transplants and dialysis Flashcards
forms of RRT?
HD
PD
transplant
types of donation
brain stem death
non heart beating
live altruistic donation
when do you see survival benefit post transplant
3m
what should you assess pre transplant to make sure patient is fit to undergo?
immunology and blood group virology ECG, ECHO, ETT, CXR, PFT peripheral vessels mental state comorbidity
contraindication to transplant
malignancy active HIV/HCV untrwated TB severe IHD severe airway disease vasculitis severe PVD hostile bladder
live donor transplant assessment
fit? enough renal function? anatomically normal? comorbidity? immunologically compatible? psychologically compatiblw? no coercion?
true/false - O donors can receive from anyone
false, they can give to anyone
AB can receive from anyone
what HLA matchingf is looked for in transplant
Class I A,B,C
Class II DP, DQ, DR
true/false - HLA mismatch will lead to total organ rejection
false - but there is an increased risk graft failure
true/false - those who have had transplants before are at increased risk rejection
true - they are sensitised so mismatch of HLA matters more
what are the sensitising events that may lead to graft failure
pregnancy
previous transplant
transfusion
what is paired donation
when two people need kidneys and there are two seperate donors
how can a person be desensitised prior to transplant
plasma exchange
b cell antibody
describe the process of a kidney transplant
L/R IF
kidneys left in situ
attached to external iliac artery and vein
complications of kidney transplant
bleeding artery stenosis venous stenosis ureteric stricture wound infection lymphocele
how can you identify immediate graft function
decrease in creatinine
good urine output
what is primary non function
transplant never worked
what is delayed graft funtion
kidney will work in 10-30 days
need HD in interim
need biopsy to find out why
what is hyperacute rejection and why does it occur
never event where preformed ab destroy graft on the table
how is acute rejection managed
increased immunosuppression
true/false - chronic rejection can be managed with increased immunosuppression
false - function will continue to decline and need new transplant
induction anti rejection immunosuppression
Pred IV
basilliximab
maintenance anti rejection immunosuppression
pred tacrolimus MMF ciclosporin azathioprine
high dose anti rejection immunosuppression
IV methylprednisolone ATG Ig plassma exchange Rituximab
what does CMV infection lead to and how is it treated
renal and hepatic dysfunction
oesophagitis, PJP, colitis
prophylactic gancyclovir and IV gancyclovir
what does BK nephropathy represent
over immunosuppression
common cancers for transplant?
BCC/SCC
lymphoma
causes of graft loss
acute rejection death with functioning graft recurrent disease chronic rejection viral nephropathy PTLD
3 principles of dialyiss
diffusion
convection
adsorption
describe the basic princiole of dialysis
cylinder with hollow filaments had blood passing through it, with ultrapure dialysate in countercurrent to remove toxins
describe the use of convection in dialysis
machine creates -ve pressure and causes water ultrafiltration, moving electrolytes and uraemic substances with it
describe adsorption and what it principally affecs
plasma proteins
stick to membrane surface and removed by binding
what are the benefits to haemodialyfiltration
less symptomatic
better survival and recovery time
similar cost to HD
minimum dialysis time
4hr 3x weekly
fluid restiction on dialysis patients?
1L daily if anuric
salt restriction on dialysis patients?
no more than 2.3g daily
phosphate and K restriction on patients
low PO4 and K diet
phosphate binders with meals
pros and cons of tunnelled central vein catheter
pros - immediate and easy to insert
cons - high risk infection, blockage, stenosis and thrombosis of central veins
most common organism in central line infection and what can it cause?
staph aureus
endocarditis or discitis
treatment of central line infection
vancomycin and gentamicin
line removsal
gold standard vascular access for dialysis?
arteriovenous fistula
pros and cons of arteriovenous fistula
good blood flow and less risk infection
cons - surgery and needs to mature, steal syndrome, thrombosis and stenosis
what is a HeRO graft
graft attached to brachial artery and into venous outflow component
good for poor central vein thrombosis or stenosis
what can go wrong in dialyiss
hypotension myocardial stunning haemorrhage from ruptured AVF arrhythmia cardiac arrest
describe the process of peritoneal dialysis
catheter in peritoneal cavity under umbilicus
sterile dialysate added and in contact with peritoneum to extract uraemic toxins and then exits by ultrafiltration
what are the common organisms for peritonitis secondary to PD
staph, strep, ecoli, klebsiella and diptheroids
complications of PD
infection, hernia, peritoneal membrane failure
what happens if there is peritoneal membrane failure
need to switch to HD
when to start dialysis - bloods?
resistance hyperkalaemia
unresonsive metabolic acidosis
eGFR <7ml/min
urea>40mmol/L
when to start dialysis - symptoms?
nausea vomiting itch fatigue fluid overload unresponsive to diuretics anorexia
who wouldnt you dialyse?
patients >75 as they will have similar hospital free days with or without HD
medical reasons to discontinue dialysis
haemodynamic instability progressive dementia agitation cardiovascular event terminal cancer
what is disequilibrium syndrome and what causes it
too rapid a correction of uraemic toxins, leading to cerebral oedema, seizure, death, confusion
