo after initiation or
For patients converting change in dose, ↑ dose by
from Erthropoietin to 25%, if >10 gm/L/2 weeks, ↓
Darbapoetin, use by 25%.
conversion table (p. If Hgb ↑ >10 g/L within any 2
81) week period, ↓ dose by 25%
If Hgb continues to ↑ and
exceeds target range, hold
dose, reinitiate at dose 25%
lower than previous dose
once Hgb ↓
Monitor for red cell aplasia
Erythropoietin
(EPREX) 100-200 Anemia Refractory hypertension Target Hgb 110-120g/L.
units/kg/week s.c. IV Known red cell aplasia. Caution in HTN or seizure hx.
with hemodialysis in 2- Requires adequate iron
3 divided doses; given stores. Patient must be
s.c. for peritoneal registered for EPREX. If ↑ in
dialysis patients Hgb <5gm/L/mo, ↑ dose by
25-50%., if >10 gm/L/2
weeks, ↓ by 25%.
*Darbepoietin is Monitor for red cell aplasia.
“preferred product” at
UHN

131
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Anti-anemia (cont) Ferrous Gluconate 300 Low iron stores Iron overload Maintain ferritin > 100 and
mg po b.i.d. -t.i.d. Iron saturation > 0.20
Fe Sulphate 300 mg Low iron stores
po b.i.d. -t.i.d Low iron stores Anemia not associated with Oral iron of limited value for
Fe fumarate 300mg po refractory to oral iron iron deficiency. HD patients.
once daily supplementation Liver failure Patient may not tolerate
G.I.side effects of tid dosing.

IV Iron Dextran or IV IV iron dextran requires test

Iron Saccharate 100 dose per protocol. MD to be
mg/HD x 10 HDs. present for test dose of iron
Maintenance dose 100 dextran.
mg/week Iron saccharate if previous
sensitivity to iron dextran.
For PD: 1000 mg in Test dose of IV iron
divided doses no less saccharate optional.
than 48-hour intervals.
Max Iron Saccharate
200 - 300 mg IV. Max
dose Iron Dextran 500
mg IV

132
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Antibiotics/Antifung Amoxicillin Drug ranges for specific Allergies to specific antibiotics. DZ per "Dosing Guidelines in
al Agents Ampicillin indications - refer to Hemodialysis", UHN
Azithromycin Housestaff/ACNP Guidelines for Antimicrobial
Cephalexin Guidebook use".
Cefazolin Other indications per Refer to UHN Guidelines for
Ceftazidime UHN Guidelines for Vancomycin.
Ciprofloxacin Antimicrobial Use Refer to Nephrology
Clindamycin Housestaff/ACNP Guidebook
Co-trimoxazole Empiric therapy until culture
Fluconazole and sensitivity are known.
Metronidazole If pt unstable, must be
Nystatin reviewed with MD.
Tobramycin Aminoglycoside dosing
Rifampin altered if residual renal
Vancomycin function (see Guidebook)

Anticoagulant/ Warfarin - dose to Prophylactic High Fall risk Hold 3 days prior to surgical
Thrombolytic maintain therapeutic anticoagulation for Active bleeding procedures. Education of pt
Agents INR central HD lines if risk Necrosis r/t warfarin re bleeding.
for clotting
Warfarin 0.5 -10 mg Atrial fibrillation, Active bleeding Consultation with MD for
p.o. once daily mechanical heart valve Necrosis r/t warfarin established target INR

Heparin IV 500-1000 Anticoagulation during Active bleeding, HIT Hold pre/post surgical
units/hr HD procedure
Heparin IP 250 - 1000 Prevention of fibrin in
units/L PD Does not cross peritoneal
membrane.
Alteplase - local, 2 mg To clear HD Active bleeding Per HD Manual Protocol.
per lumen intravascular catheter Adjust for lumen volume.
133
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Antiemetic Dimenhydrinate Nausea, vomiting Decreased LOC, severe

