Renal Replacement Renal Replacement TherapyTherapy

(RRT)(RRT)

PRESENTED BYDR SHASHANK

AGRAWALMEDICINE

ObjectivesObjectivesAt the end of this presentation the learner will be At the end of this presentation the learner will be

familiar with:familiar with:

• The stages of progressive renal failure The stages of progressive renal failure

• The renal replacement therapies available to The renal replacement therapies available to patients in North Bay and surrounding district who patients in North Bay and surrounding district who have either acute or chronic kidney failurehave either acute or chronic kidney failure

• The types of accesses required for peritoneal and The types of accesses required for peritoneal and

hemodialysishemodialysis

Primary Functions of the Primary Functions of the KidneyKidney

• Removal of metabolic wastes, drugs and Removal of metabolic wastes, drugs and other toxinsother toxins

• Fluid BalanceFluid Balance• Electrolyte BalanceElectrolyte Balance• Acid-Base RegulationAcid-Base Regulation• Blood Pressure Control Blood Pressure Control • Hormone Production ~ Erythropoietin, Hormone Production ~ Erythropoietin,

Vitamin D (Calcitriol), ReninVitamin D (Calcitriol), Renin““Master Chemists of the Body”Master Chemists of the Body”

Sidney the KidneySidney the Kidney

Stages Of Chronic Kidney DiseaseStages Of Chronic Kidney Disease

STAGE

DESCRIPTION

GFR

At Increased Risk

Risk factors for kidney disease

( e.g., diabetes, hypertension, family history, older age, ethnic group.

More than 90 mL/min

1

Kidney damage (protein in the urine) and normal GFR

More than 90 mL/min

2

Kidney damage and mild decrease

in GFR

60 to 89 mL/min

3

Moderate decrease in GFR

30 to 59 mL / min

4

Severe decrease in GFR

15 to 29 mL / min

5

Kidney Failure (dialysis or kidney

transplant needed)

Less than

15 mL/ml/min

UREMI C SYNDROME

NEUROLOGI CAL Fatigue

Sleep Disturbances Headache

Muscular I rritability Lethargy

Seizures, Coma

PSYCHOLOGI CAL Depression

Anxiety Denial

Psychosis OCULAR Red Eye Syndrome Band Keratopathy

Hypertensive Retinopathy

CARDI OVASCULAR Hypertension

CHF ASHD

Pericarditis Myocardiopathy

Uremic Lung

DERMATOLOGI CAL Pallor

Pigmentation Pruritus

Ecchymosis Excoriations

Calcium Deposition Uremic Frost

METABOLI C Carbohydrate Intolerance

Hyperlipidemia Nutrition

Gout

ENDOCRINE Hyperparathyroidism Thyroid Abnormalities

Amenorrhea I nfertility

Sexual Dysfunction

PERI PHERAL NEUROPATHY Restless Leg Syndrome

Paraesthesias Motor Weakness

Paralysis

HEMATOLOGI CAL Anemia Bleeding

GASTROI NTESTI NAL Anorexia Nausea Vomiting

Uremic Fetor on Breath Gastroenteritis

GI Bleeding Peptic Ulcer

Causes of Acute Kidney Failure:Causes of Acute Kidney Failure:

• Pre-renal factorsPre-renal factors

• Intra-renal & Nephrotoxic factorsIntra-renal & Nephrotoxic factors

• Post-renal factorsPost-renal factors

Causes of Chronic Kidney Disease:Causes of Chronic Kidney Disease:• DiabetesDiabetes• HypertensionHypertension• Renal vascular disease Renal vascular disease (also generalized vascular disease)(also generalized vascular disease)• NephritisNephritis• Pyelonephritis & chronic UT IPyelonephritis & chronic UT I• Polycystic kidney diseasePolycystic kidney disease• Renal NeoplasmsRenal Neoplasms• Analgesic nephropathyAnalgesic nephropathy• Immunological disorders: Immunological disorders: Lupus, Goodpasture syndrome, Lupus, Goodpasture syndrome,

sclerodermascleroderma• Metabolic disorders: goutMetabolic disorders: gout• Nephrotic Syndrome Nephrotic Syndrome primary or secondaryprimary or secondary

Does everyone understand Does everyone understand how important we are?how important we are?

