Renal replacement therapy

kibaru
objectives
At the end of the sessionthe students
should be able to
Define dialysis
Outline the indications of dialysis
Discuss various modalities used in renal
replacement
introduction
The optimal time to initiate
dialysis is based on a
combination of the biochemical
and clinical characteristics of the
patient.
In general, most nephrologists attempt to
initiate dialysis early enough to prevent the
development of severe fluid and electrolyte
abnormalities, malnutrition, and uremic
symptoms.
The selection of dialysis modality must
be individualized to fit the needs of each
child.

 In the North America, two thirds of

children with ESRD are treated with
peritoneal dialysis, whereas one third are
treated with hemodialysis.
Age is a defining factor in dialysis modality
selection:
◦ 88% of infants and children from birth to 5
yr of age are treated with peritoneal dialysis

◦ whereas 54% of children older than 12 yr of

age are treated with hemodialysis.
indications
GFR (measured by creatinine clearance)
of 10-15 mL/min/1.73 m2.
refractory fluid Volume overload with
evidence of hypertension and/or
pulmonary edema refractory to diuretic
therapy
electrolyte imbalance:
Hyperkalaemia (serum K+ level > 7
mEq./litre).
 acidosis unresponsive to medical
management
 growth failure
uremic symptoms, including fatigue,
nausea, and impaired school performance.
Pericarditis
 Bleeding diathesis.
 Hypertension unresponsive to
treatment.
High creatinine levels and decreased
creatinine clearance (Creatinine
clearance < 10ml/min).
Neurologic symptoms (altered mental
status, seizures)

Blood urea nitrogen greater than 100-150

mg/dL (or lower if rapidly rising)
the inability to provide adequate
nutritional intake because of the need
for severe fluid restriction.

Calcium/phosphorus imbalance, with

hypocalcemic tetany
 Duration of dialysis
In patients with ARF, dialysis
support may be necessary for days or
for up to 12 wk.

Many patients with ARF require

dialysis support for 1-3 wk
Classification of Renal replacement
This includes dialysis
(haemodialysis and peritoneal
dialysis) and renal
transplantation.
Early induction of Renal Replacement
Therapy and good nutritional support provide
better response to the treatment (less patient
morbidity and mortality).
DIALYSIS THERAPY
Definition:
 Dialysis is a process in which the solute
composition of blood is altered by exposing it to a
physiological solution (dialysate) across a
semipermeable membrane (dialysis membrane).
Solutes will move from one compartment to another
through the dialysis membrane.
Types of Dialysis
There are two forms of dialysis therapy:
 (A) Haemodialysis
 (B) Peritoneal dialysis
 Contraindications for dialysis treatment.
Absolute:
 Patient's refusing dialysis.
 Severe extrarenal illness e.g. severe cardiac disease, end
stage liver disease, severe cerebrovascular disease and
advanced malignancy.
2. Relative:
 Severe disability or handicapping.
 Paraplegia or hemiplegia
Peritoneal dialysis
 is most commonly employed in neonates and
infants with ARF

may be used in children and adolescents of all ages.

isa technique that employs the patient's peritoneal
membrane as a dialyzer

 Hyperosmolar dialysate is infused into the

peritoneal cavity via a surgically or percutaneously
placed peritoneal dialysis catheter.
The fluid is allowed to dwell for 45-60 min and is
then drained from the patient by gravity (manually
or with the use of a cycler machine),
accomplishing both fluid and electrolyte removal.

 Cycles are repeated for 8-24 hr/day based on the

patient's fluid and electrolyte balance.
 Excess body water is removed by an osmotic gradient created
by the high dextrose concentration in the dialysate

 wastes are removed by diffusion from the peritoneal capillaries

into the dialysate.

Because peritoneal dialysis is not as efficient as hemodialysis, it

must be performed on a daily basis rather than 3 times weekly
as in hemodialysis.
 Types
Peritoneal dialysis may be provided either as
continuous ambulatory peritoneal dialysis (CAPD)
or as any of several forms of automated therapies
using a cycler
◦ continuous cyclic peritoneal dialysis [CCPD]
◦ intermittent peritoneal dialysis [IPD]
◦ nocturnal intermittent peritoneal dialysis [NIPD]).
CAPD (Continuous Ambulatory Peritoneal Dialysis)

 In which the dialysate is always present in the

peritoneal cavity and is exchanged every 4-6
hours/day.

This is the commonly used form of P.D worldwide.

(2) CCPD (Continuous Cyclic Peritoneal Dialysis):

 In which the dialysate is exchanged at bed time via

a cycler (P.D. machine) 3-4 times and the last
exchange fluid is left in the abdomen during the
daytime.
(3) NIPD (Nocturnal Intermittent Peritoneal
Dialysis):

In which the dialysate is exchanged at bed time via

a cycler 5-8 times/day and the abdomen is left dry
the rest of the day.

