2RENAL REPLACEMENT THERAPY Dr Shafaq NazirHouse physicianMedical unit 1
3Contents DEFINATION CRITERIA FOR RRT HEMODIALYSIS AND ITS COMPLICATIONSHEMOFILTERATION AND COMPLICATIONSPERITONEAL DIALYSIS AND COMPLICATIONSRENAL TRANSPLANTTRANSPLANT STATISTICSTRANSPLANT REQUIREMENTS.INDICATIONSCONTRA INDICATIONSSOURCES OF DONORSCOMPATIBILITYPROCEDURECOMPLICATIONSKIDNEY PANCREASE TRANSPLANTTRANSPLANT REQUIREMENTSMCQs
4RRTIT IS A TERM USED TO ENCOMPASS LIFE SUPPORTING TREATMENTS FOR RENAL FAILURE.It includesHEMODIALYSISPERITONEAL DIALYSISHEMOFILTERATIONRENAL TRANSPLANT
5Criteria for placing a patient for RRT Presence of uremic syndrome i.eHyperkalemia(unresponsive to conventional therapy)Extra cellular volume expansionAcidosis refractory to medical therapyBleeding diathesisCreatinine clearance10ml/min per 1.73m sq
6HEMODIALYSISIt removes waste products like potassium and urea as well as free water from blood in renal failure.Principle revolves around diffusion of solutes across semi permeable membraneDialysate flows opposite to blood flow direction in extra corporeal circuit.This counter current flow maintains concentration gradient increasing efficacy of dialysis.
8COMPLICATIONS OF HEMODIALYSIS DECREASE IN BLOOD PRESSUREFATIGUECHEST PAINLEG CRAMPSNAUSEA HEADACHESEPSIS LEADING TO ENDOCARDITISOSTEOMYLITISHEPARIN ALLEGRY(RARE)LONG TERM COMPLICATIONS LIKEAMYLOIDOSISNEUROPATHYHEART DISEASE
9HEMOFILTERATIONSimilar to hemodialysis as it also requires a semi permeable membraneHowever, governed by convection rather than by diffusionDialysate is not usedRequires a positive hydrostatic pressure driving water and solutes to filterate compartmentBoth small and large solute particles are dragged through, due to hydrostatic pressure.High quality replacement fluid(isotonic) is used as ultrafilterate substitute .
10HEMOFILTERATION OUTCOME ADVANTAGES:Less hemodynamic instabilityNo exposure to dialysis fluidDISADVANTAGES:more expensive than hemodialysis
11PERITONEAL DIALYSISWorks on the principal of peritoneal membrane acting as a natural semi-permeable membraneDialysis fluid when instilled around it is removed by diffusion, excessive fluid by osmosis(by altering conc of glucose in fluid.)Simple to performLess complexUsed both children and elderlyIn diabetics and cardiovascular diseases
13TYPES OF PERITONEAL DIALYSIS Continuous ambulatory peritoneal dialysisAutomated peritoneal dialysisCAPD uses smallest quantity of of fluid daily to prevent uremia2L bags are changed 3-5 times a dayA total dialysate of 10L is produced.APD involves cyclic peritoneal dialysis,Intermittent peritoneal dialysisNight intermittent dialysisTidal intermittent dialysis
14SIDE EFFECTS OF PERITONEAL DIALYSIS Peritonitis(staph 60%, gram –ve 20%, fungi<5%)Exit site infectionCatheter malfunctionLoss of ultrafilterationObesityHerniaBack painhyperlipidemia
15WHAT IS KIDNEY TRANSPLANT? Renal transplant is the organ transplant of a kidney in a patient having end stage renal disease.
16PROGNOSIS It is a life extending procedure A patient can live 10 to 15 years longer with a kidney transplant than if kept on dialysisIdeally, transplant should be pre-emptive, i.e take place before patient starts on with dialysisStudies suggest the longer a patient is on dialysis before transplant, the less time the kidney will last.It has better prognosis in younger patients, even 75 year old recipients gain an average of 4 more years.
