• The three primary treatment options for
patients with end-stage renal disease
• hemodialysis (HD)
• peritoneal dialysis (PD) and
• kidney transplantation
• when person lose about 85 to 90 percentwhen person lose about 85 to 90 percent
of kidney function.of kidney function.
• Definition: The process of filtering the blood,
the way kidneys normally do, using a machine.
• Renal Dialysis is a process of artificial
duplication of the kidney function for separating
crystalloid and colloid substances from the blood
using a semi- permeable membrane (cellulose-
acetate membrane tube immersed in fluid) .
• The processes of diffusion and convection
[movement from high to lower pressure region]
are used for solute removal, and a combination
of osmosis and ultra filtration are used to
normalise body water.
• The kidneys purify the blood by filtering it and
then selectively reabsorbing water and useful
molecules. Each kidney is made up of about one
million microscopic filter units called nephron
and acts independently of the other.
• Waste products from the filtering process are
flushed through the ureters to the bladder and
excreted as urine. For person whose kidneys are
diseased or no longer perform their normal
function without assistance, the Renal Dialysis
process performs two functions, it:
• removes metabolic waste products
• temporarily restores imbalances in body water
and electrolyte concentration
• The dialysis therapies that are available
• Peritoneal dialysis, where the semi
permeable nature of the peritoneal
[abdominal] membrane is used to achieve
the normalisation of body fluids, and
• Haemodialysis, where an artificial kidney
or dialyser is used.
• The most common causes of renal
• Glomerulonephritis inflammation of the
kidney [caused by a variety of conditions].
• Diabetes: an inability to correctly utilise the
• Hypertension: high blood pressure.
• Analgesic Nephropathy disease caused
by the prolonged use of specific
analgesics [pain killers]
Haemodialysis: a Replacement for
• It is commonly prescribed for 3 times per week and each
session lasts from 4-5 hours.
• Each client receives between 12 and 15 hours of
Haemodialysis each week.
• The dialyser is usually cylindrical in shape and
approximately 25-30 cm [10-12 inches] long . It is made
up of two compartments separated by a fabric
[membrane] semi-permeable in nature.
• The compartment containing the client's blood is called
the blood compartment. The dialysate compartment
contains the dialysate solution which is comparable to
the body fluids of a person with normally functioning
• A patient has two catheters, or small tubes,
inserted. One catheter is placed in a vein and
the other in an artery.
• The arterial catheter removes the blood from the
patient where it then travels into a dialysis
• The dialysis machine filters the blood to rid it of
waste products, similar to the way the kidneys
normally do. The filtered blood then returns to
the patient through the venous catheter.
• The machine performs two primary
• production and monitoring of dialysate
• pumping and monitoring of blood
through the extra-corporeal circuit.
• Modern dialysis equipment monitors fluid
flow in and out of the dialyser and very
accurately controls the weight loss
• Dialysate passes through the dialysate
compartment at the rate of 500ml/minute. As a
result, 30 litres /hour are required for each 4-5
• The used dialysate is not recyclable with most
machines. Commonly, 600 litres per week of
dialysate is required.
• To maintain these volumes economically for the
client , a mixture of concentrated electrolyte
solution is diluted with purified water using the
machine at the site of the dialysis.
• dialyzers are hollow fiber devices that contain
thousands of hollow fibers housed in a hard
plastic, typically polycarbonate, shell. Blood
flows through the dialyzer on the interior (lumen)
of the fibers. Dialysate flows through the
dialyzer on the exterior (shell-side) of the fibers.
• Cellulose acetate or polysulfone
• The dialysis membrane is permeable to all
solute that is less than 2000 daltons in size and,
to a lesser degree, to solutes up to 5000
daltons. As a result, electrolytes and metabolic
waste products such as urea and creatinine can
easily pass through, while larger elements, such
as blood cells and proteins are retained.
Composition of dialysate
• Glucose serves as the osmotic agent that enhances
ultrafiltration1.5% to 4.25% dextrose
• The sodium concentration in the ultra filtrate during peritoneal
dialysis is usually less than that of extra cellular fluid, so there is
a tendency toward water loss and development of
hypernatremia so dialysates have a sodium concentration of
132 mEq/L to compensate for this tendency toward
• Bicarbonates(22mmol/L) to rectify metabolic acidosis.
• Magnesium concentrations of 0.375 and 0.5 mmol/L (i.e., 0.75
and 1.0 mEq/L or 0.9 and 1.2 mg/dL) are most frequently used.
• Phosphorus concentrations have varied from 0.65 to 2.6
• Calcium concentrations below 1.5 mmol/L,
• 1,25-dihydroxyvitamin D can be liberalized to
reduce circulating levels of parathyroid hormone
and, thus, the risk of inducing hypercalcemia.
• tCO2 concentration above 23 mmol/L Increasing
evidence suggests that correction of chronic
acidosisis of clinical benefit in terms of bone
metabolism and nutrition.
