Hemodialysis is a type of dialysis that relies on diffusion of solutes across a semipermeable membrane. It is used to treat end-stage kidney disease and involves circulating blood through a dialyzer while dialysate fluid passes on the outside of the fibers. Peritoneal dialysis infuses dialysate fluid into the peritoneal cavity, allowing diffusion and ultrafiltration of solutes. Both have risks like infections, metabolic complications, and encapsulating peritoneal sclerosis. Kidney transplantation is the treatment of choice for advanced kidney failure and has better outcomes than long-term dialysis, but requires lifelong immunosuppression.

1. By Dr. J. Stalin Roy Prof P. Vijayaraghavan’s unit Stanley Medical College

8. Dialyzer

11. Dialysis machine

13. Typical forearm loop graft access along with location of stenosis in failing grafts

19. Access to the peritoneal cavity - Various PD catheters

29. Long-term graft survival as a function of donor source and HLA matching

32. Drug Mechanism Side effect Glucocorticoids Binds cytosolic receptors and heat shock proteins. Blocks transcription of IL-1,-2,-3,-6, TNF- α , and IFN- γ Hypertension, glucose intolerance, dyslipidemia, osteoporosis Cyclosporine (CsA) Trimolecular complex with cyclophilin and calcineurin block in cytokine (e.g., IL-2) production; however, stimulates TGF- production Nephrotoxicity, hypertension, dyslipidemia, glucose intolerance, hirsutism/hyperplasia of gums Tacrolimus (FK506) Trimolecular complex with FKBP-12 and calcineurin block in cytokine (e.g., IL-2 ) production; may stimulate TGF- production Similar to CsA, but hirsutism/hyperplasia of gums unusual, and diabetes more likely Azathioprine Hepatic metabolites inhibit purine synthesis Marrow suppression (WBC > RBC > platelets) Mycophenolate mofetil (MMF) Inhibits purine synthesis via inosine monophosphate dehydrogenase Diarrhea/cramps; dose-related liver and marrow suppression is uncommon Sirolimus Complexes with FKBP-12 and then blocks p70 S6 kinase in the IL-2 receptor pathway for proliferation Hyperlipidemia, thrombocytopenia

41. Infections The Most Common Opportunistic Infections in the Renal Transplant Recipient Peritransplant (<1 month) Early (1–6 months) Late (>6 months) Wound infections Pneumocystis carinii Aspergillus Herpesvirus Cytomegalovirus Nocardia Oral candidiasis Legionella BK virus (polyoma) Urinary tract infection Listeria Herpes zoster Hepatitis B Hepatitis B Hepatitis C Hepatitis C

42. Prophylactic therapy for recipients of renal transplants comments Trimethoprim-sulfamethoxazole (TMP/SMX) Routine use eliminates the incidence of pneumocysits carinii, listeria monocytogenes, nocardia asteroides and toxoplasmosis gondii. Also reduces the incidence of UTI from 30-80% to <5-10% Monthly intravenous or aresolized pentamidine or dapsone or atovaquone Replaces TMP/SMX for patients with sulfa allergies Nystatin 4ml after meals and before bedtime For fungal prophylaxis Acyclovir, valgancyclovir, gancyclovir For CMV prophylaxis

43. Recommended immunization before and after transplantation Vaccine Before After MMR Yes - DPT Yes dT Varicella Yes Controversial Polio Yes - Hemophillus influenzae B Yes Yes Influenza yes Yes Pneumococcus Yes Yes Hepatitis B Yes Yes Hepatitis A Yes Yes

50. Risk factors for CAN Alloantigen-Dependent (immune) risk factors Alloantigen-Independent (non-immune) risk factors Acute rejection (incl subclinical) Kidney size mismatch MHC antigen mismatches Proteinuria Previous transplantation Older donor age Cadaver donor Hypertension Younger recipient age Dyslipidemia Delayed graft function Smoking CMV infection

51. Alloantigen dependent (oval shaded) and independent factors (rectangular shaded) thought to be involved in the pathogenesis of chronic allograft nephropathy.

53. Recurrence of primary disease in renal grafts

54. References: Brenner and rector’s The Kidney 8 th ed. Comprehensive Clinical Nephrology by John Feehally 3 rd ed. Harrison’s Principles of Internal Medicine 17 th ed.