Podcast
Questions and Answers
Which of the following best describes the primary function of renal replacement therapy (RRT)?
Which of the following best describes the primary function of renal replacement therapy (RRT)?
- Stimulating the regeneration of damaged kidney tissue to restore its original function.
- Augmenting endocrine functions of the kidney, such as hormone production.
- Enhancing the kidney's ability to reabsorb essential nutrients and electrolytes.
- Supporting or replacing non-endocrine kidney functions, like toxin and metabolite removal. (correct)
A patient with end-stage renal disease (ESRD) is being evaluated for renal replacement therapy (RRT). Which factor is most critical when determining the most suitable RRT modality for this patient?
A patient with end-stage renal disease (ESRD) is being evaluated for renal replacement therapy (RRT). Which factor is most critical when determining the most suitable RRT modality for this patient?
- The patient’s financial resources and insurance coverage for different RRT options.
- The availability of advanced dialysis equipment and experienced medical personnel at the treatment center.
- The patient’s blood type and HLA (human leukocyte antigen) matching with available kidney donors.
- The anticipated duration of treatment, patient characteristics, and patient preferences. (correct)
Which of the following acid-base imbalances would most likely warrant acute renal replacement therapy (RRT)?
Which of the following acid-base imbalances would most likely warrant acute renal replacement therapy (RRT)?
- Severe metabolic acidosis with a pH less than 7.1 and/or serum bicarbonate less than 12 mmol/L. (correct)
- Mild metabolic alkalosis with a pH of 7.48 and serum bicarbonate of 30 mmol/L.
- Respiratory acidosis with a pH of 7.30 and PaCO2 of 60 mmHg, responsive to mechanical ventilation.
- Compensated metabolic acidosis with a pH within normal limits and serum bicarbonate of 18 mmol/L.
A patient presents with refractory hyperkalemia (K+ >7.0 mmol/L) despite treatment with calcium gluconate, insulin, and sodium bicarbonate. Which acute indication for renal replacement therapy (RRT) does this scenario align with?
A patient presents with refractory hyperkalemia (K+ >7.0 mmol/L) despite treatment with calcium gluconate, insulin, and sodium bicarbonate. Which acute indication for renal replacement therapy (RRT) does this scenario align with?
How does haemofiltration (HF) differ fundamentally from haemodialysis (HD) in terms of solute removal?
How does haemofiltration (HF) differ fundamentally from haemodialysis (HD) in terms of solute removal?
Why is haemofiltration (HF) particularly advantageous for managing fluid and solute balance in patients susceptible to cerebral edema?
Why is haemofiltration (HF) particularly advantageous for managing fluid and solute balance in patients susceptible to cerebral edema?
What characterizes haemodiafiltration as a renal replacement therapy, and what advantage does this confer?
What characterizes haemodiafiltration as a renal replacement therapy, and what advantage does this confer?
Following a kidney transplant, the surgical team prioritizes inserting the transplanted kidney into the patient’s right iliac fossa. What advantage underlies this practice?
Following a kidney transplant, the surgical team prioritizes inserting the transplanted kidney into the patient’s right iliac fossa. What advantage underlies this practice?
A kidney transplant recipient develops acute hypotension during a dialysis session. How is this cardiovascular complication typically managed?
A kidney transplant recipient develops acute hypotension during a dialysis session. How is this cardiovascular complication typically managed?
A patient on long-term haemodialysis develops painful ischemia in their hand distal to the arteriovenous fistula (AVF). What is the most likely underlying mechanism for this complication?
A patient on long-term haemodialysis develops painful ischemia in their hand distal to the arteriovenous fistula (AVF). What is the most likely underlying mechanism for this complication?
In a patient undergoing peritoneal dialysis (PD), what clinical findings would raise suspicion for peritoneal dialysis-associated peritonitis?
In a patient undergoing peritoneal dialysis (PD), what clinical findings would raise suspicion for peritoneal dialysis-associated peritonitis?
A patient who underwent kidney transplantation six months ago presents with a gradual decline in graft function. Serological tests are negative for donor-specific antibodies. Which type of rejection is most likely in this scenario?
A patient who underwent kidney transplantation six months ago presents with a gradual decline in graft function. Serological tests are negative for donor-specific antibodies. Which type of rejection is most likely in this scenario?
A kidney transplant recipient develops polyomavirus nephropathy. What strategy is NOT likely to be used in the management for this condition?
A kidney transplant recipient develops polyomavirus nephropathy. What strategy is NOT likely to be used in the management for this condition?
During the assessment of a kidney transplant recipient with new-onset hypertension, what physical examination finding would most strongly suggest renal artery stenosis as the underlying cause?
