Renal Replacement Therapy Flashcards
At what GFR is renal replacement therapy usually indicated?
<10ml/min
What are the different kinds of renal replacement therapy?
Renal transplant
Haemodialysis
Peritoneal dialysis
Conservative kidney management
What are the pre-requisites for dialysis?
Semipermeable membrane- artificial kidney in HD or peritoneal membrane in PD
Adequate blood exposure to the membrane- extracorporeal blood in haemodialysis, mesenteric circulation in PD
Dialysis access- vascular in HD peritoneal in PD
Anticoagulation for haemodialysis
How is haemodialysis access obtained?
Permanent- arteriovenous fistula or prosthetic graft
Temporary- tunnelled or temporary venous catheter
What restrictions must be put in place for patients on dialysis?
Fluid restriction- dictated by residual urine output
Dietary restriction of potassium, sodium and phosphate
How does peritoneal dialysis work?
A balanced dialysis solution is instilled into the peritoneal cavity via a tunnelled, cuffed catheter using the peritoneal mesothelium as a dialysis membrane
After a dwell time the fluid is drained out and the fresh dialysate instilled
What are the possible complications of peritoneal dialysis?
Exit site infection
PD peritonitis
Ultrafiltration failure
Encapsulating peritoneal sclerosis
Where are gram positive and gram negative bacteria causing PD peritonitis originated from?
Gram positive- skin contaminant
Gram negative- bowel origin
What are the indications for dialysis in end stage renal disease?
Advanced uraemia (GFR 5-10ml/min)
Severe acidosis (bicarbonate <10mmol/L)
Treatment resistant hyperkalaemia (K >6.5mmol/L)
Treatment resistant fluid overload
What are the fluid restrictions placed on patient on peritoneal and haemodialysis
HD- Usually 500-800ml/24 hours
PD- more liberal
What are some dialysis related drugs?
Anaemia- erythropoietin injections, IV iron supplements
Renal bone disease- activated vitamin D, phosophate binders with meals
Heparin
Water soluble vitamins
Antihypertensives
What are the complications of haemodialysis?
Cardiovascular problems- intra-dialytic hypotension and cramps, arrhythmias
Coagulation- clotting of vascular access, heparin related problems
Allergic reactions to dialysers and tubing
Catastrophic dialysis accidents (rare)
Where is a transplanted kidney placed and to what vessels is it joined?
Placed in iliac fossa and anastomosed to iliac vessels
What are the indications for a native nephrectomy?
Size (polycystic kidneys)
Infection (chronic pyelonephritis)
What are the possible renal transplant surgical complications?
Bleeding Arterial or venous thrombosis Lymphocele Urine leak from ureter Infection
What are the immune suppression protocols related to kidney transplant?
Induction- basiliximab
Maintenance- tacrolimus and mycophenolate and steroids
What are the possible complications after renal transplantation?
Rejection- cell mediated, humoral (Ab mediated)
Cardiovascular- Hypertension, hyperlipidaemia, PT diabetes
Malignancy- skin, lymphoma, solid cancers
Infection
What is the most important transplant-related infection in kidney transplant recipients?
Cytomegalovirus
What are the risk factors for BK virus nephropathy?
Intense immune suppression Older age Male gender White ethinicity Diabetes mellitus Graft injury Ureteral stents
How is BKAN treated?
Reduce immunosuppression
Antiviral therapy- cidofovir, leflunomide
