MANAGEMENT OF CHRONIC RENAL FAILURE 1.Conservative therapy2.Renal replacement therapy
1.CONSERVATIVE THERAPYDietaryModifications Elimination of symptoms and prevention of further 1. Aim deterioration2.Initiated When patient becomes azotemic Manage diet,fluid,electrolytes and calcium phosphate3.What we do? balance
(A)DIETARY MODIFICATIONS Includes1.Dietary regulation of protein 2.Nutritional supplements,if (20 -40 g/day) needed(a)Improves acidosis,azotemia and (a)Multivitamin supplementsnausea (b) Patients with early renal(b)Reduces the excretory load of insufficiency,supplement diet withthe kidney & CaCO3 along with limited intake ofThereby intraglomerular pressure phosphate containing foodsand secondary injury to nephrons
Take Care of “BEANS”(Practical clinical approach to the management of patients with chronicrenal failure) 1. Blood pressure should be maintained in a target range lower than 130/80 mm Hg 2.Haemoglobin levels should be maintained at 10-12 g/dL 3.Hyperlipidemia should be treated with a “statin” lipid lowering medication 4.Smoking cessation should also be encouraged
(B) DIALYSIS (DIA-THROUGH , LYSIS –LOOSENING) Serum creatinine> 4.0g/dL*When the access should becreated??? GFR falls to <20 mL/min*Close monitoring of nutritional status isimportant
INDICATIONS:The decision to initiate dialysis renal failure depends on severalfactors. divided into acute or chronic indications.in the patient with acute kidney injury -vowel acronym of"AEIOU": 1.Acidemia from metabolic acidosis 2.Electrolyte abnormality, such as severe hyperkalemia, 3.Intoxication, that is, acute poisoning with a dialyzable substance. 4.Overload of fluid 5.Uremia complications, such as pericarditis, encephalopathy, or gastrointestinal bleeding.Chronic indications for dialysis: 1.Symptomatic renal failure 2.Low glomerular filtration rate (GFR) In diabetics, dialysis is started earlier <15cc/min 3.Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low
(a)Haemodialysis Dialysis (b)Peritoneal dialysis (a)Haemodialysis is the removal of nitrogenous and toxic products of metabolism from the blood by means of a haemodialyzer system #Exchange occurs between the patient’s plasma and dialysate (electrolyte composition of which mimics that of extracellular fluid) across a semi permeable membrane that allows uremic toxins to diffuse out of the plasma while retaining the formed components and protein composition of bloodNOT provides the same degree of health as renal function provides becausethere is no resorptive capability in the dialysis membrane.
COMPONENTS of dialysis unit1.Dialyzer2.Dialysate production unit3.Roller blood pump4.Heparin infusion pump5.Devices to monitor theconductivity,temperature,flow rate andpressure of dialysate
The frequency and duration of dialysis treatment are related to1. Body size2. residual renal function3.Protein intake4.Tolerance to fluid removal #The typical patient undergoes haemodialysis 3 times/week with each treatment lasting approximately 3-4 hours on standard dialysis units and slightly less time on high efficiency/high flux dialysis units NEWER FORMS :Nocturnal and daily dialysis with improved control of 1.Biochemical abnormalities 2.Blood pressure and volume status
1. In hemodialysis, the patients blood is pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane. 2.Blood flows through the fibers, dialysis solution flows around the outsideof the fibers, and water and wastes move between these two solutions.3.The cleansed blood is then returned via the circuit back to the body.***. Ultrafiltration occurs by increasing the hydrostatic pressure across thedialyzer membrane.This usually is done by applying a negative pressure to the dialysatecompartment of the dialyzer.4.This pressure gradient causes water and dissolved solutes to move fromblood to dialysate, and allows the removal of several liters of excess fluidduring a typical 3- to 5-hour treatment
Types of vascular access foe maintenancehaemodialysis**Classic construction is side to sideanastomosis b/w the radial artery andcephalic vein at the forearm1.Primary arteriovenous(AV)fistula/shunt/external cannula system:Preferred for long term treatment.2. Synthetic AV graft: Fistulae are created bymeans of autografts,PTFE grafts ,Dacron etc.A fistula is an enlarged vein (usually in yourarm), created by connecting an artery directlyto a vein.3.Double lumen4.Cuffed tunneled catheters: indwellingcentral venous catheters used
(B) Peritoneal dialysis(accounts for10% of dialysis t/t)1. access is achieved via a catheter through the abdominal wall into the peritoneum2. 1-2 liters of dialysate is placed in the peritoneal cavity and is allowed to remain for varying intervals of time3. Substances diffuse across the semipermeable peritoneal membrane to dialysate4. #Tenckhoff Silastic catheter has made peritoneal puncture for each dialysis unnecessary**little baby who needed dialysis. You can seehis Tenckhoff Catheter coming out of histummy. This type of catheter is used forperitoneal dialysis. #
Various Regimens for peritoneal dialysis:1.Chronic ambulatory patients..:2 L ofdialysis fluid instilled in the peritoneal cavity,allowed to remain for 30 mins and drained out2.Continuous cyclic peritoneal dialysis,inwhich 2-3 L of dialysate is exchanged everyhour over a 6-8 hour period overnight,7days/week *** as it allows (a)great deal of personal freedom (b)No risk of air embolism and blood leaks (c) Hepariniztion unnecessary SO used as PRIMARY therapy/as a TEMPORARY MEASURE
2.RENAL TRANSPLANTATIONTreatment of choice for patients withirreversible kidney failureHowever the use of transplantation islimited by organ availabilityINDICATIONS:1. ESRD2. Glomerulonephritis3.Pyelonephritis4.Congenital abnormalities5.Nephrotic syndrome
Other Approaches:1.Hemofilterationa) based on the principle of convection and physiologic function of glomerulusb) Standard dialysis technique is modified prediluting the blood with an electrolytesol’n and ‘ultrafiltering’ it under high hydraulic pressure2.Adjunctive techniques used withmaintenance dialysis include the use ofABSORBENT materials for solute removalThe Recirculating DialYsis System( REDY2000, REDY Sorbent system)Differs from regular single- pass dialysis inthat after passing through dialyzer, the REDYdialysate fluid is regenerated, rather thandiscarded, by passing through a sorbentcartridge.