Renal Replacement Therapy And Transplantation Flashcards
(31 cards)
What is responsible for creating the osmotic gradient in peritoneal dialysis?
What is the goal of this?
High concentration of glucose/dextrose in the dialysate fluid. Can also be amino acid or glucose polymer solutions which are used.
Draw in waste products from the blood.
What are the types of PD?
Continuous ambulatory
- 4-5 dialysis exchanges per day lasting 30-40 mins (2L each)
- Dwell time 4-8 hours (whilst patient sleeps)
- Allows them to go about their daily activities
Automated PD
- Dialysis automated cycles machine fills and drains the abdomen while the patient is sleeping - performin 3-5 exchanges over 8-10 hours.
Assisted automated PD
Give one advantage of each type of PD
Continuous
- Patient can go about normal activities whilst dialysate is in their abdomen
Continuous Ambulatory PD
- Leaves the day time free
Give 3 advantage of PD
Quality of life better than HD
Good first choice for patients starting dialysis, especially if they have some residual renal function
More individualised regimes than HD
Give 3 disadvantages of PD
Technical aspects need to be managed by the patients
Contraindications
Complications
High peritonitis risk
Give 4 contraindications to PD
Peritoneal membrane failure
Adhesions - previous surgery, hernia and stoma
Patient or carer unable to connect and disconnect
Obese or large muscular mass relative to peritoneum size
Give some complications of PD
How often does someone on average develop peritonitis on PD?
What is sclerosing version?
Peritonitis
- Every 20 months
Sclerosing (encapsulating) peritonitis
- Leads to small bowel obstruction
Catheter infection
Catheter blockage
Constipation
Fluid retention
Pleuro-peritoneal leaks (also scrotal leaks)
Hernias
Hyperglycaemia
Give 2 advantages and 2 disadvantage of HD?
Advantages
- Efficient
- Unit-based and therefore plenty of staff support
- Can be used for AKI and ESRF
Disadvantages
- Complications
- Securing access
- Travel time
- Big restriction to food and fluid intake
What are the different types of HD?
What is the typical unit-based regimen?
Home HD
Nocturnal HD
CRRT - IT and HDU usage
3 times a week - 4 hour sessions
Name some complications of haemodialysis?
Site/ line infection
Endocarditis
Stenosis at site
Hypotension
Air embolus
Anaphylaxis to sterilising agents
Steal syndrome
AVF thrombosis, bleeding
Give 1 absolute contraindication
Give 2 relative contraindications
HD
Failed vascular access
Heart failure.
Coagulopathy
What is disequilibrium syndrome?
Pathophysiology?
Common in ?
Clinical syndrome of neurological deterioration seen in patients who undergo haemodialysis
Occurs due to cerebral oedema resulting from urea removal from the blood, faster than from the CSF and brain tissue.
Results in a urea osmotic gradient responsible for moving water into brain cells.
First time dialysis Elderly and paediatric Previous CNS lesions (stroke etc) High pre-dialysis BUN Severe meta logic acidosis
Give 2 advantages of transplant compared to dialysis.
2 disadvantages?
Near normal lifestyle
Better mortality and morbidity
Risk of rejection
Risk of malignancy
Risk of infection (immunosupression)
Long waiting times
What 2 indications might warrant active conservative management of ESRF?
Why?
Age >80
WHO Performance score >/=3
In this group RRT offers no survival benefit.
Give 3 absolute contraindications of renal transplantation.
Active GN Active infection Active malignancy Overt AIDS Active hepatitis Severe co-morbidity reducing life expectancy to <2 years. Reversible renal disease Active substance abuse Uncontrolled psychiatric disease End stage heart, lung or liver disease
Remember smoking - relative contraindication.
What are the types of renal transplant?
Live-related donor transplant
Live unrelated donor transplant
- Live-donor paired exchange
- Live-donor/ deceased-donor exchnage
- Live-donor chain
- Altruistric donation
Deceased donor transplant
What is bad about deceased-donor transplantation?
Time to transplantation is years (rather than months)
Survival of kidney allograft and patients are significantly low compared to live donor transplant
Less time for preparation since it is more urgent.
What therapies dramatically reduces the rate of hyperacute transplant rejection?
Give 2 example regimes
Induction treatment - giving potent immunosuppressive drugs at the moment of transplantation.
Methylprednisolone + thymoglobulin
Methylprenisolone + basiliximab
(IL-2 monoclonal antibody)
Give some drugs used immediately after transplantation and long term to prevent acute or chronic rejection.
Steroids - prednisolone (or prednisone)
Calcineurin inhibitors - typical ones and voclosopin
Antimetabolites - mycophenolate and azathioprine
Rapamycin inhibitors - sirolimus and everolimus
T cell regualtion - Belatacept and belimumab
What vaccines are contra-indicated in renal transplant patients?
What is another contraindication to these type of vaccines?
Name some.
Live vaccines
B MY TOP VIF
BCG
MMR
Yellow fever
Typhoid
Oral polio vaccine
Plague
Varicella
Influenza
Pregnancy
What are some of the adverse effects that can occur from immunosupressive drugs use?
Accelerated CVS disease - calcineurin inhibitors - cause hypertension and hyperglycaemia
Tacrolimus causing = hyperlipidaemia
Renal failure - calcineurin inhibitors = nephrotoxic
Graft rejection = nephrotoxic
Disease recurrence in new kidney
Malignancy - minimise sun exposure to reduce SCC and BCC risk
What blood components should you monitor in a transplant patient?
What checks should they receive annually?
GFR
CNI levels
Proteinuria
Ca, phosphate and PTH
Lipids (Tacrolimus)
Glucose (CNI)
Skin cancer checks
What are the main causes of mortality in renal transplant patients?
CVS disease
Infections
Malignancies
What should be advised with regards to GU health?
Contraception = obligatory for first year
Counsel about pregnancy one year after that
