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 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
