renal replacement therapy in end stage renal disease
Download
Skip this Video
Download Presentation
RENAL REPLACEMENT THERAPY IN END-STAGE RENAL DISEASE

Loading in 2 Seconds...

play fullscreen
1 / 53

RENAL REPLACEMENT THERAPY IN END-STAGE RENAL DISEASE - PowerPoint PPT Presentation


  • 233 Views
  • Uploaded on

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.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' RENAL REPLACEMENT THERAPY IN END-STAGE RENAL DISEASE' - maeve


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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

Lecture Med Students

nkf k doqi classification of ckd 2002
NKF-K/DOQI* classification of CKD 2002

*National Kidney Foundation Kidney Disease Outcomes Quality Initiative

Lecture Med Students

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.

Lecture Med Students

uraemia
Uraemia

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

Lecture Med Students

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

Lecture Med Students

treatment modalities for esrd
Treatment modalities for ESRD

Lecture Med Students

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.

Lecture Med Students

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.

Lecture Med Students

preparation for haemodialysis
Preparation for haemodialysis
  • Vascular access

temporary

permanent

Lecture Med Students

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%

Lecture Med Students

haemodialysis circuit
Haemodialysis circuit

Lecture Med Students

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

Lecture Med Students

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

Lecture Med Students

complications of haemodialysis 3
Complications of haemodialysis 3
  • Dialysis dementia
  • Dialysis arthropathy
  • Cystic degeneration of native kidneys

Lecture Med Students

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)

Lecture Med Students

slide22

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

Lecture Med Students

16

indications for chronic pd
Indications for chronic PD
  • ESRD
  • Choice
  • Poor vascular access for HD
  • Haematological disorders precluding use of heparin
  • Poor cardiovsacular status

Lecture Med Students

contraindications to chronic pd
Contraindications to chronic PD
  • Recent abdominal surgery
  • Extensive fibrosis of the peritonium
  • Abdominal aortic graft placement
  • Large individual

Lecture Med Students

complications of peritoneal dialysis
Complications of peritoneal dialysis
  • Peritonitis
  • Catheter tunnel infection
  • Damage to/perforation of abdominal viscera
  • Loss of protein in effluent

Lecture Med Students

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

Lecture Med Students

slide29

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

Lecture Med Students

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

Lecture Med Students

slide31

Preliminary workup

  • General medical screen for obvious contraindications

hypertension

diabetes mellitus

Lecture Med Students

slide32

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)

Lecture Med Students

slide33

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

Lecture Med Students

slide34

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

Lecture Med Students

slide35

Arterial imaging

2 kidneys of normal size and appearance

Outline renal vascular and urinary drainage anatomy

  • Contrast angiography
  • Spiral CT
  • MR angiography

Lecture Med Students

slide36

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

Lecture Med Students

slide37

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

Lecture Med Students

slide38

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

Lecture Med Students

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

Lecture Med Students

slide40

Blood tests

  • FBC + Diff + ESR
  • Blood group
  • Clotting profile
  • Chemistry: E + U + creatinine, LFT\'s, glucose
  • Lipid profile
  • Parathyroid hormone
  • Calcium
  • Tissue typing + crossmatch

Lecture Med Students

slide41

Serology: CMV, EBV, HIV, HBV, HCV

Cancer screen

  • Chest radiograph
  • Mammogram
  • PAP test
  • Stool occult blood
  • Digital rectal exam
  • sigmoidoscopy

Lecture Med Students

slide42

Screen for infections

  • Life threatening infection
  • HIV
  • TB or positive PPD without adequate therapy
  • CMV

Lecture Med Students

slide43

Gastrointestinal

  • HBsAg
  • HCV ab
  • Gastroduodenoscopy: PUD
  • pancreatitis
  • Cholecystitis

Lecture Med Students

slide44

Cardiovascular

  • ECG
  • Cardiac assessment if over 40
  • Angiogram to be performed on diabetic patients
  • IHD
  • CVD

Lecture Med Students

slide45

Urological

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

Lecture Med Students

slide46

Medical risk to recipient

  • BMI > 35
  • ?age > 65 yr
  • HTN unresponsive to med management
  • DM

Lecture Med Students

slide47

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

Lecture Med Students

slide48

Psychological evaluation

  • Cognitive impairment
  • Recent alcohol or drug abuse
  • Psychiatric illness
  • Medication non-compliance

Lecture Med Students

slide49

Contraindications to transplantation

  • Active malignancy
  • Terminal illness
  • Psychiatric illness
  • Recent MI
  • Drug and alcohol abuse
  • Active infection

Lecture Med Students

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.

Lecture Med Students

slide53

Thanks for your patience

Lecture Med Students

ad