Renal replacement therapy in end stage renal disease
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RENAL REPLACEMENT THERAPY IN END-STAGE RENAL DISEASE. C K IJOMA. Outline. Definitions Classification Clinical features Treatment modalities: 1) Dialysis 2) Kidney Transplantation. NKF-K/DOQI* Definition of CKD KDIGO** Modifications (Amsterdam 2004.

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RENAL REPLACEMENT THERAPY IN END-STAGE RENAL DISEASE

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Renal replacement therapy in end stage renal disease

RENAL REPLACEMENT THERAPY IN END-STAGE RENAL DISEASE

C K IJOMA

Lecture Med Students


Outline

Outline

  • Definitions

  • Classification

  • Clinical features

  • Treatment modalities:

    1) Dialysis

    2) Kidney Transplantation

Lecture Med Students


Nkf k doqi definition of ckd kdigo modifications amsterdam 2004

NKF-K/DOQI* Definition of CKDKDIGO** Modifications (Amsterdam 2004

Chronic kidney disease defined as

  • kidney damagefor ≥ 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either:

  • pathological abnormalities;

    or

  • markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests.

  • Kidney transplantation

  • GFR <60mL/min/1.73m2 for ≥ 3 months, with or without kidney damage.

    *National Kidney Foundation Kidney Disease Outcomes Quality Initiative

    **K/DIGO: kidney disease, increasing global outcome

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Nkf k doqi classification of ckd 2002

NKF-K/DOQI* classification of CKD 2002

*National Kidney Foundation Kidney Disease Outcomes Quality Initiative

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End stage renal disease

End Stage Renal Disease

A clinical state in which there has been

  • An irreversible loss of endogenous renal function

  • Of a degree sufficient to render the patient permanently dependent upon renal replacement therapy (dialysis or transplantation) in order to avoid life threatening uraemia.

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Uraemia

Uraemia

Clinical and laboratory syndrome, reflecting dysfunction of all organ systems as a result of untreated and undertreated acute or chronic renal failure.

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Renal replacement therapy

Renal replacement therapy

  • Dialysis

    a) haemodialysis

    b) peritoneal dialysis

    i) continuous ambulatory peritoneal dialysis (CAPD)

    ii) continuous cyclic peritoneal dialysis

    (CCPD)

    2. Kidney transplantation

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Treatment modalities for esrd

Treatment modalities for ESRD

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Dialysis

Dialysis.

Definition.

Process of separating elements in solution by diffusion across a semipermeable membrane down a concentration gradient

Principal process of removing end products of nitrogen metabolism (urea, creatinine, uric acid), and for repletion of bicarbonate deficit of metabolic acidosis associated with renal failure.

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Indications to start dialysis

Indications to start dialysis

  • GFR ≤ 10 ml/min/1.73m2. (15 ml/min/1.73m2 in DM)

  • Pt loses stamina to sustain normal daily work and activity

  • Symptoms: nausea, vomiting, anorexia, fatiguability, diminished sensorium

  • Signs: pericardial friction rub, refractory pulmonary oedema, metabolic acidosis, foot or wrist drop, asterixis.

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Preparation for haemodialysis

Preparation for haemodialysis

  • Vascular access

    temporary

    permanent

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Renal replacement therapy in end stage renal disease

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Haemodialysis

Haemodialysis

  • The extracorporeal circuit

  • The dialyzer

  • Water treatment

  • The dialysis machine

  • Dialysis prescription

  • Adequacy of HD: urea kinetic model, urea reduction ratio. Targets, UKM=1.3. URR≥70%

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Haemodialysis circuit

Haemodialysis circuit

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Renal replacement therapy in end stage renal disease

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Renal replacement therapy in end stage renal disease

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Renal replacement therapy in end stage renal disease

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Complications of haemodialysis

Complications of haemodialysis

  • Anaphylactic and anaphylactoid reactions:

    First-use reactions, Re-use reactions, Bradykinin-mediated reactions (pts on ACEI dialyzed with AN69 dialyzers)

  • Microbial contamination

  • Hypotension

  • Hypertension

  • Cardiac arrhythmias

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Complications of haemodialysis 2

Complications of haemodialysis 2

  • Sudden death (Vent fibrillation)

