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RENAL REPLACEMENT THERAPY Dr Shafaq Nazir House physician Medical unit 1.

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Presentation on theme: "RENAL REPLACEMENT THERAPY Dr Shafaq Nazir House physician Medical unit 1."— Presentation transcript:

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2 RENAL REPLACEMENT THERAPY Dr Shafaq Nazir House physician Medical unit 1

3 Contents DEFINATION DEFINATION CRITERIA FOR RRT CRITERIA FOR RRT HEMODIALYSIS AND ITS COMPLICATIONS HEMODIALYSIS AND ITS COMPLICATIONS HEMOFILTERATION AND COMPLICATIONS HEMOFILTERATION AND COMPLICATIONS PERITONEAL DIALYSIS AND COMPLICATIONS PERITONEAL DIALYSIS AND COMPLICATIONS RENAL TRANSPLANT RENAL TRANSPLANT TRANSPLANT STATISTICS TRANSPLANT STATISTICS TRANSPLANT REQUIREMENTS. TRANSPLANT REQUIREMENTS. INDICATIONS INDICATIONS CONTRA INDICATIONS CONTRA INDICATIONS SOURCES OF DONORS SOURCES OF DONORS COMPATIBILITY COMPATIBILITY PROCEDURE PROCEDURE COMPLICATIONS COMPLICATIONS KIDNEY PANCREASE TRANSPLANT KIDNEY PANCREASE TRANSPLANT TRANSPLANT REQUIREMENTS TRANSPLANT REQUIREMENTS COMPLICATIONS COMPLICATIONS MCQs MCQs

4 RRT IT IS A TERM USED TO ENCOMPASS LIFE SUPPORTING TREATMENTS FOR RENAL FAILURE. IT IS A TERM USED TO ENCOMPASS LIFE SUPPORTING TREATMENTS FOR RENAL FAILURE. It includes It includes HEMODIALYSIS HEMODIALYSIS PERITONEAL DIALYSIS PERITONEAL DIALYSIS HEMOFILTERATION HEMOFILTERATION RENAL TRANSPLANT RENAL TRANSPLANT

5 Criteria for placing a patient for RRT Presence of uremic syndrome i.e 1. Hyperkalemia(unresponsive to conventional therapy) 2. Extra cellular volume expansion 3. Acidosis refractory to medical therapy 4. Bleeding diathesis 5. Creatinine clearance10ml/min per 1.73m sq

6 HEMODIALYSIS It removes waste products like potassium and urea as well as free water from blood in renal failure. It 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 membrane Principle revolves around diffusion of solutes across semi permeable membrane Dialysate flows opposite to blood flow direction in extra corporeal circuit. Dialysate flows opposite to blood flow direction in extra corporeal circuit. This counter current flow maintains concentration gradient increasing efficacy of dialysis. This counter current flow maintains concentration gradient increasing efficacy of dialysis.

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8 COMPLICATIONS OF HEMODIALYSIS DECREASE IN BLOOD PRESSURE DECREASE IN BLOOD PRESSURE FATIGUE FATIGUE CHEST PAIN CHEST PAIN LEG CRAMPS LEG CRAMPS NAUSEA HEADACHE NAUSEA HEADACHE SEPSIS LEADING TO ENDOCARDITIS SEPSIS LEADING TO ENDOCARDITIS OSTEOMYLITIS OSTEOMYLITIS HEPARIN ALLEGRY(RARE) HEPARIN ALLEGRY(RARE) LONG TERM COMPLICATIONS LIKE LONG TERM COMPLICATIONS LIKE AMYLOIDOSIS AMYLOIDOSIS NEUROPATHY NEUROPATHY HEART DISEASE HEART DISEASE

9 HEMOFILTERATION Similar to hemodialysis as it also requires a semi permeable membrane Similar to hemodialysis as it also requires a semi permeable membrane However, governed by convection rather than by diffusion However, governed by convection rather than by diffusion Dialysate is not used Dialysate is not used Requires a positive hydrostatic pressure driving water and solutes to filterate compartment Requires a positive hydrostatic pressure driving water and solutes to filterate compartment Both small and large solute particles are dragged through, due to hydrostatic pressure. Both small and large solute particles are dragged through, due to hydrostatic pressure. High quality replacement fluid(isotonic) is used as ultrafilterate substitute. High quality replacement fluid(isotonic) is used as ultrafilterate substitute.

