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Renal Replacement Therapies

Renal Replacement Therapies. Dr Dana Ahmed Sharif.

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Renal Replacement Therapies

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  1. Renal Replacement Therapies Dr Dana Ahmed Sharif

  2. Median life expectancy on RRT by age group Median life expectancy on RRT by age groupincident patient starting RRT from 2000-2007 incident of diabetic patient starting RRT from 2000-2007UK renal registry data, annual report 2011

  3. When to start dialysis? 1- 50 years old male with GFR 13, K 5.4, mild leg oedema otherwise well 2- 55 years old female with GFR 12, K: 5.2 with nausea, itching and anorexia 3- 48 years old female with GFR 9, K: 5.0 good urine output, BP 155/90mmHg 4- 52 years old male with GFR 8, K: 5.0 with tiredness

  4. When to start dialysis? • GFR < 15ml/min with uraemic symptoms • GFR < 10ml/min whether symptomatic or not • Refractory hyperkalaemia, acidosis, pulmonary oedema, pericarditis, encephalopathy and neuropathy ( all need urgent dialysis) • There is no clear evidence that an early start to dialysis confers a survival benefit* • Pre-emptive transplant is the treatment of choice of ESRF. Consider when GFR < 15ml/min *RCT of Early versus late initiation of dialysis, N Engl J Med 2010; 363:609-619, August 12/ 2010

  5. Principles of dialysis Salt Water Electrolytes Acidosis Toxins

  6. Haemodialysis • Largely hospital based • Efficient • Requires access to circulation • Limited by staff and space

  7. Haemodialysis • Artificial membrane used for exchange • Extracorporeal circuit • Direct access to blood

  8. Haemodialysis access Tunnelled dialysis line A-V fistula

  9. Haemodialysis 1- Diffusion: Diffusionof solutes between solutions across a semipermeable membrane down a concentration gradient

  10. Principles of dialysis

  11. Principles of dialysis • Determining factors: - Concentration gradient • Size + protein binding of molecule removed • Permeability + surface area of membrane

  12. Haemodialysis 2- Ultrafiltration: - Water can be driven through the membrane by hydrostatic force - By varying the trans-membrane pressure (TMP) the amount of water removed can be controlled

  13. Haemofiltration Convection - Flow of water + dissolved solutes (convection) down a pressure gradient caused by hydrostatic or osmotic forces - Rate of filtration depends on pressure gradient

  14. Haemofiltration

  15. Basic principles • Haemodialysis • Solute removal by diffusion of substances between blood + dialysate • Fluid removed by filtration (driven by pressure gradient across membrane) • Haemofiltration • Fluid removal by filtration • Solute removal by convection of substances in filtrate

  16. Haemodialysis(HD) Haemofiltration(HF)

  17. Haemodialysis(HD) Haemofiltration(HF)

  18. Haemodiafiltration • Combines both HD and HF • Set for HD with high TMP • Both dialysate and fluid replacement required

  19. Haemodialysis- complications • Access complications: - Thrombosis - Infection - Lack of access • Dialysis complication: - Reactions (hypersensitivity, inflammation) - Hypotension - Haemorrhage - Air embolism - Cardiac arrhythmias

  20. Peritoneal Dialysis

  21. CAPD: principles

  22. Peritoneal dialysis • Partly relies on residual renal function • Home based • Ambulant • Flexible • Continuous / intermittent

  23. Peritoneal dialysis- CAPD • 4 x 2L exchanges a day • Each exchange takes ~ ½ - 1 hour • Complications - Peritonitis - Loss of membrane function

  24. Automated Peritoneal Dialysis • Night time exchanges only • Convenient for people in employment

  25. Peritoneal dialysis • Advantages: - continuous, independence - home based, flexible • Disadvantages: - patient competence - peritonitis - membrane failure - ultrafiltration failure - catheter exit site infection - sclerosing peritonitis

  26. Transplantation

  27. Compatibility • Blood group • HLA – tissue type • Antibodies

  28. Blood group • ABO antigens are expressed on endothelial cells in the kidney • Naturally occurring anti-blood group antibodies develop at 6 months of age , possibly in response to bacterial carbohydrate antigens • The same role apply for transplantation and blood transfusions (ie blood group ‘O’ are universal donor and ‘AB’ are universal recipient) • ABO incompatible transplant are generally avoided

  29. Tissue typing • Class I : HLA -A and –B • Class II: HLA –DR • So HLA identical donors have 0,0,0 mismatch(MM) • Whereas those pairs which share 1 HLA- A, 1 HLA –B and 1 HLA –DR have 1,1,1 MM

  30. Benefits of well matched graft • Lower acute rejection rate • Better long term graft survival • Fewer subsequent anti HLA antibodies • Lower incidence of delayed graft function

  31. Anti- HLA Antibodies (sensitization) • Previous mismatched organ transplant • Mismatched paternal HLA antigen in Pregnancy • Blood transfusion

  32. Donor type • Live donor - related - non related • Cadaveric donor - Heart beating ( brain death) - Non heart beating

  33. Medication post transplant • Immunosuppressive drugs: - Calcineurin inhibitors (Ciclosporin, Tacrolimus) - Antiproliferative ( Mycofenolatemofetil MMF, azathioprine) - mTOR inhibitors (sirolimus, Everolimus) - Steroids

  34. Complications • Infections - Bacterial - Fungal - Viral – EBV, CMV - atypical • Cancer - Skin - Lymphomas – PTLD ( post transplant lympho-proliferative disorder) - Solid tumours • Metabolic - Diabetes - Hypertension - Osteoporosis

  35. Contraindication to renal transplant • Absolute: 1- Active malignancy, a period of 2 years of complete remission recommended for most tumors 2- Active vasculitis or recent anti-GBM disease 3- Severe heart failure 4- Severe occlusive aorto-iliac vascular disease • Relative: 1- Age: not routinely offered to < 1 yr or >75 yrs 2- High risk of disease recurrence in the transplant kidney 3- Disease of the lower urinary tract such as bladder dysfunction 4- Significant comorbidity

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