25 - 50 mg p.o./i.m./IV hypotension
q4-6h prn
Prochlorperazine Decreased LOC, severe Adjust dose in elderly.
(Stemetil®) 5-10 mg hypotension, bone marrow
IM/p.o. t.i.d.-q.i.d. depression
Antidiarrheal agent Loperamide 4 mg p.o., Diarrhea Ulcerative colitis, Caution with hepatic
then 2 mg p.o. post q pseudomembranous colistis dysfunction. Monitor for
loose stool to max 16 assoc. with antibiotics constipation. Check for
mg/day infective causes (e.g. C.
difficile) prior to initiation.
Anti Gout agents Allopurinol 100 - 200 Gout Once on dialysis, usually
mg/d po lower dose to 100 mg daily
po. Monitor liver function
tests.
Antihistamines Diphenhydramine 25- Pruritus Effective for uremic pruritus.
50 mg p.o. b.i.d./PRN Dose is adjusted for renal
failure
Hydroxyzine 10-25 mg If decreased LOC, glaucoma
p.o. once daily- Pruritus or asthma, review with MD.
q.i.d./PRN Not DZ in PD
If decreased LOC, review
with MD
Anxiolytic sedatives Lorazepam 0.5-1.0 mg Sedation, anxiety. Decreased LOC, COPD Caution in elderly. Slight DZ
*Note: MD’s, not p.o. /s.l. 1-2 times daily
ACNP’s to order PRN
controlled Oxazepam 7.5-30 mg Sedation, anxiety Decreased LOC,COPD Decreased dose in renal
substances. po hs PRN failure.
Zopiclone 3.75 mg to Sedation Caution in elderly.
7.5 mg po hs prn

134
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Beta Blockers Atenolol 25 mg p.o. Hypertension, IHD Severe COPD, asthma. Mod DZ. HD removal of
once daily Sinus Bradycardia metabolites, give after HD
Care with diabetics, PVD, Hx
Metoprolol 6.25 - 100 Hypertension, IHD of heart failure. Severe heart
mg b.i.d. p.o. failure. Do not stop abruptly if
used for angina.
Bronchodilators Salbutamol puffer 100 Treat and prevent When a patient is admitted on
mcg/puff. 2 puffs q.i.d. bronchospasm bronchodilator other than
& PRN those listed, the ACNP may
Salbutamol 5 mg/ml - order the specific
1ml in 2 ml Normal bronchodilator at the patient's
Saline - inhalation 1-4h prescribed dose.
prn If pt has glaucoma, CV
disease, hypokalemia, review
with MD
Calcium Channel Amlodipine 5 - 10 mg/d Hypertension, angina All CCBs:
Blockers p.o. No data re DZ, but highly
Diltiazem HCl CD protein bound (90-99%), likely
once daily 120-240 poorly DZ
mg/d p.o. Caution with aortic stenosis,
Felodipine 2.5 - 10 severve LV dysfunction,
mg/d p.o. hepatic dysfunction, elderly.
Nifedipine PA20-60 May need dose adjustment
mg/d p.o.(b.i.d-t.i.d) with ranitidine.
Nifedipine XL 30 -60
mg p.o. (once daily)
Verapamil 80-160 mg
t.i.d. p.o. Monitor LFT's. Not DZ.
Verapamil SR 180-240 Caution with digoxin
mg po once daily

135
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Calcium/Phosphate Ca CO3 0.5 - 1.5 g Hyperphosphatemia Hypercalcemia CaCO3 WITH meals to be

Supplements/ elemental Ca p.o. with effective as PO4 binder.
Phosphate Binders meals
Ca CO3 0.5-1.5 g p.o. Hypocalcemia Hypercalcemia CaCO3 BETWEEN meals if
between meals used for low CaCO3

Aluminum Hydroxide Hyperphosphatemia Known Aluminum bone Use for short course, if Ca++
300-600 mg p.o. w/ disease and PO4 increased - risk of
meals alum bone disease in renal
x 3-5 days pts w/ long term use.

Oral sodium Hypophosphatemia Hyperphosphatemia If PO4 below 0.65. Review

Phosphate solution 5 dietary PO4.
mLpo once daily -tid x Monitor Ca and PO4
3-5 days
Phosphate Novartis Maximum duration of therapy,
500 mg tabs. 1-2 tabs 3 to 5 days
once daily-bid
Fleet PO4 enema 30- During HD to inhibit removal
90 ml into HD dialysate and promote uptake of PO4
Vitamin D Calcitriol 0.125 - 0.50 Hyperphosphatemia/ PTH < 19 Monitor Calcium, corrected
Analogues µg p.o. once/day or q2 Hypocalcemia Cacorrected x PO4 < 5 for albumin, Target PTH 20-
day, or IV 3x/wk with Hyperparathyroidism 30
HD
Diuretics Furosemide 20 - 320 Edema, fluid retention Anuria due to renal failure; Useful only with residual renal
mg/d p.o. (daily - refractory hypokalemia. function. Likely requires
b.i.d.) Hypovolemia, hypotension higher doses with advancing
renal failure. Monitor for
ECFV depletion. Not DZ.
Metolazone 2.5 - 10
mg p.o. daily
136
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Gastro-intestinal Metoclopramide 2.5-10 GI dysmotility, GI obstruction, hemorrhage, Decreased dose in renal

