Kidney Replacement Therapy

Question 1

What are the indications for kidney replacement therapy?

Answer 1

1. Medically resistant hyperkalaemia.
2. Medically resistant pulmonary oedema.
3. Medically resistant acidosis.
4. Uraemic pericarditis.
5. Uraemic encephalopathy.
   These can either be acute or chronic

Question 2

What are the symptoms of uraemia?

Answer 2

• Anorexia,
• Itch,
• Vomiting,
• Restless legs,
• Weight loss,
• Metalic taste

Question 3

What level of GFR indicates KRT?

Answer 3

No absolute rule and is assessed on individual patient basis.
Generally an eGFR of 5-10ml/min

Question 4

What are the different types of kidney replacement therapy?

Answer 4

• Haemodialysis,
• Peritoneal dialysis (CAPD or APD)
• Renal transplant

Question 5

What are the factors to consider when choosing type of kidney replacement therapy?

Answer 5

• Lifestyle,
• Frailty,
• Vascular access,
• Time (to travel to and from hospital)
• Carers,
• Concurrent medical problems

Question 6

What are the principles of haemodialysis?

Answer 6

• Aims to remove solutes (potassium and urea) via diffusion and removal of fluid ultrafiltration via hydrostatic filtration.
• Access to blood via a TCVC (tunnelled central venous catheter) or AVF access (AVF is gold standard but requires good veins to create fistula or graft)

Question 7

What are the practicalities of haemodialysis?

Answer 7

• Mainly a hospital based treatment which requires patients to normally come in for 4h, 3x a week. (However can have other options)
• Home treatment can be an option but this requires training

Question 8

What are some complications of haemodialysis

Answer 8

• Acute hypotension (crash)
• Access problems,
• Cramps
• Fatigue,
• Hypokalaemia,
• Blood loss,
• Dialysis disequilibrium,
• Air emboli

Question 9

Explain the principles of peritoneal dialysis

Answer 9

• Fluid is delivered into the peritoneal cavity which has a varying level of glucose. The electrolytes and water then diffuse out of the peritoneal capillaries into the peritoneal fluid. The fluid is the drained from the cavity.
• It is a home based therapy which works better when patients have some residual renal function. The different glucose levels allow for more/less ultrafiltration. Gradual treatment so not used in AKI

Question 10

What are the complications of peritoneal dialysis

Answer 10

• Infection (peritonitis),
• Glucose load may result in development or worsening of diabetes.
• Mechanical issues (hernia)
• Peritoneal membrane failure,
• Hypoalbuminemia,
• Encapsulating peritoneal sclerosis
• Not suitable in grossly obese or frail pts, or in intra-abdominal adhesions

Question 11

What issues of kidney disease are not solved by dialysis?

Answer 11

• Anaemia (thus pt requires erythropoiesis stimulating agent and iron)
• Renal bone disease (pt needs vitamin D and phosphate binder)
• Neuropathy,
• Endocrine disturbances,
• Parathyroid
• Dialysis only gives around 10ml/min so not as good as transplant! and it doesn’t fix hormonal issues

Question 12

What are the pros and cons of renal transplantation

Answer 12

Pros - no dialysis, much better level of renal function, live independantly, better life expectancy and better fertility.
Cons - Immunosuppressive medication, increased CV risk, increased infection risk, post transplant diabetes, skin malignancies

Question 13

Describe features of conservative care in chronic kidney disease

Answer 13

• It is increasingly used in frail/elderly population and focuses on symptoms management.
• Sometimes the survival rate can be as good as with dialysis