Dialysis and Transplant

Question 1

4 Causes of ESRD

Answer 1

• DM
• HTN
• Glomerulonephritis
• Cystic Kidney Disease

Question 2

5 Indications for Dialysis

Answer 2

• A - acidosis
• E - electrolyte abnormalities (esp if EKG changes)
• I - intoxications w/ water soluble drugs
• O - overload (salt and water retention)
  
  • If refractory to diuretics and cardiac drugs
  • If causing CHF, pulmonary edema, HTN
• U- uremia symptoms (pericarditis, intractable nausea, vomiting, anorexia, uremic bleeding)

Question 3

3 Types of Vascular Access (timing?)

Answer 3

• Create A/V fistula (connect artery to vein so vein becomes high pressure and arteralizes - inc diameter and wall thickness); takes 6-8 wks to mature but do 6-12 mo in advance
• AV Graft (synthetic w/ PTFE); take 2-3 wks to endothelialize; risk of clot, infection and short half-life
• Catheter if need immediate dialysis (usually IJ vein)
  
  • If 3+ wks, use tunneled dialysis catheter to reduce infection risk

Question 4

Ultrafiltration in Hemodialysis v. Peritoneal Dialysis

Answer 4

Hemo- inc resistance to blood flow as it leaves dialyzer –> inc hydrostatic P –> inc filtration of water then solvent drag - small molecules follow water

Peritoneal -enhance by glucose in injection - works as oncotic driver to force water across peritoneal membrane into peritoneal cavity

Question 5

Adv and Disadv of Hemodialysis

Answer 5

• Adv = Most efficient
• Disadv
  • Thrombosis
  • Infection
  • Steal syndrome - dec blood flow distal to A/V fistula –> gangrene, pain, ischemia
  • Cardiac overload from A/V fistula
  • Acute complications- hypotension, cramps from dec Na or hypotension, nausea/vomiting (esp 1st times)

Question 6

Adv and Disadv of Peritoneal Dialysis

Answer 6

• Adv
  
  • Fewer cardiac effects
  • Done at home and easier for travel
  • Diet is more liberal
  • Cont rather than daily so less disequilibrium problems
  • Can admin meds in the peritoneal dialysis solution (insulin or abx)
• Disadv
  
  • Acute peritonitis will lead to faster clearance
  • Chronic peritonitis –> scars –> slower clearance
  • Hard to do on own (intellect)/ burn out
  • INFECTION
  • Not as effective as hemodialysis
  • Cannot use if peritoneal fibrosis or adhesions; cannot use for 1 wk after ab surgery
  • Complications - kinks in catheter, constipation can occlude it catheter, fibrin occlusion of catheter, peritoneal -pleural leak –> pleural effusion OR subQ leaks

Question 7

Calcineurin Inhibitors

Answer 7

cyclosporine and tacrolimus

• block IL-2 release from T cells to prevent T cell proliferation

Question 8

Azathioprine

Answer 8

• inhibits DNA/RNA synthesis to dec lymphocyte prod

Question 9

Mycophenolate

Answer 9

• inhibit IMPDH to dec B and T lymphocyte prod (purine metabolic pathway)

Question 10

Sirolimus

Answer 10

• inhibit T lymphocyte activation by suppressing IL-2 and IL-4

Question 11

Belatacept

Answer 11

• co-stimulatory blockade