Renal replacement therapy

Dr Khaya Shweni
 Introduction
 When kidneys fail to:
Eliminate metabolic waste,
balance electrolytes
optimise acid-base milieu
balance fluids: leads to symptomatic pt that
require RRT
 RRT preserves life and reduces morbidity
and mortality
 Contents
 A) Indications for RRT

 B) Forms of RRT

 C) Q&A
 Indications
1) GFR (MDRD formula)
 <15ml/min K/DOQI, note symptoms

 UK/European 10-6ml/min

Elderly and diabetics may be symptomatic at

>10ml/min and therefore require RRT
 Indications
2) Uraemic symptoms;
Ralated to
Rate of accumulation of ureamic waste.
Age, nutritional state/muscle bulk, diet

Symptoms include: Malaise, fatigue

Coma, seizures, confussion, tremor
Anorexia, nausea, LOW, gastritis
Pericarditis with/out effusion
Uraemic frost
 Indications
3)Fluid overload
Oligo/ anuria resulting in fluid, toxin and
electrolyte abnormalities

Clinically : oedematous, JVP, S3 gallop,

bibasal crackles, and may present with
hypertensive emergency
Ureamic and acidotic
 Indications
4) Hyperkalaemia (K+ 6.0 – 6.5mmol/L)
K+ elimination >>> in kidney
An intracellular electrolytes
Shifts in/out (acid/base, insulin,B2 agonists)
by diet, drugs, rhabdomyolysis, trauma
Severely K+ → lethal cardiac arrhythmias
ECG ∆ correlated with severity
K+ shift employed whilst awaiting dialysis
 Indications
5)Metabolic acidosis
pH, HCO3,BE on ABG and CO2 on U&E

Consequence: cardiovascular depression

Low intervention threshold in AKI vs. CKD

Includes met. acidosis of non renal origin

Administer HCO3 infusion as temporary Rx

 Indication
6) Refractory cardiac failure/pulmonary edema

Failed medical therapy

Does not correct cardiac lesion

Support while treating reversible cardiac Lx

 Preparedness for RRT
 CRP workup

 Vascular access

 PO4 binder and EPO

 Choice vs. resource limitations

 When to start RRT
 CKD progressed to ESRD: GFR 10-6ml/min
 Symptomatic

 After having tried to retard progression

(lowering BP, GM, Cholesterol,
smoking,BMI)

 AKI with failure as per RIFLE criteria

 Forms of RRT
 Dialysis

 Renal graft transplantation

 Dialysis
 Haemodialysis: acute/ chronic

 Peritoneal dialysis: acute/ long term

HD machine
 Acute haemodialysis
 Setting: ICU and high-care
 Crash-landers or decompensated AKI
 Poorly defined targets
 Caution not to worsen acute state
 Intermitant or continuous acute dialysis
 Intermittent: iHD or PIRRT (SLED)
 Continuous: CVVHD, CAVHD
 Chronic haemodialysis
 After admission to CRP (with iHD, HF, HDF)
 Dialysed until transplantation
 Targets are better defined:
Clinical well-being
Nutritional state
CaXPO4-BMDx
Hb
URR/Kt/V
Dry weight and BP control
 Peritoneal dialysis
 Acute: stick catheter
Commonly used in KEH?ADH?RKK and MGMH
(Limited HD slots)

Against 1st world trend

Disadvantages: Perforations, infections, pain in an

already acutely ill population
 Peritonial dialysis
 Long term peritoneal dialysis

APD

Tidal APD

CAPD- continuous ambulatory peritoneal

dialysis
 Advantages of PD
 Available

 Pt freedom

 Preservation of residual renal function

esp in 1st 2years of RRT

Lax fluid restrictions

 Transplantation
 Only second best to prevention (40% 5 year mortality with
dialysis)
 LRD, LURD or cadaver
 Tissue typing and ABO PRA and CMV status

 Resume renal function, minimised morb & mort

 Socio-economic productivity
 Cheaper than dialysis

 Compliances with immunosupressive Thx

 Treat infections and monitor malignancies
 Challenges
 Paucity of awareness regarding KD

 Failing 1° and 2° preventation of risk factors

 Appropriate , prompt referrals with

reasonable expectations in a resource
limited state
 Systems failure
 Renal 101
 Prevention

 Diagnosis U&E, eGFR and symptoms

 Refer eGFR<60ml/min

 Seek advice

 Promote transplantation