Dialysis + Renal Transplant

Question 1

What are the indications for acute dialysis?

Answer 1

Severe AKI –> AEIOU:

• Acidosis (no responding to treatment)
• Electrolytes (severe + unresponsive hyperkalaemia)
• Intoxication (certain overdoses)
• Oedema (severe + unresponsive pulmonary oedema)
• Uraemia symptoms e.g. seizures or reduced consciousness

Question 2

What are the indications for long term dialysis?

Answer 2

End stage renal failure
–> CKD stage 5 (eGFR <15)
Any acute indications continuing long term

Question 3

What are the three main options for long term dialysis?

Answer 3

Continuous Ambulatory Peritoneal Dialysis
Automated Peritoneal Dialysis
Haemodialysis

Question 4

How does peritoneal dialysis work?

Answer 4

Dialysis solution containing dextrose is added to peritoneal cavity via a Tenckhoff catheter
Ultrafiltration occurs across peritoneal membrane

Question 5

What are the complications of peritoneal dialysis?

Answer 5

Bacterial peritonitis (glucose in solution - great place for bacteria)
Peritoneal sclerosis (scarring of membrane)
Ultrafiltration failure (starts to absorb the dextrose reducing gradient)
Weight gain (dextrose)
Psychological effects

Question 6

What are the options for access in haemodialysis?

Answer 6

Tunnelled cuffed catheter

Arterio-venous fistula

Question 7

What is a tunnelled cuffed catheter?

Answer 7

Tube inserted into subclavian or jugular vein with a tip that sits in SVC or RA
Two lumens - one where blood exits and one where blood enters
‘Dacron cuff’ surrounds catheter to promote healing, making it more permanent

Question 8

Where is an AV fistula usually formed?

Answer 8

Forearm:

• radio-cephalic
• brachio-cephalic
• brachio-basilic (less common)

Question 9

How long after an AV fistula is formed can it be used?

Answer 9

4 weeks to 4 months

Question 10

What should you look for on examination of an AV fistula?

Answer 10

Skin integrity
Aneurysms
Palpable thrill (fine vibration)
Machinery murmur on auscultation

Question 11

What are the complications associated with an AV fistula?

Answer 11

Aneurysm
Infection
Thrombosis
Stenosis
STEAL syndrome
High output heart failure

Question 12

What is STEAL syndrome?

Answer 12

Inadequate blood flow to the limb distal to the AV fistula –> distal ischaemia

Question 13

Why does an AV fistula cause high output cardiac failure?

Answer 13

Rapid return of blood to the heart as it flows quickly from arterial to venous via the fistula
–> increased preload –> hypertrophy and HF

Question 14

How are patients matched to donor kidneys for transplant?

Answer 14

HLA types
(don't have to be a complete match but increases the risk of rejection)

Question 15

How can you tell on examination that a patient has had a kidney transplant?

Answer 15

Can usually be palpated in the iliac fossa area

‘hockey stick’ scar

Question 16

How is the risk of transplant rejection reduced?

Answer 16

Life long immunosuppression:

- tacrolimus, mycophenolate + prednisolone

Question 17

What are the complications of renal transplant?

Answer 17

Rejection (hyperacute, acute + chronic)
Transplant failure
Electrolyte imbalances
Complications of Immunosuppression

Question 18

Which immunosuppression complications might be seen in transplant patients?

Answer 18

Ischaemic heart disease
Type 2 diabetes (steroids)
Infections more likely + more severe
Unusual infection (PCP, CMV, PJP, TB)
Non-hodgkins lymphoma
Skin cancer, esp SCC