This document discusses management of end-stage renal disease (ESRD) through dialysis and transplantation. It describes the main types of dialysis as hemodialysis and peritoneal dialysis. Hemodialysis is the most common method and involves purifying the blood through diffusion and ultrafiltration. Peritoneal dialysis uses the peritoneal membrane in the abdominal cavity for diffusion and ultrafiltration. Kidney transplantation is also discussed as the best treatment for ESRD when a donor organ is available. The document outlines donor sources, compatibility testing, transplantation procedure, and potential complications.

1. MANAGEMENT OF CKD-5 (ESRD)
DIALYSIS AND TRANSPLANTATION
Dr Muzafar Maqsood Wani
Consultant Nephrologist
SKIMS, SOURA

2. CKD STAGES

3. CKD STAGES

4. Therapy For ESRD patients
ESRD
Hemodialysis
Kidney Transplant
Peritoneal Dialysis
Comfort Care

5. Modality Selection
• Most patients (>80%) can do either modality and the decision is not a primarily
medical one although some factors may favor one modality over the other
• Modality selection should take into account medical issues, patient’s social
circumstances, wishes of patient but also overall economic circumstances in
which the dialysis program operates

6. DIALYSIS
• Dialysis is used to remove fluid & uremic waste products from the body
when kidneys are unable to do so
• Need for dialysis may be acute or chronic
• It is also be used to remove certain medications or other toxins from the
blood (poisoning, medication overdose)

7. TYPES OF DIALYSIS
1.HEMODIALYSIS (HD) (Intermittent Haemodialysis - IHD)
-in centre-2 or 3/week
-home-nocturnal, daily small sessions
Special forms – Continuous - CAVHD, CVVHD, CVVHDF, SCUF, SLED
2.PERITONEAL DIALYSIS (PD)-
- IPD- intermittent
- CAPD – Continuous Ambulatory
- CCPD – Continuous Cyclic
- APD – Ambulatory

8. HEMODIALYSIS (HD)
• HD is the most common method of dialysis.
• It is the process of purifying the blood & removing the waste products from the
blood & re-infusing the purified blood.
• For patients with CKD, HD prevents death, it does not cure renal disease & does
not compensate for the loss of endocrine or metabolic activity of kidneys
• Done usually 3 times a week for 3 to 4 hrs/treatment – (9-12 hrs /week)
• The anticoagulant heparin is administered to keep blood from clotting in dialysis
circuit.

9. HEMODIALYSIS

10. Dialyzer

11. Hemodialysis Vascular Access
Polytetrafluoroethylene

12. Dialysis Access
• AV Fistula
• Vein attached end-to-side to artery
• High-pressure flow dilates and thickens vein
• Takes 1-2 months to mature
• AV Graft
• Tube made of biocompatible material (gortex) attached end-to-side to
artery and vein
• Ready to use when swelling resolves (~2 weeks)

13. WORKING OF HEMODIALYSIS

14. COMPOSITION OF DIALYSATE FLUID
• Sodium 140.0
• Potassium 1.0
• Calcium 1.25
• Bicarbonate 34.0
• Magnesium 0.5
• Chloride 107.5
• Glucose 5.5

15. PRINCIPLE
•Diffusion - The toxins & waste in the blood are removed by diffusion that is
they move from an area of higher concentration in blood to an area of lower
concentration dialysate
•Osmosis - In which water moves from an area of lesser solute concentration
(the blood) to an area of more solute concentration (the dialysate bath)
•Ultra-filtration - Water moves under high pressure to an area low pressure. It
is accomplished by applying negative pressure or a suctioning force to the
dialysis membrane

16. COMPLICATIONS
• FEBRILE REACTIONS
• DIALYSIS DISEQUILIBRIUM SYNDROMES
• HYPOVOLEMIA
• HYPERNATREMIA
• HYPERGLYCEMIA
• HYPOTENSION
• ARRYTHIMIAS

17. PERITONEAL DIALYSIS (PD)

18. Peritoneal Dialysis (PD)
PD
Continuous Intermittent
• Worldwide, 12% of dialysis patients are maintained on PD
• This varies greatly between countries
• >50% on PD in New Zealand, Hong Kong, and Mexico
• <8% on PD in Japan ,Germany and Taiwan

19. PD CATHETER

21. Principle of PD Treatment

22. • Abdominal cavity is lined by a vascular peritoneal membrane which acts as a
semi-permeable membrane
• Diffusion of solutes (urea, creatinine, …) from blood into the dialysate
contained in the abdominal cavity
• Removal of excess water (ultrafiltration) due to osmotic gradient generated by
glucose in dialysate
Principle of PD Treatment

23. Indications for PD
Absolute indications
• Poor cardiac function
• Peripheral vascular disease (not able to make vascular access)
Relative indications
• Free life style
• Want to take care themselves
• Long distance to hemodialysis center

24. Contraindications to PD
• Inability to make connections and lack of family member or other person
willing or able to help
(dementia ,stroke ,arthritis , blindness, debilitation etc)
• Previous complicated abdominal surgery with adhesions, ostomies etc
• Lack of space to store PD solutions

25. Continuous PD Regimens
Multiple sequential exchanges are performed during the day and night so
that dialysis occurs 24 hours a day, 7 days a week
CAPD: Continuous
Ambulatory PD
CCPD: Continuous
Cyclic PD

26. Intermittent PD Regimens
PD is performed every day but only during certain hours
DAPD: Daytime
Ambulatory PD.
Multiple manual exchanges
during waking hours
NPD: Nightly PD.
Performed while patient
asleep using an automated
cycler machine.
Sometimes,
1 or 2 day-time manual
exchanges are added to
enhance solute clearances `

27. Complications
IMMEDIATE
• Technical failure
• Bowel/viscera/vascular perforation
LATE
• Peritonitis- Bacterial, fungal, tubercular, sclerosizing
• Tunnel or exit site infection
• Catheter migration/malfunction
• Ultra filtration failure
• Hernia/s

29. PERITONITIS
• Remains the biggest cause of PD technique failure in most countries
• Also causes hospitalization, catheter loss and even death
• Rates have fallen over past 2 decades , mainly due to improved connectology
• Abdominal pain, cloudy effluent, high PD fluid cell count,
gram stain positive, culture positive

30. KIDNEY TRANSPLANTATION

31. KIDNEY TRANSPLANTATION

32. KIDNEY TRANSPLANTATION

33. KIDNEY TRANSPLANTATION
• DONORS
• Physically fit, willing, evaluated in detail
• No long term harm
• Live related, unrelated
• Cadaveric (Brain Dead – Beating Heart, Donation after Cardiac arrest)
• Donor Nephrectomy – open, laparoscopic

34. KIDNEY TRANSPLANTATION (Compatibility)
• Donor and Recipient ABO compatible, but now ABO incompatible also possible
• HLA match done before, how many major and minor antigens they share
• A cross match before transplant is a must
• Immunosuppressive medications (steroids, CNI, antimetabolites) given to prevent
graft loss by rejection

35. KIDNEY TRANSPLANTATION

36. KIDNEY TRANSPLANTATION (Complications)
• Rejection (Hyperacute, Acute, Chronic)
• Infections (Viral, Bacterial, Fungal) and sepsis
• Drug related complications( steroid, cyclosporine, tacrolimus, azathioprine,
mycophenolate, induction agents)
• Post transplant malignancies
• Electrolyte and metabolic complications

37. Thank you