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I don't measure a man's success by how high
he climbs but
how high he bounces when he hits
bottom….. -George Patton!!
Renal Replacement Therapy
Dr. Sandeep G Huilgol
Dept of Nephrology and
Transplantation
Some Historical aspects……






First hemodialysis in a human being was by Hass
(February 28, 1924).
Dr. Willem Kolff was the first to construct a
working dialyzer in 1943.
The first documented kidney transplant in the
United States was performed June 17, 1950, on
Ruth Tucker, a 44-year-old woman with polycystic
kidney disease.
In 1954, at Brigham Hospital Dr. Joseph E.
Murray and Dr. J. Hartwell Harrison performed
the world's first successful renal transplant
between genetically identical patients, for which
Dr. Murray received the Nobel Prize for Medicine
in 1990.


The first ever human kidney transplant performed in India
was done at the King Edward Memorial Hospital at Bombay in
May 1965, using a cadaver donor in a non-renal failure
patient who had had hypernephroma.



The first successful Live Donor renal transplant in India was
done at the CMC Hospital, Vellore in January 1971

VN Acharya. RENAL TRANSPLANTATION

Journal of post graduate medicine,1994; 40,3: 158-61
RENAL REPLACEMENT
THERAPY
A) Dialysis Therapy
Hemodialysis
Peritoneal Dialysis

B) Renal Transplant
Dialysis Therapy

Extracorporeal:
Intermittent Hemodialysis
Slow Low efficiency Dialysis (SLED)
Continuous Hemofiltration
CAVH
SCUF
CVVH
CAVHDF
CVVHDF
Intracorporeal:
Peritoneal Dialysis
PD:
-

It is a substitution therapy
- Replaces partially the excretory
function and contributes to the
maintenance of fluid, electrolyte and
acid base balance
Renal replacement therapy
Patient undergoing Peritoneal Dialysis (CAPD)
Peritoneal dialysis
Advantages







Simple to set up &
perform
Easy to use in infants
Hemodynamic stability
No anti-coagulation
Bedside peritoneal
access
Treat severe
hypothermia or
hyperthermia

Disadvantages









Unreliable ultrafiltration
Slow fluid & solute
removal
Drainage failure & leakage
Catheter obstruction
Respiratory compromise
Hyperglycemia
Peritonitis
Not good for
hyperammonemia or
intoxication with
dialyzable poisons
Forms of PD:
1.Manual procedure:
a) Acute PD: rapid cycling on
intermittent basis,3-4 times per
week, each session for 2-3days
b) Cont. Ambulatory PD : 3-4 hr daytime dwells + a
long bedtime exchange
2.Automated Procedure:
a) Acute PD - same but using automatic PD
machine
b) Continuous cycling PD - long day dwell with
multiple short night time exchange
c) Nocturnal intermittent PD – no day dwell but
with
multiple short night time exchanges
d) Tidal PD – the fluid in the abdomen is not
completely drained. The dialysate
fluid left in the abdomen helps in continuous
dialysis without the break
PD Machine
Indications of PD:
Biochemical
indications

Clinical indications

1.

2.

2.

Metabolic Acidosis
Hyperkalemia
(Sr K:> 6mEq/L)

1.
3.

Refractory edema
Pulmonary edema
Symptomatic uremia
 Uses

Of PD :

1. Renal failure
2. Poisoning : salicylate
phenobarbitone
phenytoin sodium
3. Inborn errors of metabolism:
hyperammonia syndrome
urea cycle defect
Hemodialysis
Extracorporeal therapy:
Acute Intermittent Hemodialysis
CRRT
Mechanisms1.
Hemodialysis- most commonly used therapy
2.
Hemofiltration
3.
Hemodiafiltration
4.
Hemoperfusion
5.
Apheresis
Renal replacement therapy
Renal replacement therapy
Renal replacement therapy
Haemodialysis
Can be through a
Central Venous
Catheter
 AV Shunt
OR
 Through a Arterio
– Venous Fistula
 Sythetic Graft

Renal replacement therapy
Renal replacement therapy
Synthetic Graft
Blood pump
Trip chamber

A

B
Intermittent Hemodialysis


For critically ill patients may be it is limited or
ineffective due to the critical nature of the
illness.
Volume overload and hemodynamic instability
may not be treated adequately.