 This is the new trend nowadays, but it is limited

because of the high cost of the cycler.
(4) TPD (Tidal Peritoneal Dialysis):

This is still an experimental form of NIPD which

was designed to optimize solute clearance by
leaving large volume of dialysate in the peritoneal
cavity throughout the dialysis session.
 Indications for PD:

Because it provides the best rehabilitation potential

as it is safe and easy,
it is used for all ages and all sizes of patients with
end stage renal failure.
Specific indications for peritoneal dialysis include
the following:
1- Infant and very young children
2- End stage renal failure patients with
cardiovascular or haemodynamic instability.
3- Haemodialysis patients with vascular access
failure (especially diabetics)
4- Patients for whom vascular access can not be
created (especially diabetics)
 ADVANTAGES of peritoneal dialysis

Ability to perform dialysis treatment at home

Technically easier than hemodialysis, especially in
infants
Ability to live a greater distance from medical
center
Freedom to attend school and after-school activities
Less restrictive diet
Less expensive than hemodialysis
DISADVANTAGES
Catheter malfunction
Catheter-related infections (peritonitis, exit-site)
Impaired appetite (due to full peritoneal cavity)
Negative body image
Caregiver "burnout"
Haemodialysis
Definition
 It is the movement of solutes and water
from the patient's blood across a
semipermeable membrane which is the
dialyzer.

usually performed in a hospital setting.

Children and adolescents typically have three 3-4
hour sessions per week during which fluid and
solute wastes are removed.

 Access to the child's circulation is achieved by a

surgically created arteriovenous fistula, graft, or
indwelling subclavian or internal jugular catheter.
This is carried out via vascular access where the
blood is pumped by a haemodialysis machine into
the dialyzer then the blood returns back filtered to
the patients circulation
The extracorporeal
blood circuit showing the usual location of the different dialysis monitors
 Complications:
(I) Common complications:
 (A) Hypotension:
This is the commonest complication and may be due
to:
- High ultrafiltration rate
- Dialysis solution sodium level is too low
- Acetate-containing dialysis solution
- Dialysis solution is too warm
- Food ingestion (splanchnic vasodilatation)
- Autonomic neuropathy (e.g. diabetic
patients)
- Diastolic dysfunction
- haemorrhage - Septicaemia
- Arrhythmia - Dialyzer reaction
(B) Muscle Cramps.
(C) Nausea and Vomiting.
(D) Headache.
(E) Chest pain and back pain.
(F) Itching.
(G) Fever and chills.
(II)Less Common Complications:
 Although they are less common, they are serious
complications.
 Disequilibrium Syndrome:

Definition:
Disequilibrium syndrome is a set of systemic and
neurologic symptoms which are often associated with
characteristic EEG findings that can occur either during
or soon after dialysis.

Early manifestations include headache, nausea, vomiting,

convulsions and may be coma.
 In severe cases, death can occur if not treated properly.
 Dialyzer reactions:
 Type A (anaphylactic type):
The manifestations of this type may be mild in the form of
itching,
cough, urticaria, sneezing, coryza or watery eyes; or may
be severe in the form of dyspnea, chest tightness, cardiac
arrest or even death.
 Treatment:
 • Stop dialysis immediately
 • Antihistaminics
 • Steroids
Type B (Non specific type):
The patients may complain of back pain or chest
pain.
 Etiology:
 Complement activation

Treatment:
 No specific treatment
(C) Arrhythmia:
 Arrhythmias during dialysis are common especially
in patients receiving digitalis

(D) Cardiac tamponade:

Unexpected or recurrent hypotension during
dialysis may be a sign of pericardial effusion or
impending tamponade.
(E) Intracranial bleeding:
 Underlying vascular disease and
hypertension combined with
heparin administration can sometimes
result in intracarnial bleeding.

(F) Seizures: This occur more often in

children
(G) Haemolysis:
 Acute haemolysis during dialysis may be a medical
emergency

(H) Air embolism:
 It is a potential catastrophe that can lead to death if
not quickly detected and treated.
 Intermittent hemodialysis
isuseful in patients with relatively stable
hemodynamic status.

This highly efficient process accomplishes both

fluid and electrolyte removal in 3-4 hr sessions
using a pump-driven extracorporeal circuit and
large central venous catheter.
Intermittenthemodialysis may be
performed three to seven times a week
based on the patient's fluid and electrolyte
balance.
conclusion
Renal replacement is used in both end
stage renal failure and acute renal failure
with poor response to medical treatment

Early renal replacement provide better

results

In children peritoneal dialysis mainly

used