prokinetic agent mg p.o. q.i.d ac & hs gastroparesis perforation. failure
5 mg/L IP qCAPD Non-ulcer dyspepsia May cause extrapyramidal
exchange GI reflux effects in elderly.
Nausea
Domperidone maleate GI obstruction, hemorrhage,
5-20 mg q.i.d.-a.c & Gastroparesis, nausea perforation
h.s. 92% protein bound, likely not
DZ
Hypoglycemic Insulin: Diabetes, Type I or 2 Hypoglycemia Insulin:
agents Regular s.c. injection (Insulin for indications No data re DZ, large
30 min prior to meal other than diabetes (eg molecular size, likely poorly
and prn per blood hyperkalemia) would dialyzed.
glucose results NOT be ordered by the Pts often require less insulin
ACNP once in RF
IP to each dialysis Use in peritoneal dialysis
exchange per dialysate solutions requires increased
strength and blood doses, use only Regular (i.e.
glucose Humulin/Novolin R, Toronto)
See protocol for IP insulin in
Long Acting Housestaff/ACNP Manual
Combination e.g.
30/70 s.c. injection Dose adjustment based on
once or twice daily, Endocrine handbook &
usually 30 min prior to titration with blood glucose
breakfast, supper or hs levels.

Drug Classification Drug Name and Indications Contraindications Special Considerations

137
 Dosage Range

Hypoglycemic Regular Diabetes Type 1 and 2 Severe hypoglycemia. Consider type of surgery,
agents (cont) Continuous IV infusion Going for surgery Poorly controlled diabetics to dialysis, diabetes, anaesthetic
be managed in consultation
Glyburide 1.25-7.5 mg Diabetes Type 2 with MD No data re DZ, likely not DZ
p.o. once daily - bid Dose range reflects renal
dosing. Metformin to be
avoided in renal failure.
H2 Receptor Ranitidine 150 mg p.o. Gastroesophageal Dose adjusted for renal failure
Blockers/ Mucosal once daily reflux
Protective agent
Misoprostol 200 mcg Prophylaxis in NSAID Monitor for diarrhea
b.i.d.-q.i..d induced GI bleed
Laxatives Sodium Docusate 100 Stool softening For all laxatives: Decreased fibre in dialysis
- 400 mg/d p.o. GI hemorrhage appendicitis. diets
Senokot tabs, 1-4 tabs Constipation Assess that pt does NOT have
p.o.once daily- bid signs or symptoms of ileus or
obstruction
Bisacodyl 5-10 mg Constipation
p.o.once daily, 10 mg
p.r. once daily

Lactulose 15-30 mL Constipation

once-q.i.d. p.o. prn

Fleet Mineral Oil Constipation NOT regular Fleet (avoid

enema®, I p.r.prn phosphate)
Glycerine supp 1-2 p.r. Constipation
daily prn

138
Drug Classification Drug Name and Indications Contraindications Special Considerations
Dosage Range

Laxatives (cont) Colonic washout Bowel prep Does not cross GI wall, no
solution (Colyte) 1 - 4 L ECFV effect. Avoid Golytely
p.o as bowel prep in PD
(increased risk of peritonitis)

Colonic washout Constipation

solution (Colyte) 100-
300 ml po once daily
PRN
Local anaesthetics Lidocaine 2% w/out Peritoneal dialysis Abdominal pain - etiology
epinephrine IP 1.25 - 5 inflow pain unknown (e.g. possible
mL/L q CAPD exch prn peritonitis)

Tunnelled HD catheter
removal 1-10 ml s.c. Local infiltration for
excision of catheter
cuff.
Lipid lowering Atorvastatin 10-80 mg Hypercholesterolemia Impaired liver function Fibrates should be avoided in
agents po qhs renal failure.