Kidneys UrineKidneys Urine

Types of DialysisTypes of DialysisDialysis is a way to clean blood of wastes, fluids and Dialysis is a way to clean blood of wastes, fluids and salts that build up in the body when the kidneys fail. salts that build up in the body when the kidneys fail. There are 2 kinds of Dialysis:There are 2 kinds of Dialysis:

• Peritoneal Dialysis:Peritoneal Dialysis:• Uses the peritoneal membrane as the filter. The Uses the peritoneal membrane as the filter. The

membrane covers the abdominal organs and lines the membrane covers the abdominal organs and lines the abdominal wall. This takes place abdominal wall. This takes place insideinside the body and the body and requires placement of a catheter in the peritoneal cavity requires placement of a catheter in the peritoneal cavity to allow fluid to be instilled and drained out.to allow fluid to be instilled and drained out.

• Hemodialysis:Hemodialysis: • Uses a dialyzer or artificial kidney to filter the blood. Uses a dialyzer or artificial kidney to filter the blood.

This takes place This takes place outsideoutside the body and requires some the body and requires some form of access to the circulatory system. Accomplished form of access to the circulatory system. Accomplished with the use of a sophisticated computerized control unit with the use of a sophisticated computerized control unit (dialysis machine (dialysis machine ))

Other choicesOther choices• kidney transplantation:kidney transplantation:

• To be placed on a transplant list the patient To be placed on a transplant list the patient must be on some form of renal replacement must be on some form of renal replacement therapy, whether it is peritoneal dialysis or therapy, whether it is peritoneal dialysis or hemodialysishemodialysis

• Once a patient is accepted for transplant, the Once a patient is accepted for transplant, the date of start of dialysis is the date they are date of start of dialysis is the date they are active on the list active on the list

• If the patient has a living donor who has been If the patient has a living donor who has been accepted as healthy donor, it is possible to accepted as healthy donor, it is possible to have a pre-emptive transplant, bypassing have a pre-emptive transplant, bypassing dialysis.dialysis.

• No treatment or palliative careNo treatment or palliative care

Peritoneal DialysisPeritoneal Dialysis• Uses the peritoneal membrane as the filter. The Uses the peritoneal membrane as the filter. The

membrane covers the abdominal organs and lines the membrane covers the abdominal organs and lines the abdominal wall. The membrane size is 1 – 2 mabdominal wall. The membrane size is 1 – 2 m22 and and approximates the body surface area. Uses the following approximates the body surface area. Uses the following principles:principles:

• DiffusionDiffusion: movement of solutes across the peritoneal : movement of solutes across the peritoneal membrane from an area of higher concentration to an membrane from an area of higher concentration to an area of lower concentrationarea of lower concentration

• OsmosisOsmosis:: movement of water across the peritoneal movement of water across the peritoneal membrane from an area of lower solute concentration to membrane from an area of lower solute concentration to an area of higher solute concentration.an area of higher solute concentration.

• Ultrafiltration:Ultrafiltration: water removal related to an osmotic water removal related to an osmotic pressure gradient with the use of various concentrations pressure gradient with the use of various concentrations of dialysate fluidof dialysate fluid

How does PD work?How does PD work?• Fluid called DIALYSATE is put into the Fluid called DIALYSATE is put into the

abdomen through a PD catheter. This fluid abdomen through a PD catheter. This fluid is left to dwell in the peritoneum for is left to dwell in the peritoneum for several hours.several hours.

• While in the abdomen, the fluid collects While in the abdomen, the fluid collects wastes that have been filtered through the wastes that have been filtered through the peritoneal membrane. These wastes pass peritoneal membrane. These wastes pass from the body when the fluid is drained.from the body when the fluid is drained.

