Renal replacement therapy
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Renal Replacement Therapy. Optimal Pre-ESRD Management. Preventing or slowing progression Preventing complications of uremia such as anemia, ROD & malnutrition Preparing the patient for the RRT Planning for the creation of a permanent access for hemodialysis

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Renal Replacement Therapy

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Renal Replacement Therapy


Optimal Pre-ESRD Management

  • Preventing or slowing progression

  • Preventing complications of uremia such as anemia, ROD & malnutrition

  • Preparing the patient for the RRT

  • Planning for the creation of a permanent access for hemodialysis

  • Planning for hemodialysis initiation before major symptoms of uremia arise


Renal Replacement Therapy

  • Dialysis

    • Hemodialysis

      • In-center

      • Home

    • Peritoneal dialysis

      • IPD

      • CAPD

      • Cycler dialysis

  • Transplantation


History

  • Dialysis is a Greek word meaning "loosening from something else".

  • Dialysis is referred to as "selective diffusion." Diffusion is the movement of material from higher concentration to lower concentration through a given membrane

  • Thomas Graham, Chairman of Chemistry at University College, London, first discovered this idea of selective diffusion


Dialysate

  • A chemical bath used in dialysis to draw fluids and toxins out of the bloodstream and supply electrolytes and other chemicals to the bloodstream.


Composition of HD concentrate


AVF Creation in CRF

  • Cr clearance < 25 ml/min

  • Serum Cr > 4 mg/dl

  • Within 1 year of the anticipated need for maintenance dialysis therapy


Starting HD IN CRF

  • HD should be initiated at a level of residual renal function above which the major symptoms of uremia usually supervene:

    • 9 < Cr cl < 14 ml/min

  • It may be necessary to initiate patients even earlier in their course if they have otherwise uncorrectable symptoms or signs of renal failure


Hemodialysis Treatment

Progress in Therapy and

Technology Increases

Quality of Life for the Patients


HemodialysisTreatment byFreseniusMedicalCare


Initiation of dialysis in patients with ARF

  • Refractory fluid overload

  • Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels

  • Metabolic acidosis (pH < 7.1)

  • Azotemia (BUN > 80 to 100 mg/ dl)


Initiation of dialysis in patients with ARF

5.Signs of uremia, such as pericarditis, or an otherwise unexplained decline in mental status

6.Severe dysnatremias (155 < Na < 120 meq/L)

7. Hyperthermia

8. Overdose with a dialyzable drug/toxin


Indications For Heparin-Free dialysis

  • Pericaditis

  • Recent surgery, with bleeding complications or risk. Especially:

    • Vascular & cardiac surgery (within 7 days)

    • Eye surgery (retinal & cataract)

    • Renal transplant

    • Brain surgery (within 14 days)


Indications For Heparin-Free dialysis

  • Coagulopathy

  • Thrombocytopenia

  • ICH

  • Active bleeding

  • Routine use for dialysis of acutely ill patients by many centers


In Hospital Management of Patients with CRF & ESRF

  • Diet regimen

  • Prevention of ARF

  • Restriction of blood sampling

  • Restriction of blood transfusion

  • Treatment of uremic bleeding defects

  • Dose adjustments of drugs

  • Pre-operation dialysis


Risk Factors of ARF

  • Renal Hypoperfusion

  • Preexisting Azotemia

  • Sepsis

  • Nephrotoxins

  • Electrolyte Disorders


Treatment of uremic bleeding defects

  • Dialysis

  • DDAVP

    0.3 μg/kg IV

    3 μg/kg IN

  • Cryoprecipitate

  • RBC Transfusion

  • Conjugated estrogens

  • FFP


Drug Doses in Renal Failure


Renal Transplantation

  • Cadaveric Donor

  • Living Donor

    • Non related

    • Related

    • Spouse


Exclusionary Conditions for Renal Transplantation

  • Patient will not live more than 1 year

  • Metastatic malignancy, not responsive to therapy

  • Acute or chronic infections that are not controlled

  • Severe psychiatric disease that impairs patient's consent & compliance

  • Medical incompliance

  • Substance abuse

  • Immunologic incompatibilities


Criteria That Exclude a live Donor

  • Age < 18

  • Severe HTN

  • DM

  • Hx of nephrolithiasis

  • Impaired renal function

  • Morbid obesity

  • Strong family history of DM

  • FHx of hereditary nephritis or polycystic kidney disease

  • Hypercoagulability

  • HIV, HB, HC infection

  • Uncontrolled psychiatric disorders


Drugs Used in Maintenance Immunosuppression

  • Calcineurin Inhibitors

    • Cyclosporine

    • Tacrolimus

  • Azathioprine

  • Mycophenolate Mofetil

  • Glucocorticoids


In Hospital Management of Renal Transplant Patients

  • Diet regimen

  • Prevention of ARF

  • Restriction of blood sampling

  • Restriction of blood transfusion

  • Drugs interactions

  • Secondary adrenal insufficiency

  • Prevention of infection

  • Transplant drugs usage


HD in ARF

CAN DIALYSIS DELAY RECOVERY OF RENAL FUNCTION?

  • There is at least theoretical concern that dialysis might have detrimental effects on renal function. Three factors may be important in this regard:

    • a reduction in urine output

    • induction of hypotension

    • complement activation resulting from a blood-dialysis membrane interaction.


Dry Weight

  • The lowest weight a patient can tolerate without the development of signs or symptoms of intravascular hypovolemia.


Dry Weight

  • Estimating dry Weight:

    Liters of actual body water =

    142 × liters of NTBW = 142 × (60% × 60) = 38.72

    Predialysis serum Na 132

    38.72 – 36 = 2.72 lit

    NTBW= Normal Total Body Water


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