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Urogenital Y2 > L5 - Renal Replacement Therapy > Flashcards

L5 - Renal Replacement Therapy Flashcards

1. Describe the principles of normal kidney function 2. Describe principles of haemodialysis, haemofiltration and haemodiafiltration and how they differ from normal kidneys 3. Describe principples of peritoneal dialysis 4. Explain indications for renal replacement therapies 5. Explain principles of kidney transplantation 6. Compare and contrast each RRT method 7. Survival of patients on kidney replacement therapies and conservative management as RRT method

1
Q

Summarise renal failure

A
  1. Acute
    - pre-renal
    - renal
    - post-renal
  2. Chronic
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2
Q

Chronic renal failure

A

Permanent loss of renal function, may lead to ESRF

- end stage renal failure

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3
Q

Cause and example:

Pre-renal

A

Cause: poor renal perfusion

Examples: Blood loss, sepsis, Ace inhibitors, NSAIDs

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4
Q

Cause and example:

Renal

A

Cause: tubular damage

Examples: Crush injury (myoglobin), mismatched transfusion (haemoglobin), poison (mercury, clostridium toxin)

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5
Q

Cause and example:

Post-renal

A

Cause: Obstruction

Examples: bilateral ureteric obstruction (stone, tumour, retroperionteal fibrosis or surgical injury) Unilateral obstruction of solitary kidney

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6
Q

Crush Syndrome

A

Crush injury - prolonged continuous pressure on muscle tissue

  • Muscle injury
  • can cause large quantities of potassium, phosphate, myoglobin, creatine kinase and urate
  • to leak into the circulation.
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7
Q

Give brief investigation of renal failure

A
  1. Urine assessed for haematuria, proteinuria, looked at microscopically for casts
  2. USS, kidney size: hydronephrosis?
  3. X-ray: stones in UT
  4. RBC: microscopically
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8
Q

Fragmented or dysmorphic RBC found in urine sample may indicate..

A

Glomerular region

- see in proliferative glomerulonephritis and immuniglobin A nephropathy

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9
Q

Describe how CAPD may be carried out?

Chronic abumlatory peritoneal dialysis

A
  1. Silicon catheter inserted into abdo cavity.
  2. Dialysate fluid runs through multiple holes into abdomen.
  3. Left for several hours
  4. Fluid allowed to drain out
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10
Q

When is CAPD not possible?

A

If patient has undergone lots of previous abdominal surgery with adhesion.

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11
Q

Complications of CAPD

loads

A 
Peritonitis. 
Hernia (incisional, inguinal, umbilical) 
Genital oedema 
Gram negative sepsis 
Staphylococcus 
Back pain 
Fluid retention
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12
Q

Describe haemodialysis

A
  • Blood from patient flows through dialysing membrane.

- Solutes allowed to pass into dialysis fluid thus purifying blood.

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13
Q

How common is death by myocardial infarction (heart attack) in dialysis patients and why?

A

20x more likely in dialysis patients.

Due to:

  • Hyperlipidaemia
  • Hypertension
  • Left ventricular hypertrophy
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14
Q

The immunocompromised nature of ESRF patients undergoing dialysis may lead them at risk of…

A
  • Malignancy
  • Hepatitis
  • Tuberculosis
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15
Q

Describe method of dialysis

A
  1. Create peripheral fistula
  2. Creates large hypertrophied vessel that can repeatedly be needled allowing blood to be diverted into dialysis machine.
  3. OR permanent plastic catheter inserted into internal jugular or subclavian vein
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16
Q

Describe the formation of the arteriovenous fistula

A
  1. Artery and vein anastomosed.
  2. Usually radial/ brachial artery and cephalic vein.
  3. Creates large hypertrophied vessel.
    - hypertrophy refers to an increase and growth of muscle cells.
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17
Q

During renal transplantation what is the role of the Carrel patch?

A
  1. Patch of aortic wall.

2. Excised with renal artery to facilitate arterial anastomosis onto the recipients external iliac artery.

18
Q

Which kidney is normally removed in a donor?

A

Left kidney.

  • Has a longer renal vein
  • makes operation easier
19
Q

Briefly describe the recipient surgery during kidney transplantation?

A
  1. Aortic patch present.
    - Renal vein anastomosed end to side with the external iliac vein
    - Renal artery anastomosed end to side with the external iliac artery
  2. Ureter then anastomosed to bladder mucosa.
20
Q

Briefly describe recipient surgery during kidney transplantation, when there is no aortic patch?