10 HEMOFILTERATION OUTCOME ADVANTAGES: Less hemodynamic instability Less hemodynamic instability No exposure to dialysis fluid No exposure to dialysis fluidDISADVANTAGES: more expensive than hemodialysis more expensive than hemodialysis

11 PERITONEAL DIALYSIS Works on the principal of peritoneal membrane acting as a natural semi-permeable membrane Works on the principal of peritoneal membrane acting as a natural semi-permeable membrane Dialysis fluid when instilled around it is removed by diffusion, excessive fluid by osmosis(by altering conc of glucose in fluid.) Dialysis fluid when instilled around it is removed by diffusion, excessive fluid by osmosis(by altering conc of glucose in fluid.) Simple to perform Simple to perform Less complex Less complex Used both children and elderly Used both children and elderly In diabetics and cardiovascular diseases In diabetics and cardiovascular diseases

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13 TYPES OF PERITONEAL DIALYSIS Continuous ambulatory peritoneal dialysis Continuous ambulatory peritoneal dialysis Automated peritoneal dialysis Automated peritoneal dialysis CAPD uses smallest quantity of of fluid daily to prevent uremia CAPD uses smallest quantity of of fluid daily to prevent uremia 2L bags are changed 3-5 times a day 2L bags are changed 3-5 times a day A total dialysate of 10L is produced. A total dialysate of 10L is produced. APD involves cyclic peritoneal dialysis, APD involves cyclic peritoneal dialysis, Intermittent peritoneal dialysis Intermittent peritoneal dialysis Night intermittent dialysis Night intermittent dialysis Tidal intermittent dialysis Tidal intermittent dialysis

14 SIDE EFFECTS OF PERITONEAL DIALYSIS SIDE EFFECTS OF PERITONEAL DIALYSIS Peritonitis(staph 60%, gram –ve 20%, fungi<5%) Peritonitis(staph 60%, gram –ve 20%, fungi<5%) Exit site infection Exit site infection Catheter malfunction Catheter malfunction Loss of ultrafilteration Loss of ultrafilteration Obesity Obesity Hernia Hernia Back pain Back pain hyperlipidemia hyperlipidemia

15 WHAT IS KIDNEY TRANSPLANT? Renal transplant is the organ transplant of a kidney in a patient having end stage renal disease. Renal transplant is the organ transplant of a kidney in a patient having end stage renal disease.

16 PROGNOSIS It is a life extending procedure It is a life extending procedure A patient can live 10 to 15 years longer with a kidney transplant than if kept on dialysis A patient can live 10 to 15 years longer with a kidney transplant than if kept on dialysis Ideally, transplant should be pre-emptive, i.e take place before patient starts on with dialysis Ideally, transplant should be pre-emptive, i.e take place before patient starts on with dialysis Studies suggest the longer a patient is on dialysis before transplant, the less time the kidney will last. Studies 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. It has better prognosis in younger patients, even 75 year old recipients gain an average of 4 more years.

17 TRANSPLANT STATISTICS Country Year Cadaveric donor Living donor Total Transplant Canada France Italy Spain United Kingdom United States Pakistan - SIUT

18 TRANSPLANT REQUIREMENTS Vary from program to program, country to country. Vary from program to program, country to country. Age must be less than 69 years Age must be less than 69 years TRANSPLANT EXCLUSION CRITERIA Mental illness, Mental illness, substance abuse, substance abuse, significant cardiovascular disease, significant cardiovascular disease, terminal incurable infectious diseases terminal incurable infectious diseases cancer cancer HIV IS NO LONGER A CONTRA-INDICATION TO TRANSPLANT HIV IS NO LONGER A CONTRA-INDICATION TO TRANSPLANT

19 INDICATIONS OF TRANSPLANT ESRD(end stage renal disease), regardless of primary cause I.e drop in GFR 20-25% of normal. ESRD(end stage renal disease), regardless of primary cause I.e drop in GFR 20-25% of normal. Malignant hypertension Malignant hypertension Infections Infections Diabetes mellitus Diabetes mellitus Glomerulonephritis Glomerulonephritis Poly cystic kidney disease Poly cystic kidney disease Auto immune conditions like Lupus and good pastures syndrome Auto immune conditions like Lupus and good pastures syndrome

20 CONTRA INDICATIONS Cardio pulmonary insufficiency Cardio pulmonary insufficiency Hepatic insufficiency Hepatic insufficiency Recent cancer Recent cancer Substance abuse Substance abuse Tobacco use and morbid obesity risks for surgical complications Tobacco use and morbid obesity risks for surgical complications