During the assessment of a kidney transplant recipient with new-onset hypertension, what physical examination finding would most strongly suggest renal artery stenosis as the underlying cause?
A kidney transplant recipient develops a fever, graft tenderness, and oliguria 24 hours after transplantation. What is the most concerning diagnosis that must be immediately ruled out?
A kidney transplant recipient develops a fever, graft tenderness, and oliguria 24 hours after transplantation. What is the most concerning diagnosis that must be immediately ruled out?
Which of the following best describes the rationale for administering high-dose glucocorticoids as a first-line treatment for acute cellular rejection in kidney transplant recipients?
Which of the following best describes the rationale for administering high-dose glucocorticoids as a first-line treatment for acute cellular rejection in kidney transplant recipients?
A kidney transplant recipient is diagnosed with chronic allograft rejection. Which general measure should be included in the management of this patient?
A kidney transplant recipient is diagnosed with chronic allograft rejection. Which general measure should be included in the management of this patient?
In a patient presenting with symptoms of uremia, such as pericarditis, pruritus, and encephalopathy, which of the AEIOU indications for acute RRT is most applicable?
In a patient presenting with symptoms of uremia, such as pericarditis, pruritus, and encephalopathy, which of the AEIOU indications for acute RRT is most applicable?
What is the primary immunological mechanism underlying acute cellular rejection in kidney transplantation?
What is the primary immunological mechanism underlying acute cellular rejection in kidney transplantation?
Which of the following is the MOST common vascular complication occurring in the late phase ( > 12 weeks) after kidney transplantation?
Which of the following is the MOST common vascular complication occurring in the late phase ( > 12 weeks) after kidney transplantation?
What is the most significant long-term risk associated with the use of immunosuppressive medications following kidney transplantation?
What is the most significant long-term risk associated with the use of immunosuppressive medications following kidney transplantation?
How does the timing of delayed graft function (DGF) presentation relate to other post-transplant complications?
How does the timing of delayed graft function (DGF) presentation relate to other post-transplant complications?
What is the relationship between hypertension and renal artery stenosis in a post-transplant situation?
What is the relationship between hypertension and renal artery stenosis in a post-transplant situation?
When is a kidney-pancreas transplant suggested?
When is a kidney-pancreas transplant suggested?
Which test is the MOST appropriate to exclude infection or outflow obstruction as a cause of kidney dysfunction in Renal Transplant?
Which test is the MOST appropriate to exclude infection or outflow obstruction as a cause of kidney dysfunction in Renal Transplant?
First-line for acute cellular rejection is high-dose glucocorticoids, what is the second-line?
First-line for acute cellular rejection is high-dose glucocorticoids, what is the second-line?
In Chronic active antibody-mediated rejection, which benefit is unproven?
In Chronic active antibody-mediated rejection, which benefit is unproven?
Which of the following best describes the function of the assessment of immune suppressant levels (tacrolimus/ciclosporin) in a blood analysis?
Which of the following best describes the function of the assessment of immune suppressant levels (tacrolimus/ciclosporin) in a blood analysis?
What is a key component underlying the mechanism of action in haemofiltration?
What is a key component underlying the mechanism of action in haemofiltration?
What characterises hyperacute rejection?
What characterises hyperacute rejection?
The need for RRT should be:
The need for RRT should be:
In Acute humoral rejection, what may be used as an adjunct?
In Acute humoral rejection, what may be used as an adjunct?
What are the two components on the membrane of the kidney that allow dialysis?
What are the two components on the membrane of the kidney that allow dialysis?
What causes Kidney Transplant rejection?
What causes Kidney Transplant rejection?
Which of the following causes AKI damage to the renal tubules?
Which of the following causes AKI damage to the renal tubules?
Common strategies to treat Chronic Rejection do NOT include:
Common strategies to treat Chronic Rejection do NOT include:
A patient on haemodialysis develops dialysis disequilibrium syndrome (DDS). Which underlying mechanism primarily contributes to the neurological symptoms observed in this syndrome?
A patient on haemodialysis develops dialysis disequilibrium syndrome (DDS). Which underlying mechanism primarily contributes to the neurological symptoms observed in this syndrome?
A kidney transplant recipient who is on triple immunosuppression presents with new skin lesions. Which feature is MOST suggestive of post-transplant skin cancer rather than a benign skin condition?
A kidney transplant recipient who is on triple immunosuppression presents with new skin lesions. Which feature is MOST suggestive of post-transplant skin cancer rather than a benign skin condition?
A patient undergoing peritoneal dialysis (PD) is suspected of having peritoneal dialysis-associated peritonitis. After sending a sample of the effluent for analysis, which finding would MOST strongly support this diagnosis?
