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GU1 - Nephrology > Clin Med - RRT & Transplant > Flashcards

Clin Med - RRT & Transplant Flashcards

1
Q

Define Renal replacement therapy (RRT)

A

required in patients with AKI or CKD when the residual native function is insufficient to maintain volume, electrolyte, and acid-base balance.

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2
Q

RRT is also used in patients when…

A

uremic factors trigger systemic complications such as mental status changes, bleeding diathesis, and pericarditis.

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3
Q

Put simply, RRT replaces…

A

non-endocrine kidney function in patients with renal failure and is occasionally used for some forms of poisoning.

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4
Q

What are the acute indications for RRT?

A 
AEIOU
A-acidosis
E-electrolyte abnormalities
I-intoxications
O-overload
U-uremia
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5
Q

Acidosis indication for RRT

A

life threatening metabolic acidosis with a pH <7.2, not responsive to conservative management.

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6
Q

Electrolyte abnormalities indication for RRT

A

life threatening hyperkalemia (>6) associated with ECG changes and symptomatic hypermagnesemia (>8) and hypercalcemia. BUN >100.

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7
Q

Intoxications abnormalities indication for RRT

A

considered in patients with deteriorating mental status. Can be d/t alcohols, metals, variety of drugs.

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8
Q

Overload indication for RRT

A

fluid overload or pulmonary edema not responsive to aggressive diuresis (including refractory heart failure).

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9
Q

Uremia indication for RRT

A

mental status changes attributable to uremia, uremic pericarditis, or neuropathy, bleeding diathesis, or vomiting associated with uremia.

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10
Q

When do patients usually require dialysis?

A
  • consider estimated GFR and S/sx of uremia.
  • using GFR levels alone is no longer recommended

Start when uremic symptoms develop + estimated GFR falls below 10 (no diabetes) or below 15 (with diabetes)

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11
Q

What are the 3 choices for RRT in patients with ESRD?

A
  1. Conservative care and symptom control
  2. Dialysis - either peritoneal of hemodialysis (HD)
  3. Kidney transplant
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12
Q

What is the MC form of RRT?

A

Hemodialysis (HD)

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13
Q

MC underlying diagnosis for HD

A

Diabetes is the most common underlying diagnosis, followed by HTN, glomerulonephritis, and congenital and cystic kidney disease.

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14
Q

Increased mortality in HD patients

A

CVD the leading cause of death among patients on HD, followed by septicemia.

Probability of death in the first 5 years after starting HD is 63%
(71% in diabetics)

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15
Q

What is the goal of HD?

A

to replace the basic functions of the failing kidney.

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16
Q

What are the 3 types of dialysis access?

A
  1. AVF - arteriovenous fistulas
  2. AVG - arteriovenous grafts
  3. Dialysis catheters
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17
Q

What is AVF?

A

side-to-side anastomosis between artery and vein or side-of-artery to end-of-vein anastomosis

  • Can take 3-4 months to mature
  • Lower complications compared to AVG
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18
Q

What is AVG?

A
  • placed in patients for whom an AVF cannot be created.
  • long-term patency rates are less impressive than those obtained with AVF
  • shorter maturation time (3-4 weeks)
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19
Q

What is the least desirable form of vascular access?

A

HD Catheter

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20
Q

Where is HD cath placed?

A

Typically placed in the right internal jugular vein, with a tunneled exit site just below the ipsilateral clavicle.

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21
Q

When would you use HD cath?

A

Last resort in patients with poor vessel access.

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22
Q

What 2 processes occur in HD?

A

Diffusion and ultrafiltration

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23
Q

Diffusion in HD

A

mechanisms responsible for the balance of solutes and electrolytes.

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24
Q

Ultrafiltration in HD

A

mechanism responsible for the removal of fluid.

