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Dialysis And Transplantation Flashcards

(61 cards)

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1
Q

When is dialysis and transplant needed

A

When the kidney can no longer maintain homeostasis of fluids, electrolytes, and acid/base balance and cannot excrete metabolic wastes or synthesise the normal renal hormones as in stage 5 CKD
That treatment it is a terminal illnessq

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2
Q

What functions can dialysis replace

What can dialysis not replace

A

Homeostatic function
But cannot control BP, cannot replace EPO and cannot replace vitamin d synthesis endocrine function need to be replaced separately

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3
Q

What functions can transplant replace

A

All kidney functions

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4
Q

What are the 2 main forms of dialysis

A

Peritoneal

Haemodialysis

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5
Q

What type of therapy is dialysis and what does it do

A

It is an extra corporeal therapy where fluid and solutes are removed from or added to the patients blood
It is able to achieve a GFR of <15ml/min compare to 125ml/min normally it is still able to maintain life

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6
Q

What does peritoneal dialysis use

A

Uses the body’s own peritoneal membrane
- capillary endothelium, interstitium and peritoneal mesothelioma
It acts as a semi permeable membrane to separate the patients blood from the dialysis fluid

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7
Q

What is in the dialysis fluid

A

Dextrose, some electrolytes and HCO3 buffer

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8
Q

What accumulates in the patients blood

A

Water, urea, hydrogen ions, electrolytes - sodium and potassium

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9
Q

How is water removed

A

By osmosis created by the dextrose in the dialysis solution

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10
Q

How are the solutes in the blood removed

A

Diffusion and ultrafiltration

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11
Q

Why is there HCO3 is the dialysis solution

A

Because H+ cannot cross into the dialysis fluid from the blood so HCO3- in the dialysis solution passes into the blood to buffer the decrease pH

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12
Q

Advantages of peritoneal dialysis

A

Continuous therapy that can be carried out in the community

More convenient than haemodialysis

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13
Q

What are the types of peritoneal dialysis are there

A

Can be done continuously through the day - CAPD continuous ambulatory peritoneal dialysis where 2.5l batches over 4-6hrs
Or over night - APD automated peritoneal dialysis with a machine which drains and refills the peritoneal cavity

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14
Q

What happens in hadmodialysis

A

The patients blood is removed and introduced to an artificial membrane - hollow microfibres material which acts as the semipermeable membrane to separate the blood and dialysis fluid.
Machine is called the dialyser
Blood and fluid flow in opposite directions this counter current ensures the concentrations gradients between the blood and fluid are maintained

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15
Q

What happens at the machine

A

Blood is removed from an artery
Access the artery through a Tesio line or an arterial-venous fistula
Blood is then pumped through a blood pump and heparin pump to prevent clotting into the dialyser
Passes through an air trap and air detector before being returned to the body by the venous system
Blood pressure through the machine is continually measured

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16
Q

What are the solute concentrations of the dialysis solution

A

They are either above or below normal depending on which way the excess or lack of a solute needs to move towards normal

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17
Q

How are water and solutes removed from the blood

A

Ultrafiltration pressure gradient is applied - diffusion does not happen because flow is too fast

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18
Q

What happens with the H+ ions

A

Too low in serum concentrations
Acid load cannot be removed by dialysis alone so alkali is therefore added to the patient from the dialysis solution as the concentration of alkali in solution is greater than the plasma

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19
Q

When is haemodialysis done

A

Hospital outpatient clinics

4 hour intervals 3x a week

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20
Q

What are the limitations to dialysis

A

GFR achieved is low, dietary restrictions if fluids and electrolytes in necessary, EPO and vit D are not replaced and blood pressure control is necessary, as well as this 20% of patients on dialysis will die each year this is generally due to infection or CVD

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21
Q

Why does CVD risk increase with CKD

A

Due to left ventricular hypertrophy in response to anaemia, hypertension, and fluid overload
And calcification of arteries
And lipid abnormalities

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22
Q

What is there are high risk if in both types of dialysis

A

Infection

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23
Q

Risk if in peritoneal dialysis concerned with the entry site

A

Lots of scarring
Adhesion to the peritoneal wall
The Port can become dislodged and meaning that dialysis cannot take place
The port. is inserted under local anaesthetic or general anaesthetic

