Renal replacement therapy

Question 1

What are the indications for Renal replacement therapy

Answer 1

eGFR <10-15 ml/min
Refractory pulmonary oedema despite diuretic treatment
Persistent hyperkalaemia
Severe metabolic acidosis (pH <7.2)
Symptomatic uraemia
Uraemic pericarditis or encephalopathy
Drug overdose: BLAST
-Barbituates, Lithium, Alcohol, Salicylates, Theophyline

Question 2

List the types of Renal replacement therapy

Answer 2

Haemodialysis
Haemofiltration: acute settings, haemodynamic instability
Peritoneal dialysis
Renal transplant

Question 3

What routes of administration are used in haemodialysis?

Answer 3

Central venous catheter: urgent dialysis
AV fistula
AV graft: poor veins or arterial disease

Question 4

Describe the benefits and risks of administering haemodialysis via a central venous catheter versus AV fistula

Answer 4

Central line: can be used to provide urgent dialysis. Travels at a slower rate, with increased risk of infection and stenosis.

AV fistula: lowest risk of infection, but takes weeks to prepare. Risk of aneurysm and rupture.

Question 5

Name 3 specific complications of haemodialysis

Answer 5

Access malfunction, thrombosis, or bleeding
Infection: bacteraemia ➔ septic arthritis, endocarditis, spinal vertebritis
Dialysis disequilibrium ➔ cerebral oedema and seizures
Intradialytic hypotension
Amyloidosis, carpal tunnel syndrome, dialysis arthropathy

Question 6

Compare haemodialysis with peritoneal dialysis

Answer 6

Haemodialysis: three weekly 4-5hrly sessions with no further treatment in-between. Sessions are inflexible, and requires certain dietary (phosphate, potassium, sodium) and fluid restrictions.

Peritoneal dialysis: portable dialysate inserted into peritoneum. Requires changing every 3-5 hours. Provides patient freedom and control, with less dietary restrictions.

Question 7

Name 3 specific complications of peritoneal dialysis

Answer 7

Bacterial peritonitis
Sclerosing peritonitis* ➔ small bowel obstruction
Catheter exit-site infections
Hernias and back pain
Obesity

Question 8

Which patients should be considered for renal transplant? Who is excluded?

Answer 8

Consider for patients with ESRD who are dialysis dependent or likely to be in the immediate future.

Exclusion criteria: active malignancy, old age

Question 9

Explain the types of graft failure

Answer 9

Hyperacute acute rejection: minutes to hours
-rarely seen due to HLA matching

Acute graft failure (10-30%): <6 months

• usually due to mismatched HLA
• CMV: commonest viral infection post-transplant
• Opportunist Pneumocystis jiroveci
• may be reversible with steroids and immunosuppressants

Chronic graft failure: >6 months

• fibrosis ➔ chronic allograft nephropathy
• recurrence of original renal disease

Question 10

Name 3 late complications of renal transplant

Answer 10

Post-transplant lymphoproliferative disorder
Immunosuppresive therapy ➔ BCC and SCC, RCC
Cardiovascular disease (50%)
Post-transplant osteoporosis: due to steroid use
Recurrent renal disease: primary FSGS often recurs and causes chronic graft failure