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REN > Dialysis And Transplantation > Flashcards

Dialysis And Transplantation Flashcards

1
Q

When is dialysis and transplant needed

A

When the kidney can no longer maintain homeostasis of fluids, electrolytes, and acid/base balance and cannot excrete metabolic wastes or synthesise the normal renal hormones as in stage 5 CKD
That treatment it is a terminal illnessq

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2
Q

What functions can dialysis replace

What can dialysis not replace

A

Homeostatic function
But cannot control BP, cannot replace EPO and cannot replace vitamin d synthesis endocrine function need to be replaced separately

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3
Q

What functions can transplant replace

A

All kidney functions

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4
Q

What are the 2 main forms of dialysis

A

Peritoneal

Haemodialysis

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5
Q

What type of therapy is dialysis and what does it do

A

It is an extra corporeal therapy where fluid and solutes are removed from or added to the patients blood
It is able to achieve a GFR of <15ml/min compare to 125ml/min normally it is still able to maintain life

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6
Q

What does peritoneal dialysis use

A

Uses the body’s own peritoneal membrane
- capillary endothelium, interstitium and peritoneal mesothelioma
It acts as a semi permeable membrane to separate the patients blood from the dialysis fluid

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7
Q

What is in the dialysis fluid

A

Dextrose, some electrolytes and HCO3 buffer

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8
Q

What accumulates in the patients blood

A

Water, urea, hydrogen ions, electrolytes - sodium and potassium

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9
Q

How is water removed

A

By osmosis created by the dextrose in the dialysis solution

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10
Q

How are the solutes in the blood removed

A

Diffusion and ultrafiltration

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11
Q

Why is there HCO3 is the dialysis solution

A

Because H+ cannot cross into the dialysis fluid from the blood so HCO3- in the dialysis solution passes into the blood to buffer the decrease pH

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12
Q

Advantages of peritoneal dialysis

A

Continuous therapy that can be carried out in the community

More convenient than haemodialysis

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13
Q

What are the types of peritoneal dialysis are there

A

Can be done continuously through the day - CAPD continuous ambulatory peritoneal dialysis where 2.5l batches over 4-6hrs
Or over night - APD automated peritoneal dialysis with a machine which drains and refills the peritoneal cavity

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14
Q

What happens in hadmodialysis

A

The patients blood is removed and introduced to an artificial membrane - hollow microfibres material which acts as the semipermeable membrane to separate the blood and dialysis fluid.
Machine is called the dialyser
Blood and fluid flow in opposite directions this counter current ensures the concentrations gradients between the blood and fluid are maintained

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15
Q

What happens at the machine

A

Blood is removed from an artery
Access the artery through a Tesio line or an arterial-venous fistula
Blood is then pumped through a blood pump and heparin pump to prevent clotting into the dialyser
Passes through an air trap and air detector before being returned to the body by the venous system
Blood pressure through the machine is continually measured

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16
Q

What are the solute concentrations of the dialysis solution

A

They are either above or below normal depending on which way the excess or lack of a solute needs to move towards normal

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17
Q

How are water and solutes removed from the blood

A

Ultrafiltration pressure gradient is applied - diffusion does not happen because flow is too fast

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18
Q

What happens with the H+ ions

A

Too low in serum concentrations
Acid load cannot be removed by dialysis alone so alkali is therefore added to the patient from the dialysis solution as the concentration of alkali in solution is greater than the plasma

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19
Q

When is haemodialysis done

A

Hospital outpatient clinics

4 hour intervals 3x a week

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20
Q

What are the limitations to dialysis

A

GFR achieved is low, dietary restrictions if fluids and electrolytes in necessary, EPO and vit D are not replaced and blood pressure control is necessary, as well as this 20% of patients on dialysis will die each year this is generally due to infection or CVD

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21
Q

Why does CVD risk increase with CKD

A

Due to left ventricular hypertrophy in response to anaemia, hypertension, and fluid overload
And calcification of arteries
And lipid abnormalities

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22
Q

What is there are high risk if in both types of dialysis

A

Infection

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23
Q

Risk if in peritoneal dialysis concerned with the entry site

A

Lots of scarring
Adhesion to the peritoneal wall
The Port can become dislodged and meaning that dialysis cannot take place
The port. is inserted under local anaesthetic or general anaesthetic

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24
Q

What is the risk to diabetic patients of the dialysis fluid

A

High amount of dextrose can be dangerous

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25
Q

What does kidney transplantation involve

A

Transfer of a functional organ from donor to recipient

This can be a living match donor or a dead donor

26
Q

What must the donor have for the organ to be viable

A

Cardiovascular system so the kidney is viable and being perfused upon removal

27
Q

What happens in the surgery

A

Diseases kidneys are left in place
And the kidney is put in the iliac fossa and connected the the iliac vessels this is due to the difficulty in retroperitoneal surgery

28
Q

Which iliac fossa is the kidney node susceptible to trauma

A

Left

29
Q

transplant -Is it better or worse outcome and survival than dialysis

A

Better

30
Q

Why is transplant not the treatment of choice for end stage renal failure

A

Organ shortage

31
Q

What is at higher risk with people with transplants

A

CVD
Cancer risks due to immune Suppression
Infection risk due to immune suppression

32
Q

Who should transplantation be discussed with

A

Every patient and absolute contra indications need to be ruled out in this process age is not
It is associated with higher comorbidity and higher risk

