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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
Q

Overall effect of HD

A

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

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26
Q

What is dry weight?

A

weight at which the patient is euvolemic on a minimal number of BP meds
*assess by nephrologist frequently

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27
Q

What is Kt/V?

A

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

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28
Q

What type of abnormalities would you see in a patient with end stage renal disease that has missed dialysis sessions?

A
  • Hyperkalemia
  • Edema
  • Hypocalcemia
  • Metabolic issues
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29
Q

When is peritoneal dialysis favored?

A
  • Infants or young children
  • Severe cardiovascular disease
  • Difficult vascular access (diabetic patients)
  • Those who desire greater freedom to travel
  • Highly motivated and independent patients
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30
Q

What is peritoneal dialysis?

A

form of RRT that utilizes the patient’s natural peritoneum as a semipermeable membrane between the blood and an infused dialysis solution

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31
Q

How long do you have to wait before using PD catheter?

A

10-14 days

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32
Q

Absolute contraindications to PD

A

Those with an unsuitable peritoneum due to the presence of adhesions, abdominal wall defects, fibrosis, recent surgery, or malignancy.

33
Q

Contraindications to PD

A
  • Problems in the bowel: IBD, ischemic colitis, morbid obesity, malnutrition, frequent episodes of diverticulitis
  • **Peritonitis- most common organism=Staphylococcus
34
Q

Dialysis limitations…

A

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
Q

Which RRT has the best long-term outcome and who should be considered?

A
  • Kidney transplant

- All patients with ESRD

36
Q

Review transplant survival data from ppt - take home message

A

Much higher survival and quality of life with transplant versus dialysis.

37
Q

Journey to the transplant list - referral

A
  • Nephrologist/dialysis is MC
  • Self referrals
  • As part of evaluation of another organ (patients are often dual-organ transplant)
38
Q

Listing requirements - extensive

A

Cardiac testing, PFT’s, psych and cognitive, financial, oncology, vascular, GI, gynecological, dental eval

39
Q

Absolute contraindications to transplant

A
  • *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
Q

Relative contraindications for transplant

A
  • Smoking
  • Documented non-compliance
  • BMI > 40
  • Active PUD
  • HIV status
41
Q

What is UNOS?

A

United Network for Organ Sharing

42
Q

What is organ match?

A

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
Q

Organ Matching Criteria

A
  • Medical urgency
  • Tissue type
  • Blood type
  • Waiting time
  • Dialysis backdate
  • Expected benefit
  • Organ size
  • Immune status
  • Geographic distance
44
Q

Preserving organs - cold time

A

Kidney 24-36 hours
Pancreas 12-18 hours
Liver 8-12 hours
Heart/Lung 4-6 hours

45
Q

What is KDPI?

A
  • 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
Q

Is it better to have a higher or lower KDPI score?

A

The higher the KDPI, the less time the computer predicts that kidney will last.

KDPI 0-20% are given to children.

47
Q

Common organ donation scenarious

A
  • donation after brain death

- donation after cardiac death (if patient doesn’t expire in 45-60 minutes, organ donation is not possible)

48
Q

Organ matching - ABO blood-type

A
  • 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
Q

Define tissue typing

A
  • 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
Q

HLA histocompatibility

A

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
Q

HLA Classes

A

I (HLA-A, -B, -C) and II (HLA-DQ, -DR, -DP) are the primary focus

52
Q

HLA Cross-Reaction test

A
  • 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
Q

What patients are broadly sensitized to HLA?

A

Patients with ESRD via previously:

  • administered blood products
  • pregnancy
  • prior transplantation
54
Q

What is a cross-match test?

A

One technique of tissue typing, “mixed leukocyte reaction”, is performed by culturing lymphocytes from the donor together with those from the recipient

55
Q

Desensitization protocols

A

High dose IVIg or plasmapheresis/low dose IVIg

56
Q

Where do kidney’s come from?

A
  • Deceased Kidney Donor (75%)
  • Paired Exchange Kidney Donation
  • Living Kidney Donor (25%)
  • Altruistic Donor
  • Directed Donation
57
Q

Living donor surgical procedure

A
  • 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
Q

What is post-op course POD#1?

A

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
Q

Complications of transplant - 5 W’S

A

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
Q

Primary cause of graft loss

A

The primary cause of graft loss is patient death with a functioning graft.

61
Q

What meds are avoided in immediate perioperative period?

A

ACEi d/t hemodynamic effects

62
Q

Common complications

A
  • HTN
  • Hyperlipidemia
  • Patients developing diabetes s/p transplant
63
Q

What unconventional/uncommon viral infections can occur after transplant?

A

CMV and BK

64
Q

Post-Op Concerns - delayed graft function

A

Requires dialysis within 3 days of transplant- at some centers occurs 20-30% of the time, related greatly to the surgical technique

65
Q

Post-Op Concerns - slow graft function

A

<25% decrease in Cr (vs. Immediate Graft Function > 25%)

66
Q

What is hyperacute rejection?

A
  • 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
Q

What is definitive diagnosis of rejection?

A

Kidney biopsy/DSA’s

68
Q

What is acute rejection?

A
  • 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
Q

What is chronic rejection?

A

Takes months to years to develop

*initial cause of ESRD re-occurs, leading to eventual rejection

70
Q

Anti-Rejection therapy

A

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
Q

Common immunosuppressive regiment

A

Cellcept, prednisone, prograf

72
Q

Common calcineurin inhibitor ADRS

A
  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
Q

Stimulates (inducers) that decrease drug level

A
  • St. John’s wart
  • rifampin (anti-TB)
  • anti-convulsants
74
Q

Inhibitors that increase drug level

A

GRAPEFRUIT

  • CCBs
  • Non-dyhydro - verapamil
  • Azoles
  • Macrolides
  • Anti-HZIV
75
Q

How to increase organ donations

A
  • register more people

- expand criteria for potential decreased donors

76
Q

Primary care in the dialysis patient

A
  • 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
Q

ACEi and ARB’s role in prevention

A

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
Q

Advanced care planning

A
  • 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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