• The use of an ethanol-enriched dialysate, along
with intravenous ethanol administration, has
been found to be helpful in the management of
patients with methanol poisoning.3 A dialysate
ethanol level of 100 mg/dL (22 mmol/L) is often
• intravenous administration comprise iron
dextran, iron saccharate (from 2 to 70
mg/dL) (iron sucrose), and iron gluconate.
The administration of all these iron
formulations can be associated with
hypotension and anaphylactoid reactions.
• urea concentration is high prior to dialysis,
there is a risk of developing the dialysis
• Transport rate of low MW solutes >> high
Principle involve in dialysis
• 1. Diffusion is the exchange of things dissolved in fluid
(solutes) across the membrane due to differences in the
amounts of the solutes on the two sides (concentration
• If there is a higher concentration of a given solute on one
side of the membrane than on the other, then diffusion
will occur . By controlling the chemicals in the dialysate,
the dialysis machine controls this transfer of solutes
according to the doctor's prescription.
• Dialysis machines control the chemicals in the dialysate
by mixing dialysis fluid concentrates, which are strong
versions of the chemicals, (acetate or sodium
bicarbonate plus acetic acid based solutions) with
• 2. Ultrafiltration, also referred to as convection, is
fluid flow through the membrane, forced by a difference
in pressure on the two sides of the dialyzer (pressure
• This controls the patient's weight loss over the course of
the treatment. While earlier dialysis machines either
controlled dialysate pressure or the pressure difference
across the membrane in order to achieve ultrafiltration,
modern dialysis machines are generally volumetric,
meaning they control the volume of fluid removed from
the patient directly and allowing dialysate pressure to
change as it will in order to achieve the prescribed
• Volumetric control is generally achieved either by
controlling the flow of dialysate in and out of the dialyzer
at different rates with two flow controllers, or by having
equal flow rates in and out of the dialyzer and removing
fluid between these equal flows.
• Osmosis is the net movement of water across a
selectively permeable membrane driven by a
difference in the amounts of solute on the two
sides of the membrane.
• In dialysis, this refers not to water movement
across the hemodialyzer membrane, but across
cell membranes within the body-either from
within the red cells to the blood plasma, or from
within cells of the various tissues in the body
(like muscles) to interstitial fluid (the fluid in
• Sodium profiling, as described in the "diffusion"
section, can be used to increase the rate of
osmosis early in the treatment by increasing the
sodium level of the plasma
Peritoneal Dialysis (PD)
• Dialysis fluid is introduced to the peritoneal cavity
through a catheter placed in the lower part of the
• A thin membrane, called the peritoneum, lines the
walls of the peritoneal cavity and covers all the
organs contained in it.
• In PD the peritoneum serves as the dialysis
membrane. The peritoneal cavity can often hold
more then 3 litres, but in clinical practice only 1.5 –
2.5L of fluid are used.
• This is an intra-corporeal blood purification as no
blood ever leaves the body of the patient.
The abdominal cavity, hold the large organs
of the digestive system, is lined by the
In PD, special fluid is instilled through a
permanent catheter in the lower abdomen.
• An osmotic pressure gradient is applied by
the addition to the dialysis fluid of an
osmotic agent which will “suck” fluid from
• The concentration of this osmotic agent is
chosen to give just the fluid removal
needed. In most cases glucose is used to
create the osmotic pressure.
• Fluid is removed by ultra-filtration driven
by an osmotic pressure gradient. (Eg.
• The abdominal cavity and all the organs
contained in it are lined by a thin smooth
membrane, the peritoneum.
• It is a loose connective tissue containing
blood vessels and nerves.
• If put under the microscope, three layers
can be identified between the peritoneal
cavity and the blood stream.
• The capillary wall / the interstitium / the
• Each of these is a barrier to the transport
of fluid and solutes.
• Solutes are
the membrane by
force is the conc
gradient between the
PD fluid and the
present in the blood
per fusing the
diffuse from the blood
vessels into the
• The dialysis fluid should
be instilled for 4 to 6
• When the dialysis fluid is
drained from the
abdominal cavity, it
contains waste products
and excess fluid
extracted from the blood.
• PD is most often applied
and effective as a
continuous therapy. In
this way it is a more
then Haemodialysis (HD)
RENAL TRANSPLANTATIONRENAL TRANSPLANTATION
• A kidney transplant is an operation in which a
person whose own kidneys have failed receives
a new kidney to take over the work of cleaning
• All patients with ESRD are candidates for KT
• Systemic malignancy.
• Chronic infection.
• Severe cardiovascular disease.
• Neuropsychiatric disorder.
• Extremes of age (relative).
KIDNEY DONORKIDNEY DONOR
• Living related.Living related.
• Living unrelated (emotionally motivated).Living unrelated (emotionally motivated).
• Cadaveric (Brain-dead)Cadaveric (Brain-dead)
• Beating and non-beating heartBeating and non-beating heart
CRITERIA FOR LIVING DONORCRITERIA FOR LIVING DONOR
- Blood relative.Blood relative.