Complications of IHD:
 Systemic hypotension which might lead to
Multi-organ dysfunction
 Arrhythmias
 Hypoxemia
 Hemorrhage
IHD
Advantages






Maximum solute
clearance of 3
modalities
Best therapy for
severe hyperkalemia
Limited anticoagulation time
Bedside vascular
access can be used

Disadvantages







Hemodynamic
instability
Hypoxemia
Rapid fluid and
electrolyte shifts
Complex equipment
Specialized personnel
Difficult in small
infants
 Continuous

Renal Replacement Therapy:

- Based on principles of Hemofiltration

- Substitute for impaired renal function
over an extended period of time and
applied for 24 hours a day.
What is CRRT
 Continuous

the ICU
 The

Dialysis of Critically Ill Patients in

concept behind CRRT is to dialyze patients in
a more physiologic way, slowly over 24 hours, just
like the kidney. Intensive care patients are
particularly suited as they are by definition, bed
bound and when acutely sick, intolerant to fluid
swings associated to IHD






Electrolyte Management / dialysate mirrors ideal
blood composition
Allows for provision of nutritional support
Management of sepsis / plasma cytokine filter
Probable advantage in terms of renal recovery
Improved nutritional support (full protein diet)
CRRT Modalities
 SCUF- Slow Continuous Ultra filtration
 Ultra

filtration
 CVVH- Continuous Veno-Venous Hemofiltration
 Convection
 CVVHD- Continuous Veno-Venous Hemodialysis
 Diffusion
 CVVHDF- Continuous Veno-Venous
Hemodiafiltration
 Diffusion and Convection
Renal Transplantation
Outline
 Basics

of transplantation
 Benefits of transplantation
 Immunosuppressive medications
 Common post-transplant problems
Basics of Transplantation
 Kidney

transplantation is the most effective therapy
for end-stage renal disease.
 The transplanted organ can come from either a live
donor or deceased donor.
 Thorough donor evaluation should be done
- medical history, physical exam., blood group, HLA
typing, LFT, RFT, Urine analysis, screening for
HIV, HBV, HCV,TB, psychological testing, ECG,
CXR, Echo ,USG & spiral CT for renal anatomy.
Recipient Selection
 Very

few contraindications.
 Screening for HIV,HBV,HCV,CMV,EBV,TB.
 Cardiovascular screening.
 Immunize as per schedule- hepatitis B,varicella
 Optimize nutritional status
 Thorough history & physical exam
 B.G.,HLA Type, RFT, LFT
 Thorough evaluation of lower urinary tract
 Some children require bladder reconstruction
surgeries prior to transplant



Socioeconomic factors
Investigate the cause of ESRD- since certain
diseases can recur in the graft viz., FSGS, MPGN,
atypical HUS.
Pre, intra & immediate post transplant
management:
 Fluid

and electrolytes therapy
 Immunosuppressive therapy
pre-op.: single dose of MMF / Azathioprine + anti
IL-2R antibody
peri-op.: I/V Methylprednisolone
post-op.:CsA/FK506 + MMF/Azathioprine +
steroids
 Anti-infective prophylaxis:
Cefazolin for 24 hrs for peri-operative period
Ganciclovir for CMV prophylaxis- for 4-6 months
Septran : prophylaxis of PCP & UTI
Nystatin : for fungal infections
Immunosuppressive Medications
 Induction:
Corticosteroids

Anti-thymocyte

globulin (ATG)

OKT3
IL-2

receptor antagonists
 Maintenance:
Corticosteroids
Calcineurin inhibitors (CNIs)
mTOR inhibitors
Antimetabolites
Common Complications of Transplantation


Early complications
 Surgical complications
 Delayed or slow graft function
 Lymphocele



Allograft rejection
 Hyper acute rejection (Antibody-mediated
rejection) : within min. to hr of perfusing of
allograft
- due to preformed antibodies to the ABO &
HLA antigens.
 Acute rejection – within 3 months of transplant
 Chronic rejection





Infectious complications
 Cytomegalovirus
 BK virus
 Others
Hypertension- diet therapy, ACEI, CCB
Hematologic complications : anemia, leukopenia,
thrombocytopenia







Metabolic complications- hypomagnesaemia,
hypophosphatemia, Hypercalcemia, Hyperkalemia,
RTA, dyslipidemia
Malignancy- Post transplant lymphoproliferative
disorder
Recurrence of Primary Disease in the AllograftFSGS, MPGN, atypical HUS,WG.
Treatment :CsA, Cyclophosphamide.
Chronic allograft dysfunction
Surgical Complications





