Renal Replacement Therapy Flashcards
The kidneys play a role in the activation of which vitamin?
Vitamin D
What do the kidneys produce which helps to maintain haemoglobin?
Erythropoietin
Is end-stage kidney disease reversible?
No
At what stages of CKD may the patient become symptomatic?
Usually asymptomatic until around stage 4/5
What is the name of the syndrome of advanced CKD?
Uraemia
What are the two types of renal replacement therapy?
Dialysis
Kidney transplant
At what eGFR is renal replacement therapy usually indicated at?
eGFR <10m/lmin
What are the two types of dialysis?
Haemodialysis
Peritoneal dialysis
Which type of renal replacement therapy has the best outcomes in terms of mortality and morbidity?
Renal transplant
Which type of dialysis can be done at home?
Haemodialysis
If a patient is on haemodialysis and comes to the hospital/satellite unit for their treatment rather than doing it at home, how many times per week do they go in?
Three times per week
What are the two types of peritoneal dialysis?
Continuous ambulatory peritoneal dialysis (CAPD)
Intermittent peritoneal dialysis (IPD)
What is dialysis?
Process whereby the solute composition of solution A is altered by exposing solution A to a second solution, B, through a semipermeable membrane
What are the two principles of dialysis?
Diffusion
Ultrafiltration
->dialysis may involve both or one or the other
List the things required for dialysis to occur.
- Semi-permeable membrane
- Adequate blood exposure to the membrane
- Dialysis access
- Anticoagulation in haemodialysis
Name two permanent ways for haemodialysis access.
Arteriovenous fistula
AV prosthetic graft
Name two temporary ways for haemodialysis access.
Tunnelled venous catheter
Temporary venous catheter
Which electrolytes don’t get changed about too much in dialysis?
Sodium and calcium
->potassium gets moved slightly
Which two components are not present in the dialysate (dialysis solution) and need to be shifted over from the blood?
Creatinine and urea
What is there a lot of in the dialysate which moves over to the blood?
Bicarbonate
->this is because the blood of patient’s on dialysis can go acidic after dialysis for a bit
What are some of the restrictions for dialysis patients?
Fluid restriction
Diet restriction
What is restricted in the diet of dialysis patients?
Potassium
Sodium
Phosphate
How much fluid can be removed from a patient during dialysis before they start to become unwell due to low BP?
2.5-3L
Where is the catheter for a patient on haemodialysis?
AV fistula or graft in the arm
Neck
Where is the catheter for a patient on peritoneal dialysis?
Peritoneum in the pelvic region
In CAPD, does dialysis occur during the day or night?
Day
In APD, does dialysis occur during the day or night?
Night
What happens in CAPD?
You fill your abdomen with dialysate, let it remain there for the dwell time, then drain the fluid. Gravity moves the fluid through the catheter and into and out of your abdomen.
What happens in APD?
Machine called an automated cycler exchanges for you at night while you sleep. It fills your abdomen with dialysate and lets it dwell there. Then it drains the fluid into a sterile bag that you empty in the morning.
What are the complications of peritoneal dialysis?
Exit site infection
Peritonitis
Ultrafiltration failure
Encapsulating peritoneal sclerosis
If there is peritoneal dialysis peritonitis, if the bacteria is gram negative, where is it’s origin?
Bowel origin
If there is peritoneal dialysis peritonitis, if the bacteria is gram positive, where is it’s origin?
Skin origin
PD membrane is exposed to constant inflammation which can result in complications.
Therefore, after how long is PD usually stopped?
2-3years
What should fluid look like in PD before and after?
Should be clear in both
If PD fluid is cloudy, what is this usually indicative of
Infection
What is the treatment for PD peritonitis?
Antibiotics, usually Vancomycin to cover gram-positive infections and Ciprofloxacin to cover gram-negative
What are the indications for starting dialysis in patients with end-stage kidney disease?
Advanced uraemia (GFR 5-10ml/min)
Severe acidosis (bicarbonate <10mmol/L)
Treatment resistant hyperkalaemia (K>6.5 mmol/L)
Treatment resistant fluid overload
What is the fluid balance for patients on haemodialysis?
Usually restricted to 500-800ml/24hrs = urine output + insensible losses
What is the fluid balance for patients on peritoneal dialysis?
Usually more liberal intake as continuous ultrafiltration is often achieved
Patients on dialysis often need to take a lot of drugs. This is because dialysis is trying to replace the function of the kidneys but the kidneys have many different functions.
Which drugs do dialysis patients need to take to prevent anaemia?
Erythropoietin injections
IV iron supplements
Patients on dialysis often need to take a lot of drugs. This is because dialysis is trying to replace the function of the kidneys but the kidneys have many different functions.
Which drugs do dialysis patients need to take to prevent renal bone disease?
Activated Vitamin D (calcitriol)
Phosphate binders with meals (CaCo3)
Patients on dialysis often need to take a lot of drugs. This is because dialysis is trying to replace the function of the kidneys but the kidneys have many different functions.
Which other drugs will dialysis patients need to take?
Heparin- to prevent clotting of the socket
Water soluble vitamins
Often require antihypertensive drugs
What are some of the potential cardiac complications of haemodialysis?
