1. RENAL REPLACEMENT THERAPY
(RRT)

2. RRT: Modalities Hemodialysis Peritoneal Dialysis Renal Transplantation
Living-Related, Living-Unrelated
Cadaveric
CRRT
CAVH, CVVH, SCUF
CAVHD,CVVHD, CAVHDF, CVVHDF

3. RRT: Absolute Indications for Dialysis
Fluid Overload
Hyperkalemia
Severe Metabolic Acidosis
Uremic Pericarditis
Uremic Enchephalopathy
Intoxication: Methanol, ethylene glycol ASA, & Lithium

4. RRT: Relative Indications for Dialysis
Uremic Neuropathy
Malnutrition of CRF
Correct bleeding time before surgery
Cr. clearance <10 ml/minute
Level of urea & creatinine ??

5. Hemodialysis: Dialyzer
Arterial
blood from
Patient
out going dialysate
Incoming
Dialysate
solution
Venous blood to patient

6. Hemodialysis: Principles
Solutes are effectively removed by diffusion
Water is removed by convection (UF)
Both mechanisms contribute to solute removal

7. Peritoneal Dialysis: Types
Continuos Ambulatory Peritoneal Dialysis (CAPD)
4 cycles of 2 liter of dialysate
Intermittent Peritoneal Dialysis (IPD)
Whole day or night for 2-3 times/ week
Continuos Cyclic Peritoneal Dialysis (CCPD)
Eight , 2 liters exchanges during night

8. Peritoneal Dialysis: Principle
Diffusion: for solutes
From high concentration gradient to low concentration gradient
Osmosis: for water
Depends on concentration of sugar in the dialysate fluid
The fluid and solute removal can be enhanced by increasing the volume of dialysate and the number of exchanges

9. Peritoneal Dialysis: CAPD, IPD
Hanger
PD dialysate solution
Connection
set
PD Catheter
draining bag

10. PD: Advantages A more normal life-style Better residual renal function
Less stringent fluid and diet restriction
Stable solutes concentration
(no dysequilibrium)
Better hemoglobin level
More economic: 2/3 of HD cost

11. PD: Complications CAPD PERITONITIS Abdominal pain Fever
Turbid effluent
WBC in effluent >400
Organisms:
Staph. aureus and epidermedis
Gram negative: Klebseilla, pseudomonas
Candida

12. CAPD PERITONITIS: Treatment
3 flushes in & out
Loading dose Intraperitoneal antibiotics:
Cefazoline and Tobramycin Or
Vancomycin & Tobramycin
Maintenance dose IP antibiotics:
Change antibiotics according to sensitivity

13. CAPD: Complications & Treat.
Tunnel infection
Pain and swelling at tunnel site
Fever
Treatment: Vancomycin IV
Exit site infection
Redness at exit site with discharge
Cloxacillin or Vancomycin

14. CAPD: Complications & Treat.
Catheter leak
Treatment: Temporary conversion to HD
Catheter dysfunction: causes
Constipation: laxatives
Fibrin: IP heparin
Omental wrap
May require replacement

15. CAPD: Complications Obesity & hypertriglyceridemia
Due to excessive absorption of glucose
Protein loss & hypoalbuminemia
Loss with the effluent
Bloody Effluent:
Ruptured corpus leutium (ovulation)
Endometriosis

16. CRRT: Types CAVH: UF only CVVH: UF only SCUF: slow UF CAVHD: Dialysis
CVVHD: Dialysis
CAVHDF: UF & Dialysis
CVVHDF: UF & Dialysis

17. CRRT: Principle Ultrafiltration: The main driving force
Diffusion: slow and efficient only with time
Patient need replacement of fluid loss up to 18 liters/ day (in CAVH, CVVH, CAVHDF & CVVHDF)

18. CRRT: CAVH Replacement Arterial Venous Qb=50-100 ml/min
Qf= 8-12 ml/min UF

19. CRRT: CAVHD Dialysate In Arterial Venous Qb=50-100 ml/min
Qd=10-20 ml/min
Qf= 1-3 ml/min
Dialysate out

20. CRRT: CVVH Replacement Venous Venous Pump Qb=50-200 ml/min
Qf= ml/min UF

21. CRRT: CVVHD Dialysate In Pump Venous Venous Qb=50-200 ml/min
Qd=10-30 ml/min
Qf= 1-5 ml/min
Dialysate out

22. CRRT: Indications
Acute Renal failure in hemodynamically unstable patient & MOF
Volume control in septic patient with no Renal failure
Removal of mediators of sepsis
Refractory Congestive Heart Failure
ARF in acute and chronic liver disease
Tumor lysis syndrome, lithium intox.?