Renal Replacement Therapies

Question 1

two types of renal replacement therapies

Answer 1

1. dialysis

2. transplant

Question 2

what does dialysis do?

Answer 2

removes urea, K+ and Na+ while infusing bicarbonate

Question 3

two types of dialysis

Answer 3

1. haemodialysis

2. peritoneal dialysis

Question 4

describe HD

Answer 4

solutes are dragged across a semi-permeable membrane in response to a pressure gradient (ultrafiltration)

Question 5

routine of HD

Answer 5

going to hospital for 4 hours, 3 times a week

Question 6

what does HD require?

Answer 6

vascular access

Question 7

two vascular access options for HD

Answer 7

1. fistula

2. tunnelled venous catheter

Question 8

what is a fistula in terms of HD?

Answer 8

artery and vein connected creating an enlarged vein (AVF)

Question 9

potential sites for a fistula in HD

Answer 9

radio-cephalic (RC AVF)
brachio-cephalic (BC AVF)
brachio-basilic transposition (BB AVF)

Question 10

benefits of fistula

Answer 10

less likely to cause infection

Question 11

consequences of fistula

Answer 11

requires surgery
maturation 6-12 weeks
can reduce blood flow to distal arm

Question 12

what is a tunnelled venous catheter?

Answer 12

catheter into a large vein (IJV)

Question 13

benefits of tunnelled venous catheter

Answer 13

use immediately

Question 14

risks with a tunnelled venous catheter

Answer 14

infection

blockage

Question 15

what does peritoneal dialysis use?

Answer 15

peritoneal membrane

Question 16

benefit of PD over HD

Answer 16

can be done at home

Question 17

two types of peritoneal dialysis

Answer 17

1. continuous ambulatory peritoneal dialysis (CAPD)

2. automated peritoneal dialysis (APD)

Question 18

what does CAPD use?

Answer 18

4 x 2L bag exchanges per day

Question 19

what does APD use?

Answer 19

1 bag all day and overnight machine drainage

Question 20

risks in PD

Answer 20

infection (exit site or gut bacteria)
peritoneal membrane failure
hernia (increased abdominal pressure)

Question 21

complications of dialysis

Answer 21

hypotension
haemorrhage (ruptured AVF)
arrhythmias (electrolyte imbalances)

Question 22

what is intra-dialytic hypotension?

Answer 22

myocardial stunning after removal of large volumes of H2O leading to underfilling of intravascular space and low BP

Question 23

indications that dialysis should be started

Answer 23

resistant hyperkalaemia
eGFR <7ml/min
urea >40mmol/L
unresponsive metabolic acidosis
symptomatic (itch, nausea, anorexia, fatigue, fluid overload)

Question 24

criteria for transplant recipients

Answer 24

life expectancy >5 years

be able to survive the operation

Question 25

what must be checked in the patient and donor before the transplant?

Answer 25

``` immunology e.g. tissue typing- blood group and HLA antibody screen virology cardiorespiratory peripheral vessels bladder function mental state co-morbidities ```

Question 26

additional test in donor?

Answer 26

physical fitness assessment to live with only one kidney

Question 27

describe the surgical procedure of a kidney transplant

Answer 27

extraperitoneal procedure that inserts the transplant into the iliac fossa and attaches to the external iliac's with ureter into the bladder

Question 28

three lengths of time it can take the kidney to work

Answer 28

1. immediate graft function 2. delayed graft function 3. primary non-function (never works)

Question 29

how long does delayed graft function take to work?

Answer 29

10-30 days | HD in interim

Question 30

types of transplant rejection

Answer 30

1. hyperacute 2. acute 3. chronic rejection

Question 31

what is required in hyperacute rejection?

Answer 31

nephrectomy

Question 32

what is required in acute rejection?

Answer 32

increase immunosuppression

Question 33

what is chronic rejection?

Answer 33

slow decline in function

Question 34

immunosuppressants used in transplant patients

Answer 34

basiliximab/dacluzimab (monoclonal antibodies blocking IL-2 on CD4) prednisolone tacrolimus ciclosporin (calcineurin inhibitors inhibit T cells) MMF azathioprine (anti-metabolites block purine synthesis and proliferation of lymphocytes)

Question 35

what virus is associated with early graft loss in the first 3 months?

Answer 35

CMV

Question 36

management of CMV in transplant patient

Answer 36

valganciclovir (prophylaxis) | ganciclovir (if infection)

Question 37

risks with immunosuppression

Answer 37

BK nephropathy non-melanoma skin cancer lymphoma (EBV)