Renal transplant esrd & rrt

Renal transplant esrd & rrt

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

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2. Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,

Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. Definition

Renal replacement therapy is a term used to
encompass life-supporting treatments for renal failure

Treatment modalities: Dialysis and Transplantation

First hemodialysis in human being was done by Dr.
HASS in 1924

 First to construct a working dialyzer was Dr .
WILLIAM KOLFF in 1943.
Dept Of Urology, KMC and GRH, Chennai 3

4. INDICATIONS FOR RRT
 Biochemical indications
Refractory hyperkalemia> 6.5 mmol/L
Serum urea > 50 mmol/L not due to hypovolemia
Refractory metabolic acidosis pH ≤ 7.1
Clinical indications
End-organ damage: pericarditis, encephalopathy,
neuropathy, myopathy, uremic bleeding, weight loss
Refractory volume overload
Dept Of Urology, KMC and GRH, Chennai 4

5. PRINCIPLES
Whatever be the technique of RRT, the fundamental
principle is the removal of unwanted SOLUTES &
WATER through a semipermeable membrane and
maintain hemostasis

WATER : Removal of water occurs through a process of
ULTRAFILTRATION
Dept Of Urology, KMC and GRH, Chennai 5

6. It is achieved by generating a TRANS MEMBRANE
PRESSURE , which is greater than the plasma oncotic
pressure ( HF, IHD)

By increasing the osmolarity of the dialysate ( PD)
Dept Of Urology, KMC and GRH, Chennai 6

7. SOLUTE REMOVAL
It occurs by either DIFFUSION or by CONVECTION (
SOLVENT DRAG ).
In diffusion an electro-chemical gradient is created
across the membrane with a dialysate solution.
Dept Of Urology, KMC and GRH, Chennai 7

8. Dept Of Urology, KMC and GRH, Chennai 8

9. Dialysis is any process that changes the concentration of
solutes in the plasma by exposure to a second solution
( the dialysis solution ) across a semipermeable membrane
.
Definition
Dept Of Urology, KMC and GRH, Chennai 9

10. Hemo dialysis
 The 3 essential components of HD are :
Dialyzer
Composition of dialysate
Blood delivery system
Dept Of Urology, KMC and GRH, Chennai 10

11. DIALYZER

 Hollow-fiber dialyzer, the most commonly used type
of dialyzer
composed of bundles of capillary tubes through which
blood circulates and the dialysate travels on the
outside of the fiber bundles.
 The blood and the dialysate may circulate in the same
or in opposite directions in co-current and
countercurrent techniques, respectively
Dept Of Urology, KMC and GRH, Chennai 11

12. Dialysis membrane
It can be synthetic or biological.
Cellulose :
Has low flux
poor in removing middle MW molecules.
More complement and leucocyte activation.
Not desirable in ICU patients.
Worsening of the organ damage.
Dialysis membrane :
•
Dept Of Urology, KMC and GRH, Chennai 12

13. SYNTHETIC

High flux membranes.
Made up of PMMA, PAN, Polyamide, Polysulphone
(PS).
 Allows convective therapy and removal of middle MW
substances.
 Better biocompatibility, less leucocyte/complement
activation and end organ dysfunction
Dept Of Urology, KMC and GRH, Chennai 13

14. Dialysate
Dept Of Urology, KMC and GRH, Chennai 14

15. When to start dialysis

 To treat or to prevent life - threatening
hyperkalemia, acidosis, or hypervolemic pulmonary
edema,
or
 To treat complications of chronic renal failure
such as pericarditis, neuropathy, seizures, and
coma.

Modern renal replacement uses dialysis to
remove unwanted solutes by diffusion and
hemofiltration to remove water, which carries
with it unwanted soluble substances.

