INDICATIONS OF DIALYSIS BASIC PRINCIPLES OF DIALYSIS WITH AN ARTIFICIAL KIDNRY PERITONEAL DIALYSIS INDICATIONS OF RENAL TRANSPLANTION

1. DIALYSIS, ARTIFICIAL KIDNEY
AND RENAL TRANSPLANT
Pandian M.
DEPT. OF PHYSIOLOGY
D.Y. PATIL MEDICAL COLLEGE KOLHAPUR

2. OBJECTIVES
 INDICATIONS OF DIALYSIS
BASIC PRINCIPLES OF DIALYSIS WITH AN
ARTIFICIAL KIDNRY
PERITONEAL DIALYSIS
INDICATIONS OF RENAL TRANSPLANTION

3. DIALYSIS
The term dialysis refers to diffusion of solutes from
an area of higher concentration to the area of lower
concentration through a semipermeable
membrane.
This principle has been used to dialyse the blood of
patients with renal failure especially those
developing uremia.

4. Dialysis is the procedure to correct electrolyte
imbalances and to remove waste products in renal
failure.
It does not correct endocrine functions of kidney.
Hence dialysis is not a cure for renal failure.

5. INDICATIONS
The need for dialysis may be acute or chronic.
Acute dialysis is indicated :-
high & rising levels of serum potassium.
Fluid overload or impending edema.
Increasing acidosis
Pericarditis
Chronic dialysis is indicated :-
Chronic renal failure or end stage renal disease(ESRD)

6. Chronic kidney disease is defined as either kidney damage or
glomerular filtration rate < 60 ml/mim/1.73m2 for 3 months.
STAGE DESCRIPTION GFR
1 Kidney damage with
normal or raised GFR
> 90
2 Kidney damage with mildly
decreased GFR
60-89
3 Moderately decreased GFR 30-59
4 Severely decreased GFR 15-29
5 kidney failure <15

7. Uremia develops when more than 75% of nephrons are
damaged and is charecterised by :
Accumulation of nitrogenous waste products in the blood.
Metabolic acidosis.
Hyperkelemia.
Uremic coma is terminal event in chronic renal failure.

8. TYPES OF DIALYSIS
HEMODIALYSIS OR ARITIFICIAL KIDNEY.
PERITONEAL DIALYSIS.

9. HEMODAILYSIS OR ARTIFICIAL KIDNEY
It is most commonly used method of dialysis for patients
who are acutely ill and require short term dialysis (days
to week).
It can save the life in many types of acute renal failure
produced by reversible pathological process , specially
circulatory shock or mercury poisoning.
The intermittent dialysis may prolong the life of many
patients with chronic renal failure, which may lead for an
active life for many useful years.

10. REQUIREMENTS FOR HEMODIALYSIS
Access to patients circulation-
arterio venous fistula
arterio venous graft
central venous catheter
Dialysis machine & dialyzer with semipermeable
membrane.
Appropriate dialyzing fluid

12. PROCEDURE:
 Hemodialysis machine is also called as artificial kidney.
 Hemodialysis is done in hospitalized patient through IV line
for 3-5 hours.
 During hemodialysis the patient’s radial artery is connected
to the hemodialysis machine.
 Inside the hemodialysis machine the blood is passed through
a long coiled cellophone tube immersed in a dialysis fluid.
 Heparin is used as an anticoagulant while passing blood
through the machine.

13. COMPOSITION OF DILAZYING FLUID
The composition of dialyzing fluid is similar to that of
plasma, except it is free of waste products like urea, uric
acid, etc.
The fluid contains less amount of sodium , potassium
and chloride ions than in uremic blood.
But the quantity of glucose , bicarbonate and calcium
ions are more in the dialyzing fluid than in the uremic
blood.

14. CONSTITUENT UREMIC PLASMA DIALYZING FLUID
ELECTROLYTES(mEq/L)
-Na+
-K+
-Ca
-Mg
-Cl
-HCO
-Lactate
-HPO
-urate
-SO
NONELECTROLYTES
-Glucose
-urea
creatinine
142
7
2
1.5
103
14
1.2
9
2
3
100
200
6
142
4
3
1.5
107
27
1.2
0
0
0
125
0
0

15. PRINCIPLE OF HEMODIALYSIS
DIFFUSION- movement from higher concentration
(blood) to lower concentration (dialysate).
OSMOSIS- excess water is removed from the blood by
osmosis, in which water moves from an area of higher
concentration to an area of lower concentration.
ULTAFILTRATION- Water moving under high pressure to
an area of lower pressure by negative pressure of a
suctioning force to the dialysis membrane.

16. DIALYZER
-Cannula in artery
-into vein
Uremic blood
from the person
Toxins diffuse through the membrane
Purified blood to the person

18.  During hemolysis , the semipermeable cellophane membrane
permits the free diffusion of constituents of plasma except proteins.
 In this way , the dialysis of patient’s blood removes the toxic waste
products and restores normal electrolyte concentration in plasma.
 The dialyzed blood is returned to the patient via peripheral vein.
 At a time about 500ml is passed through the artificial kidney.
 Hemodialysis is done usually thrice a week in severe uremia.

