Renal Replacement Therapy

Question 1

When is renal replacement therapy needed?

Answer 1

When renal function declines to a level no longer adequate to support health
eGFR 8-10

Question 2

Types of renal replacement therapy

Answer 2

Haemodialysis
Peritoneal dialysis
Renal transplant

Question 3

Outline haemodialysis

Answer 3

• shunt (push through multiple veins + arteries together)
• anticoagulant added into blood
• blood is run through machine + filtered
• waste solute, salt + excess fluid removed from blood
• run through air trap to remove air
• added back to body

Question 4

Advantages and disadvantages of haemodialysis

Answer 4

Advantages:
- less responsibility
- days off
- proven effective long term
- unit based (support from staff)

Disadvantages:
- tied to dialysis time
- access/line problems
- fluid/food restricted
- muscle cramps
- infection
- AVF steal syndrome

Question 5

What is AVF steal syndrome?

Answer 5

• Complications which an occur after construction of vascular access for haemodialysis > reduced blood flow to issues
• causes hand numbness, pain, coldness + weakness
• in severe cases gangrene can occur > loss of fingers

Question 6

Outline peritoneal dialysis

Answer 6

• solution infused into peritoneal cavity through catheter
• solution contains sugar which draws out waste + extra fluid
• waste and fluid passes from blood vessels through peritoneum
• solution drained out

Question 7

Advantages and disadvantages of peritoneal dialysis

Answer 7

Advantages:
- continuously at home - independence
- less fluid/food restrictions
- easy to travel
- renal function may be better preserved initially

Disadvantages:
- frequent daily exchanges/overnight
- responsibility
- peritonitis
- less long term survival data
- unsuitable for patient with stoma/previous surgery
- hydrothroax

Question 8

Types of peritoneal dialysis

Answer 8

Automated PD
Continuous Ambulatory PD
Assisted Automated PD

Question 9

What is automated PD?

Answer 9

• Carried out with an automated cycler machine performed at night
• 10-12L usually exchanged over 8-10 hours
• leaves daytime free

Question 10

What is Continuous Ambulatory PD?

Answer 10

• usually consists of 4-5 dialysis exchanges per day of 2 litres each
• exchanges are performed at regular intervals through day with long overnight dwell

Question 11

What is assisted automated PD?

Answer 11

Trained healthcare assistants visits patient’s home to help with seeing up APD

Question 12

Advantage+ disadvantages of renal transplant

Answer 12

Advantages:
- near normal lifestyle
- better mortality/morbidity
.
Disadvantages:
- criteria to meet suitability to safety undergo operation
- compliance with lifelong medicine
- risk of rejection
- risk of malignancies over time
- risk of infection (must be on immunosuppression)
- long wait times for cadaveric organ

Question 13

Contraindications of kidney transplantation

Answer 13

• active infection or malignancy
• severe heart disease not suitable for correction
• severe lung disease
• reversible renal disease
• uncontrolled substance abuse or psychiatric illness
• short life expectancy
• on going treatment non adherence

Question 14

What are the 4 forms of living untreated donor transplantation?

Answer 14

• live donor paired exchange
• live donor/deceased donor exchange
• live donor chain
• altruistic donation

Question 15

What immunosuppressive drugs are given to those with kidney transplant?

Answer 15

Methylprednisiolone with basiliximab or thymoglobulin

Question 16

What drugs are used in maintenance treatment of renal transplants?
Class + names

Answer 16

• steroids: prednisolone
• calcinerurin inhibitors: tacrolimus, cyclosporine
• antimetabolite meds: azathioprine, mycophenolate
• T cell regulation: belatacept, belimumab
• rapamycin inhibitors: sirolimus, everolimus*

Question 17

Long term care of renal transplant patient

Answer 17

• follow up appointments
• monitor GFR, CNI levels, proteinuria, Ca2+, phosphate, PTH, lipids + glucose
• screen for infection
• vaccination
• monitor + control cardiovascular disease + bone mineral diease
• screen for malignancies (3x more likely)
• contraception needed for 1st year + counsel about pregnancy after 1 year

Question 18

Complications of transplantation

Answer 18

• acute complications post transplant related to surgery or infection
• new onset diabetes after transplantation (NODAT)
• increased risk of malignancies (3x risk)

Question 19

What are important infections to consider post renal transplant?

Answer 19

• hepatitis B
• HSV
• varicella zoster
• EBV
• tuberculosis
• listeria
• pneumocystis jirovecii

Question 20

Why might a renal transplant patient have enlarged gums?

Answer 20

They might be on cyclosporine which causes gum hypertrophy

Question 21

What are patient and donor kidneys matched based on?

Answer 21

Human leukocyte antigen (HLA) type A, B + C on chromosome 6

Question 22

Outline a renal transplant procedure

Answer 22

• the patient’s kidneys are left in place
• hockey stick incision made leaving a hockey stick scar
• donor kidney blood vessels are anastomosed with pelvic vessels (often external iliac)
• ureter of donor kidney anastomosed with bladder
• donor kidney placed an anteriorly in abdomen in iliac fossa region