Case 3 - Renal replacement therapy Flashcards
3 types of RRT
- Haemodialysis
- Peritoneal dialysis
- Transplantation
What are the 3 types of peritoneal dialysis?
- Automated PD- automated cycler machine at night, 10-12L exchanged over 8-10hrs
- Continious ambulatory PD - 4-5 dialysis exchanges per day, regular intervals with a long overnight swell
- Assisted automated PD - HCA visits pts home to help with setting up
What is peritoneal dialysis?
- Home based therapy
- Uses patients peritoneal membrane as dialysis membrane
- Solutes move from patients blood across peritoneal membrane down conc gradient to dialysate fluid
How is osmotic gradient created in peritoneal dialysis?
- High concentration of glucose (ocassionally amino acids or glucose polymer solutions are used) in dialysate fluid - removes water from patient
What moves across from blood into dialysate fluid in peritoneal dialysis?
- Urea
- Electrolytes
- Creatinine
Advantages of peritoneal dialysis
- Quality of life good
- Excellent first choice when starting dialysis - esp when have residual renal function
- Regimes are much more individualised than HD
Disadvantages of PD
- Need to be able to manage technical aspects of dialysis
- Unsuitable if have stoma/pervious surgery
- Risk of infection eg PD peritonitis
Complications of PD
- Drainge problems
- Malposition
- Leaks
- Herniae
- Hydrothorax (pleural effusion)
- Long term use –> encapsulating peritoneal sclerosis
When is haemodialysis used?
- AKI
- ESRF
So can be temporary or permanent
How does haemodialysis work?
- Dialysis machine pumps blood from patient through disposable tubing
- Through dialyser/artifical kidney
- Back to patient
- Waste solute, salt and excess fluid is removed from blood as it passes through dialyser
Advantages of haemodialysis
- Efficient
- Unit based - support from staff
Disadvantages of haemodialysis
- Access needs to be secured for dialysis
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Complications of haemodialysis
- Infection/bacteraemia
- Haemodynamic instability
- Reactions to dialysers
- Haematomas/risk of bleeding
- Muscle cramps
- Anaemia due to clotted lines/haemolysis
- AVF steal syndrome
- SVCO from central lines
3 types of haemodialyssi
- Home HD - offer training at home for more frequent dialysis
- Nocturnal - overnight slow and long
- CRRT - continious renal replacement therapy mainly used in acute setting eg ITU/HDU
Who is renal transplant used for?
Treatment of choice for most patients with ESRF
Where does renal transplant come from?
- Live related/non related
- Deceased donor
Advantages of transplant
- Near normal lifestyle
- Better mortality and morbidity
Disadvantages of transplant
- Criteria to meet suitability for operation
- Compliance with lifelong medication
- Risk of rejection
- Risk of maliganncies
- Risk of infection
- Long waiting times for cadaveric organ
How do we make the decision for renal replacement therapy?
- Discuss with patient and family
- Multiple clinic visits and after patient is fully informed of risks and benefits of each mode
Who does WHO suggest is not suitable for any RRT?
- Age >80 OR
- WHO perfomance score of 3 or more - offers no survival benefit
- Often unsuitable for or choose to not have invasive RR therapy so do conservative management instead
Conservative management of ESRF
- Symptom control - enhance QOL
- Respect patinets preferrred place of care
- Advanced care plan
- MDT approach
- Support system for patient and family
Principles of managing CKD end stage mineral bone disease
- Decreased phosphorus intake - high in processed foods
- Calcitriol - active vitamin D, decreases PTH
- Calcium and vitamin D supplements
- Calcimimentics - decrease PTH
- Phosphate binders
- Parathyroidectomy if not managed with medication
Managing anaemia in CKD?
- Treat iron deficiency - oral if not on HD, if are = IV infusion
- IV or subcut erythropoesis stimulating agents eg epoetin alpha
Pros vs cons of live organ vs deceased donor
Pros live:
* Decreased risk rejection
* Shorter wait
* Planned surgery
* Lasts longer
* Can usually have before starting dialysis
Cons:
* Complex chain sometimes - fall through?
* Find match
