Renal Replacement Therapy 1

Question 1

What are functions of the kidneys?

Answer 1

• Excretion of nitrogenous waste products
• Maintenance of acid and electrolyte balance
• Control of blood pressure
• Drug metabolism and disposal
• Activation of vitamin D
• Production of erythropoietin

Question 2

What does ESRD stand for?

Answer 2

Irreversible damage to kidneys affecting their ability to remove waste products, so to maintain life needs dialysis of kidney transplant

Question 3

What is end stage renal disease (ESRD)?

Answer 3

Irreversible damage to kidneys affecting their ability to remove waste products, so to maintain life needs dialysis of kidney transplant

Question 4

What are clinical features of advanced CKD?

Answer 4

• Until CKD stage 4 or 5 may be asymptomatic
• Syndrome of advanced CKD is called uraemia
• Uraemic symptoms can involve almost every organ system but earliest symptoms are malaise and fatigue

Question 5

What is the syndrome of advanced CKD called?

Answer 5

Uraemia

Question 6

What eGFR indicates renal replacement therapy?

Answer 6

<10ml/min

Question 7

What are some types of renal replacement therapy?

Answer 7

• Renal transplant
• Haemodialysis
  
  • Home haemodialysis
  • Satellite/hospital haemodialysis
• Peritoneal dialysis
  
  • Continuous ambulatory peritoneal dialysis (CAPD)
  • Intermittent peritoneal dialysis (IPD)
• Conservative kidney management

Question 8

What does CAPD stand for?

Answer 8

Continuous ambulatory peritoneal dialysis

Question 9

What does IPD stand for?

Answer 9

• Intermittent peritoneal dialysis (IPD)

Question 10

What is dialysis?

Answer 10

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

Question 11

What are the principles of dialysis?

Answer 11

• Diffusion
• Ultrafiltration

Question 12

What are pre-requisites for dialysis?

Answer 12

• Semipermeable membrane (artificial kidney in haemodialysis or peritoneal membrane)
• Adequate blood exposure to the membrane (extracorporeal blood in haemodialysis, mesenteric circulation in PD)
• Dialysis access (vascular in haemodialysis, peritoneal in PD)
• Anticoagulation in haemodialysis

Question 13

What are the different kinds of haemodialysis access?

Answer 13

• Permanent
  
  • Arteriovenous fistula
  • AV prosthetic graft
• Temporary
  
  • Tunnelled venous catheter
  • Temporary venous catheter

Question 14

What are some restrictions for dialysis patients?

Answer 14

• Fluid restrictions
  
  • Dictated by residual urine output
  • Interdialytic weight gain
• Dietary restriction
  
  • Potassium
  • Sodium
  • Phosphate

Question 15

What is peritoneal dialysis?

Answer 15

A balanced dialysis solution is instilled into the peritoneal cavity via a tunnelled, cuffed catheter using the peritoneal mesothelium as a dialysis membrane:

• After a dwell time the fluid is drained out and fresh dialysate is instilled

Question 16

What are different kinds of peritoneal dialysis?

Answer 16

• Continuous ambulatory peritoneal dialysis (CAPD)
• Automated peritoneal dialysis (APD)
• Hybrid

Question 17

In peritoneal dialysis, what does the dialysate contain?

Answer 17

Balanced concentration of electrolytes

Question 18

In peritoneal dialysis, what is the most important agent for ultrafiltration of fluid?

Answer 18

Glucose

Question 19

How can peritoneal transport characteristics very?

Answer 19

Peritoneal transport characteristics can vary from high transporter to low transporter:

• Dwell times can be adjusted according to transport characteristics

Question 20

What are some complications of peritoneal dialysis?

Answer 20

• Exit site infection
• PD peritonitis
  
  • Gram position – skin contaminant
  • Gram negative – bowel origin
  • Mixed – suspect complicated peritonitis such as perforation
• Ultrafiltration failure
• Encapsulating peritoneal sclerosis

Question 21

What are some indications for dialysis in ESRD?

Answer 21

• Advanced uraemia (GFR 5-10ml/min)
• Severe acidosis (bicarbonate <10mmol/L)
• Treatment resistant hyperkalaemia (K>6.5mmol/L)
• Treatment resistant fluid overload

Question 22

What are the fluid restrictions in haemodialysis?

Answer 22

• Usually restricted to 500-800ml/24 hours intake allowed which is equal to urine output and insensible loss

Question 23

What are the fluid restrictions in peritoneal dialysis?

Answer 23

• Usually more liberal intake as continuous ultrafiltration if often achieved

Question 24

What are some dialysis related drugs?

Answer 24

• Anaemia
  
  • Erythropoietin injections
  • IV iron supplements
• Renal bone disease
  
  • Activated vitamin D (eg calcitriol)
  • Phosphate binder with meals (CaCo₃)
• Heparin
• Water soluble vitamins

Question 25

What are some complications of haemodialysis?

Answer 25

Cardiovascular problems:

• Intra-dialytic hypotension and cramps
• Arrhythmias

Coagulation:

• Clotting of vascular access
• Heparin related problems

Other:

• Allergic reactions to dialysers and tubing
• Catastrophic dialysis accidents (rare)

Question 26

What are some complications of peritoneal dialysis?

Answer 26

Infection:

• Exit site infection
• Tunnel infection
• Peritonitis

Mechanical:

• Tube malfunction
• Abdominal wall herniae

Ultrafiltration problems

Question 27

How is the kind of dialysis choosed?

Answer 27

Patients choice:

• Education
• Shared decision making

Perceptions of effectiveness and cost

Question 28

How is conservative kidney management given for ESRF instead of dialysis?

Answer 28

• Supportive care
  
  • Priority for symptomatic management
  • Holistic multi-professional approach
  • Anticipatory care planning