Dialysis and Renal Transplantation Flashcards by S B

what is the purpose of dialysis

removes toxins

urea
potassium
sodium

infusion of bicarbonate

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how much dialysis does a patient need a week

4 hours

3 days a week

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what are the restrictions put on patients on dialysis

Fluid
If anuric 1litre per day (including food based fluid)

Salt
Low salt diet to reduce thirst and help with fluid balance

Potassium
Low potassium diet.

Phosphate
Low phosphate diet
Phosphate binders with meals (6-12 pills per day)

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what is the gold standard for dialysis access

fistula

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what is a fistula

Joins an artery and a vein to make an enlarged thick walled vein called an Areteriovenous Fistula

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what are the pros of a fistula

Good blood flow

Unlikely to cause infection

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what are the cons of fistulas

Requires surgery
Requires maturation of about 6 weeks before can be used
Can limit blood flow to distal arm “steal”
Can block

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what can be used instead of a fistula and what is it

Tunneled Venous Catheter

A catheter inserted into a large vein- Jugular, subclavian or femoral

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what are pros of Tunnelled Venous Catheter

Easy to insert (usually)

Can be used immediately

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what are the cons of tunnelled venous catheter

High risk of infection
Can cause damage to veins making placing replacements difficult
Become blocked

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what can happen is a tunnelled venous catheter becomes infected

Endocarditis
Discitis
Death

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Ix for tunnelled venous catheter infection

Blood Cultures
FBC and CRP
Exit site swab

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Tx for tunnelled venous catheter infection

Antibiotics
- Vancomycin

Line removal or exchange

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what are possible complications of dialysis

Fluid overload
Blood leaks
Loss of vascular access
Hypokalaemia and cardiac arrest

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how does peritoneal dialysis work

Solute removal by diffusion of solutes across the peritoneal membrane.

Water removal by osmosis (water moving to equalise a concentration gradient) driven by high glucose concentration in dialysate fluid.

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what are the two types of peritoneal dialysis

CAPD - Continous peritoneal dialysis

APD - automated peritoneal dialysis

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what are possible complications in peritoneal dialysis

infection
- peritonitis or exit site infection

membrane failure
hernias

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what bugs can cause infection in peritoneal dialysis

Staphylococci
Streptococci
Diptheroids
E. Coli
Klebseilla

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Tx for peritoneal dialysis infection

Culture PD Fluid

Intraperitoneal Antibiotics

what happens in membrane failure

Inability to remove enough water so become fluid overloaded

Requires switch to Haemodialysis

what causes hernias in peritoneal dialysis

Increased intraabdominal pressure

Requires hernia repair and smaller fill volumes

what are metabolic complications seen in ESKD

Bone Mineral Metabolism

Phosphate retention
Low 1-25 Vit D
Hypocalcaemia
Raised PTH&raquo_space; takes calcium away from the bones. Osteomalacia

what are metabolic complications seen in ESKD

Anaemia

Epo deficiency

Iron deficiency

other complications seen in ESKD

Sodium and water retention

Accelerated CV disease

what are the two ways to decide when to start dialysis

start based on bloods | start based on symptoms

what is the criteria for starting dialysis based on bloods

Resistant Hyperkalaemia GFR 45 Unresponsive acidosis

what is the criteria for starting dialysis based on symptoms

``` Fatigue Itch Unresponsive fluid overload Nausea Vomiting Loss of appetite ```

what blood group is compatible for all blood groups of recipients

what are HLA and what do they do

cell surface proteins expressed on cells | activate the immune system

what are the 3 important types of HLA in transplant

HLA A HLA B HLA DR

why is HLA important

Donor Specific HLA Antibodies (Ab) - A patient may have been exposed to a HLA Ag previously and formed Ab to this. >> This leads to rejection

what are the different forms of transplant rejection

Hyperacute Acute Chronic

what happens in hyper acute rejection

Due to +ve Xmatch (preformed antibodies to the Tx) Unsalvageable Remove kidney

what happens in acute rejection

Usually early T cell or B cell mediated response Can be treated with increased immunosupression

what happens in chronic rejection

Immunological and vascular deterioration of the Tx

what are Calcineurin Inhibitors

immune suppressors

how do Calcineurin Inhibitors work

Act by inhibiting activation of T helper cells Reduce NK cells activation Reduce Cytotoxic T cell activation Decrease cytokine release so prevent B cell proliferation and antibody production

side effects of Calcineurin Inhibitors

Renal Dysfunction, Hypertension, Diabetes, Tremors

how do Azathioprine and Mycophenolate work

Antimetabolites by blocking purine synthesis | Leads to suppression of proliferation of lymphocytes and B cells

what are side effects of azathioprine

Leucopaenia, Anaemia, GI side effects

what should never be given along side azathioprine

Allopurinol

how do steroids work

Act non selectively to suppress activity of T cells and proliferation of B cells.

what are indicates for suitability for transplantation

Patient should have reasonable life expectancy ( >5 years) | Well enough for an operation

contraindications for surgery

Malignancy - current or previous within in 2 years ``` Untreated TB Severe IHD Severe airway disease Acute vasculitis Severe PVD ```

what is the surgery for renal transplant

Extraperitoneal procedure | - Stent inserted between ureter and bladder

what are possible surgical complications

``` Bleeding (arterial or venous) Arterial Stenosis / Thrombosis Venous stenosis / Thrombosis Ureteric Stricture and hydronephrosis Wound infection ```

what drugs can cause a graft to be lost

Cyclosporine/ Tacrolimus toxicity