I don't measure a man's success I don't measure a man's success by how high he climbs but by how high he climbs but

how high he bounces when he hits how high he bounces when he hits bottom….. -bottom….. -George PattonGeorge Patton!!!!

Renal Replacement Renal Replacement TherapyTherapyDr. Sandeep G Huilgol

Dept of Nephrology and Transplantation

Some Historical Some Historical aspects…… aspects……

First hemodialysis in a human being was by Hass (February 28, 1924).

Dr. Willem Kolff was the first to construct a working dialyzer in 1943.

The first documented kidney transplant in the United States was performed June 17, 1950, on Ruth Tucker, a 44-year-old woman with polycystic kidney disease.

In 1954, at Brigham Hospital Dr. Joseph E. Murray and Dr. J. Hartwell Harrison performed the world's first successful renal transplant between genetically identical patients, for which Dr. Murray received the Nobel Prize for Medicine in 1990.

The first ever human kidney transplant performed in India was done at the King Edward Memorial Hospital at Bombay in May 1965, using a cadaver donor in a non-renal failure patient who had had hypernephroma.

The first successful Live Donor renal transplant in India was done at the CMC Hospital, Vellore in January 1971

VN Acharya. VN Acharya. RENAL TRANSPLANTATION RENAL TRANSPLANTATION Journal of post graduate medicine,1994; 40,3: 158-Journal of post graduate medicine,1994; 40,3: 158-6161

RENAL REPLACEMENT RENAL REPLACEMENT THERAPYTHERAPY

A) Dialysis TherapyA) Dialysis Therapy Hemodialysis

Peritoneal Dialysis

B) Renal TransplantB) Renal Transplant

Dialysis TherapyExtracorporealExtracorporeal:: Intermittent HemodialysisIntermittent Hemodialysis

Slow Low efficiency Dialysis (SLED)Slow Low efficiency Dialysis (SLED) Continuous HemofiltrationContinuous Hemofiltration

CAVHCAVH SCUFSCUF CVVHCVVH CAVHDFCAVHDF CVVHDFCVVHDF

IntracorporeaIntracorporeal:l: Peritoneal DialysisPeritoneal Dialysis

PD: - It is a substitution therapy - Replaces partially the excretory function and contributes to the maintenance of fluid, electrolyte and acid base balance

Patient undergoing Peritoneal Dialysis (CAPD)

Peritoneal dialysis

Simple to set up & Simple to set up & performperform

Easy to use in infantsEasy to use in infants Hemodynamic stabilityHemodynamic stability No anti-coagulationNo anti-coagulation Bedside peritoneal Bedside peritoneal

accessaccess Treat severe Treat severe

hypothermia or hypothermia or hyperthermiahyperthermia

Unreliable ultrafiltrationUnreliable ultrafiltration Slow fluid & solute Slow fluid & solute

removalremoval Drainage failure & Drainage failure &

leakageleakage Catheter obstructionCatheter obstruction Respiratory compromiseRespiratory compromise HyperglycemiaHyperglycemia PeritonitisPeritonitis Not good for Not good for

hyperammonemia or hyperammonemia or intoxication with intoxication with dialyzable poisonsdialyzable poisons

Advantages Disadvantages

Forms of PDForms of PD::1.Manual procedure:1.Manual procedure: a) Acute PD: rapid cycling ona) Acute PD: rapid cycling on intermittent basis,3-4 times perintermittent basis,3-4 times per week, each session for 2-3daysweek, each session for 2-3days b) Cont. Ambulatory PD : 3-4 hr daytime dwells + b) Cont. Ambulatory PD : 3-4 hr daytime dwells +

a long bedtime exchangea long bedtime exchange

2.Automated Procedure: a) Acute PD - same but using automatic PD machine b) Continuous cycling PD - long day dwell with multiple short night time exchange c) Nocturnal intermittent PD – no day dwell

but with multiple short night time exchanges d) Tidal PD – the fluid in the abdomen is not completely drained. The dialysate fluid

left in the abdomen helps in continuous dialysis without the break

PD Machine

Indications of PD:Indications of PD:

Biochemical indications

1. Metabolic Acidosis2. Hyperkalemia

(Sr K:> 6mEq/L)

Clinical indications1. Refractory edema2. Pulmonary edema3. Symptomatic

uremia

Uses Of PD: 1. Renal failure 2. Poisoning : salicylate phenobarbitone phenytoin sodium 3. Inborn errors of metabolism: hyperammonia syndrome urea cycle defect

HemodialysisExtracorporeal therapyExtracorporeal therapy:: Acute Intermittent HemodialysisAcute Intermittent Hemodialysis CRRTCRRT

Mechanisms-Mechanisms-1.1. Hemodialysis- most commonly used therapyHemodialysis- most commonly used therapy2.2. HemofiltrationHemofiltration3.3. HemodiafiltrationHemodiafiltration4.4. HemoperfusionHemoperfusion5.5. Apheresis Apheresis

