Renal replacement therapy (RRT) replaces some or most of the functions of the normal kidney when renal function is less than 10-15%. It includes dialysis and renal transplantation. The two main forms of dialysis are hemodialysis, which filters waste through an artificial kidney, and peritoneal dialysis, which uses the peritoneal membrane for filtration. Renal transplantation is the preferred therapy for children with end-stage renal disease as it allows them to live a near-normal life.

1. RENAL
REPLACEMENT
THERAPY
PROFESSOR ENOBONG IKPEME

2. WHAT IS RENAL REPLACEMENT
THERAPY
RRT is a therapy that replaces
some or most of the functions of
the normal kidney when the renal
function is at less than 10-15
percent.
 It comprises of dialysis and renal
transplantation.

3. DIALYSIS
There are two forms of dialysis:
1. Haemodialysis
2. Peritoneal dialysis

4. PERITONEAL DIALYSIS
This is a form of dialysis in which the
peritoneal membrane acts as a dialyzing
membrane.
It is the preferred form of dialysis in children
because it maintains a near steady state
biochemical balance.
Also the peritoneal surface area in children is
larger than adults.

5. Mechanisms of dialysis in PD
 Based on 2 interrelated transport mechanisms:
1. Diffusion
2. Convection
DIFFUSION – refers to the movement of solutes
down an electro-chemical concentration gradient.
CONVECTION –refers to movement of solutes
along a fluid flux.

6. Dialysis fluid
 Isotonic or hypertonic based on the concentration of
dextrose (1.5-4.5%) determining the tonicity of the fluid.
 Sodium in the fluid is same concentration as plasma.
 The fluid characteristically does not contain potassium,
urea, creatinine.
 Thus in ARF with azotaemia, the retained nitrogenous waste
products and potassium diffuse out of the blood vessels
into the dialysate in the peritoneal cavity

7. Methods of PD
1. Continuous ambulatory PD
2. Intermittent PD e.g continuous cyclic PD
TECHNIQUE
PD fluid(dialysate) is put into the abdomen through a
PD catheter ( stiff, tenckhoff) and left to dwell for some
time,
In the abdomen,the fluid collects waste that have
beem filtered through the peritoneal membrane and
then drained from the body.

8. INDICATIONS FOR PD
1. ARF
2. CRF
3. Severe metabolic acidosis
4. Severe hyperkalaemia K+ >6.0 mmol/l
5. Intractable cardiac failure
6. Accidental poisoning
7. Reye’s syndrome
8. Hepatic coma
9. Pulmonary oedema

9. Contraindications to PD
1. Abdominal surgery
2. Peritonitis
3. Abdominal malignancies
4. Omphalocoele
5. Gastroschisis
6. Diaphragmatic hernia

10. Complications of PD
1. Peritonitis- Gram +ve (50%), Gram –ve (20%)
,Fungal (<2%).
E.coli, Klebsiella, Proteus and pseudomonas.
PD fluid is cloudy, increased neutrophil count 50-
100cell/mm3.
2. Perforation of viscera
3. Progressive renal osteodystrophy

11. HEMODIALYSIS
 Blood from the patient is circulated through an
artificial kidney the dialyzer of the dialysis machine
which has two compartments: the blood and the
dialysate separated by a thin semi-permeable
membrane
 Waste and excess water pass from the blood side and
is discarded in the drain. The cleared blood is
returned to the patient.
 It functions by the principles of diffusion based mass
transfer (urea, Cr, lytes) and ultrafiltration( pressure
driven water removal)

12. Indications
 Acute –poisonings, ARF
 Chronic- ESRD
 TECHNIQUE
1.Vascular access to the blood stream:
- arteriovenous fistula
- Arteriovenous graft
- Temporary catheter
- Long term catheter

13. Technique ……..
2. Dialysers- filters metabolic waste
products from the blood , then returns the
purified blood to the patient

14. Complications of HD
Dialysis disequilibrum syndrome
Infections (HIV,HCV,HBV)
Catheter dislodgement
Arterial or venous thrombosis
Hemodynamic changes (hypotension)
Pschychosocial problems

15. RENAL TRANSPLANTATION
This is the preferred therapy for children
with ESRD because it affords them the
opportunity to to live a near normal life.
Sources of the donor kidney may be a
living (50%)related or non related donor
and cadaveric donors

16. Indications for renal transplantation
 All children with ESRD
 Growth failure in children with CRF.
 CONTRAINDICATIONS
1. HIV infection
2. Pre-existing malignancy
3. Severe neurological dysfunction
4. Potential recurrence of primary disease e.g FSGS,
cystinosis
5. Chronic infection with HBV , HCV

17. PRE-TRANSPLANT PREPARATION
1. Correct malnutrition, anaemia, urinary tract anomalies.
2. Good hx and examination
3. Investigations – FBC, Clotting studies, E/U/Cr, LFT, Lipid
profile,serum calcium and phosphate,PTH,urinalysis,
urine MCS, Blood grouping, Human Leucocyte antigen
HLA typing , ABO grouping, viral screen-HCV,HBV,HIV,
Serological test- CMV,EBV,VZV,MMR.
4. RADIOLOGICAL TEST- VCUG,CXR
5. IMMUNIZATION- DPT,OPV,MMR,Hib, PCV

18. IMMUNOSUPPRESSION
Aim of this is to reduce the chances of graft
rejecton.
Induction –steroids,azathioprine,cyclosporine
and tacrolimus
Maintenance –cyclosporine and tacrolimus
are the main drugs.
Adjuncts include steroids, mycophenolate,
mofetil MMF and azathioprine

19. Complications
IMMEDIATE
1. Graft dysfunction
2. Graft rejection:
a. Hyperacute <24 hours
b. Acute < 6months
c. Chronic > 6 months

20. Complications (Late)
3. Infections –viral and bacterial
4. Hypertension
5. Hyperlipidaemia
6. Lymphoproliferative disease
7. Malignancies
8. Growth retardation-depends on bone
age prior to transplant.