A patient undergoing peritoneal dialysis (PD) is suspected of having peritoneal dialysis-associated peritonitis. After sending a sample of the effluent for analysis, which finding would MOST strongly support this diagnosis?
In managing chronic allograft rejection, what distinguishes antibody-mediated rejection from T cell-mediated rejection in terms of therapeutic strategies?
In managing chronic allograft rejection, what distinguishes antibody-mediated rejection from T cell-mediated rejection in terms of therapeutic strategies?
A patient develops acute kidney injury (AKI) following kidney transplantation. Which clinical scenario is MOST suggestive of acute tubular necrosis (ATN) as the cause of the AKI?
A patient develops acute kidney injury (AKI) following kidney transplantation. Which clinical scenario is MOST suggestive of acute tubular necrosis (ATN) as the cause of the AKI?
Which of the following physiological processes is NOT directly supported or replaced by renal replacement therapy (RRT)?
Which of the following physiological processes is NOT directly supported or replaced by renal replacement therapy (RRT)?
A patient with chronic kidney disease (CKD) is being considered for renal replacement therapy (RRT). Which of the following factors would MOST strongly influence the choice of RRT modality?
A patient with chronic kidney disease (CKD) is being considered for renal replacement therapy (RRT). Which of the following factors would MOST strongly influence the choice of RRT modality?
A patient with acute kidney injury (AKI) has a serum potassium level of 7.2 mmol/L despite initial management. Which of the following AEIOU indications for acute RRT is MOST clearly demonstrated in this scenario?
A patient with acute kidney injury (AKI) has a serum potassium level of 7.2 mmol/L despite initial management. Which of the following AEIOU indications for acute RRT is MOST clearly demonstrated in this scenario?
Which of the following scenarios would be LEAST likely to warrant the initiation of acute renal replacement therapy (RRT) based on the AEIOU criteria?
Which of the following scenarios would be LEAST likely to warrant the initiation of acute renal replacement therapy (RRT) based on the AEIOU criteria?
How does the mechanism of solute removal in hemodialysis (HD) primarily differ from that in haemofiltration (HF)?
How does the mechanism of solute removal in hemodialysis (HD) primarily differ from that in haemofiltration (HF)?
In which clinical scenario might haemofiltration (HF) be particularly advantageous over hemodialysis (HD) for managing acute kidney injury (AKI)?
In which clinical scenario might haemofiltration (HF) be particularly advantageous over hemodialysis (HD) for managing acute kidney injury (AKI)?
What is the defining characteristic of haemodiafiltration (HDF) that distinguishes it from both haemodialysis (HD) and haemofiltration (HF)?
What is the defining characteristic of haemodiafiltration (HDF) that distinguishes it from both haemodialysis (HD) and haemofiltration (HF)?
What is the PRIMARY immunological mechanism targeted by immunosuppressant medications to prevent rejection in kidney transplant recipients?
What is the PRIMARY immunological mechanism targeted by immunosuppressant medications to prevent rejection in kidney transplant recipients?
During a kidney transplant evaluation, what factor would LEAST likely influence the decision to proceed with transplantation?
During a kidney transplant evaluation, what factor would LEAST likely influence the decision to proceed with transplantation?
Which of the following best describes the primary goal of triple immunosuppression therapy following kidney transplantation?
Which of the following best describes the primary goal of triple immunosuppression therapy following kidney transplantation?
A kidney transplant recipient presents with fever, graft tenderness, and a rapid decline in urine output within the first week post-transplant. Which of the following is the MOST likely diagnosis?
A kidney transplant recipient presents with fever, graft tenderness, and a rapid decline in urine output within the first week post-transplant. Which of the following is the MOST likely diagnosis?
What is the usual first-line treatment for acute cellular rejection in kidney transplant recipients?
What is the usual first-line treatment for acute cellular rejection in kidney transplant recipients?
What is the MOST significant long-term cardiovascular risk associated with chronic kidney disease (CKD)?
What is the MOST significant long-term cardiovascular risk associated with chronic kidney disease (CKD)?
A patient on haemodialysis develops dialysis disequilibrium syndrome (DDS). Which factor contributes to the neurological symptoms?
A patient on haemodialysis develops dialysis disequilibrium syndrome (DDS). Which factor contributes to the neurological symptoms?
A patient undergoing peritoneal dialysis (PD) develops peritonitis. Which is the MOST common causative organism?
A patient undergoing peritoneal dialysis (PD) develops peritonitis. Which is the MOST common causative organism?
What is the underlying physiological principle of peritoneal dialysis (PD) in removing waste and excess fluid?
What is the underlying physiological principle of peritoneal dialysis (PD) in removing waste and excess fluid?
A patient with Chronic Kidney Disease has an estimated GFR of under 10. Which of the following symptoms would MOST suggest the need for commencement of RRT?
