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Renal > Renal Replacement Therapy > Flashcards

Renal Replacement Therapy Flashcards

1
Q

What does the term renal replacement therapy encompass?

A

All forms of dialysis and transplantation.

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2
Q

What are the indications for dialysis?

A

BASED ON BLOODS: Resistant hyperkalaemia, GFR < 7, urea > 40, unresponsive acidosis
BASED ON SYMPTOMS: fatigue, itch, unresponsive fluid overload (pulmonary and peripheral oedema etc), nausea, vomiting, loss of appetite

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3
Q

Is there any benefit to starting dialysis early?

A

No

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4
Q

Describe how dialysis works?

A

Uses principles of diffusion from solutes moving to high to low concentration
Allows removal of toxins and infusion of bicarbonate
As patient has lots of K, urea and Na these diffuse out and bicarbonate diffuses in
Water is removed in haemodialysis by negative pressure filtration/ convection

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5
Q

Minimum haemodialysis?

A

4hrs 3x a week

increases can increase survival but issues with QOL

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6
Q

GFR provided by a dialysis machine is? How does this compare to healthy individual GFR?

A

Dialysis GFR = 10-12

Normal GFR = at least 60

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7
Q

2 ways to get access for haemodialysis?

A

Arteriovenous Fistula

Tunneled venous catheter

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8
Q

What is the gold standard of dialysis access?

A

Arteriovenous fistula

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9
Q

Describe what an arteriovenous fistula is?

A

Joining of an artery and vein in the arm usually to make an enlarged thick wall vein allowing good vascular access for haemodialysis

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10
Q

Pros and cons of arteriovenous fistula?

A

Pros: good blood flow and less likely to cause infection
Cons: Requires surgery, requires maturation of about 6 week before use, can limit blood flow to the distal arm

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11
Q

Describe what a tunnelled venous catheter is?

A

A catheter is inserted into a large vein e.g. jugular, subclavian or femoral

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12
Q

Pros and cons of a tunnelled venous catheter?

A

Pros: easy to insert and can be used right away
Cons: High risk of infection, untreated infection can lead to endocarditis, discitis and death. Can also cause damage to the veins making replacement difficult and the catheters can become blocked.

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13
Q

Describe infection of tunnelled venous catheter?

A

High risk of infection particularly by Staph A. If untreated can lead to endocarditis, discitis and death. Often presents as rigors on dialysis.

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14
Q

How does infection of tunnelled venous catheter often present?

A

Rigors on dialysis

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15
Q

Rigors on dialysis?

A

Infection of tunnelled venous catheter

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16
Q

Describe restriction for dialysis patients?

A

Fluid: If anuric 1 litre per day (including food based fluid)
Salt: Low salt diet to reduce thirst and help with fluid balance
Potassium: low potassium diet no bananas, chocolates, potatoes, avocado
Phosphate: low phosphate diet, phosphate binders with meals (6-12 pills per day), no diet coke!

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17
Q

Describe 5 complications of dialysis?

A

Fluid overload
Blood leaks and exsanguination due to needle that returns blood to arm being dislodged but large volumes of blood still being removed from patient
Loss of vascular access
Hypokalaemia and cardiac arrest
Intradialytic hypotension: removing large volumes of fluid at once vs small volumes constantly

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18
Q

Describe how peritoneal dialysis work?

A

Peritoneal membrane is used as a filter, solute removal is by diffusion of solutes across the peritoneal membrane. Water removal is by osmosis and is driven by high glucose concentration in the dialysate fluid.

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19
Q

If a dialysis patient is fluid overloaded?

A

Don’t give them diuretics- they can’t pee so won’t work

Need dialysis done

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20
Q

Is peritoneal dialysis as efficient as haemodialysis?

A

No

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21
Q

Describe the two types of peritoneal dialysis?

A

CAPD (contiguous ambulatory): 4 bag exchanges per day, fluid drained then fresh fluid instilled. 1/2 hr per exchange.
APD (automated): 1 bag of fluid stays in all day and overnight machine drains in and out fluid for 9-10 hrs per night.

22
Q

3 complications of peritoneal dialysis?

A

Infection- peritonitis due to contamination or gut bacteria translocation
Membrane Failure- due to sugary solution, patient becomes fluid overloaded as can’t remove enough water, this requires switch to haemodialysis
Hernias- due to increased intrabdominal pressure

23
Q

Is there a survival difference between PD and HD?

A

No pretty much the same overall
If younger an fitter PD may be better in the beginning
Haemodialysis probably better for older patients

24
Q

Sign someone has had a kidney transplant?

A

Scar in iliac fossa and a mass

25
Q

Why do a kidney transplant vs dialysis?

A

Survival and quality of life is better
Transplant allows freedom from fluid and diet restrictions
Anaemia is corrected

26
Q

What does transplant surgery involve?

A

Anastamosis of an explanted human kidney either from deceased or living donor on the iliac vessels of the recipient. Ureter from the donor is placed into recipient bladder. Tend to leave old non functioning kidneys in.
Unless donor is genetically identical then need life long immunosuppression. Donors generally come to no harm

27
Q

What happens if blood group is not compatible in a transplant?