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25
Overall effect of HD
remove small molecules that are likely to be toxins in high concentrations (potassium, phosphorus, and urea) *fluid can also be removed for volume overloaded patients
26
What is dry weight?
weight at which the patient is euvolemic on a minimal number of BP meds *assess by nephrologist frequently
27
What is Kt/V?
number used to quantify hemodialysis and peritoneal dialysis treatment adequacy. K - dialyzer clearance of urea. t - dialysis time. V - volume of distribution of urea, approximately equal to patient's total body water
28
What type of abnormalities would you see in a patient with end stage renal disease that has missed dialysis sessions?
- Hyperkalemia - Edema - Hypocalcemia - Metabolic issues
29
When is peritoneal dialysis favored?
- Infants or young children - Severe cardiovascular disease - Difficult vascular access (diabetic patients) - Those who desire greater freedom to travel - Highly motivated and independent patients
30
What is peritoneal dialysis?
form of RRT that utilizes the patient’s natural peritoneum as a semipermeable membrane between the blood and an infused dialysis solution
31
How long do you have to wait before using PD catheter?
10-14 days
32
Absolute contraindications to PD
Those with an unsuitable peritoneum due to the presence of adhesions, abdominal wall defects, fibrosis, recent surgery, or malignancy.
33
Contraindications to PD
* Problems in the bowel: IBD, ischemic colitis, morbid obesity, malnutrition, frequent episodes of diverticulitis * **Peritonitis- most common organism=Staphylococcus
34
Dialysis limitations...
a working kidney is able to remove poisons from a person’s body 24 hours a day, while dialysis can only do 10% of the work of a functioning kidney
35
Which RRT has the best long-term outcome and who should be considered?
- Kidney transplant | - All patients with ESRD
36
Review transplant survival data from ppt - take home message
Much higher survival and quality of life with transplant versus dialysis.
37
Journey to the transplant list - referral
- Nephrologist/dialysis is MC - Self referrals - As part of evaluation of another organ (patients are often dual-organ transplant)
38
Listing requirements - extensive
Cardiac testing, PFT's, psych and cognitive, financial, oncology, vascular, GI, gynecological, dental eval
39
Absolute contraindications to transplant
* *active infection - Current malignancy - Refractory cardiac failure - Advanced PVD - Hepatic disease - End-stage lung disease - Lack of financial resources - Psychosocial issues (psych disease, drug/alcohol addiction, lack of social support)
40
Relative contraindications for transplant
- Smoking - Documented non-compliance - BMI > 40 - Active PUD - HIV status
41
What is UNOS?
United Network for Organ Sharing
42
What is organ match?
Using the combination of donor and candidate information (blood type, medical urgency, location), the UNOS computer system generates a “match run,” a rank-order list of candidates to be offered each organ. This match is unique to each donor and each organ.
43
Organ Matching Criteria
- Medical urgency - Tissue type - Blood type - Waiting time - Dialysis backdate - Expected benefit - Organ size - Immune status - Geographic distance
44
Preserving organs - cold time
Kidney 24-36 hours Pancreas 12-18 hours Liver 8-12 hours Heart/Lung 4-6 hours
45
What is KDPI?
- Every kidney offered for a transplant will have a Kidney Donor Profile Index (KDPI) score - This is a percentage score that ranges from 0-100% -Score is associated with how long the kidney is likely to function when compared to other kidneys
46
Is it better to have a higher or lower KDPI score?
The higher the KDPI, the less time the computer predicts that kidney will last. KDPI 0-20% are given to children.
47
Common organ donation scenarious
- donation after brain death | - donation after cardiac death (if patient doesn't expire in 45-60 minutes, organ donation is not possible)
48
Organ matching - ABO blood-type
- Absent other complications, type O kidneys can be transplanted into any patient - Type A or type B kidneys can be transplanted into same type or type AB patients - Type AB kidneys can only be transplanted into type AB patients. - Type O patients can only receive type O kidneys.
49
Define tissue typing
- testing of lymphocytes for their human leukocyte antigens (HLA) - tissue typing of recipient and donor determines their HLA match - coded on chromosome 6 - half (1 haplotype) inherited from each parent
50
HLA histocompatibility
