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RENAL REPLACEMENT THERAPY

RENAL REPLACEMENT THERAPY. Dr Shafaq Nazir House physician Medical unit 1. Contents. DEFINATION CRITERIA FOR RRT HEMODIALYSIS AND ITS COMPLICATIONS HEMOFILTERATION AND COMPLICATIONS PERITONEAL DIALYSIS AND COMPLICATIONS RENAL TRANSPLANT TRANSPLANT STATISTICS

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RENAL REPLACEMENT THERAPY

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  1. RENAL REPLACEMENT THERAPY Dr Shafaq Nazir House physician Medical unit 1

  2. Contents • DEFINATION • CRITERIA FOR RRT • HEMODIALYSIS AND ITS COMPLICATIONS • HEMOFILTERATION AND COMPLICATIONS • PERITONEAL DIALYSIS AND COMPLICATIONS • RENAL TRANSPLANT • TRANSPLANT STATISTICS • TRANSPLANT REQUIREMENTS. • INDICATIONS • CONTRA INDICATIONS • SOURCES OF DONORS • COMPATIBILITY • PROCEDURE • COMPLICATIONS • KIDNEY PANCREASE TRANSPLANT • TRANSPLANT REQUIREMENTS • COMPLICATIONS • MCQs

  3. RRT • IT IS A TERM USED TO ENCOMPASS LIFE SUPPORTING TREATMENTS FOR RENAL FAILURE. • It includes • HEMODIALYSIS • PERITONEAL DIALYSIS • HEMOFILTERATION • RENAL TRANSPLANT

  4. Criteria for placing a patient for RRT Presence of uremic syndrome i.e • Hyperkalemia(unresponsive to conventional therapy) • Extra cellular volume expansion • Acidosis refractory to medical therapy • Bleeding diathesis • Creatinineclearance10ml/min per 1.73m sq

  5. HEMODIALYSIS • It removes waste products like potassium and urea as well as free water from blood in renal failure. • Principle revolves around diffusion of solutes across semi permeable membrane • Dialysate flows opposite to blood flow direction in extra corporeal circuit. • This counter current flow maintains concentration gradient increasing efficacy of dialysis.

  6. COMPLICATIONS OF HEMODIALYSIS • DECREASE IN BLOOD PRESSURE • FATIGUE • CHEST PAIN • LEG CRAMPS • NAUSEA HEADACHE • SEPSIS LEADING TO ENDOCARDITIS • OSTEOMYLITIS • HEPARIN ALLEGRY(RARE) LONG TERM COMPLICATIONS LIKE • AMYLOIDOSIS • NEUROPATHY • HEART DISEASE

  7. HEMOFILTERATION • Similar to hemodialysis as it also requires a semi permeable membrane • However, governed by convection rather than by diffusion • Dialysate is not used • Requires a positive hydrostatic pressure driving water and solutes to filterate compartment • Both small and large solute particles are dragged through, due to hydrostatic pressure. • High quality replacement fluid(isotonic) is used as ultrafilterate substitute .

  8. HEMOFILTERATION OUTCOME ADVANTAGES: • Less hemodynamic instability • No exposure to dialysis fluid DISADVANTAGES: • more expensive than hemodialysis

  9. PERITONEAL DIALYSIS • Works on the principal of peritoneal membrane acting as a natural semi-permeable membrane • Dialysis fluid when instilled around it is removed by diffusion, excessive fluid by osmosis(by altering conc of glucose in fluid.) • Simple to perform • Less complex • Used both children and elderly • In diabetics and cardiovascular diseases

  10. TYPES OF PERITONEAL DIALYSIS • Continuous ambulatory peritoneal dialysis • Automated peritoneal dialysis • CAPD uses smallest quantity of of fluid daily to prevent uremia • 2L bags are changed 3-5 times a day • A total dialysate of 10L is produced. • APD involves cyclic peritoneal dialysis, • Intermittent peritoneal dialysis • Night intermittent dialysis • Tidal intermittent dialysis

  11. SIDE EFFECTS OF PERITONEAL DIALYSIS • Peritonitis(staph 60%, gram –ve 20%, fungi<5%) • Exit site infection • Catheter malfunction • Loss of ultrafilteration • Obesity • Hernia • Back pain • hyperlipidemia

  12. WHAT IS KIDNEY TRANSPLANT? • Renal transplant is the organ transplant of a kidney in a patient having end stage renal disease.