A patient with Chronic Kidney Disease has an estimated GFR of under 10. Which of the following symptoms would MOST suggest the need for commencement of RRT?
Which vascular access option is MOST appropriate for a patient requiring immediate, but temporary, haemodialysis?
Which vascular access option is MOST appropriate for a patient requiring immediate, but temporary, haemodialysis?
What is the main difference between Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD)?
What is the main difference between Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD)?
Volume removed in Haemofiltration is termed:
Volume removed in Haemofiltration is termed:
A kidney transplant recipient has an abrupt decline in graft function four days post-transplant. Which action takes priority?
A kidney transplant recipient has an abrupt decline in graft function four days post-transplant. Which action takes priority?
A patient presents with a post-transplant infection and is taking Tacrolimus for immunosuppression. What side effect of Tacrolimus is MOST likely?
A patient presents with a post-transplant infection and is taking Tacrolimus for immunosuppression. What side effect of Tacrolimus is MOST likely?
Following kidney transplantation, a patient develops polyomavirus nephropathy. What monitoring strategy is MOST important?
Following kidney transplantation, a patient develops polyomavirus nephropathy. What monitoring strategy is MOST important?
A kidney transplant recipient who is on triple immunosuppression presents with a history of weight gain. What medication is MOST likely the cause?
A kidney transplant recipient who is on triple immunosuppression presents with a history of weight gain. What medication is MOST likely the cause?
If corticosteroids are ineffective against first-line acute cellular rejection, what is the next step?
If corticosteroids are ineffective against first-line acute cellular rejection, what is the next step?
A transplant recipient shows signs similar to acute kidney injury. What investigation MUST be done?
A transplant recipient shows signs similar to acute kidney injury. What investigation MUST be done?
What is a common cause of urinary tract obstruction in kidney transplant recipients?
What is a common cause of urinary tract obstruction in kidney transplant recipients?
Which of these scenarios presents a relatively HIGHER risk for the transplant recipient:
Which of these scenarios presents a relatively HIGHER risk for the transplant recipient:
A patient who underwent kidney transplantation six months ago develops a persistent cough, shortness of breath, and fever. Which infection is the MOST likely differential diagnosis?
A patient who underwent kidney transplantation six months ago develops a persistent cough, shortness of breath, and fever. Which infection is the MOST likely differential diagnosis?
A patient presents with renal dysfunction, hypertension and hypokalemia a year after transplant surgery, what is the MOST likely cause?
A patient presents with renal dysfunction, hypertension and hypokalemia a year after transplant surgery, what is the MOST likely cause?
During insertion of a dialysis line, a patient gets a bloodstream infection. What is the MOST likely infection?
During insertion of a dialysis line, a patient gets a bloodstream infection. What is the MOST likely infection?
Which of the following immunosuppressant drug combinations is NOT commonly used in kidney transplantation?
Which of the following immunosuppressant drug combinations is NOT commonly used in kidney transplantation?
How does delayed graft function (DGF) typically manifest in the immediate post-transplant period?
How does delayed graft function (DGF) typically manifest in the immediate post-transplant period?
What is a common symptom of kidney transplant rejection?
What is a common symptom of kidney transplant rejection?
If the potassium serum level is > 7mmol/L, what indication is this under in the AEIOU mnemonic?
If the potassium serum level is > 7mmol/L, what indication is this under in the AEIOU mnemonic?
What does each letter stand for in AEIOU mnemonic?
What does each letter stand for in AEIOU mnemonic?
The MOST common vascular access complication in haemodialysis is:
The MOST common vascular access complication in haemodialysis is:
What long-term CV risk can arise from living with CKD?
What long-term CV risk can arise from living with CKD?
What is a common skin manifestation of a kidney transplant?
What is a common skin manifestation of a kidney transplant?
A patient with end-stage renal disease (ESRD) and a history of poorly controlled diabetes is being evaluated for renal replacement therapy (RRT). Which RRT modality would be LEAST suitable?
A patient with end-stage renal disease (ESRD) and a history of poorly controlled diabetes is being evaluated for renal replacement therapy (RRT). Which RRT modality would be LEAST suitable?
A patient on haemodialysis develops increasing shortness of breath and lower extremity edema. Initial assessment reveals elevated jugular venous pressure and bilateral crackles on auscultation. Which complication of haemodialysis is MOST likely?
A patient on haemodialysis develops increasing shortness of breath and lower extremity edema. Initial assessment reveals elevated jugular venous pressure and bilateral crackles on auscultation. Which complication of haemodialysis is MOST likely?
A kidney transplant recipient presents with new onset hypertension and hypokalemia 1 year post-transplant. Diagnostic workup reveals renal artery stenosis. Which of the following mechanism is MOST likely?
