RENAL REPLACEMENT RENAL REPLACEMENT THERAPYTHERAPY

Dr Shafaq NazirDr Shafaq Nazir

House physician House physician

Medical unit 1Medical unit 1

ContentsContents DEFINATIONDEFINATION CRITERIA FOR RRTCRITERIA FOR RRT HEMODIALYSIS AND ITS COMPLICATIONSHEMODIALYSIS AND ITS COMPLICATIONS HEMOFILTERATION AND COMPLICATIONSHEMOFILTERATION AND COMPLICATIONS PERITONEAL DIALYSIS AND COMPLICATIONS PERITONEAL DIALYSIS AND COMPLICATIONS RENAL TRANSPLANTRENAL TRANSPLANT TRANSPLANT STATISTICSTRANSPLANT STATISTICS TRANSPLANT REQUIREMENTS.TRANSPLANT REQUIREMENTS. INDICATIONSINDICATIONS CONTRA INDICATIONSCONTRA INDICATIONS SOURCES OF DONORSSOURCES OF DONORS COMPATIBILITYCOMPATIBILITY PROCEDUREPROCEDURE COMPLICATIONSCOMPLICATIONS KIDNEY PANCREASE TRANSPLANTKIDNEY PANCREASE TRANSPLANT TRANSPLANT REQUIREMENTSTRANSPLANT REQUIREMENTS COMPLICATIONSCOMPLICATIONS MCQsMCQs

RRTRRT

IT IS A TERM USED TO ENCOMPASS IT IS A TERM USED TO ENCOMPASS LIFE SUPPORTING TREATMENTS FOR LIFE SUPPORTING TREATMENTS FOR RENAL FAILURE.RENAL FAILURE.

It includesIt includes HEMODIALYSISHEMODIALYSIS PERITONEAL DIALYSISPERITONEAL DIALYSIS HEMOFILTERATIONHEMOFILTERATION RENAL TRANSPLANT RENAL TRANSPLANT

Criteria for placing a patient for Criteria for placing a patient for RRTRRT

Presence of uremic syndrome i.ePresence of uremic syndrome i.e

1.1. HyperkalemiaHyperkalemia(unresponsive to (unresponsive to conventional therapy)conventional therapy)

2.2. Extra cellular volume expansionExtra cellular volume expansion

3.3. AcidosisAcidosis refractory to medical therapy refractory to medical therapy

4.4. BleedingBleeding diathesis diathesis

5.5. CreatinineCreatinine clearanceclearance10ml/min per 10ml/min per 1.73m sq 1.73m sq

HEMODIALYSISHEMODIALYSIS

It removes waste products like potassium and It removes waste products like potassium and urea as well as free water from blood in renal urea as well as free water from blood in renal failure.failure.

Principle revolves around diffusion of solutes Principle revolves around diffusion of solutes across semi permeable membraneacross semi permeable membrane

Dialysate flows opposite to blood flow direction Dialysate flows opposite to blood flow direction in extra corporeal circuit.in extra corporeal circuit.

This counter current flow maintains This counter current flow maintains concentration gradient increasing efficacy of concentration gradient increasing efficacy of dialysis. dialysis.

COMPLICATIONS OF COMPLICATIONS OF HEMODIALYSISHEMODIALYSIS

DECREASE IN BLOOD PRESSUREDECREASE IN BLOOD PRESSURE FATIGUEFATIGUE CHEST PAINCHEST PAIN LEG CRAMPSLEG CRAMPS NAUSEA HEADACHENAUSEA HEADACHE SEPSIS LEADING TO ENDOCARDITISSEPSIS LEADING TO ENDOCARDITIS OSTEOMYLITISOSTEOMYLITIS HEPARIN ALLEGRY(RARE)HEPARIN ALLEGRY(RARE) LONG TERM COMPLICATIONS LIKELONG TERM COMPLICATIONS LIKE AMYLOIDOSISAMYLOIDOSIS NEUROPATHY NEUROPATHY HEART DISEASEHEART DISEASE