Pravastatin 10-40 mg
po qhs
Monitor for rhabdomyolysis
Simvastatin 5-40 mg (proximal weakness, muscle
po qhs pain, hyperkalemia, elevated
CK). Monitor LFT's

Drug Classification Drug Name and Indications Contraindications Special Considerations

139
 Dosage Range

Nitrates Isorbide Dinitrate 5 - Angina Hypotension (SBP < 90) All nitrates: Hold before HD -
40 mg t.i.d. on qid vasodilation.
schedule Nitrate-free interval of 12 - 14
Nitrogylcerin ointment hours.
1 - 2" t.i.d. on q.i.d.
schedule; patch 0.2-
0.8 mg/h; spray 0.4
mg/spray, 1 spray
q5min x 3 prn;
sublingual tablets 0.3 -
0.6 mg q5min x 3 s.l.
prn
Potassium binders Sodium polystyrene Hyperkalemia Obstructive bowel disease Consider sodium load.
15-30 g 1-3 x/day in Preferentially use Calcium
Sorbitol 70% or other resonium unless
liquid 30-50 ml. p.o. Hypercalcemia, obstructive hypercalcemic.
Calcium resonium 15- bowel disease Ensure that patient is passing
30 g 1-3 x/day in stools.
Sorbitol as above
Potassium Slow K 8mEq tab once Hypokalemia Hyperkalemia Monitor K+ closely.
replacements daily - tid
K Elixer 20 mEq/15 ml,
once - bid
K Dur 20 mEq/tab,
once - bid
KCl 2 - 10 mmol/L IP q IP dose does not replace K+
exch loss, but reduces peritoneal
losses.

Drug Classification Drug Name and Indications Contraindications Special Considerations

Dosage Range

140
 Proton Pump Omeprazole 20-40 mg GERD, prevention Limited for 8-12 weeks for
Inhibitor p.o. once daily-b.i.d. NSAID induced ulcer, confirmed GERD
esophagitis For failure of ranitidine.
duodenal, gastric ulcers Per UHN Guidelines
Rectal Protectant Anusol ® Cream 1" p.r. Hemorrhoid pain relief
daily to q.i.d. prn
Topical agents Urea emollient Pruritis First choice after education
(i.e.Uremol®) 10-20% re: emollients, phosphate
once daily - tid control

Menthol 0.25% + Pruritis

camphor 0.25% + Beta Second choice if uremol not
methasone 0.05% successful.
cream

A535 cream top.od- tid Muscle aches Active GI bleed , active peptic If known GI bleed, limit use to
ulcers,anaphylactic reaction to 1-2 days, ~15% absorption of
ASA, other NSAID's. methyl salicylate.
Vaccines Hepatitis B Vaccine 40 Hepatitis Vaccine for Severe febrile infections. Nephrology Hep B consent
mcg i.m. per protocol HepB Ag/Ab negativity and documentation form
Delay if s/s infection.
Pneumococcal For all dialysis patients. Consent. Monitor conversion
Vaccine 0.5 mL i.m. q Prevention of of Hep B Ag/Ab status.
5 years pneumococcal
pneumonia

Influenza Vaccine 1 Influenza vaccine Hypersensitivity to eggs. Consent. Monitor & educate
mL i.m. annually Sept - re effects
Nov.

Drug Classification Drug Name and Indications Contraindications Special Considerations

Dosage Range

Vitamins Multivitamins per Vitamin therapy Monitor folate levels.

141
Nephrology Avoid fat soluble vitamins.
recommendations
Replavite® or
substitute such as B
Complex 50, once
daily

Folic Acid 1 - 5 mg/d Folic acid replacement Monitor folate levels

p.o.

142
TELEPHONE DIRECTORY

Emerg TG 14-3947
TW 13-2777
Angio 3370
Chiropodist - Tracy Oliver 6007 pgr. 790-6771
Fracture Clinic TW 13-5858
Hemodialysis Unit EG 4072
Hemodialysis Unit GG 5707
Hemodialysis Unit TRI 597-3422 ext 3801
Home Peritoneal Dialysis 12ES 5672 fax 4169
Home Hemodialysis 3736
Interventional Radiology 4260
Inpatient Nephrology Unit 13ES 3860 fax 4867
Kidney Foundation: Roselyn 3821, 445-0373 x 244
Labs 5898
Rapid Response 3542
Micro 2526
NP’s: Betty Kelman 790-7758
Diane Watson 790-7775
O’Neill Centre 536-1116 fax ext 250
Psych Consult 4451
Pathology – Dr. Andrew Herzenberg 14-4560
Renal Coordination Office -
Evie 3588 Maria 6053
Monica 3056 Geraldine 6389
Dietitians: Holly Dickinson 6530
Karla Dawdy (In Pt) 4625
Social Workers: Michael Gaglione 3618 pgr 719-2876
Christine Smith 6047 pgr 719-3731
Michelle Veridirame 3983 pgr 719-2812
Translation Services 13-6400
Transplant Unit 5163
Vascular Access Coordinator- Cyndi 3518
Vascular Lab 3589
Nephrologists (Assistant) Address Office Pager