A kidney transplant recipient presents with new onset hypertension and hypokalemia 1 year post-transplant. Diagnostic workup reveals renal artery stenosis. Which of the following mechanism is MOST likely?
A kidney transplant recipient develops acute cellular rejection within the first few weeks after transplantation. After initial treatment with high-dose glucocorticoids, the patient's renal function does not improve. Which step in the management is MOST appropriate?
A kidney transplant recipient develops acute cellular rejection within the first few weeks after transplantation. After initial treatment with high-dose glucocorticoids, the patient's renal function does not improve. Which step in the management is MOST appropriate?
A patient on continuous ambulatory peritoneal dialysis (CAPD) presents with abdominal pain, fever, and cloudy dialysate effluent. After sending a sample of the effluent for analysis, empiric antibiotic therapy is initiated. Which additional intervention is MOST important and IMMEDIATE?
A patient on continuous ambulatory peritoneal dialysis (CAPD) presents with abdominal pain, fever, and cloudy dialysate effluent. After sending a sample of the effluent for analysis, empiric antibiotic therapy is initiated. Which additional intervention is MOST important and IMMEDIATE?
Flashcards
Renal Replacement Therapy (RRT)
Renal Replacement Therapy (RRT)
Renal replacement therapy (RRT) supports or replaces non-endocrine kidney function by removing toxins, metabolites, and/or water.
Dialysis
Dialysis
Dialysis involves removing toxins and excess fluid from the blood using a machine or the peritoneum.
Continuous Renal Replacement Therapy (CRRT)
Continuous Renal Replacement Therapy (CRRT)
CRRT is a continuous form of dialysis, typically used in the ICU for patients who are hemodynamically unstable.
Kidney Transplantation
Kidney Transplantation
Signup and view all the flashcards
Indications for Acute RRT (AEIOU)
Indications for Acute RRT (AEIOU)
Signup and view all the flashcards
RRT in CKD
RRT in CKD
Signup and view all the flashcards
Haemodialysis (HD)
Haemodialysis (HD)
Signup and view all the flashcards
Where can Haemodialysis be done?
Where can Haemodialysis be done?
Signup and view all the flashcards
Diffusion in Dialysis
Diffusion in Dialysis
Signup and view all the flashcards
Peritoneal Dialysis (PD)
Peritoneal Dialysis (PD)
Signup and view all the flashcards
Complications of PD
Complications of PD
Signup and view all the flashcards
Complications of HD
Complications of HD
Signup and view all the flashcards
Vascular Access Complications
Vascular Access Complications
Signup and view all the flashcards
Cardiovascular complications of Heamodialysis
Cardiovascular complications of Heamodialysis
Signup and view all the flashcards
Individualized RRT approach
Individualized RRT approach
Signup and view all the flashcards
Post-Transplant Complications
Post-Transplant Complications
Signup and view all the flashcards
Types of Graft Rejection
Types of Graft Rejection
Signup and view all the flashcards
First-line Tx Acute Cellular Rejection
First-line Tx Acute Cellular Rejection
Signup and view all the flashcards
Treat Acute Humoral Rejection
Treat Acute Humoral Rejection
Signup and view all the flashcards
Immuno-suppression complications
Immuno-suppression complications
Signup and view all the flashcards
Side Effects: Tacrolimus
Side Effects: Tacrolimus
Signup and view all the flashcards
Side Effects: Mycophenolate
Side Effects: Mycophenolate
Signup and view all the flashcards
Late (>12 weeks) post-transplant complications
Late (>12 weeks) post-transplant complications
Signup and view all the flashcards
Urinary tract obstruction S/S
Urinary tract obstruction S/S
Signup and view all the flashcards
Signs of Skin cancer
Signs of Skin cancer
Signup and view all the flashcards
Renal artery stenosis signs
Renal artery stenosis signs
Signup and view all the flashcards
Principles of post-transplant investigations
Principles of post-transplant investigations
Signup and view all the flashcards
Post transplant Imaging
Post transplant Imaging
Signup and view all the flashcards
Urine tests post transplant
Urine tests post transplant
Signup and view all the flashcards
blood work- post transplant
blood work- post transplant
Signup and view all the flashcards
Dialysis disequilibrium syndrome
Dialysis disequilibrium syndrome
Signup and view all the flashcards
post-transplant complications
post-transplant complications
Signup and view all the flashcards
ischemic/hypoxic damage
ischemic/hypoxic damage
Signup and view all the flashcards
The mnemonic 'A WET BED'
The mnemonic 'A WET BED'
Signup and view all the flashcards
Temporal Dialysis Line
Temporal Dialysis Line
Signup and view all the flashcards
Tunneled line
Tunneled line
Signup and view all the flashcards
Arteriovenous fistula (AVF)
Arteriovenous fistula (AVF)
Signup and view all the flashcards
Haemofiltration (HF)
Haemofiltration (HF)
Signup and view all the flashcards
HF relative to HD
HF relative to HD
Signup and view all the flashcards
Blood pumping & HDF
Blood pumping & HDF
Signup and view all the flashcards
Chronic active antibody-mediated rejection
Chronic active antibody-mediated rejection
Signup and view all the flashcards
Etiology & Renal vein thrombus (acute)
Etiology & Renal vein thrombus (acute)
Signup and view all the flashcards
Rejection
Rejection
Signup and view all the flashcards
Signs & Renal vein thrombus (acute)
Signs & Renal vein thrombus (acute)
Signup and view all the flashcards
Signs & symptoms: Renal artery stenosis (late)
Signs & symptoms: Renal artery stenosis (late)
Signup and view all the flashcards
Bloods post transplant
Bloods post transplant
Signup and view all the flashcards
When can Renal artery stenosis occur?
