RENAL REPLACEMENT THERAPY

Dialysis

‘Uraemic toxins' are efficiently removed from the blood by the process of diffusion across a semipermeable membrane towards the low concentrations present in dialysis fluid (Fig. 9.8). The gradient is maintained by replacing used dialysis fluid with fresh solution. In haemodialysis, blood in an extra-corporeal circulation is exposed to dialysis fluid separated by an artificial semipermeable membrane. In peritoneal dialysis the peritoneum is used as

Table 9.16 Indications for referral of a patient with CKD to a nephrologist

Patient group

Assessment

Severe CKD

GFR < 30 mL/min/1.73 m2

Rapidly deteriorating kidney function

Fall in eGFR > 5 mL/min in 1 year or >10 mL/min/year in 5 years

Higher levels of proteinuria

ACR ≥ 70 mg/mmol or PCR ≥ 100 mg/ mmol

Proteinuria and haematuria

Proteinuria with ≥+1 blood on urine dipstick

Poorly controlled hypertension

Despite use of four antihypertensive drugs

Suspected rare or genetic cause of CKD

ACR, albumin:creatinine ratio; PCR, protein:creatinine ratio.

Fig. 9.8 The principle of haemodialysis.

the semipermeable membrane and dialysis fluid is instilled into the peritoneal cavity.

Haemodialysis

Adequate dialysis requires a blood flow of at least 200 mL/min and the most reliable way of achieving this is by surgical construction of an arterio-venous fistula, usually in the forearm. This provides a permanent and easily accessible site for the insertion of needles. An adult of average size usually requires 4-5 hours of haemodialysis three times a week, which may be performed in hospital or at home. All patients are anticoagulated during treatment (usually with heparin) because contact of blood with foreign sur-faces activates the clotting cascade. The most common acute complication of haemodialysis is hypotension, caused in part by excessive removal of extracellular fluid.

Peritoneal dialysis

A permanent tube (Tenkoff catheter) is placed into the peritoneal cavity via a subcutaneous tunnel. The bags of dialysate are connected to the catheter using a sterile, no-touch technique and the fluid run into the peritoneal cavity. Urea, creatinine, phosphate and other uraemic toxins pass into the dialysate down their concentration gradients and the dialysate is then collected. With continuous ambulatory peritoneal dialysis (CAPD) 1.5-3 L of dialysate are introduced and exchanged three to five times a day. Bacterial peritonitis, often with Staph. epidermidis, is the most common serious complication of peritoneal dialysis. Treatment is with appropriate antibiotics, often given intraperitoneally.

Haemotiltration

Haemofiltration involves the removal of plasma water and its dissolved con-stituents (e.g. Na+, K+, urea, phosphate) and replacing it with a solution of the desired biochemical composition. The procedure employs a highly perme-able membrane, which allows large amounts of fluid and solute to be removed from the patient (Fig. 9.9). It is used mostly in the intensive care setting in the management of AKI.

Complications of all long-term dialysis

Cardiovascular disease (as a result of atheroma) and sepsis are the leading causes of death in long-term dialysis patients. Causes of fatal sepsis include peritonitis complicating peritoneal dialysis and Staph. aureus infection (including endocarditis) complicating the use of indwelling access devices for haemodialysis. Amyloidosis is the result of the accumulation and polymeriza-tion of β2-microglobulin. This molecule (a component of human leucocyte antigen [HLA] proteins on most cell membranes) is normally excreted by the kidneys, but is not removed by dialysis membranes. Deposition results in the carpal tunnel syndrome and joint pains, particularly of the shoulders.

Transplantation

Successful renal transplantation offers the potential for complete rehabilita-tion in, and is the treatment of choice for most patients with, end-stage renal failure. In the best centres graft survival is 80% at 10 years. Kidneys are obtained from cadavers or, less frequently, a living donor, e.g. a close rela-tive. The donor must be ABO compatible, and good HLA matching increases the chances of successful transplantation. The donor kidney is placed in the iliac fossa and anastomosed to the iliac vessels of the recipient; the donor ureter is placed into the recipient's bladder.

Long-term immunosuppressive treatment is necessary (unless the donor is an identical twin, i.e. genetically identical) to reduce the incidence of graft rejection. This treatment comprises corticosteroids, azathioprine or myco-phenolate mofetil and ciclosporin or tacrolimus. Monoclonal and polyclonal antibodies such as antilymphocyte and anti-thymocyte globulin or basiliximab and daclizumab are potent immunosuppressives and are used in selected patients. The complications of renal transplantation and immunosuppression include opportunistic infection (e.g. with Pneumocystis jiroveci), hyperten-sion, development of tumours (skin malignancies and lymphomas) and, occa-sionally, recurrence of the renal disease (e.g. Goodpasture's syndrome).

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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