Tutorial: Dialysis and kidney transplant

Question 1

LO:

Answer 1

• 1-BRS-URO-3: Genitourinary disorders: Summarise the pathology and pathophysiology of genitourinary disorders.
• 1-BRS-URO-4: Genitourinary disorders: Describe the clinical features and treatment options of genitourinary disorders.

Question 2

Case: Mr Shah, 59-year-old Indian origin male with a medical history of hypertension, who works as a consultant with a multinational company has to frequently travel overseas for work. While abroad, he developed gastroenteritis, resulting in 5 days of diarrhoea, vomiting and limited oral intake. He purchased ibuprofen to treat abdominal pain and headaches, which he took for 7 days. Fourteen days after symptom onset, on return to the UK, he reported to his GP complaining of loss of appetite, vomiting, chronic fatigue, swelling in ankles and breathlessness. He was referred to the nephrology clinic and initial tests revealed his GFR value was 10ml/min. Blood tests found the Blood Urea Nitrogen (BUN) was 30mg/dL, potassium was 6.2mmol/L, and serum creatinine was 1500umol/L. Both the kidneys were measured to be 11cm each through ultrasound.

What is your differential diagnosis?

Answer 2

The normal BUN level is between about 7 and 21 milligrams per deciliter (mg/dL). So his is high

A GFR of 90 mL/min or higher is normal in most healthy people. So his GFR is very low

High creatine and potassium

=

Acute kidney injury-more likely than chronic kidney disease as normal size kidneys haven’t been told about progressive rise in creatinine and we expect he has had baseline investigation before so probs more acute

Chronic is progressive rise and you accommodate it more easily so less key symptoms

Chronic kidney disease

Question 3

Identify probable cause(s) for his disorder.

Answer 3

• sequelae of gastroeneteritis ie got dehydrated with diarrhoea and vomiting, ecoli can cause haemolytic uraemic syndrome and that usually has bloody diarrhoae, would find anaemia with this too
• NSAID use-dehydrated and taking NSAID is even worse-nephrotoxic
• hypertension, may have underlying CKD which makes him more vulnerable to AKI
• dehydration causes hypovolemia so reduced blood flow to kidney so get acute tubular necrosis

Question 4

What treatment should be considered for Mr Shah?

Answer 4

Acute dialysis given if-hyperkalemia resistant to treatment, or have pulmonary odema with no urine output which he doesn’t have

So have time to move to dialysis output, if not getting better with conservative consider dialysis for him

Potassium is only 6.2 and no abnormal ECG so don’t give insulin dextrose

Give potassium binder, laxative, IV sodium bicarbonate, diuretics to treat hyperkalaemia

Don’t give diuretics at same time as fluids

If peeing give furosemide

If hypovolemic give fluids

Question 5

Dialysis methods

Answer 5

haemodialysis-blood pumped into dialyzer-blood in one direction and dialysis solution going in other direction. Semi permeable membrane, so solutes move by diffusion. Dialysis solution is chosen according to patient needs and filtered blood goes back to patient

Peritoneal dialysis-Here peritoneum serves as semi-permeable membrane. Visceral surrounds organs, solution pumped into abdominal cavity, across visceral membrane diffusion occurs and after some time solution is pumped out

Question 6

Dialysis methods comparison:

Answer 6

Question 7

The consultant decided to start Mr Shah on dialysis. Please research in your groups the different types of dialysis, and the considerations with each type. Submit your choice of dialysis method with reasoning.

Answer 7

Dialysis works by osmosis across semi-permeable membrane. There are 2 different forms of chronic ie long term dialysis-vascular access for haemo, peritoneal access for peritoneal. 3 times a week for 4 hrs for haemo, continuous or overnight for peritoneal.

=This guy needs to travel and we need to preserve his lifestyle. Peritoneal dialysis is easier to travel with.

Hemodialysis is the most common type of dialysis. This process uses an artificial kidney (hemodialyzer) to remove waste and extra fluid from the blood. The blood is removed from the body and filtered through the artificial kidney. The filtered blood is then returned to the body with the help of a dialysis machine.

Peritoneal dialysis involves surgery to implant a peritoneal dialysis (PD) catheter into your abdomen. The catheter helps filter your blood through the peritoneum, a membrane in your abdomen. During treatment, a special fluid called dialysate flows into the peritoneum. The dialysate absorbs waste. Once the dialysate draws waste out of the bloodstream, it’s drained from your abdomen. This process takes a few hours and needs to be repeated four to six times per day. However, the exchange of fluids can be performed while you’re sleeping or awake.

Question 8

After being for 2 years on dialysis, after initially refusing, Mr Shah has decided to opt for kidney transplant. What factors are considered in determining a candidate as a suitable live kidney donor?

Answer 8

• donor match
• Age-don’t give 70 year old kidney to 20 year old
• person should be able to get through operation
• age 20 don’t know what will happen in future eg may get type 2 diabetes so prefer older patients donating
• Future pregnancy possible-prefer other donor if possible
• Good Kidney function (for recipient and so that donor will not be impaired if it is removed). Assess kidney function using nuclear medicine (so can see which kidney is performing best and leave this with donor)
• ABO compatibility to prevent hyperrejection (plasma exchange and rutiximab is given if you do transplant across blood type but this requires more immunosuppression, so less favoured)
• donor must not be coerced or bribed
• Comorbidities (diabetes and HBP)-as don’t want to leave donor likely to get CKD
• HLA typing so less likely to get rejection and less immunosuppression needed
• Donor shouldn’t donate after certain time if had cancer
• No active infection-HIV/Hep

Question 9

Please research and list recommendations for a patient who has undergone a kidney transplant surgery to lead a healthy life while managing his condition.

Answer 9

• Medicine compliance education: Explain they need to take immunosuppression medication as if they don’t they will lose their organ
• Low salt and sugar diet, regular fluid intake, not excessive alcohol as affects drug levels
• Exercise
• patients who immunosuppressed may be more susceptible to infection so avoid raw foods
• Rare interaction with tacrolimus and grapefruit which increases drug level
• Healthy BMI
• Cancer check advise as have increased risk of skin cancer
• Monitor and screen for diabetes as have increased risk of diabetes
• Monitor for complications of transplant in long term

Question 10

Kidney transplanatun

Answer 10

3 connections:

Between donor artery and recipent artery

Between donor vein and recipient vein

Between transplanted ureter and recipient bladder

Following transplant-kidney is in heterotrophic position.

Native kidneys are very damaged and they may have little bit of resdidual function, especially in preemptive kidney transplant ie before they’ve been on dialysis. But then their function decreases and urine output declines, kidnyes shrivel and in most cases they don’t cause problems, can get cysts and tumours in native kidneys that may be removed but don’t need to do much often, unless they have an inherited disorder eg polycyctic kidney disease (native kidneys are big so need to remove to make room for transplanted kidney).