When can Renal artery stenosis occur?
Signup and view all the flashcards
Allorecognition
Allorecognition
Signup and view all the flashcards
Study Notes
Renal Replacement Therapy (RRT)
- Used to support or replace non-endocrine kidney function
- Non-endocrine kidney function includes removing toxins, metabolites, and/or water from the body
RRT Modalities:
- Dialysis (either haemodialysis or peritoneal dialysis)
- Continuous renal replacement therapies (CRRT)
- Kidney transplantation (living related/unrelated or deceased donor)
- The choice of RRT depends on the anticipated duration of treatment, indications for treatment, patient characteristics, and patient preference.
Primary Functions of the Kidneys
- The mnemonic "A WET BED" can be used to recall the primary functions
- A: Acid-base balance
- W: Water Removal
- E: Erythropoiesis
- T: Toxin removal
- B: Blood pressure control
- E: Electrolyte balance
- D: Vitamin D activation
Indications for RRT in CKD
- Decision of when to start dialysis is complex and individualized
- Decision is based on patient's eGFR and symptoms
- CKD with eGFR <10
- Symptomatic uremia: pruritus, encephalopathy, pericarditis, anorexia, nausea
Indications for Acute RRT
- The mnemonic "AEIOU" can be used to recall indications
- Acidosis: severe metabolic acidosis, e.g., pH < 7.1 and/or serum bicarbonate < 12 mmol/L
- Electrolytes: Refractory severe electrolyte abnormalities, e.g.; K+ >7.0mmol/L or refractory hyperkalaemia
- Intoxications: Poisoning or overdose with a dialyzable substance, e.g., lithium, toxic alcohols
- Overload: Fluid overload refractory to medical management, e.g., in CKD, CHF
- Uraemia: Symptoms of uraemia (pericarditis, pruritus, encephalopathy, nausea and vomiting, bleeding diathesis secondary to uremia)
Haemodialysis (HD)
- Can be given continuously or intermittently 3 times a week for 3.5 - 4 hours
- Can be done in-center, in satellite units, or self-care (home haemodialysis)
Dialysis
- Diffusion and a small degree of ultrafiltration remove solutes and water from the blood
- More effective at removing small molecules (e.g., urea, creatinine, ammonia) than larger molecules
- Molecules diffuse across a semipermeable membrane down their concentration gradient
- The rate of this is influenced by the molecular size and flow rate
- It can be done as an intermittent or continuous process
- Includes haemodialysis and peritoneal dialysis
Haemodialysis Access
- Access type depends on anticipated duration of RRT and patient factors
- Central Line
- Arteriovenous fistula (AVF)
- Temporal Dialysis Line - AKI patients needing urgent dialysis may require a central line. This can be removed once kidney function improves
- Tunnelled Line - For long term dialysis
- Arteriovenous Fistula (AVF) - Surgically connecting an artery to a vein can take 6-12 weeks to mature before being ready to use
- Synthetic grafts AVF
Peritoneal Dialysis (PD)
- Uses the same physiological principles as haemodialysis (diffusion and ultrafiltration)
- The peritoneal membranes act as the semi-permeable membrane
- Dialysate is instilled into the abdomen and left for a set period (dwell time) to allow diffusion
- Hypertonic dialysate draws water across the peritoneal membrane via osmosis
- The effluent (removing fluid and solutes) is removed at the end of the dwell time, and new dialysate can then be instilled
- This process is known as an exchange
Peritoneal Dialysis Subtypes and Access
- Exchanges can be done manually 3-5 times/day by a patient or their carer (Continuous ambulatory peritoneal dialysis)
- Exchanges automatically in automated peritoneal dialysis, consisting of automated exchange cycles, typically scheduled overnight while patients are connected to a machine
- Access is via a Tenckoff catheter surgically placed into the peritoneal cavity and tunneled to an exit site
- The type of PD depends on patient preference, the ability to manage the process, and effectiveness over time
Haemofiltration (HF)
- Relies on convection through a larger pore hemofilter (semi permeable membrane)
- Key difference is the absence of dialysate; pressure is applied across the hemofilter, and solutes are pushed through the membrane along with plasma water
- The removed volume is termed ultrafiltrate (parallels the physiology involving Bowman's capsule and the glomerular capillary bed)