Intra-dialytic hypotension and cramps
Arrhythmias
What are some of the potential coagulation complications of haemodialysis?
Clotting of vascular access
Heparin related problems
What are some of the other potential complications of haemodialysis?
Allergic reactions to dialysers and tubing
Catastrophic complications e.g. haemorrhage (rare)
What are some of the potential complications of peritoneal dialysis?
Infection- exit site, tunnel infection, peritonitis
Tube malfunction, abnormal wall herniae
How is it decided which type of dialysis a patient might have?
Patient choice- shared decision making based of effectiveness, etc.
Involves a lot of patient education
When may someone be unsuitable for peritoneal dialysis?
If they have had multiple abdominal surgeries
Previous problems with vascular access
Stenosis of central vessels
Which type of dialysis can be done at home?
Haemodialysis
In Scotland, is organ donation opt in or opt out?
Opt out
Describe what happens in a renal transplant process.
Transplanted kidneys is placed into the iliac fossa and anastomosed to iliac vessels and the ureter to the bladder
What is done with the kidney after being taken from a living donor?
Preservation of the kidney using cold storage solutions
Oedema of the kidneys is minimised
Tissue integrity is preserved
Can the kidney survive long between taking it from the donor and inserting it into the patient?
Quicker the better as ischaemia can develop
->longer the wait, less likely the kidney will be good enough to transplant
What are some of the transplant surgical complications?
Bleeding
Arterial thrombosis
Venous thrombosis
Lymphocele formation
Urine leak
Infection
What can be done to interfere with the antigens not recognising the new kidney and provoking an immune reponse?
-Calcineurin inhibitors (inhibition of signal 1)
-Co-stimulation using the CTLA-4 immunoglobulin (inhibition of signal 2)
-Interference with CD25 (inhibition of signal 3)
What can be used as antiproliferative agents in a kidney transplant?
Azathioprine
Mycophenolic acid
Commonly, to summarise, which drugs are given as immunosuppressive agents in a kidney transplant?
-An induction agent e.g. basiliximab
-A calcineurin inhibitor e.g. tacrolimus
-An antiproliferative agent e.g. mycophenolate mofetil
What are the side effects of corticosteroids?
Hypertension
Hyperglycaemia
Infections
Bone loss
GI bleeding
What are the side effects of Tacrolimus?
Hyperglycaemia
AKI
Tremor
What are the side effects of cyclosporin?
Hypertension
AKI
Gout
What are the side effects of mycophenolate mofetil?
Cytopenia
GI upset
What are the side effects of sirolimus?
Lipidogenic
Diabetogenic
Pneumonia
In immunosuppression protocol, which drug is used in the induction?
Basiliximab
In immunosuppression protocol, which drug is used in the maintenence?
Tacrolimus
Mcycophenolate
Steroids
What is meant by a deceased donor?
Someone donating organs after brain death when the heart is still beating.
Some after cardiac death when heart is no longer beating
What is meant by a living donor?
A match, usually related to the patient but can be unrelated
What is meant by expanded criteria of organ donation?
Helps to identify organs which are not as likely to work effectively
What is the expanded criteria for organ donation?
Donors aged > 60y
Donors aged 50-59 with history of hypertension, death from a cerebrovascular accident or a terminal creatinine >133
What is better for the patient- living donor donation or deceased donor donation?
Living donor
Waiting time for a kidney donor can vary based on what?
Matches, geographic location, blood type, ethnicity
Do transplants tend to be more common in older or younger patients w ESKD?
Younger patients as less risk of complications
Briefly describe what is meant by paired donation?
Two groups of people, one needing a transplant and the other willing to donate but it does not match, link up with another pair in the same position in which the two donors will match the other’s recipient
->can be done in bigger groups known as pooled donation
What are some things that are looked at in a living donor before they are able to donate their kidney?
Age
Sex
Ethnicity
Hypertension
Smoker
High BMI
GFR
What are some potential complications after renal transplantation?
Rejection
Cardiovascular issues
Infection
Malignancy
What are the two types of renal mediated rejection?
T cells
or
Acute antibody mediated rejection
Which classification is used for renal rejection?
Banff classification
What is the difference between type 1 and 2 renal rejection according to Banff classification?
Type 1- tubulointerstitial rejection without arteritis
Type 2- vascular rejection with arteritis
What is the treatment for organ rejection?
Immunosuppression by means of steroids
What condition can occur after any transplantation?
Diabetes due to use of steroids and immunosuppression
->higher risk if recipient has high BMI
When after transplantation is infection risk higher?
Higher in first 3-6 months after transplant
Name an infection which can occur after transplant.
Cytomegalovirus
How can cytomegalovirus affect patients who have undergone an organ replacement?
Transmission from donor tissue
or
Reactivation of latent virus
BK virus can also infect patients after organ transplant.
How can this manifest?
Ureteral stenosis
Interstitial nephritis
ESRF
What are some of the risk factors for BK virus?
Intense immunosuppression
Older age
Male
Ureteral stents
Treatment for BK virus?
Reduction in immunosuppressants
Over time, the risk of malignancy increasing following transplantation.
Which types are most common?
Skin
Lymphoma
