nephrology

1. RENAL REPLACEMENT
THERAPY
Hamad Emad H. Dhuhayr

2. CONTENTS
• SOEPEL
• Dialysis
• Renal transplantation
• Reffrences

3. SOEPEL
• S- O 65years old Saudi male. he complained of pain in her upper abdominal
from 4 day with nausea, loos appetite and bone pain.
• O- taking history and physical examination
• E- peptic ulcer, eosophegitis, AKD
• P- cbc, urinalysis and creatinine level in plasma
• E- hemofiltration
• L- renal replacement therapy

4. Renal replacement therapy

5. Types of dialysis
Dialysis is a way to clean blood of wastes, fluids and salts that build up in the body when
the kidneys fail. There are 2 kinds of dialysis:
• Peritoneal dialysis:
• Uses the peritoneal membrane as the filter. The membrane covers the abdominal organs and
lines the abdominal wall. This takes place inside the body and requires placement of a
catheter in the peritoneal cavity to allow fluid to be instilled and drained out.
• Hemodialysis:
• Uses a dialyzer or artificial kidney to filter the blood. This takes place outside the body and
requires some form of access to the circulatory system. Accomplished with the use of a
sophisticated computerized control unit.

6. • Kidney transplantation:
• To be placed on a transplant list the patient must be on some form of
renal replacement therapy, whether it is peritoneal dialysis or
hemodialysis
• Once a patient is accepted for transplant, the date of start of dialysis is
the date they are active on the list
• If the patient has a living donor who has been accepted as healthy
donor, it is possible to have a pre-emptive transplant, bypassing
dialysis.
• No treatment or palliative care

7. Peritoneal dialysis
• Uses the peritoneal membrane as the filter. The membrane covers the abdominal organs and
lines the abdominal wall. The membrane size is 1 – 2 m2 and approximates the body surface
area. Uses the following principles:
• Diffusion: movement of solutes across the peritoneal membrane from an area of higher
concentration to an area of lower concentration
• Osmosis: movement of water across the peritoneal membrane from an area of lower solute
concentration to an area of higher solute concentration.
• Ultrafiltration: water removal related to an osmotic pressure gradient with the use of various
concentrations of dialysate fluid.

8. • Fluid called DIALYSATE is put into the abdomen
through a PD catheter. This fluid is left to dwell in the
peritoneum for several hours.
• While in the abdomen, the fluid collects wastes that
have been filtered through the peritoneal membrane.
These wastes pass from the body when the fluid is
drained.

9. Peritoneal dialysis
• Performed daily, by the patient at home, more physiological
• Allows for independence, patients can work or travel
• Fewer fluid and dietary restrictions
• Often fewer medications or lower doses required
• Residual renal function preserved
• Ministry of health funded home therapy

10. Peritoneal dialysis
Patients
• Must have a clean room to perform exchanges and a large
enough area to store all supplies
• No pets allowed in the room
• Must learn to monitor their own weight and blood pressures
• Must be able to follow important instructions to prevent
infection in the peritoneum
• Must also be able to determine the choice of dialysate fluid
and when to use it

12. Patient undergoing Peritoneal Dialysis (CAPD)

13. Types of peritoneal dialysis
CAPD ~ continuous ambulatory peritoneal dialysis
• The blood is cleaned constantly by dialysate fluid while it is in the abdomen.
• Capd does not require the use of a machine, the exchanges are completed manually.
Apd ~ automated peritoneal dialysis
• Requires the use of a machine called a cycler
• The CYCLER is used during the night and is set to deliver the fluid in and out of the
abdomen.

14. • Indications
1. bleeding tendency
2. Hypotension
3. Diabetic nephropathy
• Complications
1. Peritonitis
2. Injury of viscus
3. Abdominal hernia
4. Leakage of dialysate into pleural cavity or scrotom

15. Hemodialysis
• Blood is circulated through an artificial kidney which has two compartments:
blood & dialysate, separated by a thin semi-permeable membrane
• Waste and excess water pass from the blood side to the dialysate side and is
discarded in the drain the cleaned blood is returned to the patient.
• Usually done 3x /week ~ 4hrs m-w-f or t-th-sat

16. • Hemodialysis treatments every other day are not as physiological as
peritoneal dialysis
• Requires a trip to the hospital up to 3 times weekly
• Patients can travel to other units but must be pre-arranged and space is
not always available
• Patients are more restricted in dietary and fluid intake between treatments
• Medication requirements different than for those on peritoneal dialysis
e.G. Require more antihypertensive meds, higher doses of erythropoietin

20. Hemodialysis
• Requires access to the blood stream
• Arterio – venous fistula
• Arterio – venous graft
• Temporary catheter
• Long – term catheter

21. HEMODIALYSIS ~ FISTULA

23. Temporary hemodialysis catheter
Exit site at
surface of the
skin
Inserted in
the jugular
vein
Tip located
at junction
of SVC and
right Atrium

24. Tunneled hemodialysis catheter
Exit site
Catheter tunnel
Inserted in
the jugular
vein
Tip located
at junction
of SVC and
right Atrium
Dacron cuff

25. INDICATION
• ARF
• CRF
• HYPERKALEMIA
• HYPERCALCEMIA
• DRUG TOXICITY
• SEVER TEMPERATURE DISORDER

26. COMPLICATION
1. A-V shunt complication:
· Throbmosis. · Infection.
· Aneursysm. · HF.
2. bleeding.
3. Hepatitis B, C.
4. Loss of folic acid, vit B complex & hormones .
5. Dialysis disequilibrium syndrome.
7. Al dementia due to chronic dialysis using hard water to dissolve dialysate.
8. Hypotension.
9. Air embolism.
10. Depression.

27. TRANSPLANTATION

28. • Technique:
Source:
Living related donor with HLA & ABO matching.
. Unrelated donor with hla.With paratial matching.
. Cadaveric kidney.
• Operative
. Nephrectomy
. The kidney is perfused with cold solution till transplantation(cold ischemic time)
. The kidney is placed in iliac fossa & anastmosed to iliac vessels & ureter is
placed in
Bladder.
• Indications
all patients of ESRD without contraindications for transplantation & with
available donor.

29. 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

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

31. Metabolic complications- hypomagnesaemia, hypophosphatemia, hypercalcemia,
hyperkalemia, RTA, dyslipidemia
Malignancy- post transplant lymphoproliferative disorder
Recurrence of primary disease in the allograft- FSGS, MPGN, atypical HUS
Treatment :csa, cyclophosphamide.
Chronic allograft dysfunction

32. 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.

33. Immunosuppressive medications
• Induction:
• Corticosteroids
• Anti-thymocyte globulin (ATG)
• Okt3
• IL-2 receptor antagonists
• Maintenance:
• Corticosteroids
• Calcineurin inhibitors (cnis)
• Mtor inhibitors
• Antimetabolites