Renal replacement therapyDr Bhupendra Shah(AP)B.P.koirala institute of health sciences

Modes of Renal replacement therapy

Hemodialysis

Peritoneal dialysis

Renal transplantation

Hemodialysis

Done in Acute kidney injury as well as Chronic kidney disease

Renal impairment interferes with the excretion of water, electrolytes, and organic solutes

Hemodialysis in AKIMetabolic acidosis ( pH<7.10 )BUN>100 mg/dlAnuriaHyperkalemia (≥6.5meq/l)

Uremic symptomsRapid rise in urea/creatinineCertain alcohol and drug intoxications 

Dialysis in AKI

Late initiation of dialysis: Risk of avoidable volume, electrolyte, and metabolic complications

Initiating dialysis too early: Unnecessarily exposure to intravenous lines and invasive

procedures Risks of infection, bleeding, and procedural complications

BUT DO NOT WAIT FOR A LIFE THREATENING COMPLICATION

Hemodialysis The most common form of renal replacement therapy for AKI

Vascular access via the femoral, internal jugular, or subclavian veins

Removes solutes through diffusive and convective clearance

Typically performed 3–4 h per day, three to four times per week

Peritoneal dialysis often better tolerated than intermittent procedures like hemodialysis

in hypotensive patients

How is hemodialysis done?

Dialyser

Small solutes are removed across a semipermeable membrane

Complications during HD

Hypotension — 25 to 55 percent Cramps — 5 to 20 percent Nausea and vomiting — 5 to 15 percent Headache — 5 percent Chest pain — 2 to 5 percent Back pain — 2 to 5 percent Itching — 5 percent Fever and chills — Less than 1 percent

Peritoneal dialysis

Performed through a temporary intraperitoneal catheter

Enjoyed widespread use internationally, particularly when hemodialysis technology is not available

Dialysate solution is instilled into and removed from the peritoneal cavity at regular intervals in order to achieve diffusive and convective clearance of solutes across the peritoneal membrane

Peritoneal dialysis

Osmotic gradient across the peritoneal membrane achieved by high concentrations of dextrose in the dialysate solution

Often better tolerated than intermittent procedures like hemodialysis in hypotensive patients

Main problem is inadequate solute clearance

Peritoneal dialysis: You can do it at home

Hemodialysis in CKD

Uremic encephalopathy (confusion, asterixis, myoclonus, wrist drop)Uremic gastritisUremic pericarditisUremic neuropathyPersistent hyperkalemiaPersistent volume overloadBleeding diasthesis attributable to uremiaHypertension refractory to antihypertensives

Vascular access for HD in CKD patients A-V fistula

Central catheters

Femoral catheter

Initiation of HD in CKD

CKD: No difference in survival between early or late initiation of dialysis

Dialysis initiation should be based upon clinical factors rather than the estimated GFR alone

Advantages of early dialysis: control of hypertension and increased dietary intake

Delaying initiation of diaysis: maturation of vascular access and chances of renal transplantation

How frequently?

For the majority of patients with ESRD, between 9 and 12 h of dialysis are required each week, usually divided into three equal sessions

Peritoneal dialysis in CKD

Can be done at home

Not as efficient as hemodialysis

Has complications of its own

Done through a peritoneal catheter

1.5–3 L of a dextrose-containing solution is infused into the peritoneal cavity and allowed to dwell for a set period of time, usually 2–4 h

Toxic materials are removed through a combination of convective clearance generated through ultrafiltration and diffusive clearance

Choice is yours

Renal transplantation

Renal transplantation

Survival benefits of renal transplantation over dialysis therapy are well established for patients with end-stage renal disease

Post transplant outcomes are better these days

Living-donor grafts have a 96% 1-year survival

Problems with transplantation

Paucity of donors

Rejection

Technically difficult

Use of drugs post-transplant including immunosuppresive agents

Thank you