19. COMPLICATIONS OF
HEMODIALYSIS
During dialysis-hypotension, arrhythmias,
exsanguination, seziures, fever.
Between treatments-hyper/hypotension , edema ,
pulmonary edema , hyperkalemia , clotting.
Long term- hyperparathyroidism ,CHF , AV access
failure , pulmonary edema , neuropathy , anemia , GI
bleeding.
Others-infection , catheter clotting , central vein
thrombosis, stenosis, ischemia of hand, aneurysm.

20. PERITONEAL DIALYSIS
In this type of dialysis, the peritoneum is used as
semipermeable membrane.
Continuous ambulatory peritoneal dialysis is a form
of long-term dialysis done by patients at home or at
work.

21. INDICATIONS FOR PERITONEAL DIALYSIS
Vascular access failure.
Intolerance to hemodialysis.
Congestive heart failure.
Prosthetic valvular disease.

22. PROCEDURE
Under strict aseptic precautions 2 litres of dialyzing
fluid is introduced through a permanent intra
peritoneal catheter.
It is then kept in peritoneal cavity for exchange to
take place for a period of 15-20 minutes, called as
dwell time.
Strict input and output chart is maintained. The
whole procedure constitutes one cycle.

23. It is done at 6hours interval(4 cycles per day), even
when patient is ambulatory or mobile.
There is no need for hospitalization.
It is useful for young children and old patients with
cardiac disorders.
It prolongs survival in patients with chronic renal
failure for many years.

24. before medications are added, the dialysate is
warmed to body temperature to prevent patient
discomfort , abdominal pain and to dilate vessels of
peritoneum to increase urea clearance.
Solutions that are to cold cause pain and
vasoconstriction and reduce clearance. Solutions that
are too hot burn the peritoneum.

26. COMPLICATIONS
PERITONITIS
BLEEDING AT CATHETER SITE.
RESPIRATORY DIFFICULTY
PERITONEAL FLUID LEAK
CATHETER RELATED INFECTIONS
HYPER/HYPOVOLEMIA.

27. RENAL TRANSPLANT
Kidney transplant is the treatment of choice for end-
stage renal disease.
It provides better long term survival and improved
quality of life compared to dialysis.

28. INDICATIONS
ESRD GFR< 15ml/min.
Malignancy
 Hypertension
Diabetes mellitus
genetic diseases-
polycystic kidney disease
Metabolic disorders
CONTRAINDICATIONS
 Cardiac and pulmonary
insufficiency.
 Hepatic diseases.
 Concurrent tobacco use
and morbid obesity
 HIV

29. BENEFITS
 Significantly reduced risk of
mortality.
 Increased life expectancy
 Improved quality of life
 More likely to stay
employed
RISKS
 Acute rejection or failure
 Anti-rejection medication
effects—infection
--malignancies
--increased risk of
HTN/DM
-graft loss over time.

30. TYPES OF DONORS
LIVING DONORS-
Genetically related-parents , sibling, twin.
Living-unrelated.
Criteria:-
 AGE-18-70 yrs
 BMI<35
No cancer or active infection
Adequate renal function
Compatablity.

31. DECEASED DONORS
BRAIN DEAD DONORS
DONATION AFTER CARDIAC DEATH

32. COMPTABILITY
The patient has to be ABO compatible.
The recipient should share as many as HLA antigens
and minor antigens as possible.
Immunosupressent drugs are given to prevent anti
body reactions.
BLOOD GROUP , TISSUE TYPE AND CROSS
MATCHING TO BE DONE.

33. DRUGS USED IN RENAL TRANSPLANT
INDUCTION
 Monoclonal antibodies-
muromonab basiliximab
daclizimab
 Polyclonal antibodies
Antithymocyte globulin
(equine/rabbit)
MAINTENANCE
 Calcineurin inhibitors
cyclosporine tacrolimus
 Purine synthesis inhibitors
azathioprine
mycophenolate moeftil
Steroids -prednisolone
MTOR inhibitors-
sirolimus

34. PROCEDURE
 TIME-3HRS approx.
 Donor kidney is placed in the lower abdomen.
 Usually left kidney of donor is transplanted to right iliac fossa of
recipient.
 Arteries , veins from the recipient are connected to new kidney.
 Final step is to connect the ureter to new kidney.
 New kidney starts working immediately.
 Living kidney takes 3-5 days and cadaveric kidney upto7-15 days.

35. COMPLICATIONS
TRANSPLANT REJECTION
INFECTION AND SEPSIS
POST TRANSPLANT LYMPHOPROLIFERATIVE
DISORDER.
ELECTROLYTE IMBALANCE
IATROGENIC SIDE EFFECTS

36. REFRENCES
 1.Text book of medical physiology
-Guyton and hall, 12th edition.
 2.Ganong’s review of medical physiology
-23rd edition
 3.text of medical physiology
-2nd edition
 4.net sources (acknowledge for all online sources)
 5.text book of medical physiology
--A.K. JAIN
 6.text book of medical physiology
---indu khurana