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Urinary System > Lecture 20: Renal Replacement Therapy > Flashcards

Lecture 20: Renal Replacement Therapy Flashcards

1
Q

list the functions of the kidneys

A
  • excretion of nitrogenous waste products
  • maintenance of acid and electrolyte balance
  • control of blood pressure
  • drug metabolism and disposal
  • activation of vitamin D
  • production of erythropoietin
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2
Q

clinical features of advanced CKD

A
  • until CDK stage 4 or 5 the patient may be asymptomatic.
  • the syndrome of advanced CDK is called uraemia.
  • uraemic symptoms can involve almost every organ
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3
Q

what eGFR value is renal replacement therapy indicated?

A

usually indicated when eGFR < 10ml/min

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4
Q

list the types of renal replacement therapy

A
  • renal transplant
  • haemodialysis: home or satellite/hospital
  • peritoneal dialysis: continuous ambulatory peritoneal dialysis (CAPD) or intermittent peritoneal dialysis (IPD)
  • conservative kidney management
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5
Q

what is dialysis?

A

Dialysis is a process whereby the solute composition of a solution, A, is altered by exposing solution A to a second solution, B, through a semipermeable membrane (artificial kidney in haemodialysis or peritoneal membrane).

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6
Q

pre-requisites for dialysis

A
  • semipermeable membrane (artificial kidney in haemodialysis or peritoneal membrane)
  • adequate blood exposure to the membrane (extracorporeal blood in haemodialysis, mesenteric circulation in PD)
  • dialysis access: vascular in haemodialysis, peritoneal in PD
  • anticoagulation in haemodialysis
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7
Q

list permanent and temporary haemodialysis access types

A

permanent:
- arteriovenous fistula
- AV prosthetic graft

temporary:
- tunnelled venous catheter
- temporary venous catheter

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8
Q

list the restrictions for dialysis patients

A

fluid restriction:
- dictated by residual urine output
- interdialytic weight gain

dietary restriction:
- sodium
- potassium
- phosphate

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9
Q

describe peritoneal dialysis

A
  • a balanced dialysis solution is instilled into the peritoneal cavity via a tunnelled, cuffed catheter, using the peritoneal mesothelium as a dialysis membrane.
  • after a dwell time the fluid is drained out and fresh dialysate is instilled.
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10
Q

what is the most common osmotic agent for ultrafiltration of fluid in peritoneal dialysis?

A

glucose

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11
Q

what are the complications of peritoneal dialysis?

A
  • exit site infection
  • ultrafiltration failure
  • encapsulating peritoneal sclerosis

PD peritonitis:
- gram positive - skin contaminant
- gram negative - bowel origin
- mixed - suspect complicated peritonitis e.g. perforation

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12
Q

what are the indications for dialysis in end-stage renal disease?

A
  • advanced uraemia, (GFR 5-10ml/min)
  • severe acidosis (bicarbonate < 10mmol/l)
  • treatment resistant hyperkalaemia (K > 6.5mmol/l)
  • treatment resistant fluid overload
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13
Q

discuss the fluid balance in haemodialysis and peritoneal dialysis patients

i.e. how much fluid can they consume

A

Haemodialysis:
- usually restricted to 500-800 ml/24hrs
- intake allowed = urine output + insensible loss

Peritoneal:
- usually more liberal intake as continuous ultrafiltration is often achieved

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14
Q

list some dialysis related drugs

A

Anaemia:
- erythropoietin injections
- IV iron supplements

Renal bone disease:
- activated vitamin D (e.g. calcitriol)
- phosphate binders with meals (CaCO3)

  • heparin to prevent blood clotting
  • water soluble vitamins
  • ?antihypertensives
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15
Q

list the complications of haemodialysis

A

CV problems:
- intra-dialytic hypotension and cramps
- arrhythmias

Coagulation:
- clotting of vascular access
- heparin related problems

Other:
- allergic reactions to dialysers and tubing
- catastrophic dialysis accidents (rare)

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16
Q

list the complications of peritoneal dialysis

A

Infection:
- exit site infection
- tunnel infection
- peritonitis

Mechanical:
- tube malfunction
- abdominal wall hernia

Ultrafiltration problems

17
Q

what does conservative kidney management involve?

A

Supportive care:
- priority for symptomatic management
- holistic multi-professional approach
- anticipatory care planning

18
Q

do patients on dialysis have increased or decreased morbidity and mortality?

