Renal Support

Question 1

What is ESRD (end stage renal disease)

Answer 1

End stage renal disease/failure (ESRD) – when death is likely without renal replacement therapy i.e eGFR < 15ml/min.

Question 2

What are some of the symptoms of ESRD?

Answer 2

Symptoms of ESRD – overwhelmingly tired, physically and mentally incapacitated, feelings of guilt and ineptitude at needing rest, difficulty sleeping and difficulty concentrating.
Signs of volume overload, nausea and vomiting, reduced appetite (especially protein), restless legs and cramps, pruritus (severe itching), sexual dysfunction and reduced fertility and increased infections (reduced cellular and humeral immunity).

Question 3

How does the volume of urine produced in a day change with ESRD and why?

Answer 3

Normally we can pee in the range of 0.5l to 30l in a day. CKD they have a much reduced GFR but still have the same amount of solute that they need to excrete however due to the low filtration rate it becomes increasingly hard to get rid of liquid from the body so this dramatically limits the amount they can pee out to between 1-2L.

Question 4

What effect does acidosis have on bone disease and muscles?

Answer 4

Acidosis worsens bone disease and can cause muscle wasting.

Question 5

How do we deal with the acid-base and electrolyte disturbances in ESRD patients?

Answer 5

Generally asymptomatic, can require additional medication such as sodium bicarbonate (makes patients windy) and alteration of medication such as stopping ACE inhibitors.

Question 6

What effects does the build up of waste products cause?

Answer 6

Contributes to uraemic symptoms, reduced appetite, nausea, vomiting and pruritus.

Question 7

What is haemodialysis?

Answer 7

Allowing a machine to filter someone’s blood for them, requires a fistula being put into someone’s arm. 4 hours 3 times a week.

Question 8

What are the advantages and disadvantages of haemodilaysis?

Answer 8

Advantages – less responsibility, days off. disadvantages – travel time/waiting, tied to dialysis times and big restriction on fluid food intake. On average they are on 19 pills

Question 9

What contraindications are there for haemodialysis?

Answer 9

Failed vascular access, heart failure, coagulopathy

Question 10

What complications can occur with haemodilaysis?

Answer 10

Lines – infection, thrombosis and venous stenosis, AVFthombosis, bleeding, access failure, steal syndrome, CVS instability, feel chronically unwell and accumulate morbidity (CVS bone etc.)

Question 11

What is Home/Nocturnal HD?

Answer 11

Home HD/Nocturnal HD are options for haemodialysis. Patients often feel much better as they get more hours and can watch TV or something whilst doing it. Must have carer with you. Often need fewer medications.

Question 12

What is peritoneum dialysis?

Answer 12

Uses peritoneum as a filter and fill with dialysis liquid then remove liquid later once full of waste products.

Question 13

What are the advantages and disadvantages of peritoneum dialysis?

Answer 13

Advantages: self-sufficient, generally less fluid/food restriction, fairly easy to travel with CAPD (continuous ambulatory peritoneal dialysis) and renal function may be better preserved initially. Disadvantages – frequent daily exchanges or overnight and responsibility. On average are only on 10 tablets.

Question 14

What contraindications are there for peritoneum dialysis?

Answer 14

Failure of peritoneal membrane, adhesions, hernia, stoma, patients unable to connect/disconnect, obese or large muscle mass (peritoneal ratio).

Question 15

What complications are there for peritoneum dialysis?

Answer 15

Peritonitis, exit or tunnel site infections, ultrafiltration failure, leaks (scrotal and diaphragmatic) and development of hernia.

Question 16

How common is peritonitis in patient who have peritoneal dialysis?

Answer 16

Patients on Peritoneal dialysis have peritonitis roughly every 20 months.

Question 17

What are the advantages and disadvantages of transplant?

Answer 17

Reduced mortality, and morbidity compared to dialysis, better quality of life, peri-operative risk, malignancy risk, infection risk, risk of diabetes and hypertensive due to meds.

Question 18

Where does the transplant usually occur?

Answer 18

Usually inserts into your iliac vessels and you can have more than one on each side if you need more over your lifetime, can be put into the IVC if needs be but slightly more complicated.

Question 19

What are the three types of transplants that can be received?

Answer 19

Live donor transplant – live or related

Deceased after brain death or after circulatory death

Question 20

How do we match a kidney to someone else and how does the waiting list work?

Answer 20

Kidneys are matched per tissue types (ABO and HLA antibodies), number of points a patient has due to age and length of time on waiting list.

Question 21

How does life expectancy differ between different transplant types?

Answer 21

Average transplant life: Live related donor – 12 years, Live unrelated donor – 11 years, Deceased after brain death donor – 10 years

Question 22

Why might dialysis not be a good option for some people?

Answer 22

Only prolongs life with people who have ESRD for about 2 years.
Patients who choose conservative care can survive a substantial length of time achieving similar numbers of hospital-free days to patients who choose haemodialysis.

Question 23

What symptoms would you need to monitor if someone decides they want end of life care instead of dialysis or transplant?

Answer 23

Pain – bone, dialysis related, neuropathy musculoskeletal, Constipation, fatigue, nausea, lack of appetite, pruritus, cramps/restless legs and sleep disturbance.

Question 24

What are the most common killers in ESRD?

Answer 24

You don’t die from renal disease but other morbidities the most common of which are: cardiovascular disease, infection, cerebrovascular disease, treatment withdrawal and malignancies.