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Renal Replacement Therapy
Fichas del conjunto (29)
- 1When is long term dialysis initiated?When it becomes necessary to manage one or more symptoms of renal failure - inability to control volume status, BP; serositis; acid-base electrolyte imbalance; pruritus; nausea/vomiting/deterioration in nutritional status; cognitive impairment
- 2When should planning for RRT start?When the risk of renal failure is 10-20% within a year.
All suitable patients should be listed for a deceased donor transplantation 6 months before the anticipated start of RRT. All suitable patients should also be informed about the advantages of a pre-emptive living kidney transplant and efforts made to find a donor - 3Which RRTs can be used chronically? (2)Haemodialysis and peritoneal dialysis
- 4Explain how haemodialysis worksBlood is passed over a semipermeable membrane against dialysis fluid. Solutes move down their concentration gradient and excess water moves down a hydrostatic gradient (ultrafiltration) and into the dialysis fluid.
- 5How is access achieved in haemodialysis?An arteriovenous fistula is formed (increased blood flow and longevity, lower risk of infection compared to central venous line) prior to the need for RRT.
- 6How frequently will HD be needed?Minimum 3/week - can be done at home, daily HD can improve outcomes
- 7What are the potential complications of haemodialysis?1) Access
AV fistula: thrombosis, stenosis, steal syndrome
Tunnelled venous line: infection, blockage, recirculation of blood
2) Dialysis disequilibrium (between CSF and blood which can lead to cerebral oedema, start HD slowly)
3) Hypotension
4) Time consuming - 8Explain the principle behind peritoneal dialysisThe peritoneum is used as a semi-permeable membrane. A catheter is inserted into the peritoneal cavity and fluid is infused. Solutes diffuse slowly across. To achieve ultrafiltration, osmotic agents such as glucose, glucose polymers are added to the fluid. Continuous process with intermittent drainage and filling of the peritoneal cavity. Done at home, takes ~10 hours. Average survival = 4 years
- 9What are the complications of PD?Infection at catheter site
PD peritonitis
Hernia
Loss of membrane function over time - 10What is the principle behind haemofiltration? When is it used?Water cleared by positive pressure, which in turn drags solutes by convection. Replacement fluid can be given before or after (pre/post-dilution).
Used in acute settings in critical care (has low haemodynamic settings) when patients have low BP. - 11What are the general complications of RRT?CARDIOVASCULAR DISEASE: high BP, calcium/phosphate dysregulation, vascular stiffness, inflammation, oxidative stress and abnormal endothelial function
PROTEIN-CALORIE MALNUTRITION: Increases morbidity and mortality
RENAL BONE DISEASE: High bone turnover, renal osteodystrophy, osteitis fibrosa
INFECTION: Uraemia causes granulocyte and T-cell dysfunction with increased sepsis-related mortality
AMYLOID: B2-microglobulin accumulates in long-term dialysis causing carpal tunnel syndrome, arthralgia, visceral effects
All Renal Infections Cause Problems - 12What are the absolute, temporary and relative contraindications for renal transplant?Absolute: Cancer with metastasis
Temporary: Active infection, HIV with viral replication, unstable CVD
Relative: Congestive heart failure, CVD - 13Which type of kidney donor has the best graft survival?Living (providing it is HLA matched)
- 14What are DBD, ECD and DCD?DBD - donor after brain death (heart beating donor)
ECD - expanded criteria donor (older kidneys, or from a patient with a history of CVA, BP or CKD)
DCD - Donor after cardiac death (non-heart beating donor) - 15What are the downsides of ECD and DCD?ECD - worse graft survival (but better outcomes than dialysis)
DCD - higher risk of delayed graft function - 16What are the four classes of immunosuppressive drugs used?1) Monoclonal antibodies
2) Calcineurin inhibitors
3) Antimetabolites
4) Glucocorticosteroids - 17Which class is used at the point of transplantation? What are the pros and cons?1) Monoclonal antibodies
2) Reduces risk of acute rejection but increases likelihood of infection if not specific - 18What are tacrolimus and ciclosporin?Calcineurin inhibitors
- 19How do calcineurin inhibitors work? Disadvantages? SE?1) Prevent T-cell activation and proliferation
2) High inter-individual variation and narrow therapeutic range (requires monitoring). Clearance is dependent on cytochrome P450 so beware macrolides etc.
3) SE: Nephrotoxicity on the new graft, modification of CV risk factors (increased BP, increased cholesterol and new-onset diabetes after transplantation (NODAT)) - 20What are azathioprine and mycophenolic acid (MPA)?Anti-metabolites
- 21What are antimetabolites used for? SE?1) Prevention of acute rejection - MPA is used in preference over azathioprine (but not in pregnancy as is teratogenic)
2) Leucopenia, anaemia and GI toxicity - 22When are glucocorticoids used? SE?1) Used in acute rejection, suppresses transcription of inflammatory cytokines.
2) BP, hyperlipidaemia, DM, impaired wound healing, osteoporosis, cataracts and skin fragility. - 23What are the five classes of kidney transplant complications?1) Surgical
2) Delayed graft function (affects 40% of grafts)
3) Rejection
4) Infection
5) Malignancy - 24Surgical complications of kidney transplant?Bleed, thrombosis, infection, urinary leaks, lymphocele, hernia
- 25What are the two types of acute transplant rejection and what are they mediated by? What causes the majority of graft loss?1) Antibody-mediated (rare, generally in patients known to be pre-sensitised) and cellular (more common).
2) Most graft loss is thought to be due to an immune response by donor-specific antibodies causing damage to the kidney microcirculation. - 26What infections are people at risk of post kidney transplantation?1) Hospital acquired/donor derived in the first month
2) Opportunistic in months 1-6 (give prophylactic treatment for CMV and pneumocystis jirovecii)
3) Community-acquired infections months 6-12 months - 27By how much does the risk of malignancy increase post-kidney transplantation? Which cancers are particularly common?1) 25% (immunosuppressive drugs)
2) Skin, post-transplant lymphoproliferative disorder (PTLD), and gynaecological - 28What are the CVD complications post-kidney transplantations? How does this alter CVD risk compared to that of the general population?1) Raised BP, raised cholesterol, NODAT, rejection.
2) 3-5X higher than that of the general population, but still improved compared to being on dialysis - 29What % of transplants result in acute rejection? What is the 1 year graft survival? Long-term graft loss rate?1) <15%
2) >90%
3) ~4% a year
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- Descripción
- (Renal Medicine) Met3B Fichas sobre Renal Replacement Therapy, creado por Anna Hogarth el 08/02/2020.
- Creado por
- Anna Hogarth · feb 2020
- Actualizado
- 18 feb 2020
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