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24
Q

What is the risk to diabetic patients of the dialysis fluid

A

High amount of dextrose can be dangerous

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25
What does kidney transplantation involve
Transfer of a functional organ from donor to recipient | This can be a living match donor or a dead donor
26
What must the donor have for the organ to be viable
Cardiovascular system so the kidney is viable and being perfused upon removal
27
What happens in the surgery
Diseases kidneys are left in place And the kidney is put in the iliac fossa and connected the the iliac vessels this is due to the difficulty in retroperitoneal surgery
28
Which iliac fossa is the kidney node susceptible to trauma
Left
29
transplant -Is it better or worse outcome and survival than dialysis
Better
30
Why is transplant not the treatment of choice for end stage renal failure
Organ shortage
31
What is at higher risk with people with transplants
CVD Cancer risks due to immune Suppression Infection risk due to immune suppression
32
Who should transplantation be discussed with
Every patient and absolute contra indications need to be ruled out in this process age is not It is associated with higher comorbidity and higher risk
33
What is an absolute contraindications for organ transplant
High peri-operative mortality, poor life expectancy and active malignancy
34
What are relative contraindications
Coronary or CVD Recurrent diseases And non compliance
35
What re the main majority of kidney donors
Cadaveric, brainstem dead or no heart beating Non heart beating donors must be recovered within 30 mins to make sure it is still viable Living donors becoming more common
36
What is one of the greatest risks associated with kidney transplantation
Organ rejection
37
What drives rejection
Allogenic response immune system recognises graft as non self
38
What is the kidney called when it is not the same as the recipient
Positive cross match
39
What happens when a positive cross match kidney is reperfused
Rapid hyperacute rejection The recipients natural ABO antiobodies will bind to the blood group antigens present on the vascular endothelium of the donor This ab binding leads to compliment activation and MAC mediated cell lysis and intravascular thrombosis this means the donor kidney loses blood supply and dies
40
What must happen between donor and recipient kidneys
Must be matched
41
What types of match must happen
Species match Blood group match Better outcome in MHC 1 and 2 are matched
42
What happens in the screening process
Anti MHC ab are screened by testing the recipients reactivity with a panel of normal cells If there is a high percentage reaction it shows that the patient has lots of ab against the MHC type
43
Can rejection still occur if all 6 types of MHC are fine
Yes | As it is still not identical
44
What are transplant patients given
Immunosuppression
45
Can immunosuppressed patients still reject kidney
Yes | 30-40% are still rejected
46
What is acute allograft rejection | How is it recognised
Cell mediated or ab mediated and is characterised by the infiltration of activated lymphocytes into the graft Rise in creatinine as graft function fails Diagnosis through biopsy
47
When does ad mediated rejection occur
When the recipient have pre existing MHC antiobodies which haven't been picked up These can exist due to prior pregnancy, transplantation or blood transfusion
48
When does cell mediated rejection occur
When cellular debris From the donor remains in the graft and is picked up by dendritic cells or when there are some dendritic cells still in the graft dendritic cells then travel to the lymph nodes and activate T cells Macrophages, B cells and T cells will respond
49
What are targets of immunosuppression
Inhibit calcineurin preventing signalling through the TCR - tacromlimus Corticosteroids inhibit APCs and stop the transcription and action of il2 on the T cell Anti IL-2 receptor ab CD25 ab also block IL2 action Drugs like azathioprine inhibit the cell cycle and stop T cell proliferation
50
Problem with immunosuppression due to the non specific response of these drugs
Inc likelihood of infection, cancer, | Effects of steroids - hypertension, diabetes, lipid abnormalities, osteoporosis, and weight gain
51
What are semipermeable membrane’s
``` They are permeable to some sort of use but not all Permeability is determined by The size and charge of the solute The size of the pore Charge of the membrane ```
52
What is diffusion
random movement of ions & molecules | equilibrate ions or molecules equally on the different sides of the semipermeable membrane
53
What is osmosis
It is the movement of water particles from low to high osmolality
54
What is ultrafiltration
It is direct force/hydrostatic pressure to one side it increases the volume on one side but the mass affect of water and potassium ions there is no overall change in concentration
55
Patient prep for dialysis
Patients with progressive see KD in stage four and five are identified early receive counselling regarding Dialysis, transplant, Conservative supportive care patient decision is needed Early establishment of an AV fistula is needed HBV vaccination is needed for non-immune patients Central venous catheter for patients requiring haemodialysis without and AV fistula
56
When to start dialysis in CKD
When the EGFR is below 10 It depends on the symptoms on the control of fluid volume Should be before the patient becomes very ill And you need dialysis access beforehand
57
Went to start dialysis in AKI
Usually creatinines of above 500 I oligo or annually They have uraemia have a pericarditis encephalitis AKI cannot be controlled medically and the hyperkalaemia pulmonary oedema metabolic acidosis cannot be controlled This is emergency dialysis need access usually buy a central venous catheter
58
What fluid and diet restrictions are necessary in dialysis
Need to continue the restriction imposed before Potassium sodium phosphate and water restriction Dialysis treatment does not restore clearance back to normal
59
Problems with dialysis
20% of patients on dialysis die each year Due to infection cardiac disease Left ventricular hypertension due to hypertension and anaemia and fluid overload Calcification of arteries and lipid abnormalities Anaemia Bone disease Malnutrition
60
How has survival on dialysis changed
Survival has increased over the last 10 years Life expectancy is around 5-6 years It’s worse if a higher age when you start on dialysis Underlying kidney disease predict survival From worst to best survival Diabetes Hypertension Glomerulal nephritis PKD
61
What is an AV fistula
It is the surgical connection of an artery and vein Diversion of arterial blood into the veins therefore the vein becomes more muscularised Requires a small operation usually under local anaesthetic and need six weeks for healing

REN (8 decks)

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