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16. Indications in AKI
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17. Clinical indications to start dialysis
in CKD
Pericarditis or pleuritis
Progressive uremic encephalopathy or neuropathy
A clinically significant bleeding diathesis attributable to
uremia
Fluid overload refractory to diuretics
Persistent metabolic disturbances that are refractory to
medical therapy; these include hyperkalemia, metabolic
acidosis, hypercalcemia, and hyperphosphatemia
Persistent nausea and vomiting
Hypertension poorly responsive to antihypertensive
medications
Weight loss or signs of malnutrition
Dept Of Urology, KMC and GRH, Chennai 17

18. When not to dialyse?
Dementia
Severe peripheral arterial disease
Hypotensive heart failure
Severe mental illness
Malignant disease with poor prognosis
Dept Of Urology, KMC and GRH, Chennai 18

19. MODES OF RRT
 INTRACORPOREAL : Peritoneal dialysis
EXTRACORPOREAL :
Intermittent Hemodialysis
 Slow low efficiency dialysis (SLED)
 Continuous Hemo-filtration
 CAVH
 CVVH
 CAVHDF
 CVVHDF
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20. Dept Of Urology, KMC and GRH, Chennai 20

21. Peritoneal dialysis

Principle
Solute and fluid exchange occur between
peritoneal capillary blood and dialysis solution in the
peritoneal cavity
Dept Of Urology, KMC and GRH, Chennai 21

22. Anatomy
Largest serosal surface
Surface area is approximately equal to body surface
area 1-2sq.m in an adult
Can hold appreciable quantity of fluid without overt
physiological alterations
Parietal: more important in PD-blood supply from
the lumbar, intercostal and epigastric arteries and
drains into the IVC
Blood flow 50-100ml/min
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23. Fluid and molecules transfer

Diffusion

Osmosis
Dept Of Urology, KMC and GRH, Chennai 23

24. Three pore model
Ultrasmall pores (3–5 Å; water-selective pore), allowing
the transport of water but not solutes. About 50 per cent
of transcapillary UF occurs through these pores, inspite
of the surface area being only 1–2 per cent.

Small pores (40–50 Å; interendothelial clefts have been
considered the equivalent of small pores)—colloid
osmosis occurs at this level. (urea, creatinine, sodium,
potassium)

Large pores (>150 Å; probably less than 0.1 per cent of total
pore count), which are involved in macromolecular
transport

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25. Dept Of Urology, KMC and GRH, Chennai 25

26. In peritoneal dialysis, 1.5 – 3 L of peritoneal dialyzate
solution is infused into the peritoneal cavity and allowed to
dwell for a set period of time, usually 2 to 4 hours.
The rate of diffusion diminishes with time and eventually
stops when equilibration between plasma and dialyzate is
reached
Lactate is the preferred buffer
Icodextrin, has been found to be associated with more
efficient ultrafiltration than dextrose-containing solutions.
It may be associated with the complication of
ENCAPSULATING PERITONEAL SCLEROSIS.
Dept Of Urology, KMC and GRH, Chennai 26

27. Contraindications
Absolute:-
Loss of peritoneal function producing inadequate
clearance
Adhesions blocking flow
Abdominal hernia
Stoma
Diaphragmatic fluid leak
Dept Of Urology, KMC and GRH, Chennai 27

28. Contraindications
Relative:-
Fresh foreign body
Large polycystic kidneys
VP shunt
Morbid obesity
Severe malnutrition
Bowel disease
S.aureus carrier
Skin infections
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29. Catheter placement
Percutaneous Seldinger technique
Laparoscopic
Surgical
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30. Dept Of Urology, KMC and GRH, Chennai 30

31. Modes of PD
Intermittent peritoneal dialysis
Continuous Ambulatory (CAPD)
– 3 exchanges during waking hours
Automated or Alternative (APD)
Nocturnal Intermittent (NIPD)
- No exchange during day, 6-8 at night via cycling machine
Nocturnal Tidal (NTPD)
No exchange during day, 6-8 at night each hour with a constant
volume of ≈ 1,500 mL in peritoneal cavity
Continuous Cyclic (CCPD)
Dialysate instilled in AM, dwells during day, removed prior to bed
Hybrid devices :Night exchange device
PD plus
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32. Dept Of Urology, KMC and GRH, Chennai 32

33. Complications

Mechanical

Medical

Infectious
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34. Mechanical
Kinking of catheter
Early catheter malfunction
Late catheter malfunction
Migration
Blood
Fibrin
Peritonitis
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35. Medical
Glucose overload
Malnutrition – protein loss
Hypo / hypercalcemia
Idiopathic ascites
Haemoperitoneum
Eosinophilic peritonitis

