Renal Replacement therapy

STUDENT NAME: Afif Ahmad AlBaalbaki

STUDENT ID NUMBER: 30190022

COURSE NAME: Renal System

DEPARTMENT: Nursing

COURSE CODE: NURS373

DATE OF SUBMISSION: 22/11/2020

Comparison of Hemodialysis and Peritoneal Dialysis
Type of Dialysis Hemodialysis
Advantage  More efficient clearance
of wastes
 Short time needed for
treatment
Complication  Disequilibrium Syndrome
 Muscles Cramps
 Back pain
 Headache
 Itching
 Hemodynamic and cardiac
adverse event
 Infection
 Increase risk for subdural
and intracranial
hemorrhage from
anticoagulation and
changes in blood pressure
during dialysis
contraindications  Hemodynamic instability
or severe cardiac disease
 Severe vascular disease
that prevents vascular
access
 Serious bleeding disorders
 Uncontrolled diabetes
Access Vascular access route
Procedure  Complex requires a
second person trained in
the technique whether
completed at home or at a
dialysis unit/center
 Special training for center
personnel and in home
use, requires at least two
people to manage proces
Peritoneal Dialysis
 Flexible schedule for
exchanges
 Few hemodynamic
changes during and
following exchanges
 Less dietary and fluid
restrictions
 Protein loss
 Peritonitis
 Hyperglycemia from
dialysate
 Respiratory distress
 Bowel perforation
 Infection
 Weight gain discomfort
from carrying 1-2 liters
in abdomen during dwell
time Potential for back
pain or development of
hemia
 Extensive peritoneal
adhesions, fibrosis or
active inflammatory and
GI disease (diverticulitis,
inflammatory bowel
conditions)
 Ascites or massive
central obesity
 Recent abdominal
surgery
Intra-abdominal catheter
Simple, easier to complete at
home compared with at
hemodialysis
Less complex training, typically
managed by patient, can be
managed by one person
Continues Renal Replacement therapies

Slow Continuous Continuous Veno-Venous Continuous Veno- Continuous Veno-

UltraFiltration Hemofiltration (CVVH) Venous Venous
(SCUF) HemoDialysis HemoDiaFiltration
(CVVHD) (CVVHDF)
Primary Safe management of Solute removal and safe Solute removal and Solute removal and safe
therapeutic fluid removal management of fluid safe management of management of fluid
goal volume fluid volume volume
Primary Fluid overload Uremia, severe acid/base or Uremia, severe Uremia, severe
indications without significant electrolyte imbalance acid/base or acid/base or electrolyte
electrolyte When removal of larger electrolyte imbalance
imbalance molecular weight imbalance When removal of large
substances is required molecular weight
substances is required
Principle used ultrafiltration convection diffusion diffusion and
convection
Therapy No dialysate or Requires substitution Requires dialysate Requires dialysate fluid
characteristics substitution solution to drive convection solution to drive and substitution
solutions No dialysate solution diffusion solution to drive
Fluid removal only Effective at removing small No substitution diffusion and
and large molecules solution convection
Effective at Effective at removing
removing small to small, medium and
medium molecules large molecules
Kidney transplantation
• Transplantation from a deceased donor usually requires a prolonged waiting period with
differences in waiting time dependent on age, gender, and race, as well as the availability
of a matching blood type. Blood types B and O have the longest waiting times.
• Advantages of kidney transplant compared with dialysis
• Reverses many of the pathophysiologic changes associated with renal failure
• Eliminates dependence on dialysis
• Less expensive than dialysis after the first year
Recipient Selection
• Some transplant programs exclude patients who are morbidly obese or who continue to
smoke (despite smoking cessation interventions).
• Certain patients, particularly those with cardiovascular disease and diabetes mellitus, are
considered at high risk and must be carefully evaluated and then monitored closely after
the transplantation.
• For a small number of patients who are approaching ESRD, a preemptive transplant
(before dialysis is required) is possible if they have a living donor.
• At one time, patients diagnosed with HIV were denied the opportunity for kidney
transplantation. However, centers that have included HIV patients demonstrate similar
graft and patient survival rates for patients with HIV when compared with those in the
HIV-negative population.
Histocompatibility studies, including HLA testing and crossmatching
Donor Sources
• Compatible blood type deceased donors
• Blood relatives
• Emotionally related living donors
• Altruistic living donors
• Paired organ donation
Surgical Procedure
1- Live donor
• Live donors are required to undergo an extensive multidisciplinary evaluation to be
certain that they are in good health and have no history of disease that would place them
at risk for developing kidney failure or operative complications.
• Advantages of a live donor kidney include better patient and graft survival rates
regardless of histocompatibility match, immediate organ availability, immediate function
because of minimal cold time (kidney out of body and not getting blood supply), and the
opportunity to have the recipient in the best possible medical condition because the
surgery is elective.
• The laparoscopic approach significantly decreases the hospital stay, pain, operative blood
loss, debilitation, and length of time off work. For these reasons, the number of people
willing to donate a kidney has increased significantly.
2- Kidney transplant recipient
• Usually placed extraperitoneally in the iliac fossa
• Right iliac fossa is preferred.
• Before incision
• Urinary catheter placed into bladder
• Antibiotic solution instilled
• Distends the bladder
• Decreases risk of infection
• Crescent-shaped incision
• Rapid revascularization critical
• Donor artery anastomosed to recipient internal/external iliac artery
• Donor vein anastomosed to recipient external iliac vein
• When anastomoses complete,
clamps released and blood flow reestablished
• Urine may begin to flow, or diuretic may be given.
• Surgery takes 3 to 4 hours.
• Kidney transplants with living donors can be technically more difficult because the blood
vessel lengths can be shorter than in deceased donor transplants.
• The donor ureter in most cases is tunneled through the bladder submucosa before
entering the bladder cavity and being sutured in place. This approach is called
ureteroneocystostomy. This allows the bladder wall to compress the ureter as it contracts
for micturition, thereby preventing reflux of urine up the ureter into the transplanted
kidney.
Complications
1- Rejection
 Hyperacute (antibody-mediated, humoral) rejection
• Occurs minutes to hours after transplantation
 Acute rejection
• Occurs days to months after transplantation
 Chronic rejection
• Process that occurs over months or years and is irreversible
2- Infection
 Most common infections observed in the first month
• Pneumonia
• Wound infections
• IV line and drain infections
Underlying systemic illness such as diabetes mellitus or systemic lupus erythematosus,
malnutrition, and older age can further compound the negative effects on the immune
response.
 Fungal infections
• Candida
• Cryptococcus
• Aspergillus
• Pneumocystis jiroveci
 Viral infections
• CMV
 One of the most common
• Epstein-Barr virus
• Herpes simplex virus
 Cardiovascular disease
 Transplant recipients have increased incidence of atherosclerotic vascular disease.
 Immunosuppressant can worsen hypertension and hyperlipidemia.
  Adhere to antihypertensive regimen.
 Malignancies
 Primary cause is immunosuppressive therapy.
 Regular screening is important preventive care.
 Recurrence of original renal disease
 Glomerulonephritis
 IgA nephropathy
 Diabetes mellitus
 Focal segmental sclerosis
 Dyslipidemia
 Cataracts
 Increased incidence of infection and malignancy
 Close monitoring of side effects