- Replacement fluid is added back before and/or after the hemofilter to maintain adequate volume status in the patient
- More effective at removing medium to large solutes
- Typically done on a continuous basis, e.g., in continuous venovenous hemofiltration (CVVH) as done in ICU
- Continuously removes toxins and is more suitable to patients who are susceptible to volume shifts, e.g., cerebral odema
Hemodiafiltration
- Uses a permeable membrane that allows diffusion
- Adopts elements of dialysis and filtration
- Membrane allows both dialysis diffusion and filtration
- The process is continuous and in a critical care setting
- Blood is pumped if a venous-venous connection is made, but not with an arterio-venous connection (less common)
- It is the most effective at removing solutes
Kidney Transplant
- Indications include patients with ESRD
- Associated with reduced mortality and better quality of life compared with other forms of RRT
- Living related
- Living unrelated
- Deceased donor
- Transplanted kidney is typically inserted into the right iliac fossa
- Patients and donors require extensive work up pre transplant to ensure suitable
- Post transplant patients will typically be placed on triple immune suppression (steroid, anti-metabolite and calcineurin inhibitor) to prevent rejection of the donor kidney
- Patients with T1 Diabetes may receive a simultaneous kidney-pancreas transplant
Complications of HD
- Cardiovascular Complications - Hypotension, heart failure
- Increased Bleeding Risk - Caused by platelet dysfunction due to CKD and/or platelet contact with the dialysis membrane
- Dialysis Disequilibrium Syndrome - The development of acute cerebral Edema secondary to the rapid extraction of osmotically active substances (e.g., urea, NaCl) from the blood
- Vascular Access Complications - Loss of access due to thrombosis or stenosis, infections, local aneurysm, AV access steal syndrome, Dialysis vascular access hemorrhage
CVD as a Complication of CKD
- Cardiovascular disease is the leading cause of death in patients on dialysis and kidney transplant recipients
- Traditional risk factors include: age, hypertension, obesity, diabetes mellitus, male gender, hyperuricemia, tobacco use, family history
- Specific risk factors include: toxic metabolites, albuminuria, inflammation, oxidative stress, endothelial dysfunction, anemia, malnutrition
- Examples include cardiomyopathy, atherosclerosis, arterial stiffness, calcification, ischemic heart disease, heart failure, cerebrovascular disease, cardiovascular death
Complications of PD
- Metabolic Disturbances - Weight gain, hyperglycaemia
- Infections
- Exit site and catheter tunnel infections
- Peritoneal dialysis-associated peritonitis, often asymptomatic and identified by cloudy peritoneal effluent
- Clinical features: abdominal pain, distention, fever
- Physical examination: rebound tenderness, rigidity, and guarding
- Protein Loss: Hypoalbuminemia
- Abdominal Hernias
- Leakage of Dialysate
- Pleural Effusion (Rare)
Post-Transplant Complications
- Acute Postoperative (< 1 Week) - Acute tubular necrosis, urinary leakage, renal vein thrombosis
- Early (1-12 Weeks) - Urinary tract obstruction, Lymphocele, renal artery thrombosis
- Late (> 12 Weeks) - Renal artery stenosis, urinary tract obstruction, post transplant malignancy
- Any Time Post-Transplant - Graft rejection, adverse effects of immunosuppressants, post transplant infections, recurrence of primary disease
- Immediate Post-Transplant Period - Delayed graft function (DGF), vascular thrombosis, ureteric leak or obstruction, hyperacute rejection, recurrence of primary disease (FSGS, HUS)
Rejection
- Graft tissue is attacked by humoral and cell-mediated immune responses in the recipient
- Hyperacute Rejection - (< 48 hours after transplantation)
- Acute Rejection - (< 6 months after transplantation)
- Chronic Rejection - (> 6 months after transplantation)
Other Post-Transplant Complications
- Chronic rejection/Recurrent renal disease
- CKD and ESKD
- Cardiovascular disease – Hypertension- rule out renal artery stenosis
Acute Rejection
- Onset: < 6 months after transplantation (usually within weeks to months)
- Risk Factors: HLA incompatibility, inadequate immunosuppression, or patient nonadherence
- Pathophysiology
- Allorecognition → T lymphocyte induced cell-mediated and/or humoral immunity
- Acute cellular rejection (type IV hypersensitivity reaction)