Lymphocele
Perirenal serous fluid collection
Hematoma
Graft thrombosis:
 Caused by thrombosis of donor renal artery or
vein.
 Usually happens in first week.
 Diagnosed by ultrasound with doppler studies.
 Almost always requires explant of kidney.
Thank you

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Renal replacement therapy

  • 1. I don't measure a man's success by how high he climbs but how high he bounces when he hits bottom….. -George Patton!!
  • 2. Renal Replacement Therapy Dr. Sandeep G Huilgol Dept of Nephrology and Transplantation
  • 3. Some Historical aspects……     First hemodialysis in a human being was by Hass (February 28, 1924). Dr. Willem Kolff was the first to construct a working dialyzer in 1943. The first documented kidney transplant in the United States was performed June 17, 1950, on Ruth Tucker, a 44-year-old woman with polycystic kidney disease. In 1954, at Brigham Hospital Dr. Joseph E. Murray and Dr. J. Hartwell Harrison performed the world's first successful renal transplant between genetically identical patients, for which Dr. Murray received the Nobel Prize for Medicine in 1990.
  • 4.  The first ever human kidney transplant performed in India was done at the King Edward Memorial Hospital at Bombay in May 1965, using a cadaver donor in a non-renal failure patient who had had hypernephroma.  The first successful Live Donor renal transplant in India was done at the CMC Hospital, Vellore in January 1971 VN Acharya. RENAL TRANSPLANTATION Journal of post graduate medicine,1994; 40,3: 158-61
  • 5. RENAL REPLACEMENT THERAPY A) Dialysis Therapy Hemodialysis Peritoneal Dialysis B) Renal Transplant
  • 6. Dialysis Therapy Extracorporeal: Intermittent Hemodialysis Slow Low efficiency Dialysis (SLED) Continuous Hemofiltration CAVH SCUF CVVH CAVHDF CVVHDF Intracorporeal: Peritoneal Dialysis
  • 7. PD: - It is a substitution therapy - Replaces partially the excretory function and contributes to the maintenance of fluid, electrolyte and acid base balance
  • 10. Peritoneal dialysis Advantages       Simple to set up & perform Easy to use in infants Hemodynamic stability No anti-coagulation Bedside peritoneal access Treat severe hypothermia or hyperthermia Disadvantages         Unreliable ultrafiltration Slow fluid & solute removal Drainage failure & leakage Catheter obstruction Respiratory compromise Hyperglycemia Peritonitis Not good for hyperammonemia or intoxication with dialyzable poisons
  • 11. Forms of PD: 1.Manual procedure: a) Acute PD: rapid cycling on intermittent basis,3-4 times per week, each session for 2-3days b) Cont. Ambulatory PD : 3-4 hr daytime dwells + a long bedtime exchange
  • 12. 2.Automated Procedure: a) Acute PD - same but using automatic PD machine b) Continuous cycling PD - long day dwell with multiple short night time exchange c) Nocturnal intermittent PD – no day dwell but with multiple short night time exchanges d) Tidal PD – the fluid in the abdomen is not completely drained. The dialysate fluid left in the abdomen helps in continuous dialysis without the break
  • 14. Indications of PD: Biochemical indications Clinical indications 1. 2. 2. Metabolic Acidosis Hyperkalemia (Sr K:> 6mEq/L) 1. 3. Refractory edema Pulmonary edema Symptomatic uremia
  • 15.  Uses Of PD : 1. Renal failure 2. Poisoning : salicylate phenobarbitone phenytoin sodium 3. Inborn errors of metabolism: hyperammonia syndrome urea cycle defect
  • 16. Hemodialysis Extracorporeal therapy: Acute Intermittent Hemodialysis CRRT Mechanisms1. Hemodialysis- most commonly used therapy 2. Hemofiltration 3. Hemodiafiltration 4. Hemoperfusion 5. Apheresis
  • 20. Haemodialysis Can be through a Central Venous Catheter  AV Shunt OR  Through a Arterio – Venous Fistula  Sythetic Graft 
  • 25. Intermittent Hemodialysis  For critically ill patients may be it is limited or ineffective due to the critical nature of the illness. Volume overload and hemodynamic instability may not be treated adequately.  Complications of IHD:  Systemic hypotension which might lead to Multi-organ dysfunction  Arrhythmias  Hypoxemia  Hemorrhage
