Renal replacement therapy (dialysis + trasnplantation)

Question 1

Name 3 indications for acute dialysis (AEIOU)

Answer 1

– Acidosis (severe and not responding to treatment)
– Electrolyte abnormalities (severe and unresponsive hyperkalaemia)
– Intoxication (overdose of certain medications)
– Oedema (severe and unresponsive pulmonary oedema)
– Uraemia symptoms such as seizures or reduced consciousness

Question 2

Name a long term indication for dialysis

Answer 2

• CKD
• When any of the acute indications persist

Question 3

1) How does peritoneal dialysis work?
2) Peritoneal dialysis uses a plastic tube called what?
3) What is the difference between continuous ambulatory peritoneal dialysis and automated peritoneal dialysis?
4) Name a complication of peritoneal dialysis
5) What is the commonest cause of peritonitis secondary to peritoneal dialysis?

Answer 3

1) Peritoneal membrane is used as the filtration membrane. A dialysis solution containing dextrose is added to peritoneal cavity and ultrafiltration occurs from the blood, across the peritoneal membrane, into the dialysis solution which is then taken away
2) Tenckhoff catheter
3) In continuous ambulatory peritoneal dialysis the dialysis solution is in the peritoneum at all times, whereas automated peritoneal dialysis occurs overnight.
4) Bacterial peritonitis, peritoneal sclerosis, ultrafiltration failure, weight gain, psychological effects
5) Staphylococcus epidermidis

Question 4

1) What is the typical hemodialysis regimen?
2) What are the 2 types of haemodialysis?
3) Which of these are preferred?

Answer 4

1) 4 hours a day for 3 days a week
2) Tunnelled cuffed catheter and arterio-venous fistula
3) AV fistula

Question 5

1) Name an area an AV fistula may be done
2) Name a complication of a tunnelled cuffed catheter
3) Name a complication of an AV fistula
4) Name a sign of an AV fistula
5) What is STEAL syndrome?
6) What is high output heart failure?

Answer 5

1) Radio-cephalic, brachiocephalic
2) Infection, blood clots within the catheter
3) Aneurysm, infection, thrombosis, stenosis, STEAL syndrome, high output heart failure
4) Aneurysm, skin integrity, palpable thrill, stereotypical “machinery murmur” on auscultation
5) Where there is inadequate blood flow to the limb distal to the AV fistula
6) In an AV fistula, blood from the arterial circulation flows quickly into the venous. This faster than normal flow of blood to the heart can increase pre-load, leading to hypertrophy

Question 6

1) In a kidney transplant, patients and donor kidneys are matched based on what?
2) What is the procedure for a kidney transplant?
3) Where is the donor kidney placed?
4) Where can the donor kidney be palpated?
5) What is the incision made called?

Answer 6

1) HLA (human leukocyte antigen) A, B and C
2) Patient’s own kidneys are left in place and the donor kidneys blood vessels are anastomosed usually to the external iliac blood vessels of the recipient. Donor kidneys ureter is anastomosed directly with the patient’s bladder
3) Anterior abdomen
4) Iliac fossa
5) Hockey stick incision

Question 7

1) Name 1 of the 3 of the lifelong immunosuppression drugs patients will need after transplantation
2) Name one of the other drugs that may be used

Answer 7

1) Tacrolimus, mycophenolate, prednisolone
2) Cyclosporine, sirolimus, azathioprine

Question 8

1) Name a complication relating to the transplant
2) Name 2 complications relating to the immunosuppression after transplantation

Answer 8

1) Transplant rejection, transplant failure, electrolyte imbalances
2) Type 2 diabetes (steroids), IHD, infections are more likely and more severe, unusual infections can occur i.e. PCP, CMV, PJP and TB, non-Hodgkin lymphoma, skin cancer - particularly squamous cell carcinoma

Question 9

Why is acute rejection following transplant (within 6 months) easier to manage than chronic rejection (>6 months)?

Answer 9

Acute rejection is managed by increasing immunosuppression, whereas chronic rejection doesn’t respond to increasing immunosuppression

Question 10

Name a side effect of calcineurin inhibitor toxicity (tacrolimus)

Answer 10

• Tremor
• Headache
• Cardiomyopathy
• Peripheral neuropathy
• Diabetes

Question 11

How is a hyperacute rejection managed?

Answer 11

Removal of graft

Question 12

What is the most important and common viral infection post solid organ transplant, and how is it managed?

Answer 12

Cytomegalovirus - ganciclovir