HaemodialysisHaemodialysis Can be through Can be through

a Central a Central Venous CatheterVenous Catheter

AV Shunt AV Shunt OROR Through a Through a

Arterio – Venous Arterio – Venous FistulaFistula

Sythetic GraftSythetic Graft

Synthetic GraftSynthetic Graft

A B

Blood pump

Trip chamber

Intermittent HemodialysisIntermittent Hemodialysis For critically ill patients may be it is limited orFor critically ill patients may be it is limited or ineffective due to the critical nature of theineffective due to the critical nature of the illness. illness. Volume overload and hemodynamic instabilityVolume overload and hemodynamic instability may not be treated adequately.may not be treated adequately.

Complications of IHD:Complications of IHD: Systemic hypotension which might lead toSystemic hypotension which might lead to Multi-organ dysfunctionMulti-organ dysfunction ArrhythmiasArrhythmias HypoxemiaHypoxemia HemorrhageHemorrhage

IHDIHD

Maximum solute Maximum solute clearance of 3 clearance of 3 modalitiesmodalities

Best therapy for Best therapy for severe hyperkalemiasevere hyperkalemia

Limited anti-Limited anti-coagulation timecoagulation time

Bedside vascular Bedside vascular access can be usedaccess can be used

Hemodynamic Hemodynamic instabilityinstability

HypoxemiaHypoxemia Rapid fluid and Rapid fluid and

electrolyte shiftselectrolyte shifts Complex equipmentComplex equipment Specialized personnelSpecialized personnel Difficult in small Difficult in small

infantsinfants

Advantages

Disadvantages

Continuous Renal Replacement TherapyContinuous Renal Replacement Therapy:: - - Based on principles of HemofiltrationBased on principles of Hemofiltration - Substitute for impaired renal function- Substitute for impaired renal function over an extended period of time andover an extended period of time and applied for 24 hours a day.applied for 24 hours a day.

What is CRRT Continuous Dialysis of Critically Ill Patients Continuous Dialysis of Critically Ill Patients

in the ICU in the ICU The concept behind CRRT is to dialyze patients The concept behind CRRT is to dialyze patients

in a more physiologic way, slowly over 24 in a more physiologic way, slowly over 24 hours, just like the kidney. Intensive care hours, just like the kidney. Intensive care patients are particularly suited as they are by patients are particularly suited as they are by definition, bed bound and when acutely sick, definition, bed bound and when acutely sick, intolerant to fluid swings associated to IHDintolerant to fluid swings associated to IHD

Electrolyte Management / dialysate mirrors ideal Electrolyte Management / dialysate mirrors ideal blood compositionblood composition

Allows for provision of nutritional supportAllows for provision of nutritional support Management of sepsis / plasma cytokine filterManagement of sepsis / plasma cytokine filter Probable advantage in terms of renal recoveryProbable advantage in terms of renal recovery Improved nutritional support (full protein diet)Improved nutritional support (full protein diet)

CRRT ModalitiesCRRT Modalities SCUF- SCUF- Slow Continuous Ultra filtrationSlow Continuous Ultra filtration

Ultra filtrationUltra filtration CVVH- CVVH- Continuous Veno-Venous HemofiltrationContinuous Veno-Venous Hemofiltration

ConvectionConvection CVVHD- CVVHD- Continuous Veno-Venous HemodialysisContinuous Veno-Venous Hemodialysis

DiffusionDiffusion CVVHDF- CVVHDF- Continuous Veno-Venous Continuous Veno-Venous

HemodiafiltrationHemodiafiltration Diffusion and ConvectionDiffusion and Convection

Renal Transplantation

OutlineBasics of transplantationBasics of transplantationBenefits of transplantationBenefits of transplantation Immunosuppressive medicationsImmunosuppressive medicationsCommon post-transplant problemsCommon post-transplant problems

Basics of TransplantationBasics of TransplantationKidney transplantation is the most effective therapy Kidney transplantation is the most effective therapy

for end-stage renal disease.for end-stage renal disease.The transplanted organ can come from either a live The transplanted organ can come from either a live

donor or deceased donor.donor or deceased donor.Thorough donor evaluation should be doneThorough donor evaluation should be done - medical history, physical exam., blood group, - medical history, physical exam., blood group,

HLAHLA typing, LFT, RFT, Urine analysis, screening fortyping, LFT, RFT, Urine analysis, screening for HIV, HBV, HCV,TB, psychological testing, ECG,HIV, HBV, HCV,TB, psychological testing, ECG, CXR, Echo ,USG & spiral CT for renal anatomy. CXR, Echo ,USG & spiral CT for renal anatomy.

