RENAL REPLACEMENT THERAPY Dr Shafaq Nazir House physician Medical unit 1

Contents DEFINATION CRITERIA FOR RRT HEMODIALYSIS AND ITS COMPLICATIONS HEMOFILTERATION AND COMPLICATIONS PERITONEAL DIALYSIS AND COMPLICATIONS RENAL TRANSPLANT TRANSPLANT STATISTICS TRANSPLANT REQUIREMENTS. INDICATIONS CONTRA INDICATIONS SOURCES OF DONORS COMPATIBILITY PROCEDURE COMPLICATIONS KIDNEY PANCREASE TRANSPLANT TRANSPLANT REQUIREMENTS MCQs

RRT IT IS A TERM USED TO ENCOMPASS LIFE SUPPORTING TREATMENTS FOR RENAL FAILURE. It includes HEMODIALYSIS PERITONEAL DIALYSIS HEMOFILTERATION RENAL TRANSPLANT

Criteria for placing a patient for RRT Presence of uremic syndrome i.e Hyperkalemia(unresponsive to conventional therapy) Extra cellular volume expansion Acidosis refractory to medical therapy Bleeding diathesis Creatinine clearance10ml/min per 1.73m sq

HEMODIALYSIS It removes waste products like potassium and urea as well as free water from blood in renal failure. Principle revolves around diffusion of solutes across semi permeable membrane Dialysate flows opposite to blood flow direction in extra corporeal circuit. This counter current flow maintains concentration gradient increasing efficacy of dialysis.

COMPLICATIONS OF HEMODIALYSIS DECREASE IN BLOOD PRESSURE FATIGUE CHEST PAIN LEG CRAMPS NAUSEA HEADACHE SEPSIS LEADING TO ENDOCARDITIS OSTEOMYLITIS HEPARIN ALLEGRY(RARE) LONG TERM COMPLICATIONS LIKE AMYLOIDOSIS NEUROPATHY HEART DISEASE

HEMOFILTERATION Similar to hemodialysis as it also requires a semi permeable membrane However, governed by convection rather than by diffusion Dialysate is not used Requires a positive hydrostatic pressure driving water and solutes to filterate compartment Both small and large solute particles are dragged through, due to hydrostatic pressure. High quality replacement fluid(isotonic) is used as ultrafilterate substitute .

HEMOFILTERATION OUTCOME ADVANTAGES: Less hemodynamic instability No exposure to dialysis fluid DISADVANTAGES: more expensive than hemodialysis

PERITONEAL DIALYSIS Works on the principal of peritoneal membrane acting as a natural semi-permeable membrane Dialysis fluid when instilled around it is removed by diffusion, excessive fluid by osmosis(by altering conc of glucose in fluid.) Simple to perform Less complex Used both children and elderly In diabetics and cardiovascular diseases

TYPES OF PERITONEAL DIALYSIS Continuous ambulatory peritoneal dialysis Automated peritoneal dialysis CAPD uses smallest quantity of of fluid daily to prevent uremia 2L bags are changed 3-5 times a day A total dialysate of 10L is produced. APD involves cyclic peritoneal dialysis, Intermittent peritoneal dialysis Night intermittent dialysis Tidal intermittent dialysis

SIDE EFFECTS OF PERITONEAL DIALYSIS Peritonitis(staph 60%, gram –ve 20%, fungi<5%) Exit site infection Catheter malfunction Loss of ultrafilteration Obesity Hernia Back pain hyperlipidemia

WHAT IS KIDNEY TRANSPLANT? Renal transplant is the organ transplant of a kidney in a patient having end stage renal disease.

PROGNOSIS It is a life extending procedure A patient can live 10 to 15 years longer with a kidney transplant than if kept on dialysis Ideally, transplant should be pre-emptive, i.e take place before patient starts on with dialysis Studies suggest the longer a patient is on dialysis before transplant, the less time the kidney will last. It has better prognosis in younger patients, even 75 year old recipients gain an average of 4 more years.

