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Renal Replacement Therapy Flashcards

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1
Q

Functions of the kidneys

A 
Excretion of nitrogenous waste products
Maintenance of acid and electrolyte balance
Control of BP
Drug metabolism and disposal 
Activation of vit D
Production of erythropoietin
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2
Q

Definition of end stage renal disease

A

Irreversible damage to a persons kidney so severely affecting their ability to remove or adjust blood wastes that, to maintain life, he or she must have either dialysis or a kidney transplant

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3
Q

Until what stages of CKD may the patient be asymptomatic?

A

4 or 5

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4
Q

What is the syndrome of advanced CKD called?

A

Uraemia

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5
Q

What is the earliest cardinal symptom of uraemia?

A

Malaise and fatigue

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6
Q

What is renal replacement therapy (RRT)?

A

The means by which life is sustained in patients suffering from end-stage renal disease

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7
Q

When is RRT usually indicated?

A

eGFR < 10ml/min

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8
Q

Types of RRT

A

Renal transplant
Haemodialysis
Peritoneal dialysis
Conservative kidney management

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9
Q

Types of PD

A

Continuous ambulatory peritoneal dialysis (CAPD)

Intermittent peritoneal dialysis

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10
Q

Definition of dialysis

A

A process by which the solute composition of solute A, is altered by exposing solution A to a second solution B, through a semipermeable membrane

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11
Q

Pre-requisites for dialysis

A

Semipermeable membrane
Adequate blood exposure to the membrane
Dialysis access
Anticoagulation in haemodyalsis

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12
Q

What is the semipermeable membrane in haemodialysis?

A

Artificial kidney

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13
Q

What is the semipermeable membrane in PD?

A

Peritoneal membrane

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14
Q

How does adequate blood exposure to the membrane occur in HD?

A

Extracorpeal blood

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15
Q

How does adequate blood exposure to the membrane occur in PD?

A

Mesenteric circulation

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16
Q

What type of dialysis access is used in haemodyalsis?

A

Vascular

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17
Q

What type of dialysis access is used in PD?

A

Peritoneal

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18
Q

What must be given in haemodialysis?

A

Anticoagulation

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19
Q

Dialysis access in HD

A 
Permanent;
- AV fistula
- AV prosthetic graft 
Temporary 
- tunnelled venous catheter
- temporal venous catheter
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20
Q

What restrictions do dialysis patients have?

A

Fluid restriction

Dietary restriction

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21
Q

What is the fluid restriction of dialysis patients dictated by?

A

Residual urine output

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22
Q

What dietary restrictions are in place for haemodialysis patients?

A

Potassium
Sodium
Phosphate

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23
Q

How does PD work?

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 swell time the fluid is drained out and fresh dialysate is instilled

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24
Q

What does the PD fluid contain?

