2. DEFINITION
Renal replacement therapy is a
therapy that replaces the normal
blood filtering functioning of the
kidneys.
It is used when the kidneys are not
functioning well i.e in conditions like
Acute or Chronic Kidney Disease.
4. DIALYSIS
All dialyses modalities can be used to ensure
equivalent solute clearence and ultrafiltration.
Choice of procedure depends on
a) Age & size of the patient
b) Cardiovascular status
c) Availability of vascular status
d) Integrity of peritoneal membrane and abdominal
cavity.
e) Expertise available.
5. Indications of Dialysis in AKI
Uremia
Hyperkalemia
Hyponatremia
Fluid overload
Metabolic Acidosis
Hypercatabolic state
6. Indications in CKD
GFR <15ml/min/1.73m2 BSA.
Growth Failure
Severe HTN
Intractable intravascular volume overload
Profound electrolyte abnormalities
{hyperkalemia , hyperphosphatemia etc.}
7. ACUTE PERITONEAL DIALYSIS
ULTRAFILTRATION :
Exchange of solutes and movement of fluid across
the semipermeable peritoneal membrane.
DIFFUSIVE TRANSPORT :
Solutes are exchanged across their concentration
gradient between the peritoneal capillaries and
the dialysis solution that is instilled into the
peritoneal cavity.
10. Peritoneal Dialysis Solutions
Conventionally PD solutions contain dextrose as
the osmotic agent.
Non – dextrose containing solutions : reduce risk
of hyperglycemia
Other solutes comercially available : lactate,
sodium & calsium.
11. Complications
Bleeding after catheter insertion
Perforation of gut.
Abdominal pain
Leakage around catheter
Difficult Drainage
Exit site infections.
Peritonitis
Metabolic problems ( Hypo or hypernatremia,
hypokalemia,hyperglycemia, hypopsosphatemia
& metabolic alkalosis.
12. Chronic Peritoneal Dialysis
Accepted mode of treatment for patients awaiting
renal transplantation.
Two types :
1) CAPD ( Continuous Ambulatory Peritoneal
Dialysis )
Contains of
- Plastic bag containing dialysis fluid
- Transfer set
- Permanent Peritoneal Catheter
13. This procedure is particularly suitable for infants and
for small children.
Complications:
- Peritonitis (most important complication of
CAPD)
- Catheter malfunction
- Abdominal wall hernia
- Back pain
- Hydrothorax
- Respiratory difficulty
14. 2) CCPD (Continuous Cycling Peritoneal
Dialysis):
Most common approach involves frequent
continuous ‘cycling’ of dialysate during the night,
while the child is asleep & then leaving in a small
volume of dialysate during the daytime.
The automated device minimizes the need for
extensive manual manipulation and hence
reduces the risk of peritonitis.
The patient can carry out day to day activities and
attend school.
15. Advantages
Ability to perform dialysis at home.
Technically easy than hemodialysis, especially in
infants
Ability to live a greater distance from medical
center
Freedom to attend school
Less restrictive diet
Less expensive than hemodialysis
17. - HEMODIALYSIS -
Provides an excellent extracorporeal mode
for renal replacement.
Advances in technical aspects and
availability of pediatric size dialyzers have
made it possible to offer hemodialysis to
children in end stage renal disease.
18. Principles
The basic principles of HD are the same as
for PD :-
- A) Ultrafiltration
- B) Solute Removal ( by connective
transport and diffuse transport)
19. What differentiates HD from PD is :
A) The driving force between the two
processes
B) Technical aspects of the procedure
C) Duration/Frequency of the treatments.
21. The rate of transfer of substances
depend upon :
- The surface area and the permeability of
the dialyzer membrane
- The solute concentration gadient
- Rates of blood flow and dialysate flow
- Composition of dialysate.
22. Vascular Accesss:
A) Tunneled cuffed catheter
B) Arteriovenous (AV) fistula
C) AV graft.
23. 1) Catheters
Percutaneous temporary dual lumen catheter
Cuffed central venous catheter (Permacath)
2) Fistulas include the Radiocephalic and
Brachiocephalic fistula.
3)AV Grafts
Similar to fistulae except that an artifical graft made
of Teflon is used to join artery and vein.
24. Dialyzers and Blood Tubing
Most dialyzers currently are hollow fiber
dialyzers.
Most modern dialyzers are made of
modified cellulose or entirely made of
synthetic material.
(Advantage of being more permeable and
efficient solute removal.
The choice of dialyzer is based on the size
of the dialyzer.
25. Length & Frequency of Dialysis
The aim is for 30% reduction in BUN
during the 1s dialysis(1.5-2hrs).
50% during the 2nd treatment. (3hrs)
>70% reduction during subsequent
treatments (3.5-4hrs).
27. Advantages
Maximum solute clearance
Best tx for severe hyper- K+
Ready availability
Limited anti-coagulation time
Bedside vascular access
29. CONTINUOUS RENAL
REPLACEMENT THERAPY
Variant of HD therapies that are continuous
and prolonged.(for days to weeks).
2 types :
a) CVVH (Continuous venovenous
Hemofiltration)
Only convective transport without adding
dialytic compound.
30. b) CVVHD (Continuous venovenous
hemofiltartion dialysis)
Dialytic compound added.
The choice of CVVH or CVVHD is center
dependent and also on the need for
solute removal , which is usually greater
with CVVHD.
31. Indications for CRRT
Modality of choice in patients who are critically ill
and hemodynamically unstable patients.
Neonates and infants with cardiovascular or
abdominal surgery.
Trauma
Shock & multi-system failure.
Children with inborn errors of metabolism such as
urea cycle disorders
32. Disadvantages of CRRT
Same as seen in Hemodialysis.
Continous nature – risk greatly multiplied.
Continuous vascular access, very close
monitoring
– very expensive