A

Renal artery usually anastomosed end to end to the internal iliac artery.

Ureter then anastomosed to bladder muscosa.

21
Q

After kidney transplant, blood supply to the ureter is completely dependent on what artery?

A

Renal artery

22
Q

State criteria for patients to begin dialysis?

A

GFR has reached 10ml/min
Diabetic patients
- GFR reached 15ml/min

Uraemic symptoms.
Uncontrolled hyperkalaemia
Uncontrolled fluid overload

23
Q

Patient stage 5 CKD.

When should peritoneal dialysis be considered as 1st choice for dialysis over haemodialysis?

A
  • Patient <2 y/o
  • patient residual renal function
  • Adults without significant associated comorbidities.
24
Q

What are indications for dialysis in AKI?

A
  1. Uraemia
    - (pericarditis, gastritis, hypothermia, encephalopathy)
  2. Fluid retention
    - pulmonary oedema
  3. Sever hyperkalemia
    - >6.5mmol & unresponsive to treatment
  4. Serum Na+ out of range 120-155mmol
  5. Severe pH disturbance <7
25
Q

What levels of urea and creatinine would indicate severe renal failure?

A

Urea > 30mmol/L

Creatinine > 500umol/L

26
Q

Blood in patients needing dialysis would have high concentrations of what…

A

Urea
Creatinine
Potassium

27
Q

Briefly describe process of haemodialysis

A

Blood drawn from arteriovenous fistula.
Circulates through dialyser.
Then returned to fistula.

28
Q

What is constantly infused during dialysis and why?

A

Heparin

- anticoagulant, blood thinner

29
Q

Complications of haemodialysis

A
  • Hypotension, cardiac arrhythmia, air embolism
  • Nausea, vomiting, headache
  • Fever
30
Q

Compare haemodiafiltration with standard haemodialysis

A

RRT.
Increased clearance of larger toxins by large volume ultra filtration.

Standard haemodialysis

  • Toxin clearance by diffusion inversely proportional to radius of the toxin molecule.
  • hence larger toxins are cleared less effectively than smaller ones
31
Q

Aims of RRT

A

Mimic excretory function of normal kidneys:

  • eliminating nitrogenous, small molecular waste
  • maintain normal electrolyte concentrations
  • prevent systemic acidosis
  • maintain normal extracellular volume
32
Q

Describe principle of dialysis in a dialyser

A

Blood pumped around an extracorporeal circuit through a semi permeable membrane, before returning to circulation.

Dialysate flows opposite direction to blood.

Small solutes cross membrane via diffusion.

33
Q

What controls fluid removal in dialyser?

A

Transmembrane pressure allows controlled fluid removal by ultrafiltration.

34
Q

What composes the dialysate?

A

Acid and bicarbonate mixed to the correct strength, treated with water.

35
Q

What is an alternative to using an arteriovenous fistula?

A

permanent plastic catheter inserted into internal jugular or subclavian vein

36
Q

Describe the peritoneal membrane?

A
  1. Semi permeable fine layer of tissue lining the peritoneal cavity.
  2. Covers stomach, spleen, liver and intestine that are folded into the sac that it forms.
37
Q

Why is the peritoneal membrane ideal for filtering waste?

A

Rich blood supply.

38
Q

Describe the structure of the peritoneal membrane?

A
  1. Mesothelial cell monolayer.

2. Intersitium underneath: contains connective tissue, fibers, lymphaics and capillaries

39
Q

Describe what is meant by the tissue type of kidney?

A

Collection of HLA antigens on the tissue of either donor or recipient.

Examples:
A2, A3, B35, B40, DR6, DR71

40
Q

What is the main role of immunosupressants given post transplant?

A

Drugs are targeted at reducing T-cell proliferation

41
Q

Describe some transplant complications?

A 
Acute rejection. 
Ureteric problems. 
Cancer: skin, lymphoproliferative 
Diabetes 
Dyslipidaemia 
Hypertension 
CKD 
Primary non-function
42
Q

What is the leading cause of morbidity in haemodialysis patients?

A

Cardiovascular disease.

Cardiovascular mortality is higher for haemodialysis patients than for the normal population.

Urogenital Y2 (16 decks)

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