Recipient SelectionRecipient SelectionVery few contraindications.Very few contraindications.Screening for HIV,HBV,HCV,CMV,EBV,TB.Screening for HIV,HBV,HCV,CMV,EBV,TB.Cardiovascular screening.Cardiovascular screening. Immunize as per schedule- hepatitis B,varicellaImmunize as per schedule- hepatitis B,varicellaOptimize nutritional statusOptimize nutritional statusThorough history & physical examThorough history & physical examB.G.,HLA Type, RFT, LFTB.G.,HLA Type, RFT, LFTThorough evaluation of lower urinary tractThorough evaluation of lower urinary tractSome children require bladder reconstruction Some children require bladder reconstruction

surgeries prior to transplantsurgeries prior to transplant

Socioeconomic factorsSocioeconomic factors Investigate the cause of ESRD- since certain Investigate the cause of ESRD- since certain

diseases can recur in the graft viz., FSGS, MPGN, diseases can recur in the graft viz., FSGS, MPGN, atypical HUS.atypical HUS.

Pre, intra & immediate post Pre, intra & immediate post transplant management:transplant management:

Fluid and electrolytes therapyFluid and electrolytes therapy Immunosuppressive therapyImmunosuppressive therapy pre-op.: single dose of MMF / Azathioprine + antipre-op.: single dose of MMF / Azathioprine + anti IL-2R antibodyIL-2R antibody peri-op.: I/V Methylprednisoloneperi-op.: I/V Methylprednisolone post-op.:CsA/FK506 + MMF/Azathioprine + steroidspost-op.:CsA/FK506 + MMF/Azathioprine + steroids Anti-infective prophylaxis:Anti-infective prophylaxis: Cefazolin for 24 hrs for peri-operative periodCefazolin for 24 hrs for peri-operative period Ganciclovir for CMV prophylaxis- for 4-6 monthsGanciclovir for CMV prophylaxis- for 4-6 months Septran : prophylaxis of PCP & UTISeptran : prophylaxis of PCP & UTI Nystatin : for fungal infectionsNystatin : for fungal infections

Immunosuppressive MedicationsImmunosuppressive Medications Induction:Induction:

CorticosteroidsCorticosteroidsAnti-thymocyte globulin (ATG)Anti-thymocyte globulin (ATG)OKT3OKT3IL-2 receptor antagonistsIL-2 receptor antagonists

Maintenance:Maintenance:CorticosteroidsCorticosteroidsCalcineurin inhibitors (CNIs)Calcineurin inhibitors (CNIs)mTOR inhibitorsmTOR inhibitorsAntimetabolitesAntimetabolites

Common Complications of Common Complications of TransplantationTransplantation

Early complicationsEarly complications Surgical complicationsSurgical complications Delayed or slow graft functionDelayed or slow graft function LymphoceleLymphocele

Allograft rejectionAllograft rejection Hyper acute rejection (Antibody-mediated Hyper acute rejection (Antibody-mediated

rejection) : within min. to hr of perfusing of rejection) : within min. to hr of perfusing of allograftallograft

- due to preformed antibodies to the ABO & - due to preformed antibodies to the ABO & HLA antigens.HLA antigens.

Acute rejection – within 3 months of transplantAcute rejection – within 3 months of transplant Chronic rejectionChronic rejection

Infectious complicationsInfectious complications CytomegalovirusCytomegalovirus BK virusBK virus OthersOthers

Hypertension- diet therapy, ACEI, CCBHypertension- diet therapy, ACEI, CCB Hematologic complications : anemia, leukopenia, Hematologic complications : anemia, leukopenia,

thrombocytopeniathrombocytopenia

Metabolic complications- hypomagnesaemia, Metabolic complications- hypomagnesaemia, hypophosphatemia, Hypercalcemia, hypophosphatemia, Hypercalcemia, Hyperkalemia, RTA, dyslipidemiaHyperkalemia, RTA, dyslipidemia

Malignancy- Post transplant lymphoproliferative Malignancy- Post transplant lymphoproliferative disorderdisorder

Recurrence of Primary Disease in the Allograft- Recurrence of Primary Disease in the Allograft- FSGS, MPGN, atypical HUS,WG.FSGS, MPGN, atypical HUS,WG.

Treatment :CsA, Cyclophosphamide.Treatment :CsA, Cyclophosphamide. Chronic allograft dysfunctionChronic allograft dysfunction

Surgical ComplicationsSurgical Complications LymphoceleLymphocele Perirenal serous fluid collection Perirenal serous fluid collection HematomaHematoma Graft thrombosis:Graft thrombosis:

Caused by thrombosis of donor renal artery or Caused by thrombosis of donor renal artery or vein.vein.

Usually happens in first week.Usually happens in first week. Diagnosed by ultrasound with doppler studies.Diagnosed by ultrasound with doppler studies. Almost always requires explant of kidney.Almost always requires explant of kidney.

Thank you