- Highly motivated.Highly motivated.
- ABO blood group-compatible.ABO blood group-compatible.
- HLA-identical or haploidentical withHLA-identical or haploidentical with
negative cross-match.negative cross-match.
- Excellent medical condition with normalExcellent medical condition with normal
renal function.renal function.
CRITERIA FOR CADAVERCRITERIA FOR CADAVER
DONOR SELECTIONDONOR SELECTION
- Irreversible brain damage.Irreversible brain damage.
- Normal renal function appropriate for age.Normal renal function appropriate for age.
- No evidence of preexisting renal disease.No evidence of preexisting renal disease.
- No evidence of transmissible diseases.No evidence of transmissible diseases.
- ABO blood group-compatible.ABO blood group-compatible.
- Negative cross-match.Negative cross-match.
- Best HLA match possible, particularly at the DRBest HLA match possible, particularly at the DR
and B loci.and B loci.
Principles Involved In evaluating APrinciples Involved In evaluating A
Prospective Living Kidney DonorProspective Living Kidney Donor
Whether there is a medical condition that willWhether there is a medical condition that will
put donor at increased risk for complicationsput donor at increased risk for complications
for general anaesthesia or surgery.for general anaesthesia or surgery.
Whether the removal of one kidney willWhether the removal of one kidney will
increase the donor’s risk for developing renalincrease the donor’s risk for developing renal
Evaluation Of Kidney Function InEvaluation Of Kidney Function In
Potential Kidney DonorPotential Kidney Donor
Serum creatinine.Serum creatinine.
Creatinine clearance.Creatinine clearance.
Radionuclide glomerular filtration rate.Radionuclide glomerular filtration rate.
Urine analysis.Urine analysis.
Urine Culture.Urine Culture.
GFR > 70 ml/minGFR > 70 ml/min..
Medical Conditions That Exclude LivingMedical Conditions That Exclude Living
Kidney DonationKidney Donation
Renal parenchymal disease.Renal parenchymal disease.
Conditions that may predispose to renal diseaseConditions that may predispose to renal disease
History of stone diseaseHistory of stone disease
History of frequent UTIHistory of frequent UTI
Conditions that increase the risks of anaesthesia andConditions that increase the risks of anaesthesia and
Recent malignancyRecent malignancy..
CONTRAINDICATIONS TO RENALCONTRAINDICATIONS TO RENAL
- ABO incompatibility.ABO incompatibility.
- Cytotoxic antibodies against HLA antigens of donor.Cytotoxic antibodies against HLA antigens of donor.
- Recent or metastatic malignancy.Recent or metastatic malignancy.
- Active infection.Active infection.
- Severe extra renal disease (cardiac, pulmonary, hepatic).Severe extra renal disease (cardiac, pulmonary, hepatic).
- Active vasculitis or glomeurlonephritis.Active vasculitis or glomeurlonephritis.
- Uncorrectable lower urinary tract disease.Uncorrectable lower urinary tract disease.
- Psychiatric illness including alcoholism and drug addiction.Psychiatric illness including alcoholism and drug addiction.
- Morbid obesity.Morbid obesity.
- Age > 70 years.Age > 70 years.
- Primary oxalosis .Primary oxalosis .
- Persistent coagulation disorder.Persistent coagulation disorder.
Matching between Recipient And DonorMatching between Recipient And Donor
A- Tissue typingA- Tissue typing
• Determined by 6 antigens located on cell surfaceDetermined by 6 antigens located on cell surface
encoded for by the HLA gen located on the short arm ofencoded for by the HLA gen located on the short arm of
chromosome 6.chromosome 6.
• Class I antigens (HLA-A and HLA-B) are expressed onClass I antigens (HLA-A and HLA-B) are expressed on
the surface of most nucleated cells.the surface of most nucleated cells.
• Class II antigen (HLA-DR) are expressed on surface ofClass II antigen (HLA-DR) are expressed on surface of
APC and activated lymphocytes.APC and activated lymphocytes.
• These 6 antigens are referred to as major transplantThese 6 antigens are referred to as major transplant
• The match between donor and recipient can range fromThe match between donor and recipient can range from
0 to six.0 to six.
Matching between Recepient And DonorMatching between Recepient And Donor
B- Cross matchingB- Cross matching
• A laboratory test that determines weather a potentialA laboratory test that determines weather a potential
transplant recepient has preformed antibodies against the HLAtransplant recepient has preformed antibodies against the HLA
antigens of the potential donor. (Donor Lymphocytestantigens of the potential donor. (Donor Lymphocytest
+Recepient Serum)+Recepient Serum)
• A Final CM is mandatoryA Final CM is mandatory
C- Compatible ABO blood group.C- Compatible ABO blood group.
What Are The Major Causes Of Long-What Are The Major Causes Of Long-
Term Allograft Failure ?Term Allograft Failure ?
• Chronic rejection.Chronic rejection.
• Death with functioning graft.Death with functioning graft.