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36. Medical
Glucose overload
Malnutrition – protein loss
Hypo / hypercalcemia
Idiopathic ascites
Haemoperitoneum
Eosinophilic peritonitis

Dept Of Urology, KMC and GRH, Chennai 36

37. Other complications
Hernias (15-20%); any existing hernia should be
repaired pre PD
Fluid leaks
Prolapse
Back pain
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38. Dept Of Urology, KMC and GRH, Chennai 38

39. Principle
The use of a semipermeable membrane that will
allow the passage of water and small molecular weight
(MW) solutes, but not large molecules (e.g. proteins)
MW of urea = 60, creatinine = 113, vitamin B12 =
1355, albumin = 60 000, IgG = 140 000 Da
Dept Of Urology, KMC and GRH, Chennai 39

40. Mechanisms of solute clearance
Diffusive transport
Along concentration gradient
Small solutes
Convective transport
Smaller and larger solutes are effectively dragged along
with fluid
Depends on pore size
Ultrafiltration
Pressure gradient
Fluid and small molecules
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41. Types of vascular access
AV fistula
AV graft
Central venous catheters
Dept Of Urology, KMC and GRH, Chennai 41

42. AV fistula

Constructed in subcutaneous
plane between an artery and
vein (side of artery to side or
end of vein)
Advantages
Excellent patency
Lower rates of complications
(infection, steal, stenosis)
Disadvantages
Long maturation time
Occasional failure to
develop
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43. AV graft
Synthetic conduit, usually polytetrafluoroethylene (PTFE, also known
as Gortex), between an artery and vein
Advantages
Short maturation time
Easy cannulation and large surface area
Easier surgical handling
Disadvantages
Inferior long term patency
High infection rate than native AVF
Good alternative in patients in whom adequate AVF cannot be created

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45. Central venous catheters

Temporary catheters
(Vascath)
ARF requiring dialysis
ESRD but without
alternative access
Tunneled cuffed catheters
Alternative form of long
term vascular access for
patients in whom AV
access cannot readily be
created
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46. The circuit
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47. Blood and dialysate flow
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48. Dialysate
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49. Water
Dialysate diluted in sterile water
Ratio of 1:34
Standard 4 hour session, flow rate 500ml/min – 120 L
of water
Dept Of Urology, KMC and GRH, Chennai 49

50. Contraindications
Absolute
No vascular access possible

Relative
Difficult access
Needle phobia
Cardiac failure
Coagulopathy
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51. ANTI-COAGULANTS IN DIALYSIS
Interacting of blood with dialyzing membrane causes
activation of clotting cascade – thrombosis-dysfunction.
Commonly used anti-coagulant is HEPARIN .
 SYSTEMIC ANTICOAGULATION :
Administered in doses of 50-100u/kg at the initiation
followed by a bolus of 100u/hr
 REGIONAL ANTICOAGULATION :
circuit alone is anti-coagulated by administering 500-750
u/hr intothe arterial line and by parallel administration of
protamine 1mg/100u of heparin.
Dept Of Urology, KMC and GRH, Chennai 51

52. VARIANT OF REGIONAL ANTI-COAGULANT :
uses sodium citrate with dialysate containing no
calcium, Used for patients with high risk of bleeding.
DIALYSIS WITHOUT ANTI-COAGULANTS :
Uses the saline flush technique
HD is initiated at a higher rate to reduce the
thrombogenicity and dialyzer is flushed every 15-
20min with 50ml of saline.
DIRECT THROMBIN INHIBITORS :
Hirudin, lepirudin, Argatroban
Dept Of Urology, KMC and GRH, Chennai 52

53. Complications
Dialysis reactions
Cardiovascular
Neuromuscular
Haematologic
Pulmonary
Technical
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54. Dialysis reactions
Anaphylaxis
Microbial contamination
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55. Hypotension
10-30%
Asymptomatic to organ hypoperfusion

Trendelenburg position
Stop dialysis
Normal saline
Cool dialysate
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56. Other cardiovascular
Hypertension