TRANSPLANT STATISTICS Country   Year   Cadaveric donor   Living donor Total Transplant Canada 2000 724 388 1112 France 2003 1991 136 2127 Italy 1489 135 1624 Spain 60 2051 United Kingdom 1297 439 1736 United States 8667 6479 15137 Pakistan - SIUT 2008   1854 1900

TRANSPLANT REQUIREMENTS Vary from program to program, country to country. Age must be less than 69 years TRANSPLANT EXCLUSION CRITERIA Mental illness, substance abuse, significant cardiovascular disease, terminal incurable infectious diseases cancer HIV IS NO LONGER A CONTRA-INDICATION TO TRANSPLANT

INDICATIONS OF TRANSPLANT ESRD(end stage renal disease), regardless of primary cause I.e drop in GFR 20-25% of normal. Malignant hypertension Infections Diabetes mellitus Glomerulonephritis Poly cystic kidney disease Auto immune conditions like Lupus and good pastures syndrome

CONTRA INDICATIONS Cardio pulmonary insufficiency Hepatic insufficiency Recent cancer Substance abuse Tobacco use and morbid obesity risks for surgical complications

HOW RENAL TRANSPLANT IS DONE The barely functional kidney is not removed as it increases surgical morbidities The donated kidney is placed in the ILIAC FOSSA with a separate blood supply Donors renal artery is connected to EXTERNAL ILIAC ARTERY of recipient Renal vein is connected to EXTERNAL ILIAC VEIN of the recipient. The whole operation takes 3 hours

POST OPERATION Blood is allowed to flow through kidney to minimize the ischemia time. Final step is to connect the donors ureter to the recipient bladder Living donor kidneys require 3 to 5 days to function at normal levels Cadaveric donations take 7 to 15 days to function at normal levels.

ABOUT DONORS Donors may be “LIVING” or “DECEASED” MAY or MAY NOT be genetically related even ABO COMPATIBILITY and TISSUE MATCH are no longer a requirement. In 2004 FDA approved the Cedars- Sinai High dose IVIG therapy which stops recipient’s immune system from tissue rejection.

BD AND DCD DONORS The deceased donor may be BRAIN DEAD or DONATE AFTER CADAVERIC DEATH Brain dead donors still have their hearts pumping blood and perfusing the organs when the operation begins. DCD donors elect via living will or family to withdraw mechanical ventilation, when death is pronounced, are rushed to theater for kidney removal and storage. Kidneys from B.D donors are superior to DCD donors,since they are not exposed to warm ischemia (time between stopping and kidney being cooled)

KIDNEY PANCREAS TRANSPLANT Done occasionally in IDDM suffering from diabetic nephropathy. Mostly a deceased donor pancreas is used. It may be SKP(simultaneous kidney-panc transplant), PAK(pancreas after kidney transplant). Transplanting only ISLET CELLS is in experimental stage It requires breaking down donor pancreas, extracting islet cells and injecting via a catheter into recipient pancreas Recipient continues to take immunosuppressants to avoid rejection. Most patients require 2 or 3 such injections and in some insulin may still be needed.

COMPLICATIONS OF RENAL TRANSPLANT Transplant rejection Infection and sepsis due to immunosuppressants Post transplant lymphoproliferative disorders(lymphomas)due to immunosuppressants. Electrolyte imbalance(Ca and Ph) causing bone problems Acne, hairsuitism, hair loss, obesity, hypercholestrolemia, diabetes mellitus(type2) In case of rejection, patient may opt for a second transplant and return to dialysis intermediatly.

MCQs Which of the following procedures is superior in a patient with creatinine clearence of 10ml/min? Hemodilation Hemofilteration Renal transplant Peritoneal dialysis

MCQs Common side effect of peritoneal dialysis is peritonitis due to Staphylococci? Streptococci? Fungi? Gram negative organisms?

MCQs A patient with hepatitis C after renal transplant Does not require any treatment for HCV Can survive with ribavarin treatment only Needs both ribavirin and INF therapy for good prognosis Does not survive despite any treatment

TAKE HOME MESSAGE Never hesitate treating patients with end stage renal disease. Always go for the best available treatment option in the form of life extending procedure for patient benefit.

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