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Renal/Urology > Lecture 16 - Renal Replacement Therapy > Flashcards

Lecture 16 - Renal Replacement Therapy Flashcards

1
Q

Define end stage renal disease

A

Irreversible damage to a person’s kidneys so severely affecting their ability to remove/adjust blood wastes that, to maintain life, they must have dialysis or a transplant

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2
Q

Until what CKD stage can the patient remain asymptomatic?

A

4 or 5

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3
Q

What is the syndrome of advanced CKD called?

A

Uraemia

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4
Q

What are the two earliest and most common uraemic symptoms?

A

Malaise, fatigue

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5
Q

Define renal replacement therapy

A

Means by which life is sustained in patients suffering from ESRD

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6
Q

At what eGFR is RRT usually indicated?

A

<10ml/min

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7
Q

List the types of RRT

A

Renal transplant
Haemodialysis (home vs hospital)
Peritoneal dialysis (CAPD vs IPD)
Conservative kidney management

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8
Q

What does conservative kidney management involve?

A

Not starting dialysis or having a transplant but treating symptoms of uraemia with medication

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9
Q

Define dialysis

A

Process whereby the solute composition of a solution, A is altered by exposing solution A to a second solution, B, through a semipermeable membrane

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10
Q

What are the two main principles of dialysis?

A

Diffusion

Ultrafiltration

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11
Q

What is ultrafiltration?

A

A type of membrane filtration in which hydrostatic pressure forces a liquid against a semi permeable membrane

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12
Q

What are the 4 pre-requisites for dialysis?

A

Semipermeable membrane
Adequate blood exposure to the membrane
Dialysis access
Anticoagulation (just for haemodialysis)

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13
Q

What acts as a semipermeable membrane in haemodialysis?

A

Artificial kidney (dialysier)

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14
Q

What acts as a semipermeable membrane in peritoneal dialysis?

A

Peritoneal membrane

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15
Q

What blood is dialysed in haemodialysis?

A

Extracorpeal blood

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16
Q

What blood is dialysed in peritoneal dialysis?

A

Mesenteric circulation

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17
Q

What is the dialysis access in haemodialysis?

A

Vascular

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18
Q

What is the dialysis access in peritoneal dialysis?

A

Peritoneal

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19
Q

What are the two types of permanent haemodialysis access?

A

AV fistula

AV prosthetic graft

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20
Q

What are two types of temporary haemodialysis access?

A

Tunneled venous catheter

Temporary venous catheter

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21
Q

Describe how haemodialysis works

A

Create a dialysate of a composition such that you draw out from the blood exactly what you want to
Blood enters one end and the dialysate moves in the opposite direction to the blood coming in

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22
Q

What are the fluid restrictions for dialysis patients dependent on?

A

Residual urine output

Interdialytic weight gain

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23
Q

Foods high in which three ions should be avoided by dialysis patients?

A

Potassium
Sodium
Phosphate

(As these are the things that accumulate in ESRD)

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24
Q

Why must dialysis patients fluid restrict?

A

Because they fluid overload due to their ESRD, and this can be taken off during dialysis but it is not good for the heart to remove large volumes of fluid quickly

25
Q

How long does haemodialysis tend to last?

A

4 hours

26
Q

How often must patients get haemodialysis?

A

Usually 3x per wee

27
Q

What happens in peritoneal dialysis?

A

Balanced dialysis solution instilled into peritoneal cavity via tunneled, cuffed catheter, using peritoneal mesothelium as a dialysis membrane
After a dwell time, fluid is drained and fresh dialysate instilled

28
Q

What are the two types of peritoneal dialysis?

A

Continuous ambulatory PD (CAPD)

Automated PD

29
Q

What is the most common osmotic agent used for the ultrafiltration of fluid in PD?

A

Glucose

30
Q

Dwell times in PD need to be adjusted to what?

A

Transporter characteristics

31
Q

Describe how CAPD is carried out

A

Usually done 4x a day with none during the night

32
Q

Describe how APD is carried out

A

Machine that does instills fluid and drains it for you during the night

33
Q

What are possible complications of PD?