Dr. J. Bargman (Shelagh) 8N-840 4804 790-6317

Dr. C. Cardella (Janet) 11C-1258 4480 790-4932
Dr. D. Cattran (Jocelyn) 11C-1256 4187 790-9036
Dr. C. Chan (Tara) 8N-842 3073 790-9833

Dr. E. Cole (Ann) 11C-1262 4669 778-3582

Dr. S. Fenton (Gail) 8N-855 4073 790-7752
Dr. V. Jassal (Tara) 8N-857 3196 790-8803
Dr. A. Logan (Anna) MSH 4-435 586-5187 380-5187
Dr. C. Lok (Theo) 8N-844 4140 790-8645
Dr. J. Miller (Claudia) 8N-846 4966 790-9078
Dr. D. Oreopoulos (Margarida) TW 8E-408 13-5189 648-7007
Dr. Y. Pei (Helen) 8N-838 4257 790-8988
Dr. R. Richardson (Susan) 8N-861 3889 790-9663
Dr. D. Ryan MSH 4-435 586-5174
Dr. J. Schiff (Helen) 11C-1182 3961 790-8296
Dr. J. Scholey (Veronica) 8N-859 5093 719-4569
Dr. M. Silverman (Claudia) 8N-848 4064 790-8918
Dr. C. Whiteside (Theo) 8N-845 4140 719-4816

Doctors for Surgical Procedures

Dr. M. Cattral 3760
Dr. K. Johnston 3552
Dr. T. Lindsay 4620
Dr. J. Marshall 5204
Dr. B. Rubin 3645
Dr. D. Goldstein (for parathyroidectomy) 4767
Dr. G. Oreopoulos (Vascular) 3275

Doctors for Elective PD catheter insertions

Dr. T. Penner 13-6220
Dr. J. Escallon 13-5217
Dr. M. Robinette (for In pt PD caths) 3855, fax referral to
4500

144
Toronto & Area Nephrology
CREDIT VALLEY Mississauga HD 905-813-1100 x7488 PD 905-813-4230
Arturo Wadgymar 905-820-8770 Gordon Wong 905-820-8770
Don Kim 905-857-4772 George Wu 905-820-8770

HALTON HealthCare (Oakville Trafalgar) (905) 845-2571 HD: 905-338-4492

Daniel Sapir 905-815-8910 Sanjaya Pandeya 905-815-9283

HUMBER RIVER REGIONAL (416) 249-8111 HD: 243-4390

Andreas Pierratos 657-2669 David Mendelssohn 243-4223
Murray Berall 782-3330 Harold Bornstein 739-7558
Gavril Hercz 782-5125

HOSPITAL FOR SICK CHILDREN (416) 813-1500 HD: 813-7563

Denis Geary 813-6283 Diane Hebert 813-6287
Elizabeth Harvey 813-5082 Valerie Langlois 813-6283
Rachel Pearl 813-7654 Tino Piscione 813-7654

LAKERIDGE HEALTH CORP – Oshawa (905) 576-8711 HD 905-576-8711 ext 4371

Andrew Steele 905-721-4337 Donna Birbrager 905-721-4064
George Buldo 905-723-8551 Chuck Wei 905-686-3351
Ilan Lenga 905-576-8711 Nancy Barrese 905-576-8711

PETERBOROUGH
Claire Williams 705- 750-1786 Eliot Beaubien 705- 750-1786
Vincent Cheung 705- 750-1786 Srinu Kammila 705- 750-1786

ROYAL VICTORIA HOSP, Barrie

Merali Krishnan 705-728-9846 Derek Benjamin 705-728-9843

SCARBOROUGH CENTENARY (416) 284-8131

Patricia Chan 335-9889

SCARBOROUGH GENERAL (416) 438-2911 HD: 438-2911 x 6627

Paul Tam 279-0855 Rob Ting 279-0855 X 238
Janet Roscoe 438-9000 Jason Fung 279-0855 X 238
Tabo Sikaneta 279-0855 X 238 Paul Ng 279-0855 X 245
Steven Chow 279-0855 X 245 Gordon Ngai 279-0855 X 245