Peritoneal DialysisPeritoneal Dialysis• Performed daily, by the patient at home, Performed daily, by the patient at home,

more physiologicalmore physiological• Allows for independence, patients can Allows for independence, patients can

work or travelwork or travel• Fewer fluid and dietary restrictionsFewer fluid and dietary restrictions• Often fewer medications or lower doses Often fewer medications or lower doses

requiredrequired• Residual renal function preservedResidual renal function preserved• Ministry of Health funded home therapyMinistry of Health funded home therapy

Peritoneal DialysisPeritoneal DialysisPatients Patients

• must have a clean room to perform must have a clean room to perform exchanges and a large enough area to exchanges and a large enough area to store all suppliesstore all supplies

• no pets allowed in the roomno pets allowed in the room• must learn to monitor their own weight must learn to monitor their own weight

and blood pressuresand blood pressures• must be able to follow important must be able to follow important

instructions to prevent infection in the instructions to prevent infection in the peritoneumperitoneum

• must also be able to determine the must also be able to determine the choice of dialysate fluid and when to use choice of dialysate fluid and when to use itit

Peritoneal DialysisPeritoneal Dialysis

Peritoneal Dialysis CatheterPeritoneal Dialysis Catheter

Types of Peritoneal Types of Peritoneal DialysisDialysisCAPDCAPD ~ ~ Continuous Ambulatory Peritoneal DialysisContinuous Ambulatory Peritoneal Dialysis

• The blood is cleaned constantly by dialysate fluid The blood is cleaned constantly by dialysate fluid while it is in the abdomen.while it is in the abdomen.

• CAPD does not require the use of a machine, the CAPD does not require the use of a machine, the exchanges are completed manually.exchanges are completed manually.

APDAPD ~ Automated Peritoneal Dialysis~ Automated Peritoneal Dialysis

• Requires the use of a machine called a CYCLERRequires the use of a machine called a CYCLER• The CYCLER is used during the night and is set to The CYCLER is used during the night and is set to

deliver the fluid in and out of the abdomendeliver the fluid in and out of the abdomen..

HemodialysisHemodialysis• Blood is circulated through an artificial kidney Blood is circulated through an artificial kidney

which has two compartments: Blood & Dialysate, which has two compartments: Blood & Dialysate, separated by a thin semi-permeable membraneseparated by a thin semi-permeable membrane

• Waste and excess water pass from the blood side Waste and excess water pass from the blood side to the dialysate side and is discarded in the drain to the dialysate side and is discarded in the drain The cleaned blood is returned to the patient.The cleaned blood is returned to the patient.

• It is It is diffusion-based mass transferdiffusion-based mass transfer (BUN, Creat,(BUN, Creat, lytes) & lytes) & Pressure-driven water removal Pressure-driven water removal (ultrafiltration)(ultrafiltration)

• usually done 3x /week ~ 4hrs M-W-F or T-Th-Satusually done 3x /week ~ 4hrs M-W-F or T-Th-Sat

HemodialysisHemodialysis• Hemodialysis treatments every other day are not Hemodialysis treatments every other day are not

as physiological as peritoneal dialysisas physiological as peritoneal dialysis

• Requires a trip to the hospital up to 3 times Requires a trip to the hospital up to 3 times weeklyweekly

• Patients can travel to other units but must be pre-Patients can travel to other units but must be pre-arranged and space is not always availablearranged and space is not always available

• Patients are more restricted in dietary and fluid Patients are more restricted in dietary and fluid intake between treatments intake between treatments

• Medication requirements different than for those Medication requirements different than for those on peritoneal dialysis e.g. require more on peritoneal dialysis e.g. require more antihypertensive meds, higher doses of antihypertensive meds, higher doses of ErythropoietinErythropoietin

Hemodialysis ~ The Hemodialysis ~ The “Integra”“Integra”

HemodialysisHemodialysis• Requires access to the blood streamRequires access to the blood stream

• Arterio – venous fistulaArterio – venous fistula• Arterio – venous graftArterio – venous graft• Temporary catheterTemporary catheter• Long – term catheterLong – term catheter

Hemodialysis ~ fistulaHemodialysis ~ fistula

Hemodialysis ~ GraftHemodialysis ~ Graft

Temporary Hemodialysis Temporary Hemodialysis CatheterCatheter

Exit site at Exit site at surface of surface of the skinthe skin

Tip located Tip located at junction at junction of SVC and of SVC and right Atriumright Atrium

Inserted Inserted in the in the

jugular jugular veinvein

Tunneled Hemodialysis Tunneled Hemodialysis CatheterCatheter

Exit site Exit site

Catheter tunnelCatheter tunnel

Tip located Tip located at junction at junction of SVC and of SVC and right Atriumright Atrium

Inserted Inserted in the in the

jugular jugular veinvein

Dacron Dacron cuffcuff

TransplantationTransplantation

Thank youThank you