Arrythmias

Sudden death
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57. Neuromuscular
Cramps
5-20%
Legs
Hypo-osmolality & hypomagnesemia
Restless leg syndrome
Seizures
Dept Of Urology, KMC and GRH, Chennai 57

58. Dialysis disequilibrium syndrome
Neurologic symptoms of varying severity that are thought
to be due primarily to cerebral edema
Reverse osmotic shift
Intracerebral acidosis
Early findings
Headache, nausea, disorientation, restlessness, blurred vision
Late findings
Confusion, seizures, coma, and even death
Prevention
The initial dialysis should be gentle, but repeated frequently
The aim is a gradual reduction in BUN

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59. Haematologic
Complement activation, neutropenia
Haemolysis
Haemorrhage
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60. Pulmonary
Dialysis-Associated hypoxemia
PaO
2 decreases by 5-20mmHg
Clinically not significant
Important in patients with respiratory compromise
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61. Technical
Air embolism
Altered dialysate composition
Line disconnection
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62. Other complications
Post-dialysis syndrome
Pruritus
Priapism
Hearing & visual loss
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63. HD or PD
Ideally should be patient’s choice
Resource limitation
Physician’s prejudice
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64. Dept Of Urology, KMC and GRH, Chennai 64

65. Advantages Disadvantages
Haemodialysis Short treatment
Efficient removal
Specialised staff
and equipment
Heparinisation
Protein loss
Peritoneal
dialysis
Can be
performed
manually
No heparinisation
Longer treatment
period
Continuous
Risk of peritonitis
May cause
respiratory
compromise
Dept Of Urology, KMC and GRH, Chennai 65

66. Goals of dialysis
Achieve desired dry weight
Adequate removal of waste products
Prevent sequelae of electrolyte disturbances
Reduce morbidity and mortality
Dept Of Urology, KMC and GRH, Chennai 66

67. SLOW LOW- EFFICIENCY DIALYSIS
Conventional dialysis treatment .
Uses dialysate flow rates of 300 ml/min & low blood
flow pump speeds of 200ml/min for 6 – 12 hrs a day.
Excellent small molecule detoxification.
 Reduced anticoagulant requirement.
 11 hrs SLED is comparable to 24 hrs of CHD .

Dept Of Urology, KMC and GRH, Chennai 67

68. Haemofiltration
Solute clearance purely by convection – dragged along
with water
Large volumes removed – replace
Replacement fluid directly administered to patient
Highly permeable large membranes
High flow rate
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69. Dept Of Urology, KMC and GRH, Chennai 69

70. Dept Of Urology, KMC and GRH, Chennai 70

71. CONTINUOUS VENO-VENOUS HEMOFILTRATION
Solute clearance occurs by convection.
No dialysate , 1-2 l/hr of ultrafiltration rates used.
 Replacement fluid provided to replace the excess
volume that is being removed and replenish desired
solutes
Effective method of solute removal
Major advantage is that solute can be removed in large
quantities ,maintaining a net zero or even a positive
fluid balance
Dept Of Urology, KMC and GRH, Chennai 71

72. CONTINUOUS VENO-VENOUS HEMODIAFILTRATION
Involves the ultrafiltration of fluid across a high-flux
dialyzer with compensatory reinfusion of ultrapure
dialysate
increases middle-sized molecule clearances
Benefits of both diffusion and convection for solute
removal
 Use of replacement fluid allows for adequate removal
of solutes with zero or positive net fluid balance
Dept Of Urology, KMC and GRH, Chennai 72

73. SLOW CONTINUOUS ULTRAFILTRATION
Ultrafiltration at a rate of 100-300ml/hr is performed
to maintain fluid balance.
No fluids are administered either as dialysate or
replacement fluids.
Indicated in CCF refractory to diuretics and in volume
overload
Dept Of Urology, KMC and GRH, Chennai 73

74. Advanatges
Better removal of large substances
Improved clearance of uremic toxins
Better cardiovascular stability
Less inflammatory reactions
Suitable for patients planned for long term dialysis
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75. Thank you…
Dept Of Urology, KMC and GRH, Chennai 75