SOLDIER’S MEMORIAL, Orillia (705) 325-2201 HD (705) 327-9129

Leo Lam 705-329-0644 Vas Poulopoulos 705-325-0077

SUNNYBROOK (416) 480-6100 HD: 480-4488

Shelley Albert 480-6950 David Naimark 480-4769
Matt Oliver 480-4755 X7061 Gemini Tanna 480-6100
Sheldon Tobe 480-6901

ST.MICHAEL’S (416) 360-4000 HD: 864-5228

145
 Sandra Donnelly 867-7467 fax 363-9338 Marc Goldstein 864-5290 fax 3042
Phil McFarlane 867-3702 Mitchell Halperin 864-5292
Kamel Kamel 867-7479 Phil Marsden 978-2441
Ramesh Prasad 867-3722 Susan Quaggin 586-8266
Jordan Weinstein 978-2645 Jeff Zaltzman 867-7444
Martin Schreiber 867-7454

ST.JOSEPH’S HEALTH CENTRE (416) 530-6000 HD: 530-6395

Doug Thompson 766-1502 Stavros Karanicolas 530-6239
Joanna Sassal 530-6227 Amrit Kang 530-6227
Myurathy Rao 530-6000

TORONTO EAST GENERAL (416) 461-8272 HD: 469-6167

Steven Chow 698-0883 Paul Ng 461-0939

TRILLIUM HEALTH CENTRE Mississauga (905) 848-7100

Marion Hockley 905-272-1104

WILLIAM OSLER Brampton site (905) 451-1710 HD: 905-796-4286

Jasdip Sachdeva 905-453-0715 Hitesh Mehta 905-453-0715
Bajinder Reen 742-7161

YORK CENTRAL (905) 883-1212 HD: 905-883-2268

Bharat Nathoo 905-508-5911 Esther Szaky 905-508-5911
Arif Manuel 905-508-5911 Michael Pandes 905-508-5911
Andre Charest 905-508-5911

DMC Markham
905-470-9992
Sheppard Centre Self Care Dialysis
416-223-2013
Sussex Centre Self Care Dialysis
905-272-8334

How To Order Catheter insertions, biopsy, Doppler, anaesthesia

Order Tunnelled U/C catheter: Under Nephrology Order set: Diagnostics →
“Abd/Thoracic Angio”. Enter comment if necessary.
Book non-urgent PD catheter insertion for In-Pts: Type referral letter to Dr.
Robinette, fax to 4500
Order Kidney Biopsy: Order entry →Procedure tab, type in “Biopsy” →Select
“Abd Biopsy”(goes under Interventional)→ Kidneys (5) →Left (as approp)
→Tomorrow (4) →Reason Screen: (2) see Comment Field →(8) Comment:
"localization for kidney biopsy" →OK→Accept (A). If probs, call biopsy room
14-8257.
Book Arterial Doppler: In Mysis, Order Entry → Diagnostics→ Vascular Lab→
Arterial Doppler

146
 Book Anaesthesia consult: Fax 3698 or email to
AnesthesiaORSecretary@uhn.on.ca Pls include name, MRN, DOB, diagnosis,
location, planned OR, staff MD.

Calendar of Weekly Rounds

Monday Tuesday Wednesday Thursday Friday

0800 Sign In Rounds Sign In Rounds Sign In Rounds Sign In Rounds Sign In Rounds
8N-828 8N-828 8N-828 8N-828 8N-828 Room
Conference Conference Conference Conference
Room Room Room Room
Fluid & Electrolyte Teaching Rounds Teaching Rounds Teaching Rounds
Rounds 8N-828 Conf 8N-828 Conf 8N-828 Conf Renal Rounds
8N-828 Conf Room Room Room GW 1-534
0830 Room Hugh Orr Conf
Kardex Rounds Room
0900 13ES Conf Room
Greem Team

1000

1100

Dialysis Journal
1200 Club – 8N-828
Conf Rm

1300

1400 Nephrology
Trainee Rounds
NCSB 11 Conf
Dialysis Teaching
1500 Curriculum
NCSB 11 Conf
Sign Out
1600 Resident Rounds City Wide Rounds
8N-828 Conf Nephrology 8N-828 Conf
Room Rounds Room
NCSB 11 Conf
1630 Renal Biopsy
Rounds
1700 Signout to On Call Signout to On Call Signout to On Call 10ES-316

147
 1730 Signout to On Call

1800

Notes

148