RENAL REPLACEMENT
THERAPY
Dr Shafaq Nazir
House physician
Medical unit 1
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Contents
DEFINATION
CRITERIA FOR RRT
HEMODIALYSIS AND ITS COMPLICATIONS
HEMOFILTERATION AND COMPLICATIONS
PERITONEAL DIALYSIS AND COMPLICATIONS
RENAL TRANSPLANT
TRANSPLANT STATISTICS
TRANSPLANT REQUIREMENTS.
INDICATIONS
CONTRA INDICATIONS
SOURCES OF DONORS
COMPATIBILITY
PROCEDURE
COMPLICATIONS
KIDNEY PANCREASE TRANSPLANT
TRANSPLANT REQUIREMENTS
COMPLICATIONS
MCQs
RRT
 IT IS A TERM USED TO ENCOMPASS
LIFE SUPPORTING TREATMENTS FOR
RENAL FAILURE.
 It includes
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HEMODIALYSIS
PERITONEAL DIALYSIS
HEMOFILTERATION
RENAL TRANSPLANT
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
HEMODIALYSIS
 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
 Dialysate flows opposite to blood flow direction
in extra corporeal circuit.
 This counter current flow maintains
concentration gradient increasing efficacy of
dialysis.
COMPLICATIONS OF
HEMODIALYSIS
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DECREASE IN BLOOD PRESSURE
FATIGUE
CHEST PAIN
LEG CRAMPS
NAUSEA HEADACHE
SEPSIS LEADING TO ENDOCARDITIS
OSTEOMYLITIS
HEPARIN ALLEGRY(RARE)
LONG TERM COMPLICATIONS LIKE
 AMYLOIDOSIS
 NEUROPATHY
 HEART DISEASE
HEMOFILTERATION
 Similar to hemodialysis as it also requires a semi
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permeable membrane
However, governed by convection rather than by
diffusion
Dialysate is not used
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.
High quality replacement fluid(isotonic) is used
as ultrafilterate substitute .
HEMOFILTERATION
OUTCOME
ADVANTAGES:
 Less hemodynamic instability
 No exposure to dialysis fluid
DISADVANTAGES:
 more expensive than hemodialysis
PERITONEAL DIALYSIS
 Works on the principal of peritoneal membrane
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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.)
Simple to perform
Less complex
Used both children and elderly
In diabetics and cardiovascular diseases
TYPES OF PERITONEAL
DIALYSIS
 Continuous ambulatory peritoneal dialysis
 Automated peritoneal dialysis
 CAPD uses smallest quantity of of fluid daily to
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prevent uremia
2L bags are changed 3-5 times a day
A total dialysate of 10L is produced.
APD involves cyclic peritoneal dialysis,
Intermittent peritoneal dialysis
Night intermittent dialysis
Tidal intermittent dialysis
SIDE EFFECTS OF PERITONEAL
DIALYSIS
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Peritonitis(staph 60%, gram –ve 20%, fungi<5%)
Exit site infection
Catheter malfunction
Loss of ultrafilteration
Obesity
Hernia
Back pain
hyperlipidemia
WHAT IS KIDNEY
TRANSPLANT?
 Renal transplant is the organ transplant of
a kidney in a patient having end stage
renal disease.
PROGNOSIS
 It is a life extending procedure
 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
 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.
TRANSPLANT STATISTICS
Country
Year
Cadaveric
donor
Living
donor
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
Total Transplant
TRANSPLANT
REQUIREMENTS
Vary from program to program, country to country.
 Age must be less than 69 years
TRANSPLANT EXCLUSION CRITERIA
 Mental illness,
 substance abuse,
 significant cardiovascular disease,
 terminal incurable infectious diseases
 cancer
HIV IS NO LONGER A CONTRA-INDICATION
TO TRANSPLANT
INDICATIONS OF
TRANSPLANT
 ESRD(end stage renal disease), regardless of
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primary cause I.e drop in GFR 20-25% of
normal.
Malignant hypertension
Infections
Diabetes mellitus
Glomerulonephritis
Poly cystic kidney disease
Auto immune conditions like Lupus and good
pastures syndrome
CONTRA INDICATIONS
 Cardio pulmonary insufficiency
 Hepatic insufficiency
 Recent cancer
 Substance abuse
 Tobacco use and morbid obesity risks
for surgical complications
HOW RENAL TRANSPLANT IS
DONE
 The barely functional kidney is not removed
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as it increases surgical morbidities
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
Renal vein is connected to EXTERNAL ILIAC
VEIN of the recipient.
The whole operation takes 3 hours
POST OPERATION
 Blood is allowed to flow through kidney to
minimize the ischemia time.
 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
 Cadaveric donations take 7 to 15 days to
function at normal levels.
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 recipient’s
immune system from tissue rejection.
BD AND DCD DONORS
 The deceased donor may be
 BRAIN DEAD or DONATE AFTER CADAVERIC
DEATH
 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.
 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)
KIDNEY PANCREAS
TRANSPLANT
 Done occasionally in IDDM suffering from diabetic
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nephropathy.
Mostly a deceased donor pancreas is used.
It may be SKP(simultaneous kidney-panc
transplant), PAK(pancreas after kidney transplant).
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
Recipient continues to take immunosuppressants to
avoid rejection.
Most patients require 2 or 3 such injections and in some
insulin may still be needed.
COMPLICATIONS OF RENAL
TRANSPLANT
 Transplant rejection
 Infection and sepsis due to immunosuppressants
 Post transplant lymphoproliferative
disorders(lymphomas)due to immunosuppressants.
 Electrolyte imbalance(Ca and Ph) causing bone
problems
 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.
MCQs
 Which of the following procedures is
1.
2.
3.
4.
superior in a patient with creatinine
clearence of 10ml/min?
Hemodilation
Hemofilteration
Renal transplant
Peritoneal dialysis
MCQs
Common side effect of peritoneal dialysis is
peritonitis due to
1. Staphylococci?
2. Streptococci?
3. Fungi?
4. Gram negative organisms?
MCQs
A patient with hepatitis C after renal
transplant
 Does not require any treatment for HCV
 Can survive with ribavarin treatment only
 Needs both ribavirin and INF therapy for
good prognosis
 Does not survive despite any treatment
TAKE HOME MESSAGE
 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.
THANK YOU