RRT

Question 1

What are the types of RRT?

Answer 1

Dialysis and renal transplant

Question 2

When is long term dialysis needed?

Answer 2

When it is necessary to manage one or more symptoms of renal failure including:
-Inability to control volume status, including pulmonary oedema
-Inability to control blood pressure
-Serositis
-Acid-base or electrolyte abnormalities
-Pruritus
-Nausea/vomiting
-Cognitive impairment
GFR is usually 5-10 ml/min/1.73 at the start of dialysis.

Question 3

What are the two types of dialysis?

Answer 3

Haemodialysis

Peritoneal dialysis

Question 4

How does haemodialysis occur?

Answer 4

Blood is passed over a semi-permeable membrane against dialysis fluid following in the opposite direction.
There’s a diffusion of solutes occurring down the conc. gradient.

Question 5

Which access is preferred for haemodialysis?

Answer 5

AV fistula as it provides increased blood flow and longevity.
AV fistula is created prior to the need for RRT to avoid infection risk associated with central venous dialysis catheters.

Question 6

Problems with haemodialysis

Answer 6

Access (AV fistula: thrombosis, stenosis, steal syndrome, Tunnelled venous line: infection, blockage, recirculation of blood) 
Dialysis dysequilibrium (between cerebral and blood solutes leading to cerebral oedema)

Question 7

What is peritoneal dialysis?

Answer 7

Uses the peritoneum as a semi-permeable membrane
A catheter is inserted into the peritoneal cavity and fluid infused.
Solutes diffuse slowly across.
Ultrafiltration is achieved by adding osmotic agents (glucose) to the fluid.
A continuous process with intermittent drainage and refilling of the peritoneal cavity.

Question 8

Problems of peritoneal dialysis

Answer 8

Catheter site infection, PD peritonitis, hernia, loss of membrane function over time.

Question 9

Complications of RRT

Answer 9

Annual mortality is significant, mostly due to CVD disease: increased BP, calcium /phosphate dysregulation, vascular stiffness, inflammation, oxidative stress, abnormal endothelial function.

Infection: uraemia causes granulocyte and T-cell dysfunction with increased sepsis-related mortality.

Question 10

What if a patient doesn’t want RRT?

Answer 10

For those who opt not to receive RRT due to lack of benefit on quality or quantity of life.
Focus is on preserving residual renal function, symptom control, and advanced planning with patient and family for end of life care.

Question 11

When is transplantation considered?

Answer 11

Transplantation should be considered for every patient with or progressing towards stage 5 kidney disease.
It is the treatment of choice for kidney failure provided risks do not exceed benefits.

Question 12

Why don’t some people make the transplant list?

Answer 12

Many will not make the transplant list due to comorbidity or frailty.

Question 13

When is a kidney transplant CI?

Answer 13

Absolute- cancer with metastases
Temporary- active infection, HIV with viral replication, unstable CVD
Relative- CHF, CVD

Question 14

What are the types of graft for kidney transplantation?

Answer 14

Living donor-
best graft function and survival, especially if HLA matched.
Deceased donor-
Donor after brain death
Expanded criteria donor is from an older kidney or from a patient with a hx of CVA, BP or CKD
Donor after cardiac death with increased risk of delayed graft function

Question 15

Immunosuppression in kidney transplant

Answer 15

-A combination of drugs is used.
-The aim is to use the minimal effective dose with the lowest drug-related toxicity.
-The protocol used depends upon the immunological risk of the recipient and type of donated kidney
Monoclonal antibodies- basiliximab, daclizumab (used for induction)- reduced acute rejection and graft loss but increased infection risk
Calcineurin inhibitors- tacrolimus, ciclosporin. These drugs inhibit T-cell activation and proliferation. SE: nephrotoxicity in the graft, increased BP, increased cholesterol
Antimetabolites: Mycophenolic acid, azathioprine SE: anaemia, leucopenia and GI toxicity
Glucocorticosteroids: First choice treatment for acute rejection
SE (BP, hyperlipidaemia, DM, impaired wound healing, osteoporosis, cataracts, skin fragility)

Question 16

Complications of kidney transplant

Answer 16

Surgical- bleed, thrombosis, infection, urinary leaks, lymphocytic, hernia
Delayed graft function
Rejection
Infection
Malignancy- up to 25x increased risk of cancer with immunosuppression
CVD: 3-5x increased risk of premature of CD

Question 17

What happens in rejection of kidney transplant?

Answer 17

Acute vs chronic- acute is divided into antibody-mediated or cellular- causes reduced renal function and treatment is with high-dose steroids and increased immunosuppression

Question 18

Prognosis with the kidney transplant

Answer 18

Most common outcome is death with a functioning transplant (i.e. transplant ‘outlives’ the patient)

Question 19

What are the indications a patient should start renal replacement therapy?

Answer 19

Fluid overload
Refractory hyperkalaemia
Uraemic symptoms:
-Nausea, vomiting, weight loss
-Neurological symptoms
-Uraemic pericarditis (rarely seen in modern-day practice)

Question 20

What are the CI of haemodialysis?

Answer 20

Inability to achieve suitable vascular access (absolute CI)
Severe dementia (relative CI)
Severe heart failure (relative CI)
A bleeding disorder (relative CI)
Low blood pressure (relative CI)
Severe active psychotic disorder (relative CI)

Question 21

What are the CI of peritoneal dialysis?

Answer 21

Inflammatory bowel disease (active) (absolute CI)
Abdominal hernias (relative CI)
Ischemic Bowel (absolute CI)
Stomas/VP shunt (relative CI)
Acute diverticulitis (absolute CI)
Previous multiple abdominal operations (relative CI)
An abdominal abscess (absolute CI)
Blind (unless having assisted APD) (relative CI)
Pregnancy 3rd trimester (absolute CI)
Poor manual dexterity (unless having assisted APD)
Obesity (relative CI)
Severe dementia (relative CI)
Severe nephrotic range proteinuria (relative CI)
Severe obstructive airway disease (relative CI)
Poor hygiene (relative CI)
Severe active psychotic disorder (relative CI)