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. Renal Replacement Therapy
Dr. Sandeep G Huilgol
Dept of Nephrology and
Transplantation

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. 
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. RENAL REPLACEMENT
THERAPY
A) Dialysis Therapy
Hemodialysis
Peritoneal Dialysis
B) Renal Transplant

6. Dialysis Therapy
Extracorporeal:
Intermittent Hemodialysis
Slow Low efficiency Dialysis (SLED)
Continuous Hemofiltration
CAVH
SCUF
CVVH
CAVHDF
CVVHDF
Intracorporeal:
Peritoneal Dialysis

7. PD:
-
It is a substitution therapy
- Replaces partially the excretory
function and contributes to the
maintenance of fluid, electrolyte and
acid base balance

9. Patient undergoing Peritoneal Dialysis (CAPD)

10. 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

11. 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

12. 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

13. PD Machine

14. 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

15.  Uses
Of PD :
1. Renal failure
2. Poisoning : salicylate
phenobarbitone
phenytoin sodium
3. Inborn errors of metabolism:
hyperammonia syndrome
urea cycle defect

16. Hemodialysis
Extracorporeal therapy:
Acute Intermittent Hemodialysis
CRRT
Mechanisms1.
Hemodialysis- most commonly used therapy
2.
Hemofiltration
3.
Hemodiafiltration
4.
Hemoperfusion
5.
Apheresis

20. Haemodialysis
Can be through a
Central Venous
Catheter
 AV Shunt
OR
 Through a Arterio
– Venous Fistula
 Sythetic Graft


23. Synthetic Graft

24. Blood pump
Trip chamber
A
B

25. 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

26. 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

27.  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.

28. 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

29. 




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)

30. 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

31. Renal Transplantation

32. Outline
 Basics
of transplantation
 Benefits of transplantation
 Immunosuppressive medications
 Common post-transplant problems

33. 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.

34. 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

35. 

Socioeconomic factors
Investigate the cause of ESRD- since certain
diseases can recur in the graft viz., FSGS, MPGN,
atypical HUS.

36. 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

37. Immunosuppressive Medications
 Induction:
Corticosteroids
Anti-thymocyte
globulin (ATG)
OKT3
IL-2
receptor antagonists
 Maintenance:
Corticosteroids
Calcineurin inhibitors (CNIs)
mTOR inhibitors
Antimetabolites

38. 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

39. 


Infectious complications
 Cytomegalovirus
 BK virus
 Others
Hypertension- diet therapy, ACEI, CCB
Hematologic complications : anemia, leukopenia,
thrombocytopenia

40. 



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

41. 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.

42. Thank you