Renal Replacement Therapy

Optimal Pre-ESRD Management 1.Preventing or slowing progression 2.Preventing complications of uremia such as anemia, ROD & malnutrition 3.Preparing the patient for the RRT 4.Planning for the creation of a permanent access for hemodialysis 5.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 solute Acetate dialysis Bicarbonate dialysis Na (mEq/L) K (mEq/L) Chloride (mEq/L) Mg (mEq/L) Acetate (mEq/L) Bicarbonate (mEq/L) Glucose (g/dL)

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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

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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

16 Hemodialysis Treatment Progress in Therapy and Technology Increases Quality of Life for the Patients

Hemodialysis Treatment by Fresenius Medical Care

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1.Refractory fluid overload 2.Hyperkalemia (plasma potassium concentration >6.5 meq/L) or rapidly rising potassium levels 3.Metabolic acidosis (pH < 7.1) 4.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 Initiation of dialysis in patients with ARF

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 1. Diet regimen 2. Prevention of ARF 3. Restriction of blood sampling 4. Restriction of blood transfusion 5. Treatment of uremic bleeding defects 6. Dose adjustments of drugs 7. Pre-operation dialysis

Risk Factors of ARF 1. Renal Hypoperfusion 2. Preexisting Azotemia 3. Sepsis 4. Nephrotoxins 5. Electrolyte Disorders

Treatment of uremic bleeding defects  Dialysis  DDAVP 0.3 μ g/kg IV 3 μ g/kg IN  Cryoprecipitate  RBC Transfusion  Conjugated estrogens  FFP

26 Drug Doses in Renal Failure Drug Dose method GFR >50 GFR GFR <10 Suppl after HD CAPDCRRT Acetamin ophen Iq4hq6hq8h None Dose for GFR Amikacin D,I % q12h % q12- 18h % q24- 48h 2/3 normal dose mg/l/ d Dose for GFR 10-50

Renal Transplantation Cadaveric Donor Living Donor Non related Related Spouse

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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 1. Age < Severe HTN 3. DM 4. Hx of nephrolithiasis 5. Impaired renal function 6. Morbid obesity 7. Strong family history of DM 8. FHx of hereditary nephritis or polycystic kidney disease 9. Hypercoagulability 10. HIV, HB, HC infection 11. Uncontrolled psychiatric disorders

Drugs Used in Maintenance Immunosuppression Calcineurin Inhibitors Cyclosporine Tacrolimus Azathioprine Mycophenolate Mofetil Glucocorticoids

In Hospital Management of Renal Transplant Patients 1. Diet regimen 2. Prevention of ARF 3. Restriction of blood sampling 4. Restriction of blood transfusion 5. Drugs interactions 6. Secondary adrenal insufficiency 7. Prevention of infection 8. 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 d ry Weight: Liters of actual body water = 142 × liters of NTBW = 142 × (60% × 60) = Predialysis serum Na – 36 = 2.72 lit NTBW= Normal Total Body Water