Renal Replacement + Transplantation Flashcards
When would you consider renal replacement therapy?
- Symptomatic uraemia (including pericarditis or tamponade)
- uncontrolled hyperkalaemia
- uncontrolled pulmonary oedema
- severe acidosis
- To remove AKI causing drugs (eg. gentamicin, lithium, severe aspirin overdose)
What are the advantages of peritoneal dialysis?
- quality of life!
- good if you have residual native renal function
- much more individualised than HD
- regular visits to dialysis unit are not required - can do at home
- fewer restrictions on diet/fluid intake compared to HD
What are the disadvantages of Peritoneal Dialysis?
- It is daily so might be disruptive and annoying
- Works by leaving a soft catheter permanently placed through the midline of your abdo wall into the peritoneal cavity - which can be upsetting
- Unsuitable in those with stoma/previous surgery
- You need to be able to manage the technical aspects of PD
- Risk of peritonitis !!!
Complications:
- Weight gain
- Drainage problems eg. due to constipation
- Malposition, Leaks, Herniae
- Bacterial peritonitis (fever, abdo pain, cloudy peritoneal dialysate. usually due to staph epi, e coli, pseudomonas, s aureus)
- Catheter site skin infections
- Encapsulating Peritoneal Sclerosis (thickening of peritoneal membrane + adhesions/stricture formation so the small bowel becomes looped = recurent small bowel obstruction)
What is the difference between Continuous Ambulatory PD and Automated PD?
Automated:
- performed at night via an automated cycler machine. So leaves the daytime free!
- But need to keep and maintain a dialysis machine in your house so not so much freedom
- 10-12L exchanged over 8-10 hours
Assisted Automated PD = trained healthcare assistants visit your house to help set up the APD for you
Continuous Ambulatory:
- 4-5 dialysis exchanges at regular intervals per day (2L each), with long overnight dwell
- Equipment is portable so can travel
What are the advantages of Haemodialysis
- Typically use the dialysis machine 3 times a week, each session lasting 4 hours. So you have 4 dialysis free days a week.
- Sessions happen in a dialysis centre, so lots of staff to support you
What are the disadvantages of Haemodialysis?
- You have to travel regularly to the dialysis clinic and work your life around these sessions
- When you travel you will have to use the “Global Dialysis” website to arrange dialysis at a unit at your destination
- Diet and Fluid is very restricted
Complications:
- Arteriovenous fistula/Catheter access can malfunction
- Infection/bacteraemia
- can disseminate to soft tissue (septic arthritis), cardiac valves (endocarditis), spinal column (vertebritis)
- Reaction to dialysers
- Haematomas/risk of bleeding
- Muscle cramps
- Anaemia due to clotted lines/haemolysis
- AVF steal syndrome
- (ischaemia due to decreased flow through the arterial segment distal to AVF)
- Superior Vena Cava obstruction from central lines
- Dialysis Disequilibrium
- (urea removed too quick so fluid moves to area of increased urea conc, across blood brain barrier = cerebral oedema + fitting)
What are the other options regarding haemodialysis?
Home HD
Nocturnal HD (overnight, slow, long HD)
Continuous Renal Replacement Therapy (mainly in ITU/HDU acute settings)
What is “Active Conservative Management” and when would you do it?
- Age >80
- WHO performance score of 3 or more
- 3 = >50% of the day in chair/bed rest.
Renal Replacement Therapy would offer no survival benefit.
This involves:
- symptom control to improve quality of life
- advanced care plan
- MDT approach
- support system for patient and family
What are some contraindications for a kidney transplant?
- active infection or malignancy
- severe heart disease
- severe lung disease
- reversible renal disease
- uncontrolled substance abuse,psychiatric illness
- Non-adherence to on going treatment
- Short life expectancy
What are the different kinds of transplantation?
Living related donor transplantation
= an elective procedure with a selected donor so higher chance of good compatability
Living unrelated donor transplantation
Deceased Donor Transplantation
= the majority of transplants fall into this category. Survival of kidney allograft and patients are significantly low compared to live donor transplantation
Describe the procedure of induction and maintenance treatment eg. drugs from the moment of transplantation
Induction:
at the moment of transplantation, immunosuppressive drugs are used to create tolerance to the graft to avoid hyperacute rejection
- Methylprednisolone + basiliximab /thymoglobulin /alentuzumab /rituximab
Maintenance:
Treatment the is commenced immediately after transplantation and continued long term to prevent acute/chronic rejection
- Steroids = prednisolone
- Calcineurin inhibitors = tacrolimus, cyclosporine, voclosporin
- Antimetabolite medications = Mycophenolate, azathioprine
- Rapamycin inhibitors = sirolimus, everolimus
- T cell regulation = belatacept, belimumab
Describe the long term care of a renal transplant patient eg. follow up.
- follw up for several times a month, then after 6 months, less often
- Monitor GFR, Calcineurin Inhibitor levels, proteinuria, Ca, Phosphate, PTH, lipids, glucose
- Screen for infections
- Vaccinations (except live or live attenuated)
- Monitor and control CVS disease, bone and mineral metabolism disease
- Annual skin checks to screen for malignancies (will cover more in complications card)
- Contraception is compulsary in first year
- Then counsel about pregnancy
What are some Short term complications of Renal transplant?
- Infection
- Minor infections can occur withint the first month eg. UTI, chest infections, wound infections
Important germs to consider:
CMV, Hep B, HSV, Varicella Zoster, EBV (causes post transplant lymphoproliferative disorders. switch to chemo), BK (BK nephropathy. decrease immunosuppressants and hope it gets better), Aspergillus, Pneumocystis jirovecii (prophylactic cotrimoxazole is given), Listeria, Mycobacterium tuberculosis, Toxoplasma gondii
- Blood clots in arteries connected to the new kidney
- Artery stenosis (narrowing) to new kidney = fix with stent
- Blocked ureter = drain with catheter or surgery
- Urine leakage into abdo/through incision from where ureter joins to bladder = repair with surgery
- Acute rejection
- Presents with declining renal function in first 3 months. Confirm with renal biopsy. Give short course of more power immunosuppressants
- ATN due to nephrotoxic drugs like immunosuppressants like calcineurin inhibitors
What are some long term complications of renal transplantation?
- Immunosuppressant side effects like increased risk of infection, increased bp, weight gain, diarrhoea, increased risk of DM, thinning of bones, bleeding/bruising easily, increased risk of cancer
- New-Onset Diabetes after transplant (NODAT)
- increased risk due to immunosuppressants, eating more after they feel better and gaining too much weight, etc.
- High BP
- increased risk due to immunosuppressants and renal disease
- Malignancy
- screen for skin (SCC, BCC, melanoma, non-melanoma), renal, cervix, breast, prostate, urothelial, liver, colorecta, lymphoma, vaginal
- Lymphoproliferative disease especially common in EBV infection
- Kaposi’s sarcoma affects both skin and internal organs
- Post transplant osteoporosis due to steroid use