- Donor MHC class II antigens react with recipient CD4+ T cells, which then differentiate into Th1 helper T cells → cytokine (INF-y) release - macrophage recruitment → parenchymal and endothelial inflammation
- Donor MHC class I antigens react with recipient CD8+ T cells → direct cytotoxic cell damage
- Acute humoral rejection (type II hypersensitivity reaction): recipient antibodies, formed before or after transplantation, react against donor HLA antigens
- Clinical Features
- Fever
- Pain and swelling in the graft region
- loss of organ function (raised creatinine and decline in general condition)
Side Effects of Immunosuppression
- Increased risk of malignancy
- Skin carcinoma very common
- Post-transplant lymphoproliferative disorders
- Cervical carcinoma – Transplant recipients should have an annual smear
- Post transplant diabetes mellitus
- Opportunistic infections – CMV, HSV, Herpes zoster, Aspergillus, BK virus (polyoma)
- Triple Therapy Side Effects:
- Calcineurin Inhibitor (Tacrolimus) - Infection, Nephrotoxic, Hair Loss, DM, Gi upset, Tremor, Neoplasms
- Antimetabolite (Mycophenolate) - Infection, Neutropenia, GI Upset, neoplasms
- Steroids (Prednisolone): Steroid Side Effects
Acute Tubular Necrosis (Acute)
- AKI that is caused by severe damage to the renal tubules and usually due to ischemia/hypoxia, or toxic damage
- May be asymptomatic or can present with anuria/oliguria, signs of fluid overload or uraemia and fatigue, confusion, and lethargy
Renal Vein Thrombus (Acute)
- Symptoms: presence of pain that is not relieved by the usual analgesic treatments
- Signs: occurrence of oligo/anuria, an excessively productive drainage or increase in macroscopic hematuria and a deterioration of renal function
- Etiology: may result from a hypercoagulable state, hematomas or lymphoceles causing compression, anastomotic stenosis, and extension of a deep venous thrombosis
Renal Artery Stenosis (Late)
- Signs & Symptoms: renal dysfunction, worsening hypertension, hypokalemia, episodes of flash pulmonary edema, abdominal bruit over the allograft
- Etiology: anastomotic failure, atheroma, immune-mediated
Urinary Tract Obstruction
- In renal transplantation, obstructive uropathy of the graft can be caused by several urologic abnormalities or ureteral scarring/ischemia
- Signs & symptoms include pain, fever, reduced urinary output, decline in kidney function, and hypertension
Skin Cancer
- Post transplant non melanomatous skin cancers are common
- The T cells in the immune system are suppressed which prevents identification and destruction of cancer cells
- Additionally immune suppression hinders the ability of cells to repair UV damage and predispose patients to oncogenic viruses
- Signs: plaque-like, nodular, papillomatous, and/or verrucous lesions which may ulcerate
Overarching Principles of Investigations
- Clinical Assessment - Perform a history, clinical exam, check vitals and fluid balance, assess volume status, any new nephrotoxic drugs, urinary tract symptoms, any evidence of infection, pain over graft. Consider pre-renal, renal and post-renal causes for dysfunction
- Check U/E, FBC, CRP levels in blood, as well as, immune suppressant levels and measurement of blood BK polyomavirus (PCR) and cytomegalovirus (CMV) viral load
- Urine: preform a urine dip (check for leucocytes, blood, protein, nitrites) +/- C &S, measure output
- Urgent transplant USS (obstruction) and Doppler (perfusion) +/- CT Angio (Renal artery stenosis)
- Transplant Biopsy
Management of Post-Transplant Complications
- Acute Cellular Rejection
- First-line: high-dose glucocorticoids
- Second-line: lymphocyte-depleting antibodies
- Acute Humoral Rejection
- Plasmapheresis
- IVIG
- Anti-CD20 antibodies
- Lymphocyte depleting antibody
- Corticosteroids may be used as an adjunct
- Chronic Allograft Rejection
- Management: general measures, BP control, ACE-I/ARB if proteinuria, CV disease prevention, avoid nephrotoxins, maintain good fluid balance
- Chronic active T cell-mediated rejection
- Generally treated as for acute T cell-mediated rejection
- Chronic active antibody-mediated rejection
- Present in many of those undergoing assessment for loss of graft function and optimum treatment
- Common strategies are optimizing general measures, switching from CIC to TAC, increasing MMF as tolerated, IVIg, PEX, and rituximab may be useful
- CKD with eGFR
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
