Renal Replacement Therapy Flashcards
When is renal replacement therapy needed?
When renal function declines to a level no longer adequate to support health
eGFR 8-10
Types of renal replacement therapy
Haemodialysis
Peritoneal dialysis
Renal transplant
Outline haemodialysis
- shunt (push through multiple veins + arteries together)
- anticoagulant (citrate or heparin) 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
Advantages and disadvantages of haemodialysis
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
What is AVF steal syndrome?
- 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
Outline peritoneal dialysis
- 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
Advantages and disadvantages of peritoneal dialysis
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
Types of peritoneal dialysis
Automated PD
Continuous Ambulatory PD
Assisted Automated PD
What is automated PD?
- Carried out with an automated cycler machine performed at night
- 10-12L usually exchanged over 8-10 hours
- leaves daytime free
What is Continuous Ambulatory PD?
- 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
What is assisted automated PD?
Trained healthcare assistants visits patient’s home to help with seeing up APD
Advantage+ disadvantages of renal transplant
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
Contraindications of kidney transplantation
- 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
What are the 4 forms of living untreated donor transplantation?
- live donor paired exchange
- live donor/deceased donor exchange
- live donor chain
- altruistic donation
What immunosuppressive drugs are given to those with kidney transplant?
Methylprednisiolone with basiliximab or thymoglobulin
What drugs are used in maintenance treatment of renal transplants?
Class + names
- steroids: prednisolone
- calcinerurin inhibitors: tacrolimus, cyclosporine
- antimetabolite meds: azathioprine, mycophenolate
- T cell regulation: belatacept, belimumab
- rapamycin inhibitors: sirolimus, everolimus*
Long term care of renal transplant patient
- 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
Complications of transplantation
- acute complications post transplant related to surgery or infection
- new onset diabetes after transplantation (NODAT)
- increased risk of malignancies (3x risk)
What are important infections to consider post renal transplant?
- hepatitis B
- HSV
- varicella zoster
- EBV
- tuberculosis
- listeria
- pneumocystis jirovecii
Why might a renal transplant patient have enlarged gums?
They might be on cyclosporine which causes gum hypertrophy
What are patient and donor kidneys matched based on?
Human leukocyte antigen (HLA) type A, B + C on chromosome 6
Outline a renal transplant procedure
- 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
Indications for acute dialysis
AEIOU
- _A_cidosis
- _E_lectrolyte abnomalities (resistant hyperkalaemia)
- _I_ntoxication (overdose)
- _O_edema
- _U_reamic symptoms such as seizures or reduced consciousness
What can be used in an acute setting for haemodialysis?
Vas cath (central venous catheter)
What are the two options for haemodialysis?
Continuous renal replacement therapy
Intermittent haemodialysis
Outline continuous renal replacement therapy
Continuous performing haemodialysis 24 hours a day
Outline intermittent haemodialysis
Running the machine + performing dialysis for set periods then having a break
What type of renal replacement therapy is used in AKI?
Haemodialysis
