2. RENAL REPLACEMENT THERAPY
Dr Shafaq Nazir
House physician
Medical unit 1

3. 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

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

5. 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

6. 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.

8. 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

9. 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 .

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

11. 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

13. 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

14. 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

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

16. 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.

17. 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

18. 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

19. 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

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

21. 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

23. 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.

24. 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.

25. 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)

26. 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.

27. 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.

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

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

30. 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

31. 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.

32. THANK YOU