Renal Replacement Therapy for paediatrics.pptx

A document on treatment for end stage renal disease

1. Renal Replacement Therapy (RRT) BY DR UZOMBA C.I Department of Paediatrics , University of Calabar , Calabar , Cross River, Nigeria.

2. Outline Introduction Dialysis Peritoneal Dialysis Haemodialysis Renal Transplantation Conclusion

3. Introduction Renal Replacement Therapy (RRT) is the process of supporting renal function of patients whose kidneys are not functioning well Two modes of RRT Dialysis and Renal Transplantation Dialysis may be acute or chronic Chronic dialysis often precedes renal transplantation in children with chronic renal disease (CKD) or may be a rescue measure in those with failed transplants

4. Dialysis Two Types: Peritoneal Dialysis (PD) Haemodialysis (HD) Main indications include: Acute Renal failure Chronic Renal failure ( With End Stage Renal Failure) Accidental Poisoning

5. Peritoneal Dialysis (PD): PD is preferred in children and twice as efficient in infants as in adults. Peritoneum acts as a semi-permeable membrane. It is preferred for acute conditions. It is easily available and requires less expertise. Goals of PD: Remove fluid ( Ultrafiltration ), Filter waste Restore balance of blood chemistries Requires peritoneal dialysis Fluid ( Dialysate )

6. Mechanism of PD Diffusion & Osmosis Diffusion: Movement of molecules across membrane from area of high concentration to lower concentration. Urea, creatinine , K+ and toxin diffuses from the body through the peritoneal membane , while HCo3, Na+ which are less, diffuse outside the body ie Solute flux

7. Osmosis: Movement of water across a semi-membrane from area of low solute to areas of high solute. In the process, various solutes dissolves in the plasma water; urea, creatinine , potassium are also dragged out along with plasma water. This is called Solvent drag.

8. Forms OF PD Intermittent peritoneal dialysis (IPD) Continuous ambulatory peritoneal dialysis (CAPD) Continuous cycling peritoneal dialysis(CCPD) Tidal peritoneal dialysis (TPD)

9. Indication for PD Acute renal failure Chronic renal failure Severe metabolic acidosis ( Serum Bicarbonate < 12 mmol /L) Severe hyperkalaemia (Serum K + >6.5mmol/L) Serum creatinine > 300µmol/L in infants and > 500µmol/L in older children Blood urea nitrogen > 150mg/dl Uncontrolled hypertension Severe fluid overload and pulmonary oedema Accidental poisoning Intractable Congestive cardiac failure Hepatic coma Reye’s syndrome

10. Contraindications of PD Peritonitis Abdominal Surgery Abdominal Malignancies Omphalocele Gastrochisis Diaphragmatic Hernia

11. Technique of PD Catheter: A temporary catheter(Polyurethane catheter) for acute dialysis or a permanent catheter( eg Tenckhoff catheter)for both chronic and acute dialysis It is inserted into the peritoneal cavity through a sub-umbilical incision or through either iliac fossae . Warm dialysis fluid 2.5% Dextrose solution before infusion (other concentration of Dextrose 1.5 and 4.25%) Antibiotics( Cephalosporins ± Gentamycin ) given IV or added to dialysis fluid Add Heparin 125IU/L of PD Fluid A dd K+ 3mEq/L of PD fluid, after 10 exchanges Fill Time = 5mins, Dwell Time= 45mins, Drain Time= 15mins Entire Cycle last one hour

12. Technique of PD

13. Complications Peritonitis: Common organisms include- E. coli, Klebsiella , Proteus, Pseudomonas, Fungi Catheter leakage Catheter Blockage Coiling of Omentum Malnutrition due to loss of protein Metabolic Complication: Hypokalaemia , hypocalcaemia, Hypo- or hypernatraemia , Metabolic alkalosis.

14. Haemodialysis (HD) Blood passes through artificial cellophane membrane ( Dialyzer contains the artifical semi-permeable membrane) Two forms of HD: Acute and chronic Indications: (Similar to PD) Acute Renal failure, Accidental poisoning, Severe hyperkalaemia , Severe fluid overload, Pulmonary oedema , ESRD awaiting transplantation and failed transplant

15. Procedure Vascular access created using arterio -venous cannular Tubings and dialyzer are primed with physiologic saline containing heparin. Heparin 1000-2000units given IV and additional doses given Intra-dialysis to maintain clotting time b/w 30-60mins Connect patient to the dialysis machine Monitor vital signs Each session lasting for 4-6 hours Dialyze three times a week

16. Complications Seizures: Due to dialysis disequilibrium syndrome as a result of cerebral oedema due to generation of idiogenic osmoles in the brain from rapid lowering of blood urea nitrogen. Hypertension followed by hypotension due to haemodynamic changes Epigastric pain and haematemesis Catheter Problems: Dislodgement, blockage Arterial or venous thrombosis Infections: HIV, Hepatitis

17. Renal Transplantation Preferred treatment in children with ESRD It helps the child to live a near normal life Patients require chronic dialysis either before or in-between transplant INDICATIONS: Children with ESRD Growth failure in patients with chronic renal insufficiency

18. Contraindications Pre-existing malignancy Children with severe neurological dysfunction Potential recurrence of primary disease eg oxalosis , cystinosis , focal segmental glomerulosclerosis Hepatitis B or C infection

19. Pre-Transplant Preparation Good history and physical examination Address complications arising from Chronic Renal Failure eg Malnutrition, anaemia , metabolic acidosis, hypertension. Correct any urinary tract anomaly which may cause obstructive uropathy . Do investigations Dentist, Social worker and Nutritionist consult Vaccination for Penta , OPV, MMR, Pneumovax , Varivax Donors: Cadaveric and live donors

20. Investigations FBC+ PLT, Clotting and Lipid profiles, U/E/Cr, LFT, Serum Ca2+ & Phosphate, Parathyroid hormone, Urinalysis, Urine M/C/S, Blood Grping & Xmatching , HLA typing & cross match with donors screening for Panel reactive antibodies (PRA) Screening for HIV, Hepatitis B & C , CMV, EBV, VZV and MMR Radiological tests: CXR, X-ray of left wrist, hand and fingers for Bone age, VCUG

21. Immunosuppression Important in reducing the chances of graft rejection Comprises of two phases: Induction and maintenance Induction: Started either b/4 the transplant or intra-operatively. Drugs for Induction: Steroids, Azathioprine , Cyclosporin , Tacrolimus Drugs for maintenance: Cyclosporin and Tacrolimus , While Steroids, mycophenolate mofetil (MMF) & Azathioprine are adjuncts Monitor serum levels of these drugs regularly due to their toxicity

22. Surgical Technique Depends on the weight of the child. Wt< 15kg, the donor’s renal vein is anastomosed to the recipient vena cava, while the renal artery goes to aorta Wt> 15kg, Transplant is extra peritoneal like in adults. Renal vein is anastomosed with common iliac or external iliac vein while renal artery goes to the common iliac artery or internal iliac artery Kidneys from adult donors can be transplanted into young children( placed in their abdomen)

23. Complications Immediate Graft dysfunction Graft Rejection: Hyperacute , acute & chronic Late Infections: Viral(CMV), Bacterial & fungi Hypertension, Hyperlipidaemia Lymphoproliferative disorders Malignancies Growth retardation

24. Conclusion Renal Replacement Therapy (RRT) is the process of supporting renal function of patient through dialysis or renal transplantation There are two types of dialysis: Peritoneal and Haemodialysis Peritoneal dialysis is used more common in children Renal Transplant is the definitive treatment in children with ESRD

25. THANK YOU