A

Dialysate contains a balanced concentration of electrolytes

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25
In PD, what is the most common osmotic agent for ultrafiltration of fluid?
Glucose
26
Complications of PD
``` Exit site infection Tunnel infection PD peritonitis Ultrafiltration failure Encapsulating peritoneal sclerosis Tube malfunction Abdominal wall herniae ```
27
Causative organisms of PD peritonitis and their origins
Gram +ve = skin contaminant Gram -ve = bowel origin Mixed; suspect complicated peritonitis e.g. perforation
28
Indications for dialysis in ESRD
``` Advanced uraemia (GFR 5-10ml) Severe acidosis (bicarbonate < 10mmol/l) Treatment resistant hyperkalaemia (K>6.5mmol/l) Treatment resistant fluid overload Nephrologists judgement ```
29
What is the usual fluid restriction in HD?
500-800ml/24 hours intake
30
What does intake allowed =?
Urine output + insensible losses
31
Why is there a more liberal intake of fluid allowed in PD compared to HD?
As continuous ultrafiltration is often achieved
32
Complications of HD
``` CVS problems - intra-dialytic hypotension and cramps - arrhythmias Coagulation - clotting of vascular access - heparin related problems Allergic reactions to dialysers and tubing Catastrophic dialysis accidents (rare) ```
33
What is the most important factor in choosing modality of dialysis?
Patient choice
34
Where is a transplanted kidney placed?
Into the iliac fossa and anastomosed to the iliac vessels
35
What happens to the native kidneys?
They remain in situ
36
Indications for a native nephrectomy
Size (polycystic kidneys) | Infection (chronic pyelonephritis)
37
Why must the donor kidney be preserved?
Minimises oedema Preserves the integrity of the tissues Buffers free radicals
38
Complications of transplant
``` Vascular - bleeding - arterial and venous thrombosis - lymphocele Ureteric - urine leak Infections ```
39
What immunosuppressive agents can be used in kidney transplant?
``` Corticosteriods Calcineurin inhibitors (TACROLIMUS, CYCLOSPORIN) Anti-proliferatives - mycophenolate mofetil - azathioprine mTOR inhibitors - sirolimus Costimulatory signal blockers - belatacept Depleting agents - basiliximab - rituximab ```
40
S/Es of corticosteriods
``` HTN Hyperglycaemia Infections Bone loss GI bleeding ```
41
S/Es of tacrolimus
Hyperglycaemia AKI Tremor
42
S/Es of cyclosporin
Hirsutism AKI HTN Gout
43
Immunosuppression protocols in kidney transplant
``` Induction = basiliximab Maintenance = tacrolimus + mycophenolate + steroids ```
44
S/Es of mycophenolate
Cytopenia | GI upset
45
Types of donors
Deceased donors | Living donors
46
Types of deceased donors
Donation after brain death (DBD) | Donation after cardiac death (DCD)
47
Types of living donors
``` Living related Living unrelated - spousal - altruistic - paired/pooled ```
48
Brain death criteria
``` Coma Unresponsive to stimuli Apnoea off ventilator (with oxygen) despite build up of CO2 Absence of cephalic reflexes Body temp above 34C Absence of drug intoxication ```
49
What are the cephalic reflexes?
``` Pupillary Oculocephalic Oculovestibular (caloric) Corneal Gag ```
50
Complications after renal transplant
``` Rejection CVS - CRF - HTN - Hyperlipidaemia - PT diabetes Infective Malignancy - skin - lymphoma - solid cancers ```
51
Types of acute rejection
Hyperacute rejection | Acute rejection
52
What is hyperacute rejection?
Pre-existing alloreactivity to donor
53
Pathology of acute rejection
``` T cell mediated rejection - tubulointerstital (Banff I) - arteritis / endothelialitis (Banff II) - arterial fibroid necrosis (Banff III) Acute antibody mediated rejection (ABMR) - ATN-like (Banff I) - capillaries and or glomerular inflammation (Banff II) - arterial inflammation (Banff III) ```
54
What does a T cell mediated rejection consist of?
Lymphocytic infiltration Tubulitis Endarteritis Endotherliathisis
55
What does an antibody mediated rejection consist of?
``` Microvascular inflammation - neutrophil infiltration - glomeruli - peritubular capillaries Donor specific antibodies Positive C4d peritubular capillaries ```
56
What is the most important transplant related infection?
Cytomegalovirus
57
What % of transplant recipients are affected by CMV, despite prophylaxis therapy?
8%
58
How do transplant recipients get CMV?
Transmission from donor tissue | Reactivation of latent virus
59
What does CMV cause?
``` Pneumonitis Retinitis Gastroenteritis Colitis Nephritis ```
60
Clinical manifestation of the BK virus in renal transplantation
Ureteral stenosis Interstitial nephritis ESRF
61
Risk factors for BKAN (BK virus)
``` Intensity of immunosuppression Patient - older - male - white - DM - negative BKV serostatus (paediatric recipients) Graft injury HLA mismatches Ureteral stents Viral determinants - changes in epitopes of viral capsid protein VP-1 ```
62
What % of patients with the BK virus loose their graft?
45-80%
63
Treatment of BK virus
Reduce immunosuppression Antiviral therapy - cidofovir +/- IVIG - leflunomide
64
What type of malignancy has the highest risk of developing after renal transplantation?
Non melanoma skin Kapsoi sarcoma Non hodgkins lymphoma
65
What is the best way to treat end stage renal disease?
Kidney transplantation
66
How long does it take for an AV fistula to develop?
6 - 8 weeks
67
What is the most common and important viral infection that develops in solid organ transplant patients?
CMV
68
Treatment for CMV
Ganciclovir
69
What is the preferred mode of access for haemodialysis?
AV fistula

Renal Pathology (13 decks)

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