  • Muscle cramps

  • Restless leg syndrome

  • Dialysis disequilibruim syndrome

  • Seizures

  • Headache

  • Intradialytic haemolysis

  • Haemorrhage

  • Air embolism

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Complications of haemodialysis 3

Complications of haemodialysis 3

  • Dialysis dementia

  • Dialysis arthropathy

  • Cystic degeneration of native kidneys

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Peritoneal dialysis

Peritoneal dialysis

A technique whereby infusion of dialysis solution into peritoneal cavity is followed by variable dwell time and subsequent drainage

Types of chronic PD

  • Continuous ambulatory peritoneal dialysis (CAPD)

  • Continuous cyclic peritoneal dialysis (CCPD)

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Renal replacement therapy in end stage renal disease

Physiological Forces in PD Treatment

Blood

PD-Solution

DiffusionFree solute movement with concentration gradient.

ConvectionSolute transport driven

by aquous fluid flow.

OsmosisWater flows across a semi- permeable membrane driven by the concentration gradient of the 'indiffusible'osmotically active solutes.

Solution Volume

25-40 mL/ kg

Buffers

HC03, lactate

Electrolytes

Na, Cl, Mg,

Ca, K

Osmotic Agent

Glucose

Peritoneum

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Indications for chronic pd

Indications for chronic PD

  • ESRD

  • Choice

  • Poor vascular access for HD

  • Haematological disorders precluding use of heparin

  • Poor cardiovsacular status

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Contraindications to chronic pd

Contraindications to chronic PD

  • Recent abdominal surgery

  • Extensive fibrosis of the peritonium

  • Abdominal aortic graft placement

  • Large individual

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Complications of peritoneal dialysis

Complications of peritoneal dialysis

  • Peritonitis

  • Catheter tunnel infection

  • Damage to/perforation of abdominal viscera

  • Loss of protein in effluent

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Renal replacement therapy in end stage renal disease

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Renal replacement therapy in end stage renal disease

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Kidney transplantation

Kidney transplantation

  • Kidney transplantation is option in ESRD

  • Improves quality of life

  • Frees from chronic dialysis and restrictive diet

  • Long term mortality risk for transplant recipient 68% lower than for patients on dialysis

  • Projected increased life span of 3 to 17 years

  • Annual death rate 6.3 per 100 patient years for dialysis patients and 3.8 per 100 patient years for transplant patient

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Renal replacement therapy in end stage renal disease

Sources of kidney.

  • Deceased donor (cadaver).

  • Living voluntary donor

    a) related (immediate and extended family)

    parent, sibling, son, daughter, aunt, uncle, cousin

    b) unrelated (longstanding relationship with patient)

    spouses, adopted/step family member, friend

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Kidney donor evaluation

Kidney donor evaluation

General principles

  • Donation is safe for both donor and recipient

  • Primary focus is protection of wellbeing of prospective donor

  • Ensure donor has no disease that can be transmitted with the kidney

  • Donation based upon altruistic ideals and not driven by economic incentive

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Renal replacement therapy in end stage renal disease

Preliminary workup

  • General medical screen for obvious contraindications

    hypertension

    diabetes mellitus

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Renal replacement therapy in end stage renal disease

Tissue typing studies

  • Blood groups ABO and crossmatch (to check for preformed antibodies)

  • HLA crossmatch

    (recipient serum with donor T lymphocyte).

    Positive crossmatch predictive of acute rejection event resulting in hyperacute rejection

  • Tissue typing: (to determine degree of HLA matching between donor and recipient)

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Renal replacement therapy in end stage renal disease

Laboratory tests

  • Complete blood count

  • Chemistry screen: E + U + creatinine, Plasma glucose, LFTs, lipid profile

  • Urinalysis and urine culture

  • Coagulation studies

  • 24 hour urine collection for creatinine clearance, proteinuria

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Renal replacement therapy in end stage renal disease

  • Serology: HIV, CMV, EBV, HBV, HCV,

  • CXR, PPD , PAP, mamogram

  • ECG: Stress ECG and full cardiac assessment if patient is over forty years or history of heart disease in family

  • Lung function tests if smoker

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Renal replacement therapy in end stage renal disease