HEMOFILTERATIONHEMOFILTERATION

Similar to hemodialysis as it also requires a semi Similar to hemodialysis as it also requires a semi permeable membranepermeable membrane

However, governed by convection rather than by However, governed by convection rather than by diffusiondiffusion

Dialysate is not used Dialysate is not used Requires a positive hydrostatic pressure driving Requires a positive hydrostatic pressure driving

water and solutes to filterate compartmentwater and solutes to filterate compartment Both small and large solute particles are dragged Both small and large solute particles are dragged

through, due to hydrostatic pressure.through, due to hydrostatic pressure. High quality replacement fluid(isotonic) is used as High quality replacement fluid(isotonic) is used as

ultrafilterate substitute . ultrafilterate substitute .

HEMOFILTERATION HEMOFILTERATION OUTCOMEOUTCOME

ADVANTAGES:ADVANTAGES: Less hemodynamic instabilityLess hemodynamic instability No exposure to dialysis fluidNo exposure to dialysis fluid

DISADVANTAGES:DISADVANTAGES: more expensive than hemodialysismore expensive than hemodialysis

PERITONEAL DIALYSISPERITONEAL DIALYSIS

Works on the principal of peritoneal membrane Works on the principal of peritoneal membrane acting as a natural semi-permeable membraneacting as a natural semi-permeable membrane

Dialysis fluid when instilled around it is removed Dialysis fluid when instilled around it is removed by diffusion, excessive fluid by osmosis(by by diffusion, excessive fluid by osmosis(by altering conc of glucose in fluid.) altering conc of glucose in fluid.)

Simple to performSimple to perform Less complexLess complex Used both children and elderlyUsed both children and elderly In diabetics and cardiovascular diseasesIn diabetics and cardiovascular diseases

TYPES OF PERITONEAL TYPES OF PERITONEAL DIALYSISDIALYSIS

Continuous ambulatory peritoneal dialysisContinuous ambulatory peritoneal dialysis Automated peritoneal dialysisAutomated peritoneal dialysis CAPD uses smallest quantity of of fluid daily to CAPD uses smallest quantity of of fluid daily to

prevent uremiaprevent uremia 2L bags are changed 3-5 times a day2L 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 dialysisIntermittent peritoneal dialysis Night intermittent dialysisNight intermittent dialysis Tidal intermittent dialysisTidal intermittent dialysis

SIDE EFFECTS OF PERITONEAL SIDE EFFECTS OF PERITONEAL DIALYSISDIALYSIS

PeritonitisPeritonitis(staph 60%, gram –ve 20%, fungi<5%)(staph 60%, gram –ve 20%, fungi<5%) Exit site infectionExit site infection Catheter malfunctionCatheter malfunction Loss of ultrafilterationLoss of ultrafilteration ObesityObesity HerniaHernia Back painBack pain hyperlipidemiahyperlipidemia

WHAT IS KIDNEY WHAT IS KIDNEY TRANSPLANT?TRANSPLANT?

Renal transplant is the organ transplant of Renal transplant is the organ transplant of a kidney in a patient having end stage a kidney in a patient having end stage renal disease.renal disease.

PROGNOSISPROGNOSIS

It is a life extending procedureIt is a life extending procedure A patient can live 10 to 15 years longer with a A patient can live 10 to 15 years longer with a

kidney transplant than if kept on dialysiskidney transplant than if kept on dialysis Ideally, transplant should be pre-emptive, i.e Ideally, transplant should be pre-emptive, i.e

take place before patient starts on with dialysistake place before patient starts on with dialysis Studies suggest the longer a patient is on Studies suggest the longer a patient is on

dialysis before transplant, the less time the dialysis before transplant, the less time the kidney will last.kidney will last.

It has better prognosis in younger patients, even It has better prognosis in younger patients, even 75 year old recipients gain an average of 4 75 year old recipients gain an average of 4 more years.more years.