33
Q

What is an absolute contraindications for organ transplant

A

High peri-operative mortality, poor life expectancy and active malignancy

34
Q

What are relative contraindications

A

Coronary or CVD
Recurrent diseases
And non compliance

35
Q

What re the main majority of kidney donors

A

Cadaveric, brainstem dead or no heart beating
Non heart beating donors must be recovered within 30 mins to make sure it is still viable

Living donors becoming more common

36
Q

What is one of the greatest risks associated with kidney transplantation

A

Organ rejection

37
Q

What drives rejection

A

Allogenic response immune system recognises graft as non self

38
Q

What is the kidney called when it is not the same as the recipient

A

Positive cross match

39
Q

What happens when a positive cross match kidney is reperfused

A

Rapid hyperacute rejection
The recipients natural ABO antiobodies will bind to the blood group antigens present on the vascular endothelium of the donor
This ab binding leads to compliment activation and MAC mediated cell lysis and intravascular thrombosis this means the donor kidney loses blood supply and dies

40
Q

What must happen between donor and recipient kidneys

A

Must be matched

41
Q

What types of match must happen

A

Species match
Blood group match
Better outcome in MHC 1 and 2 are matched

42
Q

What happens in the screening process

A

Anti MHC ab are screened by testing the recipients reactivity with a panel of normal cells
If there is a high percentage reaction it shows that the patient has lots of ab against the MHC type

43
Q

Can rejection still occur if all 6 types of MHC are fine

A

Yes

As it is still not identical

44
Q

What are transplant patients given

A

Immunosuppression

45
Q

Can immunosuppressed patients still reject kidney

A

Yes

30-40% are still rejected

46
Q

What is acute allograft rejection

How is it recognised

A

Cell mediated or ab mediated and is characterised by the infiltration of activated lymphocytes into the graft
Rise in creatinine as graft function fails
Diagnosis through biopsy

47
Q

When does ad mediated rejection occur

A

When the recipient have pre existing MHC antiobodies which haven’t been picked up
These can exist due to prior pregnancy, transplantation or blood transfusion

48
Q

When does cell mediated rejection occur

A

When cellular debris From the donor remains in the graft and is picked up by dendritic cells or when there are some dendritic cells still in the graft
dendritic cells then travel to the lymph nodes and activate T cells
Macrophages, B cells and T cells will respond

49
Q

What are targets of immunosuppression

A

Inhibit calcineurin preventing signalling through the TCR - tacromlimus
Corticosteroids inhibit APCs and stop the transcription and action of il2 on the T cell
Anti IL-2 receptor ab CD25 ab also block IL2 action
Drugs like azathioprine inhibit the cell cycle and stop T cell proliferation

50
Q

Problem with immunosuppression due to the non specific response of these drugs

A

Inc likelihood of infection, cancer,

Effects of steroids - hypertension, diabetes, lipid abnormalities, osteoporosis, and weight gain

51
Q

What are semipermeable membrane’s

A 
They are permeable to some sort of use but not all
Permeability is determined by
The size and charge of the solute 
The size of the pore
Charge of the membrane
52
Q

What is diffusion

A

random movement of ions & molecules

equilibrate ions or molecules equally on the different sides of the semipermeable membrane

53
Q

What is osmosis

A

It is the movement of water particles from low to high osmolality

54
Q

What is ultrafiltration

A

It is direct force/hydrostatic pressure to one side it increases the volume on one side but the mass affect of water and potassium ions there is no overall change in concentration

55
Q

Patient prep for dialysis

A

Patients with progressive see KD in stage four and five are identified early
receive counselling regarding Dialysis, transplant, Conservative supportive care
patient decision is needed
Early establishment of an AV fistula is needed
HBV vaccination is needed for non-immune patients
Central venous catheter for patients requiring haemodialysis without and AV fistula

56
Q

When to start dialysis in CKD

A

When the EGFR is below 10
It depends on the symptoms on the control of fluid volume
Should be before the patient becomes very ill
And you need dialysis access beforehand

57
Q

Went to start dialysis in AKI

A

Usually creatinines of above 500
I oligo or annually
They have uraemia have a pericarditis encephalitis
AKI cannot be controlled medically and the hyperkalaemia pulmonary oedema metabolic acidosis cannot be controlled
This is emergency dialysis
need access usually buy a central venous catheter

58
Q

What fluid and diet restrictions are necessary in dialysis

A

Need to continue the restriction imposed before
Potassium sodium phosphate and water restriction
Dialysis treatment does not restore clearance back to normal

59
Q

Problems with dialysis

A

20% of patients on dialysis die each year
Due to
infection
cardiac disease
Left ventricular hypertension due to hypertension and anaemia and fluid overload
Calcification of arteries and lipid abnormalities
Anaemia
Bone disease
Malnutrition

60
Q

How has survival on dialysis changed

A

Survival has increased over the last 10 years
Life expectancy is around 5-6 years
It’s worse if a higher age when you start on dialysis
Underlying kidney disease predict survival
From worst to best survival
Diabetes
Hypertension
Glomerulal nephritis
PKD

61
Q

What is an AV fistula

A

It is the surgical connection of an artery and vein
Diversion of arterial blood into the veins therefore the vein becomes more muscularised
Requires a small operation usually under local anaesthetic and need six weeks for healing

REN (8 decks)

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