Arterial imaging

2 kidneys of normal size and appearance

Outline renal vascular and urinary drainage anatomy

  • Contrast angiography

  • Spiral CT

  • MR angiography

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Renal replacement therapy in end stage renal disease

Screening for inherited renal disease

  • Family history of renal disease

  • ADPKD. >30 yr high resolution CT. 21-30 ?genetic

  • DM

  • Essential hypertension

  • ?kidney stone

  • Sickle cell trait

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Renal replacement therapy in end stage renal disease

Psychological assessment

  • Donor’s motivation: voluntary

  • Good understanding of potential outcomes for both donor and recipient

  • Psychosocial history

  • Relationship between donor and recipient

  • Pressure and coercion

  • Presence of psychiatric disorder

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Renal replacement therapy in end stage renal disease

Contraindication for live kidney donation

  • ?ABO incompatibility

  • ?HLA mis-match

  • Impaired kidney function

  • Significant non-orthostatic proteinuria (>200mg/24 hr)

  • Active malignancy

  • Active substance abuse

  • Severe chronic illness

  • pregnancy

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Recipient evaluation

Recipient evaluation

  • Candidate should have >5 yr life expectancy

  • Risk benefit evaluation

  • Diagnosis of correctable disease: coronary artery disease, infections- HIV, HBV, HCV, Tb, neoplasm

  • Strict protocol for transplantation in HIV and hepatitis

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Renal replacement therapy in end stage renal disease

Blood tests

  • FBC + Diff + ESR

  • Blood group

  • Clotting profile

  • Chemistry: E + U + creatinine, LFT's, glucose

  • Lipid profile

  • Parathyroid hormone

  • Calcium

  • Tissue typing + crossmatch

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Renal replacement therapy in end stage renal disease

Serology: CMV, EBV, HIV, HBV, HCV

Cancer screen

  • Chest radiograph

  • Mammogram

  • PAP test

  • Stool occult blood

  • Digital rectal exam

  • sigmoidoscopy

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Renal replacement therapy in end stage renal disease

Screen for infections

  • Life threatening infection

  • HIV

  • TB or positive PPD without adequate therapy

  • CMV

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Renal replacement therapy in end stage renal disease

Gastrointestinal

  • HBsAg

  • HCV ab

  • Gastroduodenoscopy: PUD

  • pancreatitis

  • Cholecystitis

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Renal replacement therapy in end stage renal disease

Cardiovascular

  • ECG

  • Cardiac assessment if over 40

  • Angiogram to be performed on diabetic patients

  • IHD

  • CVD

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Renal replacement therapy in end stage renal disease

Urological

  • VCUG: To see if there is any reflux and to ensure that the bladder is emptying completely

  • Ultrasonography

  • Cystoscopy

  • Retrograde urethrogram

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Renal replacement therapy in end stage renal disease

Medical risk to recipient

  • BMI > 35

  • ?age > 65 yr

  • HTN unresponsive to med management

  • DM

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Renal replacement therapy in end stage renal disease

Associated recurrent disease in recipient

  • ADPKD and alports syndrome do not usually recur

  • FSGS, HUS, HSP, hereditary oxalosis recur soon

  • MPGN, scleroderma, IgA nephropathy, DM recur after several years

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Renal replacement therapy in end stage renal disease

Psychological evaluation

  • Cognitive impairment

  • Recent alcohol or drug abuse

  • Psychiatric illness

  • Medication non-compliance

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Renal replacement therapy in end stage renal disease

Contraindications to transplantation

  • Active malignancy

  • Terminal illness

  • Psychiatric illness

  • Recent MI

  • Drug and alcohol abuse

  • Active infection

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Renal replacement therapy in end stage renal disease

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Immunosupression protocol

Immunosupression protocol

Therapy to prevent rejection

  • Induction protocol

    Standard: corticosteroid, AZA or MMF, cyclosporin or tacrolimus

    Antibody induction: OKT3 or antilymphocyte gamma globulin

  • Maintenance protocol

    early post transplant, late post transplant

    3.Anti rejection therapy. Methylprednisolone, OKT3, ALG, ATG.

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Rejection in kidney transplantation

Rejection in kidney transplantation

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Renal replacement therapy in end stage renal disease

Thanks for your patience

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