  13. PROGNOSIS • It is a life extending procedure • A patient can live 10 to 15 years longer with a kidney transplant than if kept on dialysis • Ideally, transplant should be pre-emptive, i.e take place before patient starts on with dialysis • Studies suggest the longer a patient is on dialysis before transplant, the less time the kidney will last. • It has better prognosis in younger patients, even 75 year old recipients gain an average of 4 more years.

  14. TRANSPLANT STATISTICS

  15. TRANSPLANT REQUIREMENTS Vary from program to program, country to country. • Age must be less than 69 years TRANSPLANT EXCLUSION CRITERIA • Mental illness, • substance abuse, • significant cardiovascular disease, • terminal incurable infectious diseases • cancer HIV IS NO LONGER A CONTRA-INDICATION TO TRANSPLANT

  16. INDICATIONS OF TRANSPLANT • ESRD(end stage renal disease), regardless of primary cause I.e drop in GFR 20-25% of normal. • Malignant hypertension • Infections • Diabetes mellitus • Glomerulonephritis • Poly cystic kidney disease • Auto immune conditions like Lupus and good pastures syndrome

  17. CONTRA INDICATIONS • Cardio pulmonary insufficiency • Hepatic insufficiency • Recent cancer • Substance abuse • Tobacco use and morbid obesity risks for surgical complications

  18. HOW RENAL TRANSPLANT IS DONE • The barely functional kidney is not removed as it increases surgical morbidities • The donated kidney is placed in the ILIAC FOSSA with a separate blood supply • Donors renal artery is connected to EXTERNAL ILIAC ARTERY of recipient • Renal vein is connected to EXTERNAL ILIAC VEIN of the recipient. • The whole operation takes 3 hours

  19. POST OPERATION • Blood is allowed to flow through kidney to minimize the ischemia time. • Final step is to connect the donors ureter to the recipient bladder • Living donor kidneys require 3 to 5 days to function at normal levels • Cadaveric donations take 7 to 15 days to function at normal levels.

  20. ABOUT DONORS • Donors may be “LIVING” or “DECEASED” • MAY or MAY NOT be genetically related • even ABO COMPATIBILITY and TISSUE MATCH are no longer a requirement. In 2004 FDA approved the Cedars- Sinai High dose IVIG therapy which stops recipient’s immune system from tissue rejection.

  21. BD AND DCD DONORS • The deceased donor may be • BRAIN DEAD or DONATE AFTER CADAVERIC DEATH • Brain dead donors still have their hearts pumping blood and perfusing the organs when the operation begins. • DCD donors elect via living will or family to withdraw mechanical ventilation, when death is pronounced, are rushed to theater for kidney removal and storage. • Kidneys from B.D donors are superior to DCD donors,since they are not exposed to warm ischemia (time between stopping and kidney being cooled)

  22. KIDNEY PANCREAS TRANSPLANT • Done occasionally in IDDM suffering from diabetic nephropathy. • Mostly a deceased donor pancreas is used. • It may be SKP(simultaneous kidney-panc transplant), PAK(pancreas after kidney transplant). • Transplanting only ISLET CELLS is in experimental stage • It requires breaking down donor pancreas, extracting islet cells and injecting via a catheter into recipient pancreas • Recipient continues to take immunosuppressants to avoid rejection. • Most patients require 2 or 3 such injections and in some insulin may still be needed.

  23. COMPLICATIONS OF RENAL TRANSPLANT • Transplant rejection • Infection and sepsis due to immunosuppressants • Post transplant lymphoproliferative disorders(lymphomas)due to immunosuppressants. • Electrolyte imbalance(Ca and Ph) causing bone problems • Acne, hairsuitism, hair loss, obesity, hypercholestrolemia, diabetes mellitus(type2) • In case of rejection, patient may opt for a second transplant and return to dialysis intermediatly.

  24. MCQs • Which of the following procedures is superior in a patient with creatinine clearence of 10ml/min? • Hemodilation • Hemofilteration • Renal transplant • Peritoneal dialysis

  25. MCQs Common side effect of peritoneal dialysis is peritonitis due to • Staphylococci? • Streptococci? • Fungi? • Gram negative organisms?

  26. MCQs A patient with hepatitis C after renal transplant • Does not require any treatment for HCV • Can survive with ribavarin treatment only • Needs both ribavirin and INF therapy for good prognosis • Does not survive despite any treatment

  27. TAKE HOME MESSAGE • Never hesitate treating patients with end stage renal disease. • Always go for the best available treatment option in the form of life extending procedure for patient benefit.

  28. THANK YOU

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