  • 26. IHD Advantages     Maximum solute clearance of 3 modalities Best therapy for severe hyperkalemia Limited anticoagulation time Bedside vascular access can be used Disadvantages       Hemodynamic instability Hypoxemia Rapid fluid and electrolyte shifts Complex equipment Specialized personnel Difficult in small infants
  • 27.  Continuous Renal Replacement Therapy: - Based on principles of Hemofiltration - Substitute for impaired renal function over an extended period of time and applied for 24 hours a day.
  • 28. What is CRRT  Continuous the ICU  The Dialysis of Critically Ill Patients in concept behind CRRT is to dialyze patients in a more physiologic way, slowly over 24 hours, just like the kidney. Intensive care patients are particularly suited as they are by definition, bed bound and when acutely sick, intolerant to fluid swings associated to IHD
  • 29.      Electrolyte Management / dialysate mirrors ideal blood composition Allows for provision of nutritional support Management of sepsis / plasma cytokine filter Probable advantage in terms of renal recovery Improved nutritional support (full protein diet)
  • 30. CRRT Modalities  SCUF- Slow Continuous Ultra filtration  Ultra filtration  CVVH- Continuous Veno-Venous Hemofiltration  Convection  CVVHD- Continuous Veno-Venous Hemodialysis  Diffusion  CVVHDF- Continuous Veno-Venous Hemodiafiltration  Diffusion and Convection
  • 32. Outline  Basics of transplantation  Benefits of transplantation  Immunosuppressive medications  Common post-transplant problems
  • 33. Basics of Transplantation  Kidney transplantation is the most effective therapy for end-stage renal disease.  The transplanted organ can come from either a live donor or deceased donor.  Thorough donor evaluation should be done - medical history, physical exam., blood group, HLA typing, LFT, RFT, Urine analysis, screening for HIV, HBV, HCV,TB, psychological testing, ECG, CXR, Echo ,USG & spiral CT for renal anatomy.
  • 34. Recipient Selection  Very few contraindications.  Screening for HIV,HBV,HCV,CMV,EBV,TB.  Cardiovascular screening.  Immunize as per schedule- hepatitis B,varicella  Optimize nutritional status  Thorough history & physical exam  B.G.,HLA Type, RFT, LFT  Thorough evaluation of lower urinary tract  Some children require bladder reconstruction surgeries prior to transplant
  • 35.   Socioeconomic factors Investigate the cause of ESRD- since certain diseases can recur in the graft viz., FSGS, MPGN, atypical HUS.
  • 36. Pre, intra & immediate post transplant management:  Fluid and electrolytes therapy  Immunosuppressive therapy pre-op.: single dose of MMF / Azathioprine + anti IL-2R antibody peri-op.: I/V Methylprednisolone post-op.:CsA/FK506 + MMF/Azathioprine + steroids  Anti-infective prophylaxis: Cefazolin for 24 hrs for peri-operative period Ganciclovir for CMV prophylaxis- for 4-6 months Septran : prophylaxis of PCP & UTI Nystatin : for fungal infections
  • 37. Immunosuppressive Medications  Induction: Corticosteroids Anti-thymocyte globulin (ATG) OKT3 IL-2 receptor antagonists  Maintenance: Corticosteroids Calcineurin inhibitors (CNIs) mTOR inhibitors Antimetabolites
  • 38. Common Complications of Transplantation  Early complications  Surgical complications  Delayed or slow graft function  Lymphocele  Allograft rejection  Hyper acute rejection (Antibody-mediated rejection) : within min. to hr of perfusing of allograft - due to preformed antibodies to the ABO & HLA antigens.  Acute rejection – within 3 months of transplant  Chronic rejection
  • 39.    Infectious complications  Cytomegalovirus  BK virus  Others Hypertension- diet therapy, ACEI, CCB Hematologic complications : anemia, leukopenia, thrombocytopenia
  • 40.     Metabolic complications- hypomagnesaemia, hypophosphatemia, Hypercalcemia, Hyperkalemia, RTA, dyslipidemia Malignancy- Post transplant lymphoproliferative disorder Recurrence of Primary Disease in the AllograftFSGS, MPGN, atypical HUS,WG. Treatment :CsA, Cyclophosphamide. Chronic allograft dysfunction
  • 41. Surgical Complications     Lymphocele Perirenal serous fluid collection Hematoma Graft thrombosis:  Caused by thrombosis of donor renal artery or vein.  Usually happens in first week.  Diagnosed by ultrasound with doppler studies.  Almost always requires explant of kidney.