RENAL REPLACEMENT THERAPY (RRT)

RRT: Modalities Hemodialysis Peritoneal Dialysis Renal Transplantation Living-Related, Living-Unrelated Cadaveric CRRT CAVH, CVVH, SCUF CAVHD,CVVHD, CAVHDF, CVVHDF

RRT: Absolute Indications for Dialysis Fluid Overload Hyperkalemia Severe Metabolic Acidosis Uremic Pericarditis Uremic Enchephalopathy Intoxication: Methanol, ethylene glycol ASA, & Lithium

RRT: Relative Indications for Dialysis Uremic Neuropathy Malnutrition of CRF Correct bleeding time before surgery Cr. clearance <10 ml/minute Level of urea & creatinine ??

Hemodialysis: Dialyzer Arterial blood from Patient out going dialysate Incoming Dialysate solution Venous blood to patient

Hemodialysis: Principles Solutes are effectively removed by diffusion Water is removed by convection (UF) Both mechanisms contribute to solute removal

Peritoneal Dialysis: Types Continuos Ambulatory Peritoneal Dialysis (CAPD) 4 cycles of 2 liter of dialysate Intermittent Peritoneal Dialysis (IPD) Whole day or night for 2-3 times/ week Continuos Cyclic Peritoneal Dialysis (CCPD) Eight , 2 liters exchanges during night

Peritoneal Dialysis: Principle Diffusion: for solutes From high concentration gradient to low concentration gradient Osmosis: for water Depends on concentration of sugar in the dialysate fluid The fluid and solute removal can be enhanced by increasing the volume of dialysate and the number of exchanges

Peritoneal Dialysis: CAPD, IPD Hanger PD dialysate solution Connection set PD Catheter draining bag

PD: Advantages A more normal life-style Better residual renal function Less stringent fluid and diet restriction Stable solutes concentration (no dysequilibrium) Better hemoglobin level More economic: 2/3 of HD cost

PD: Complications CAPD PERITONITIS Abdominal pain Fever Turbid effluent WBC in effluent >400 Organisms: Staph. aureus and epidermedis Gram negative: Klebseilla, pseudomonas Candida

CAPD PERITONITIS: Treatment 3 flushes in & out Loading dose Intraperitoneal antibiotics: Cefazoline and Tobramycin Or Vancomycin & Tobramycin Maintenance dose IP antibiotics: Change antibiotics according to sensitivity

CAPD: Complications & Treat. Tunnel infection Pain and swelling at tunnel site Fever Treatment: Vancomycin IV Exit site infection Redness at exit site with discharge Cloxacillin or Vancomycin

CAPD: Complications & Treat. Catheter leak Treatment: Temporary conversion to HD Catheter dysfunction: causes Constipation: laxatives Fibrin: IP heparin Omental wrap May require replacement

CAPD: Complications Obesity & hypertriglyceridemia Due to excessive absorption of glucose Protein loss & hypoalbuminemia Loss with the effluent Bloody Effluent: Ruptured corpus leutium (ovulation) Endometriosis

CRRT: Types CAVH: UF only CVVH: UF only SCUF: slow UF CAVHD: Dialysis CVVHD: Dialysis CAVHDF: UF & Dialysis CVVHDF: UF & Dialysis

CRRT: Principle Ultrafiltration: The main driving force Diffusion: slow and efficient only with time Patient need replacement of fluid loss up to 18 liters/ day (in CAVH, CVVH, CAVHDF & CVVHDF)

CRRT: CAVH Replacement Arterial Venous Qb=50-100 ml/min Qf= 8-12 ml/min UF

CRRT: CAVHD Dialysate In Arterial Venous Qb=50-100 ml/min Qd=10-20 ml/min Qf= 1-3 ml/min Dialysate out

CRRT: CVVH Replacement Venous Venous Pump Qb=50-200 ml/min Qf= 10-20 ml/min UF

CRRT: CVVHD Dialysate In Pump Venous Venous Qb=50-200 ml/min Qd=10-30 ml/min Qf= 1-5 ml/min Dialysate out

CRRT: Indications Acute Renal failure in hemodynamically unstable patient & MOF Volume control in septic patient with no Renal failure Removal of mediators of sepsis Refractory Congestive Heart Failure ARF in acute and chronic liver disease Tumor lysis syndrome, lithium intox.?