A

Acute vascular rejection

28
Q 
O donor can donate to \_\_\_1\_\_\_\_\_
O recipient can receive \_\_2\_\_\_\_
A recipient can receive \_\_\_\_3\_\_\_\_\_
AB recipient can receive \_\_\_\_4\_\_\_\_\_
B recipient can receive \_\_\_\_\_5\_\_\_\_\_
A

1) any group
2) only from O
3) O or A
4) A, B, AB or O
5) B or O

29
Q

3 important HLA classes for matching in kidney transplant? Describe the matching?

A

HLA A
HLA B
HLA DR
At each HLA A, B or DR there are 2 HLA types as have inherited one copy from each parent so there are loads of combinations overall.

30
Q

HLA typing is important as recipient could have donor specific antibodies, where might they have got these?

A

Blood transfusions
Previous transplants
Pregnancy

31
Q

4 types of transplant?

A

DBD - deceased brain dead
DCD- deceased cardiac death
Live donor kidney
Kidney pancreas dual

32
Q

Describe a DBD transplant?

A

Patient has been declared brainstem dead, kidneys removed while person is technically still alive and kidneys go to most suitable match across UK.

33
Q

Describe a DCD transplant?

A

Patients who die at cardiac arrest but don’t meet criteria for brain steam death but would die if ventilator turned off. They have to turn ventilator off and declare the person dead first as only allowed to remove the organs from DBD when alive. Usually these donors only donate kidneys and liver as other organs have not be perfused well enough. Organs are used by local centre due to prolonged ischaemia.

34
Q

Describe a live donor transplant?

A

Usually by sibling or parent but can be donated by other persons e.g. spouse under strict regulation

35
Q

Describe a kidney pancreas dual transplant?

A

Suitable for type 1 diabetics with kidney disease as replaces both kidney and pancreas function. Normal T1DM aren’t given just pancreatic transplants due to equal risks associated with immunosuppression but if receiving a kidney may as well get a pancreas.

36
Q

Criteria for transplants?

A

Must have a life expectancy of 5 yrs or more
Must be on dialysis or within 6 months of starting
Allocation is based predominantly on tissue typing and then time on the waiting list

37
Q

Describe assessment of recipient of a kidney transplant?

A

Assess CVS risk: ECG, cholesterol, coronary angiogram, echo
Virology: HBV, HCV, HIV, CMV, EBV all must be controlled/ treated before transplant
CXR
Bladder assessment
Investigation of any co-morbidity

38
Q

7 Contraindications for kidney transplant?

A

Untreated malignancy
History of solid tumour in last 2 yrs (5yrs for breast and colorectal)
Untreated TB
Severe IHD
Severe Airways Disease
Active Vasculitis that could recur in the transplant
PVD- would be unable to attach diseased iliac artery to kidney

39
Q

Describe assessment of a live donor?

A 
ECG
CXR
Virology
GFR (measured fully)
Quantification of proteinuria
24hr BP monitoring
Renal angiogram
X match against recipient
40
Q

3 types of rejection?

A

Hyperacute
Acute
Chronic

41
Q

Describe hyperacute rejection?

A

Occurs in minutes, already have antibodies to the kidney, unsalvageable and must remove kidney, usually due to wrong blood group

42
Q

Describe acute rejection?

A

T or B cell response, treated with immunosuppression

43
Q

Describe chronic rejection?

A

Immunological and vascular deterioration, difficult to treat

44
Q

3 groups of drugs used for immunosuppression?

A

Calcineurin inhibitors
Purine Synthesis Inhibitors
Steroids

45
Q

Calineurin inhibitors mechanism is _____
2 examples are __________
Drug reactions are _________
Side effects are __________

A

Disrupt T cell signalling
Cyclosporin and tacrolimus
numerous as metabolised by cytochrome p450
renal dysfunction, hypertension, diabetes and a tremor

46
Q

Purine synthesis inhibitors mechanism is_______
2 examples are _________
Drug reactions are __________
Side effects are ____________

A

suppression of proliferation of lymphocytes
azathioprine and mycophenolate
Allopurinol multiplies action of azathioprine 40x
leucopenia, anaemia, GI side effects

47
Q

Steroids mechanism is __________

Side effects are________

A

Suppress B cell proliferation and T cell activity

Osteoporosis, weight gain, infection, skin thinning and diabetes

48
Q

3 things that can happen post operation of kidney transplant?

A

Immediate graft function
Delayed graft function- need haemodialysis whilst waiting for it to work
Primary non-function

49
Q

Kidney transplant patients are usually discharged ______

A

1 week post surgery

50
Q

Describe follow up after kidney transplant?

A 
long term
check for acute and chronic rejection
hypertension and CVD review
UTIs
Recurrent primary renal disease
Surveillance for skin cancer
51
Q

4 reasons a graft may be lost?

A

Chronic rejection
Toxicity of drugs
Recurrent disease
Ischaemia

52
Q

What happens if a patients transplant fails?

A

Go back on dialysis

If fit enough can get another kidney

Renal (19 decks)

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