Dialysis and Kidney Transplant Tutorial Flashcards
Case 1 - 59M Mr Shah
PMH = hypertension
SH = consultant at a multinational company, travels overseas frequently
HPC = gastroenteritis whilst abroad, resulting in 5 days of diarrhoea, vomiting and limited oral intake
Ibuprofen for 7 days
PC = 14 days after symptom onset, on return to the UK, reported to GP of anorexia, vomiting, chronic fatigue, swelling in ankles and breathlessness
Referral to nephrology clinic's initial tests revealed: GFR value = 10ml/min Blood Urea Nitrogen (BUN) = 30mg/dL Potassium = 6.2mmol/L Serum creatinine = 1500umol/L Kidney ultrasound = 11cm
What is your differential diagnosis?
AKI - acute kidney injury MOST LIKELY from diarrhoea and vomiting due to gastroenteritis
CKD (chronic kidney disease) less likely due to onset of symptoms since gastroenteritis infection from abroad
Identify the probable cause(s) for his disorder?
Hypertension - prediposes him to AKI on top of his probable developing CKD
Developed gastroenteritis (infection) - 5 days of diarrhoea and vomiting = hypovolemia = reduced kidney perfusion
NSAIDs i.e. ibuprofen affect (cause constriction of) afferent and efferent arterioles = acute kidney injury
If he is on an ACEi for his hypertension - renal sides effects e.g. kidney failure
What treatment should be considered for Mr Shah?
IV fluids (given cautiously) VS diuretics (given first usually in this individual) - first need to figure out his urine output and ability to pass urine
Antibiotics for gastroenteritis
Temporary dialysis (can take up to 6 weeks to recover), long term dialysis if kidney injury is permanent
How is it decided whether the patient is placed on IV fluids or diuretics?
Assessed using whether it is to do with fluid retention and inability to pass urine = diuretics
OR
From hypovolemia and patient can pass urine = IV fluids for rehydration
How should patients presenting like this be managed?
Follow ABCDE
For the dialysis - get a tunnelled line put in as it is safer with lesser chances of infections
The consultant decided to start Mr Shah on dialysis.
What are the different types of dialysis?
- Haemodialysis -
Blood from patients body flows into machine (dialyser), after it is filtered it is pumped out and put back into the patient
Filtration uses countercurrent flow and a semi permeable membrane for diffusion
Dialysate concentrations can be adjusted for the patient’s needs
Once waste from the patient’s blood diffuses across the semi-permeable membrane and is filtered out into the diasylate, the used dialysate is pumped out - Peritoneal dialysis -
Dialysate is pumped into the peritoneal cavity (between visceral and peritoneal layers of the peritoneum)
Peritoneum serves as the semi-permeable membrane
Then waste, excess fluids and salt flows out of the capillaries into the dialysate within the peritoneal cavity
The used diasylate is then pumped out of the peritoneal cavity
What are the considerations with each type of dialysis?
Haemodialysis =
Generally requires dialysis centre visits (can also be performed at home)
3-4.5hrs of treatment 3x/week
Strict dietary constraints and salt/water intake restrictions
Needs access - ideally AV fistula (created via operation under local anaesthesia) or tunnelled central venous line (risk of infection)
Peritoneal dialysis =
Performed at home, generally overnight
Normally 7 days/ week
Lesser constraints for food and water intake
Can travel easily - machine packs into wheelie suitcase and fluid delivered by companies internationally
Day time exchanged can be done anywhere - at work, home, etc. just need to be able to wash hands
Change of infection due to catheter e.g. peritonitis
What is the suitable dialysis for Mr Shah and why?
Peritoneal dialysis = fits in better with his schedule (involves frequent flying)
PD is great - but should only be limited to 2-3 years of this, before switching to heamodialysis or a transplant; and because he travelled a lot
After being for 2 years on dialysis, after initially refusing, Mr Shah has decided to opt for kidney transplant
What factors are considered in determining a candidate as a suitable live kidney donor?
Match - body size, blood type (not essential), does not have antibodies against that blood type (issue when spouses / children want to donate kidneys to mothers), HLA match, over 18, willing to commit
Donor = no other health conditions e.g. HIV, free will (no incentive), both kidneys must work, no history of kirney stones or high BP, cannot be obese or underweight according to BMI
Conflict of interest
If donor is obese - must meet additional requirements
Age - similar ages
Family history of kidney disease
Co-morbidities - diabetes, hypertension and cancer are the main ones
Donor must have 2 healthy kidneys - identified using ultrasound (normal sized), renal function (normal GFR), no blood or protein in the urine
Financial stability - no money incentives / manipulations
Viral infections - Hep B (Anti-hep B med given to recipient), Hep C
Future pregnancies - have kids before donating kidney
Mental Health History - person understands the process, and is willing, no manipulation
Kidney match - blood type compatibility, HLA typing, serum crossmatch
What are some other considerations when undergoing a kidney transplant?
Paid leave off work
Please research and list recommendations for a patient who has undergone a kidney transplant surgery to lead a healthy life while managing his condition
Follow healthy lifestyles - low salt diet, balanced diet, starch heavy foods, moderate intensity exercise, weight control
When taking immunosuppressants, avoid eating foods carrying high risk of food poisoning
Limit alcohol, take all vaccines e.g. flu jabs
How does a kidney transplant work?
New transplanted kidney is placed in a different anatomical position ot the native kidneys
3 connections made:
- Between donor artery and recipient artery
- Between donor vein and recipient vein
- Between transplanted ureter and recipient’s urinary bladder
What happens to the original (native) kidneys?
Usually left in place due to operative risk - complex to take out the kidney (nephrectomy) while also doing a kidney transplant
Although leaving them in = increased risk of renal cell carcinoma afterwards = native kidneys surveyed every 5 years AND low threshold to rescan native kidneys
Kidneys are taken out in some scenarios e.g. polycystic kidneys = reduced space in cavity to put transplanted kidneys in, cancer, infection
These are usually done in 2 operations, first to remove kidneys, patient is then put on dialysis, then patient undergoes kidney transplant
What are the risk factors and preventative measures of these post-transplant surgery?
Risk factors - Preventative recommendations
Diabetes - active lifestyle
CVD - measure and manage BP
Cancer - use sunscreen and cover up, regularly check skin and breasts
Psychiatric disorders - being mindful and seeking help
What are the food and water post-transplant surgery recommendations?
Low salt and sugar diet
Regular fluid intake
No: raw eggs, raw meat, undercooked fish, and unpasteurised cheeses
No: food items that can interact with Tacrolimus (immunosuppressant) - seville oranges, marmalade, grapefruit
