arteficial kidney machine

1. Elimination methodsPrinciples, use in patients with acute or chronic renal failure, intoxication and other disorders Basic data on elimination methods, how to remove the waste products and pathological substances from the human body Peritoneal dialysis manual Automated PD- „cycler“ arteficial kidney machine

2. Hemodialysis- treatment with arteficial kidney- a routine in developed countries In the Czech Republic, there are more than 90 special dialysis units for adults and some 6000 pts. on Renal Replacement Therapy = RRT in 2013. In fact, in each district there is at least one center Some 4000 patients are surviving after renal transplantation But there are only 3 centers for children and adolescents (Praha, Brno, Ostrava). Renal transplantation in children and adolescents up 19th year- only Hospital Motol

3. Elimination methods- special monographs- hemodialysis, perit.dialysis, continous methods Prof. Richard Fine, N.Y

4. Different modalities of renal replacement therapy (RRT) Hemodialysis (arteficial kidney machine) CAVH (continual arterio-venous hemofiltration)- war medicine, extensive local catastrophs CVVH (continual v- v hemofiltration PD (peritoneal dialysis) TxK (renal transplantation)- cadaver donor, living donor (related or unrelated living donor)

5. Capillary dialyzers, semipermeable polysulfon material

6. How to remove substances from blood Nomenclature: Dialysis (hemo-, peritoneal dialysis Hemofiltration (ultrafiltration) Plasmapheresis Hemoperfusion (intoxications) Immunabsorption (autoimmune diseases)

7. Hemodialysis - arteficial kidney machine • 1. Convective transport- due to motion of high volume of fluid through the membrane • 2. Diffusion- transport due to gradients in cooncentration • Transmembraneous pressure (TMP) which may be set on the hemodialysis machine. TMP may be programmed during the dialysis session according need of fluid removal • The aim is to return the patient tohis or her dry weight by the end of the dialysis session.

8. Ultrafiltration using transmembraneous pressure- decreasing the pressure on the side of dialysate Blood flowing through the capillaries while dialysateis circulated on the outside of the fiber bundle. Countercurrent flow mechanism, dialysate flow ca 400- 500 ml/Min. The composition of the dialysate may be adapted to individual situation (e.g. sodium/ potassium concentration)

9. Principles of hemodialysis Arteficial kidney machine= monitor, dialyzer Vascular access - central venous catheter, a-v fistula, double needle dialysis, single needle dialysis e.g. in children.

10. Dialyzers Hemodialysis(HD) is the most commonly applied technique. In HD blood and a “cleansing fluid” called dialysate are exposed to each other separated by a semipermable membrane. The sieving properties of the membrane exclude all solutes abovea certain threshold from crossing the membrane. Solutes within the permeability range of the membrane pass it while diffusing along existing concentration gradients.Different types of dialyzers- oiginally coils, later capillaries, plates- Today capillary dialyzers prevail

11. Hemodialysis, extraorporeal circulation, heparin/citrate anticoagulans

12. Hemodialysis, extraorporeal circulation, dialysis monitor capillary dialyzers concentrated solutions

13. Hemodialysis in a center for adults e.g, major center treat 30- 50 pts. in regular dialysis program Different types of dialysis machines monitors

14. Pediatric dialysis unit in Prague- Motol arteficial kidney machine= monitors Hemodialysis in an infant (vascular access CVK) Hemodialysis in a school child mother bedside

15. Hemodialysis in an infant(central venous catheters)

16. Hemodialysis in a pre-school child

17. Mother „bed side“ dialysis session

18. A school child- hemodialysis

19. Teaching during the dialysis session, teacher „bed side“ is informed by MD

20. Combining HD and PD

21. Combining HD and PD

22. A child after renal transplantation Peritoneal catheter

23. maximum solute clearance best tx for severe hyper-K+ ready availability limited anti-coagulation time bedside vascular access hemodynamic instability hypoxemia rapid fluid + solute shifts complex equipment specialized personnel Hemodialysis treatment advantages disadvantages

24. Hemofiltration resembles GFR in glomeruli, replacement of the filtrate waste

25. Continuous venous- venous hemofiltration pump Continous= e.g. for more than 24 hours pump hemofilter ultrafiltrate o plasma Prevention of the too rapid changes (particularly ions and osmolality Replacement of fluids and minerals

26. CVVH- advantage • 1. near-complete control of the rate of fluid removal (i.e. the ultrafiltration rate) • 2. precision and stability • 3. electrolytes or any formed element of the circulation, including platelets or red or white blood cells, can be removed or added independent of changes in the volume of total body water • Indication particularly in water overload (pulmonary edema, brain edema with urea, creatinine a uric acid still in normal range)

27. CAVH (continual arterio-venous hemofiltration – only war medicine!! Patient with compensated cardiovascular system (normal blood pressure), here, the pump is patient´s heart, so this method is relatively simple to be performed

28. Indications for Continuous Renal Replacement Therapy • Particularly to remove fluids (water), to correct electrolyte disorders • To manage end stage renal disease controlling the uremia and acid-base disturbances • To remove toxins, drugs (intoxication, overdosage)

29. simple to set up + perform easy to use hemodynamic stability no anti-coagulation bedside peritoneal access unreliable ultrafiltration slow fluid + solute removal, drainage failure, leakage, catheter obstruction hyperglycemia hyperlipidemia peritonitis Peritoneal Dialysis disadvantages advantages

30. Special peritoneal catheters (Tenckhoff) for peritoneal dialysis With two dacron cuffs

31. Automated peritoneal dialysis- a major achievement in pediatrics

32. Plasmapheresis • Plasmapheresis is the removal, treatment, and return of (components of) blood plasma from blood circulation • It is thus an extracorporeal therapy • The method is also used to collect plasma, to preserve it frozen and to keep it fresh. Finally, the frozen plasma is manufactured into a variety of medications.

33. Examples of diseases that can be treated with plasmapheresis Myasthenia gravis Thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome Wegener's granulomatosis Antiphospholipid Antibody Syndrome (APS or APLS) Recurrent focal and segmental glomerulosclerosis in the transplanted kidney HIV-related neuropathy, pemphigus vulgaris, multiple sclerosis Rhabdomyolysis

34. The most common use of plasmapheresis is the therapy of autoimmune diseases • An attempt to remove rapidly disease-causing autoantibodies from the circulation. Plasma exchange offers the quickest short-term answer to removing harmful autoantibodies; • Then other medical therapy, where simultaneous medical and immunosuppressive therapy is required for long-term management (use of medications such as steroids (prednison, methylprednisolon), cyclophoshamide, cyclosporin A, mycophenolate mofetil, rituximab (monoclonal antibody against the protein CD20, which is primarily found on the surface of B cells.

35. Immunoadsorption The principle of this method is adsorption of specific substances which cause harm without to remove all plasma. Immunoadsorption is capable to eliminate huge amounts of immunoglobulins from the patient's circulation with a minimum of side effects known for plasmapheresis. In contrast, conventional plasma exchange removes antibodies and other plasmatic factors to about 50 – 75% [1]. It has to be emphasised that immunoglobulins are distributed in the intravascular and extravascular compartments in approximately equal amounts

36. Some indications for immunoadsorption • Rapidly progressive glomerulonephritisFocal and segmental glomerulosclerosisWegeners’ granulomatosis and Microscopic polyarteriitis, • Rheumatoid arthritis, Systemic lupus erythematosusThrombocytopenic purpura • Haemolytic uremic syndrome • Disadvantage of this methods is high price of special capsules. This method is available at Pediatric Department in Motol