17TRANSPLANT STATISTICS Country Year Cadaveric donor Living donorTotal TransplantCanada20007243881112France200319911362127Italy14891351624Spain602051United Kingdom12974391736United States8667647915137Pakistan - SIUT200818541900
18TRANSPLANT REQUIREMENTS Vary from program to program, country to country.Age must be less than 69 yearsTRANSPLANT EXCLUSION CRITERIAMental illness,substance abuse,significant cardiovascular disease,terminal incurable infectious diseasescancerHIV IS NO LONGER A CONTRA-INDICATION TO TRANSPLANT
19INDICATIONS OF TRANSPLANT ESRD(end stage renal disease), regardless of primary cause I.e drop in GFR 20-25% of normal.Malignant hypertensionInfectionsDiabetes mellitusGlomerulonephritisPoly cystic kidney diseaseAuto immune conditions like Lupus and good pastures syndrome
20CONTRA INDICATIONS Cardio pulmonary insufficiency Hepatic insufficiencyRecent cancerSubstance abuseTobacco use and morbid obesity risks for surgical complications
21HOW RENAL TRANSPLANT IS DONE The barely functional kidney is not removed as it increases surgical morbiditiesThe donated kidney is placed in the ILIAC FOSSA with a separate blood supplyDonors renal artery is connected to EXTERNAL ILIAC ARTERY of recipientRenal vein is connected to EXTERNAL ILIAC VEIN of the recipient.The whole operation takes 3 hours
23POST OPERATIONBlood is allowed to flow through kidney to minimize the ischemia time.Final step is to connect the donors ureter to the recipient bladderLiving donor kidneys require 3 to 5 days to function at normal levelsCadaveric donations take 7 to 15 days to function at normal levels.
24ABOUT DONORS Donors may be “LIVING” or “DECEASED” MAY or MAY NOT be genetically relatedeven ABO COMPATIBILITY and TISSUE MATCH are no longer a requirement.In 2004 FDA approved the Cedars- Sinai High dose IVIG therapy which stops recipient’s immune system from tissue rejection.
25BD AND DCD DONORS The deceased donor may be BRAIN DEAD or DONATE AFTER CADAVERIC DEATHBrain dead donors still have their hearts pumping blood and perfusing the organs when the operation begins.DCD donors elect via living will or family to withdraw mechanical ventilation, when death is pronounced, are rushed to theater for kidney removal and storage.Kidneys from B.D donors are superior to DCD donors,since they are not exposed to warm ischemia (time between stopping and kidney being cooled)
26KIDNEY PANCREAS TRANSPLANT Done occasionally in IDDM suffering from diabetic nephropathy.Mostly a deceased donor pancreas is used.It may be SKP(simultaneous kidney-panc transplant), PAK(pancreas after kidney transplant).Transplanting only ISLET CELLS is in experimental stageIt requires breaking down donor pancreas, extracting islet cells and injecting via a catheter into recipient pancreasRecipient continues to take immunosuppressants to avoid rejection.Most patients require 2 or 3 such injections and in some insulin may still be needed.
27COMPLICATIONS OF RENAL TRANSPLANT Transplant rejectionInfection and sepsis due to immunosuppressantsPost transplant lymphoproliferative disorders(lymphomas)due to immunosuppressants.Electrolyte imbalance(Ca and Ph) causing bone problemsAcne, hairsuitism, hair loss, obesity, hypercholestrolemia, diabetes mellitus(type2)In case of rejection, patient may opt for a second transplant and return to dialysis intermediatly.
28MCQsWhich of the following procedures is superior in a patient with creatinine clearence of 10ml/min?HemodilationHemofilterationRenal transplantPeritoneal dialysis
29MCQs Common side effect of peritoneal dialysis is peritonitis due to Staphylococci?Streptococci?Fungi?Gram negative organisms?
30MCQs A patient with hepatitis C after renal transplant Does not require any treatment for HCVCan survive with ribavarin treatment onlyNeeds both ribavirin and INF therapy for good prognosisDoes not survive despite any treatment
31TAKE HOME MESSAGENever hesitate treating patients with end stage renal disease.Always go for the best available treatment option in the form of life extending procedure for patient benefit.