21 HOW RENAL TRANSPLANT IS DONE The barely functional kidney is not removed as it increases surgical morbidities The barely functional kidney is not removed as it increases surgical morbidities The donated kidney is placed in the ILIAC FOSSA with a separate blood supply The donated kidney is placed in the ILIAC FOSSA with a separate blood supply Donors renal artery is connected to EXTERNAL ILIAC ARTERY of recipient Donors renal artery is connected to EXTERNAL ILIAC ARTERY of recipient Renal vein is connected to EXTERNAL ILIAC VEIN of the recipient. Renal vein is connected to EXTERNAL ILIAC VEIN of the recipient. The whole operation takes 3 hours The whole operation takes 3 hours

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23 POST OPERATION Blood is allowed to flow through kidney to minimize the ischemia time. Blood is allowed to flow through kidney to minimize the ischemia time. Final step is to connect the donors ureter to the recipient bladder Final step is to connect the donors ureter to the recipient bladder Living donor kidneys require 3 to 5 days to function at normal levels Living donor kidneys require 3 to 5 days to function at normal levels Cadaveric donations take 7 to 15 days to function at normal levels. Cadaveric donations take 7 to 15 days to function at normal levels.

24 ABOUT DONORS 1. Donors may be LIVING or DECEASED 2. MAY or MAY NOT be genetically related 3. even ABO COMPATIBILITY and TISSUE MATCH are no longer a requirement. In 2004 FDA approved the Cedars- Sinai High dose IVIG therapy which stops recipients immune system from tissue rejection.

25 BD AND DCD DONORS The deceased donor may be The deceased donor may be BRAIN DEAD or DONATE AFTER CADAVERIC DEATH BRAIN DEAD or DONATE AFTER CADAVERIC DEATH Brain dead donors still have their hearts pumping blood and perfusing the organs when the operation begins. Brain 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. 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) 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)

26 KIDNEY PANCREAS TRANSPLANT Done occasionally in IDDM suffering from diabetic nephropathy. Done occasionally in IDDM suffering from diabetic nephropathy. Mostly a deceased donor pancreas is used. Mostly a deceased donor pancreas is used. It may be SKP(simultaneous kidney-panc transplant), PAK(pancreas after kidney transplant). It may be SKP(simultaneous kidney-panc transplant), PAK(pancreas after kidney transplant). Transplanting only ISLET CELLS is in experimental stage Transplanting only ISLET CELLS is in experimental stage It requires breaking down donor pancreas, extracting islet cells and injecting via a catheter into recipient pancreas It requires breaking down donor pancreas, extracting islet cells and injecting via a catheter into recipient pancreas Recipient continues to take immunosuppressants to avoid rejection. Recipient continues to take immunosuppressants to avoid rejection. Most patients require 2 or 3 such injections and in some insulin may still be needed. Most patients require 2 or 3 such injections and in some insulin may still be needed.

27 COMPLICATIONS OF RENAL TRANSPLANT Transplant rejection Transplant rejection Infection and sepsis due to immunosuppressants Infection and sepsis due to immunosuppressants Post transplant lymphoproliferative disorders(lymphomas)due to immunosuppressants. Post transplant lymphoproliferative disorders(lymphomas)due to immunosuppressants. Electrolyte imbalance(Ca and Ph) causing bone problems Electrolyte imbalance(Ca and Ph) causing bone problems Acne, hairsuitism, hair loss, obesity, hypercholestrolemia, diabetes mellitus(type2) Acne, hairsuitism, hair loss, obesity, hypercholestrolemia, diabetes mellitus(type2) In case of rejection, patient may opt for a second transplant and return to dialysis intermediatly. In case of rejection, patient may opt for a second transplant and return to dialysis intermediatly.

28 MCQs Which of the following procedures is superior in a patient with creatinine clearence of 10ml/min? Which of the following procedures is superior in a patient with creatinine clearence of 10ml/min? 1. Hemodilation 2. Hemofilteration 3. Renal transplant 4. Peritoneal dialysis

29 MCQs Common side effect of peritoneal dialysis is peritonitis due to 1. Staphylococci? 2. Streptococci? 3. Fungi? 4. Gram negative organisms?

30 MCQs A patient with hepatitis C after renal transplant Does not require any treatment for HCV Does not require any treatment for HCV Can survive with ribavarin treatment only Can survive with ribavarin treatment only Needs both ribavirin and INF therapy for good prognosis Needs both ribavirin and INF therapy for good prognosis Does not survive despite any treatment Does not survive despite any treatment

31 TAKE HOME MESSAGE Never hesitate treating patients with end stage renal disease. Never 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. Always go for the best available treatment option in the form of life extending procedure for patient benefit.

32 THANK YOU


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