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Renal Replacement Therapies. Dr Dana Ahmed Sharif.

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renal replacement therapies

Renal Replacement Therapies

Dr Dana Ahmed Sharif

slide2

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

when to start dialysis
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

when to start dialysis1
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

principles of dialysis
Principles of dialysis

Salt

Water

Electrolytes

Acidosis

Toxins

haemodialysis
Haemodialysis
  • Largely hospital based
  • Efficient
  • Requires access to circulation
  • Limited by staff and space
haemodialysis1
Haemodialysis
  • Artificial membrane used for exchange
  • Extracorporeal circuit
  • Direct access to blood
haemodialysis access
Haemodialysis access

Tunnelled dialysis line

A-V fistula

haemodialysis2
Haemodialysis

1- Diffusion:

Diffusionof solutes between solutions across a semipermeable membrane down a concentration gradient

principles of dialysis2
Principles of dialysis
  • Determining factors:

- Concentration gradient

  • Size + protein binding of molecule removed
  • Permeability + surface area of membrane
haemodialysis3
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

haemofiltration
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

basic principles
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
haemodiafiltration
Haemodiafiltration
  • Combines both HD and HF
  • Set for HD with high

TMP

  • Both dialysate and

fluid replacement

required

haemodialysis complications
Haemodialysis- complications
  • Access complications:

- Thrombosis

- Infection

- Lack of access

  • Dialysis complication:

- Reactions (hypersensitivity, inflammation)

- Hypotension

- Haemorrhage

- Air embolism

- Cardiac arrhythmias

peritoneal dialysis1
Peritoneal dialysis
  • Partly relies on residual renal function
  • Home based
  • Ambulant
  • Flexible
  • Continuous / intermittent
peritoneal dialysis capd
Peritoneal dialysis- CAPD
  • 4 x 2L exchanges a day
  • Each exchange takes ~ ½ - 1 hour
  • Complications

- Peritonitis

- Loss of membrane function

automated peritoneal dialysis
Automated Peritoneal Dialysis
  • Night time exchanges only
  • Convenient for people in employment
peritoneal dialysis2
Peritoneal dialysis
  • Advantages:

- continuous, independence

- home based, flexible

  • Disadvantages:

- patient competence

- peritonitis

- membrane failure

- ultrafiltration failure

- catheter exit site infection

- sclerosing peritonitis

compatibility
Compatibility
  • Blood group
  • HLA – tissue type
  • Antibodies
blood group
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
tissue typing
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
benefits of well matched graft
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
anti hla antibodies sensitization
Anti- HLA Antibodies (sensitization)
  • Previous mismatched organ transplant
  • Mismatched paternal HLA antigen in Pregnancy
  • Blood transfusion
donor type
Donor type
  • Live donor

- related

- non related

  • Cadaveric donor

- Heart beating ( brain death)

- Non heart beating

medication post transplant
Medication post transplant
  • Immunosuppressive drugs:

- Calcineurin inhibitors (Ciclosporin, Tacrolimus)

- Antiproliferative ( Mycofenolatemofetil MMF,

azathioprine)

- mTOR inhibitors (sirolimus, Everolimus)

- Steroids

complications
Complications
  • Infections

- Bacterial

- Fungal

- Viral – EBV, CMV

- atypical

  • Cancer

- Skin

- Lymphomas – PTLD ( post transplant lympho-proliferative disorder)

- Solid tumours

  • Metabolic

- Diabetes

- Hypertension

- Osteoporosis

contraindication to renal transplant
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