TRANSPLANT STATISTICSTRANSPLANT STATISTICS

Country   Year  Cadaveric

donor  Living

donorTotal Transplant

Canada 2000 724 388 1112

France 2003 1991 136 2127

Italy 2003 1489 135 1624

Spain 2003 1991 60 2051

United Kingdom 2003 1297 439 1736

United States 2003 8667 6479 15137

Pakistan - SIUT 2008   1854 1900

TRANSPLANT TRANSPLANT REQUIREMENTSREQUIREMENTS

Vary from program to program, country to country.Vary from program to program, country to country. Age must be less than 69 yearsAge must be less than 69 yearsTRANSPLANT EXCLUSION CRITERIATRANSPLANT EXCLUSION CRITERIA Mental illness,Mental illness, substance abuse,substance abuse, significant cardiovascular disease,significant cardiovascular disease, terminal incurable infectious diseases terminal incurable infectious diseases cancercancer

HIV IS NO LONGER A CONTRA-INDICATION HIV IS NO LONGER A CONTRA-INDICATION TO TRANSPLANTTO TRANSPLANT

INDICATIONS OF INDICATIONS OF TRANSPLANTTRANSPLANT

ESRDESRD(end stage renal disease), regardless of (end stage renal disease), regardless of primary cause I.e drop in GFR 20-25% of primary cause I.e drop in GFR 20-25% of normal.normal.

Malignant hypertensionMalignant hypertension InfectionsInfections Diabetes mellitusDiabetes mellitus GlomerulonephritisGlomerulonephritis Poly cystic kidney diseasePoly cystic kidney disease Auto immune conditions likeAuto immune conditions like Lupus Lupus and and good good

pastures syndromepastures syndrome

CONTRA INDICATIONSCONTRA INDICATIONS

Cardio pulmonary insufficiencyCardio pulmonary insufficiency Hepatic insufficiencyHepatic insufficiency Recent cancerRecent cancer Substance abuseSubstance abuse Tobacco use and morbid obesity risks Tobacco use and morbid obesity risks

for surgical complicationsfor surgical complications

HOW RENAL TRANSPLANT IS HOW RENAL TRANSPLANT IS DONEDONE

The barely The barely functional kidney is not removedfunctional kidney is not removed as it increases surgical morbiditiesas it increases surgical morbidities

The The donated kidney is placed in the ILIAC donated kidney is placed in the ILIAC FOSSAFOSSA with a separate blood supply with a separate blood supply

Donors Donors renal artery is connected to EXTERNAL renal artery is connected to EXTERNAL ILIAC ARTERY of recipientILIAC ARTERY of recipient

Renal vein is connected to EXTERNAL ILIAC Renal vein is connected to EXTERNAL ILIAC VEIN of the recipientVEIN of the recipient..

The whole operation takes 3 hoursThe whole operation takes 3 hours

POST OPERATIONPOST OPERATION

Blood is allowed to flow through kidney to Blood is allowed to flow through kidney to minimize the ischemia time.minimize the ischemia time.

Final step is to connect the donors ureter Final step is to connect the donors ureter to the recipient bladderto the recipient bladder

Living donor kidneys require 3 to 5 days to Living donor kidneys require 3 to 5 days to function at normal levelsfunction at normal levels

Cadaveric donations take 7 to 15 days to Cadaveric donations take 7 to 15 days to function at normal levels.function at normal levels.

ABOUT DONORSABOUT DONORS

1.1. Donors may be “Donors may be “LIVING” or “DECEASED”LIVING” or “DECEASED”2.2. MAY or MAY NOTMAY or MAY NOT be genetically related be genetically related3.3. even even ABO COMPATIBILITY and TISSUE ABO COMPATIBILITY and TISSUE

MATCH are no longer a requirementMATCH are no longer a requirement..

In 2004 FDA approved the Cedars- Sinai High In 2004 FDA approved the Cedars- Sinai High dose IVIG therapy which stops recipient’s dose IVIG therapy which stops recipient’s

immune system from tissue rejection.immune system from tissue rejection.

