Renal replacement therapy


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Renal replacement therapy

  1. 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. 2. Renal Replacement Therapy Dr. Sandeep G Huilgol Dept of Nephrology and Transplantation
  3. 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. 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. 5. RENAL REPLACEMENT THERAPY A) Dialysis Therapy Hemodialysis Peritoneal Dialysis B) Renal Transplant
  6. 6. Dialysis Therapy Extracorporeal: Intermittent Hemodialysis Slow Low efficiency Dialysis (SLED) Continuous Hemofiltration CAVH SCUF CVVH CAVHDF CVVHDF Intracorporeal: Peritoneal Dialysis
  7. 7. PD: - It is a substitution therapy - Replaces partially the excretory function and contributes to the maintenance of fluid, electrolyte and acid base balance
  8. 8. Patient undergoing Peritoneal Dialysis (CAPD)
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. PD Machine
  13. 13. 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
  14. 14.  Uses Of PD : 1. Renal failure 2. Poisoning : salicylate phenobarbitone phenytoin sodium 3. Inborn errors of metabolism: hyperammonia syndrome urea cycle defect
  15. 15. Hemodialysis Extracorporeal therapy: Acute Intermittent Hemodialysis CRRT Mechanisms1. Hemodialysis- most commonly used therapy 2. Hemofiltration 3. Hemodiafiltration 4. Hemoperfusion 5. Apheresis
  16. 16. Haemodialysis Can be through a Central Venous Catheter  AV Shunt OR  Through a Arterio – Venous Fistula  Sythetic Graft 
  17. 17. Synthetic Graft
  18. 18. Blood pump Trip chamber A B
  19. 19. 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
  20. 20. 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
  21. 21.  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.
  22. 22. 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
  23. 23.      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)
  24. 24. 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
  25. 25. Renal Transplantation
  26. 26. Outline  Basics of transplantation  Benefits of transplantation  Immunosuppressive medications  Common post-transplant problems
  27. 27. 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.
  28. 28. 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
  29. 29.   Socioeconomic factors Investigate the cause of ESRD- since certain diseases can recur in the graft viz., FSGS, MPGN, atypical HUS.
  30. 30. 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
  31. 31. Immunosuppressive Medications  Induction: Corticosteroids Anti-thymocyte globulin (ATG) OKT3 IL-2 receptor antagonists  Maintenance: Corticosteroids Calcineurin inhibitors (CNIs) mTOR inhibitors Antimetabolites
  32. 32. 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
  33. 33.    Infectious complications  Cytomegalovirus  BK virus  Others Hypertension- diet therapy, ACEI, CCB Hematologic complications : anemia, leukopenia, thrombocytopenia
  34. 34.     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
  35. 35. 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.
  36. 36. Thank you