Renal replacement therapy
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Transcript of Renal replacement therapy
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