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
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
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
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
A) Dialysis Therapy
B) Renal Transplant
Simple to set up &
Easy to use in infants
Slow fluid & solute
Drainage failure & leakage
Not good for
Forms of PD:
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
a) Acute PD - same but using automatic PD
b) Continuous cycling PD - long day dwell with
multiple short night time exchange
c) Nocturnal intermittent PD – no day dwell but
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
For critically ill patients may be it is limited or
ineffective due to the critical nature of the
Volume overload and hemodynamic instability
may not be treated adequately.
Complications of IHD:
Systemic hypotension which might lead to
clearance of 3
Best therapy for
Limited anticoagulation time
access can be used
Rapid fluid and
Difficult in small
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
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
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)
Benefits of transplantation
Common post-transplant problems
Basics of Transplantation
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.
Screening for HIV,HBV,HCV,CMV,EBV,TB.
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
Investigate the cause of ESRD- since certain
diseases can recur in the graft viz., FSGS, MPGN,
Pre, intra & immediate post transplant
and electrolytes therapy
pre-op.: single dose of MMF / Azathioprine + anti
peri-op.: I/V Methylprednisolone
post-op.:CsA/FK506 + MMF/Azathioprine +
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
Common Complications of Transplantation
Delayed or slow graft function
Hyper acute rejection (Antibody-mediated
rejection) : within min. to hr of perfusing of
- due to preformed antibodies to the ABO &
Acute rejection – within 3 months of transplant
Metabolic complications- hypomagnesaemia,
hypophosphatemia, Hypercalcemia, Hyperkalemia,
Malignancy- Post transplant lymphoproliferative
Recurrence of Primary Disease in the AllograftFSGS, MPGN, atypical HUS,WG.
Treatment :CsA, Cyclophosphamide.
Chronic allograft dysfunction
Perirenal serous fluid collection
Caused by thrombosis of donor renal artery or
Usually happens in first week.
Diagnosed by ultrasound with doppler studies.
Almost always requires explant of kidney.