A

increased

19
Q

describe the process of renal transplantation

A
  • transplanted kidney is placed into the iliac fossa and anastomosed to the iliac vessels
  • native kidneys usually remain in situ
20
Q

what are the indications for removing native kidney/s when performing renal transplantation?

A
  • size (polycystic kidneys)
  • infection (chronic pyelonephritis)
21
Q

what are the surgical complications of a renal transplant?

A

vascular complications:
- bleeding: usually anastomotic sites, perirenal haematoma can be arterial or venous
- arterial thrombosis
- venous thrombosis
- lymphocele

Ureteric:
- urine leak

  • Infections
22
Q

what are the side-effects of corticosteroids?

used for immunosuppression after kidney transplant

A
  • hypertension
  • hyperglycaemia
  • infections
  • bone loss
  • GI bleeding
23
Q

what are the side effects of Tacrolimus?

Calcineurin inhibitor used for immunosuppression after kidney transplant

A
  • hyperglycaemia
  • AKI
  • tremor
24
Q

what are the side-effects of cyclosporin?

Calcineurin inhibitor used for immunosuppression after kidney transplant

A
  • hirsutism
  • hypertension
  • AKI
  • gout
25
Q

what are the side effects of mycophenolate mofetil?

anti-proliferative used for immunosuppression after kidney transplant

A

cytopenia
GI upset

26
Q

what are the side effects of Sirolimus?

mTOR inhibitor used for immunosuppression after kidney transplant

A
  • lipidogenic
  • diabetogenic
  • pneumonia
27
Q

what are the side effects of Belatacept?

Costimulatory signal blocker used for immunosuppression after transplant

A
  • infections
  • malignancy
28
Q

what are the side effects of anti-thymocyte globulin (ATG)?

depleting agent used for immunosuppression after kidney transplant

A

infections
PLTD

29
Q

describe a common immunosuppression protocol after kidney transplant

A
  • induction: Basiliximab
  • maintenance: Tacrolimus + Mycophenolate + steroids
  • steroid free is possible
  • others: CNI-free using Belatacept
30
Q

complications after renal transplantation

A

Rejection:
- cell-mediated
- humoral (Ab mediated)

Infective:
- bacterial
- viral
- fungal

CV:
- underlying renal disease
- CRF
- hypertension
- hyperlipidaemia
- PT diabetes

Malignancy:
- skin
- lymphoma
- solid cancers

31
Q

describe hyperacute transplant rejection

A

Hyperacute rejection (within minutes):
- caused by ABO/HLA incompatibility
- presents with graft thrombosis/systemic inflammatory response syndrome (SIRS) within minutes of the transplant and intra-operatively.
- this is managed by immediate graft removal. This can be prevented by pre-treatment ABO and HLA cross-matching.

32
Q

discuss acute transplant rejection

A

Acute rejection (within first 6 months):
- may be T-cell mediated and/or antibody mediated.
- Presents with an acute decline in graft. function, and there may also be fever, malaise and graft tenderness

33
Q

what is the most important transplant-related infection?

A

Cytomegalovirus:
- affects around 8% of transplant recipients, despite prophylaxis therapy
- high mortality and morbidity if untreated
- recipient affected via: transmission from donor tissue, reactivation of latent virus

34
Q

cytolomegalovirus viremia, is a tissue invasive disease causing…

the ‘itis’

A
  • pneumonitis
  • hepatitis
  • retinitis
  • gastroenteritis
  • colitis
  • nephritis
  • fever
  • deranged LFTs
35
Q

BK virus can occur as a complication of kidney transplantation, what are its clinical manifestations?

a polyomavirus

A
  • ureteral stenosis
  • interstitial nephritis
  • ESRF
36
Q

what are the risk factors for BK virus associated nephropathy (BKAN)?

A
  • intensity of immunosuppression: tacrolimus, mycophenolate mofetil, antithymyocyte globulin
  • patient determinants: older age, male gender, white ethnicity, DM, negative BKV serostatus (paediatric)
  • organ determinants: graft injury, HLA mismatches, ureteral stents
  • viral determinants: changes in epitopes of viral capsid protein protein VP-1
37
Q

what is the outcome of BKAN?

A
  • allograft dysfunction
  • loss of graft in 45-80%
38
Q

what is the treatment for BKAN?

A
  • reduce immunosuppression
  • antiviral therapy: cidofovir +/- IVIG
  • leflunomide

Urinary System (21 decks)

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