A 
Exit site infection/Tunnel infection 
PD peritonitis 
Ultrafiltration failure
Tube malfunction (e.g. catheter blockage)
Abdominal wall herniae
Encapsulating peritoneal sclerosis
Fluid retention 
Hyperglycaemia
Back pain 
Constipation 
Malnutrition
34
Q

What is a gram +ve PD peritonitis usually due to?

A

Skin contaminant

35
Q

What is a gram -ve PD peritonitis usually due to?

A

Bowel organisms

36
Q

What is a mixed PD peritonitis usually due to?

A

Suspect complication, e.g. peritonitis

37
Q

Is the fluid coming out from PD is cloudy what does this mean?

A

It is infected, i.e. patient may have PD related peritonitis

38
Q

What are indications for dialysis in ESRD?

A 
Advanced uraemia (eGFR 5-10ml/min)
Severe acidosis (bicarb <10mmol/l)
Transient resistant hyperkalaemia (K>6.5mmol/l)
Treatment resistant overload
Clinical judgement
39
Q

What is the usual restriction on fluid intake in dialysis patients?

A

Haemodialysis - 500-800ml/24h (urine output + insensible losses)
Peritoneal dialysis - usually more liberal as continuous ultrafiltration achieved

40
Q

What drugs may those on dialysis need?

A 
EPO injections/IV iron (anaemia)
Activated vit D (e.g. calcitriol), phosphate binders with meals (CaCo3) (renal bone disease) 
Heparin 
Water soluble vitamins
Antihypertensives?
41
Q

What are complications of haemodialysis?

A

CV - intra-dialytic hypotension and cramps, arrhythmia, endocarditis, air embolus
Coagulation - clotting of vascular access, heparin related problems
Other - allergic reactions to dialysers/tubing
Catastrophic accidents rare

42
Q

What are important factors in choosing a modality of dialysis?

A

Patient choice (education, shared decision making)
Patient related factors
Perception of effectiveness

43
Q

What is involved in conservative kidney management?

A

Supportive care - manage symptoms, MDT approach, anticipatory care planning

44
Q

What is the incidence of CKD?

A

1 in 8 (UK)

45
Q

What % of those with CKD go on to develop renal failure?

A

10%

46
Q

Define renal failure

A

GFR <15ml/min

47
Q

The decision about which RRT option to pick should be made jointly by the patient and healthcare team taking into account what?

A

Predicted QoL
Predicted LE
Patient preference
Co-existing medical conditions

48
Q

How long before haemodialysis begins should the patient get surgery to create the AV fistula?

A

8 weeks

49
Q

Where is the most common site for an AV fistula?

A

Lower arm

50
Q

How long does the exchange and dwell time in CAPD last?

A

Exchange - 30-40 min

Dwell - 4-8h

51
Q

In APD how many exchanges tend to occur over how long?

A

3-5 exchanges over 8-10h

52
Q

What is the average wait time for a kidney transplant?

A

3 years

53
Q

Describe what happens in a renal transplant

A

Donor kidney inserted into groin with renal vessels connected to external iliacs
Failing kidneys not removed!

54
Q

What must patients take life-long after a renal transplant?

A

Immunosupressants to prevent transplant rejection

55
Q

What is the average lifespan of a donor kidney?

A

10-12 years from deceased donors

12-15 years from living donors

56
Q

How long is the average life expectancy of a patient with ESRD that does not recieve RRT?

A

6 months

57
Q

What are symptoms of renal failure that is not being adequately managed with RRT?

A 
Breathlessness
Fatigue
Insomnia
Pruritus
Poor appetite
Swelling
Weakness
Weight gain/loss
Ab cramps
Nausea
Muscle cramps
Headaches
Cognitive impairment
Anxiety
Depression 
Sexual dysfunction
58
Q

What are complications of renal transplant?

A 
DVT/PE
Opportunistic infection 
Malignancies - esp. skin cancer, lymphoma
Bone marrow suppression 
Recurrence of original disease
Urinary tract obstruction 
CV disease
Graft rejection
59
Q

What is the most common causative organism for PD related peritonitis

A

Coagulase negative staph, e.g. staph epidermis

Renal/Urology (29 decks)

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