BD AND DCD DONORSBD AND DCD DONORS

The deceased donor may be The deceased donor may be BRAIN DEADBRAIN DEAD or or DONATE AFTER CADAVERIC DONATE AFTER CADAVERIC

DEATH DEATH Brain dead donors still have their hearts pumping blood Brain dead donors still have their hearts pumping blood

and perfusing the organs when the operation begins.and perfusing the organs when the operation begins. DCD donors elect via living will or family to withdraw DCD donors elect via living will or family to withdraw

mechanical ventilation, when death is pronounced, are mechanical ventilation, when death is pronounced, are rushed to theater for kidney removal and storage.rushed to theater for kidney removal and storage.

Kidneys from B.D donors are superior to DCD Kidneys from B.D donors are superior to DCD donors,since they are not exposed to warm ischemia donors,since they are not exposed to warm ischemia (time between stopping and kidney being cooled) (time between stopping and kidney being cooled)

KIDNEY PANCREAS KIDNEY PANCREAS TRANSPLANTTRANSPLANT

Done occasionally in IDDM suffering from diabetic Done occasionally in IDDM suffering from diabetic nephropathy.nephropathy.

Mostly a deceased donor pancreas is used.Mostly a deceased donor pancreas is used. It may beIt may be SKP SKP(simultaneous kidney-panc (simultaneous kidney-panc

transplant), transplant), PAKPAK(pancreas after kidney transplant).(pancreas after kidney transplant). Transplanting only Transplanting only ISLET CELLSISLET CELLS is in experimental stage is in experimental stage It requires breaking down donor pancreas, extracting islet It requires breaking down donor pancreas, extracting islet

cells and injecting via a catheter into recipient pancreascells and injecting via a catheter into recipient pancreas Recipient continues to take immunosuppressants to avoid Recipient continues to take immunosuppressants to avoid

rejection.rejection. Most patients require 2 or 3 such injections and in some Most patients require 2 or 3 such injections and in some

insulin may still be needed. insulin may still be needed.

COMPLICATIONS OF RENAL COMPLICATIONS OF RENAL TRANSPLANTTRANSPLANT

Transplant rejectionTransplant rejection Infection Infection and and sepsissepsis due to immunosuppressants due to immunosuppressants Post transplant lymphoproliferative Post transplant lymphoproliferative

disordersdisorders(lymphomas)due to immunosuppressants.(lymphomas)due to immunosuppressants. Electrolyte imbalanceElectrolyte imbalance(Ca and Ph) causing bone (Ca and Ph) causing bone

problemsproblems AcneAcne, , hairsuitism, hair loss, obesity, hairsuitism, hair loss, obesity,

hypercholestrolemia, diabetes mellitus(type2hypercholestrolemia, diabetes mellitus(type2)) In case of rejection, patient may opt for a second In case of rejection, patient may opt for a second

transplant and return to dialysis intermediatly.transplant and return to dialysis intermediatly.

MCQsMCQs

Which of the following procedures is Which of the following procedures is superior in a patient with creatinine superior in a patient with creatinine clearence of 10ml/min?clearence of 10ml/min?

1.1. HemodilationHemodilation

2.2. HemofilterationHemofilteration

3.3. Renal transplantRenal transplant

4.4. Peritoneal dialysisPeritoneal dialysis

MCQsMCQs

Common side effect of peritoneal dialysis is Common side effect of peritoneal dialysis is peritonitis due toperitonitis due to

1.1. Staphylococci?Staphylococci?

2.2. Streptococci?Streptococci?

3.3. Fungi?Fungi?

4.4. Gram negative organisms?Gram negative organisms?

MCQsMCQs

A patient with hepatitis C after renal A patient with hepatitis C after renal transplant transplant

Does not require any treatment for HCVDoes not require any treatment for HCV Can survive with ribavarin treatment onlyCan survive with ribavarin treatment only Needs both ribavirin and INF therapy for Needs both ribavirin and INF therapy for

good prognosisgood prognosis Does not survive despite any treatmentDoes not survive despite any treatment

TAKE HOME MESSAGETAKE HOME MESSAGE

Never hesitate treating patients with end Never hesitate treating patients with end stage renal disease.stage renal disease.

Always go for the best available treatment Always go for the best available treatment option in the form of life extending option in the form of life extending procedure for patient benefit. procedure for patient benefit.

THANK YOUTHANK YOU