HLA (human leukocyte antigens ) or Major histocompatibility complex (MHC) is a combination of six cell surface proteins essential for the acquired immune system to recognize foreign molecules.
51
HLA Classes
I (HLA-A, -B, -C) and II (HLA-DQ, -DR, -DP) are the primary focus
52
HLA Cross-Reaction test
- between potential donor cells (lymphocytes) and recipient serum - seeks to detect presence of preformed anti-HLA antibodies in the potential recipient that recognize donor HLA molecules - goal is to prevent hyperacute rejection
53
What patients are broadly sensitized to HLA?
Patients with ESRD via previously: - administered blood products - pregnancy - prior transplantation
54
What is a cross-match test?
One technique of tissue typing, "mixed leukocyte reaction", is performed by culturing lymphocytes from the donor together with those from the recipient
55
Desensitization protocols
High dose IVIg or plasmapheresis/low dose IVIg
56
Where do kidney's come from?
- Deceased Kidney Donor (75%) - Paired Exchange Kidney Donation - Living Kidney Donor (25%) - Altruistic Donor - Directed Donation
57
Living donor surgical procedure
- lower abdomen with 'hockey stick' incision - kidney taken from the right goes on the recipients left (and vice versa) - approx 3 hrs long - recovery 1-2 hrs, with 2-5 day hospital stay
58
What is post-op course POD#1?
1: 1 nursing care for first 16 hrs, then advance diet from clear liquids to regular diet then: - incentive spirometry - ambulation/PT - bowel regimen - high amounts of education
59
Complications of transplant - 5 W'S
Fever….think the 5 W’s 1. Wind-pneumonia vs atelectasis 2. Wound-surgical infection 3. Water- UTI 4. Walking- DVT vs PE 5. Weird Medication
60
Primary cause of graft loss
The primary cause of graft loss is patient death with a functioning graft.
61
What meds are avoided in immediate perioperative period?
ACEi d/t hemodynamic effects
62
Common complications
- HTN - Hyperlipidemia - Patients developing diabetes s/p transplant
63
What unconventional/uncommon viral infections can occur after transplant?
CMV and BK
64
Post-Op Concerns - delayed graft function
Requires dialysis within 3 days of transplant- at some centers occurs 20-30% of the time, related greatly to the surgical technique
65
Post-Op Concerns - slow graft function
<25% decrease in Cr (vs. Immediate Graft Function > 25%)
66
What is hyperacute rejection?
- Occurs within minutes to hours after blood flow established - Pre-existing antibodies against donor that should be picked up by pre-transplant crossmatch - Vascularization rapidly destroyed - Bluish tint - Massive thrombosis in capillaries - Kidney must be removed unless surgeon thinks blood flow salvageable
67
What is definitive diagnosis of rejection?
Kidney biopsy/DSA's
68
What is acute rejection?
- Can occur within one week, with the highest incidence occurring within the first 3 months - Can be T-cell response (cytotoxic) or B-Cell response (humoral)
69
What is chronic rejection?
Takes months to years to develop | *initial cause of ESRD re-occurs, leading to eventual rejection
70
Anti-Rejection therapy
Immunosuppression is used for induction at the time of transplant to promote graft acceptance, to prevent rejection (maintenance) and for the treatment of acute rejection
71
Common immunosuppressive regiment
Cellcept, prednisone, prograf
72
Common calcineurin inhibitor ADRS
1. cyclosporine - gum hypertrophy, hirsuitism 2. prograf - hair loss 3. cellcept - GI side effects, worse in DM 4. rapamune - decreased wound healing 5. prednisone - moon faces, abdominal and intracapsular fat, emotional instability 6. imuran - do not give with allopurinol (hemolysis)
73
Stimulates (inducers) that decrease drug level
- St. John's wart - rifampin (anti-TB) - anti-convulsants
74
Inhibitors that increase drug level
GRAPEFRUIT - CCBs - Non-dyhydro - verapamil - Azoles - Macrolides - Anti-HZIV
75
How to increase organ donations
- register more people | - expand criteria for potential decreased donors
76
Primary care in the dialysis patient
- there are too few nephrologists and too many patients at risk for kidney failure to refer everyone - aggressive tx of HTN - tight control of blood sugars
77
ACEi and ARB's role in prevention
Shown to reduce proteinuria and reduce progression of kidney disease ***However, in the pre, peri, and initial postoperative period of kidney transplantation, this medication should be avoided!
78
Advanced care planning
- End of life planning - Health screenings - Immunizations - Targets for low cholesterol - maintain BP goal: <130/80 or <125/75 with significant proteinuria

GU1 - Nephrology (16 decks)

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