Treatment options: Kidney Failure

Jomin Joykutty

Renal Nurse

MRHTullamore.

• Haemodialysis

• Haemodiafiltration

Peritoneal dialysis Inside the body

Treatment options for Renal failure

Outside the body

• Peritoneal dialysis Inside the body

• Renal Transplantation Best option

Function

Salt, water, and acid-base balanceWater balanceSodium balancePotassium balanceBicarbonate balanceMagnesium balancePhosphate balance

Excretion of nitrogenous end productsUreaCreatinineUric acid

Dysfunction

Fluid retention and hyponatremiaEdema, congestive heart failure, hypertensionHyperkalemiaMetabolic acidosisHypermagnesemiaHyperphosphatemia, osteodystrophy

?Anorexia, nausea, pruritus, pericarditis, polyneuropathy,encephalopathyUric acid

Endocrine-metabolicConversion of vitamin D to active metaboliteProduction of erythropoietinRenin

Osteomalacia, osteodystrophy

AnemiaHypertension

• Two normally functioning kidneys filter about 180 litres of blood a day, extracting about two litres of waste and extra water.

• Functional unit of kidney is the NEPHRON

• One healthy Kidney has approximately ONE MILLION NEPHRONS.

• However dialysis is a process in which blood is filtered to remove excess fluid, it uses a filter(membrane) and to remove excess fluid, it uses a filter(membrane) and special dialysate to remove the fluid and waste.

• Haemodialysis: synthetic/cellulose membrane

• Peritoneal dialysis: Peritoneal membrane

Dialysis CAN

• Remove waste products (e.g. urea, creatinine, phosphorus, etc.)• Remove excess water• Correct high or imbalanced levels of potassium, chloride, sodium, etc.

Dialysis CANNOT

• Automatically regulate blood pressure• Produce hormones like Erythropoetin (EPO)• Regulate normal calcium levels

Haemodialysis Extracorporeal circuit

Blood leak

detector

Modified Kolff rotating drum dialyzer

Photo of first Kolff rotating drum

dialyzer

Kill Flat Plate Dialyser

Artificial Kidney Hollow fibre Dialyser

Blood inlet Blood outlet

Dialysate inletDialysate outlet

Closer look of hollow fibres

Access for HameodialysisProtect My access: This is my life line

∗ AVFistulas (preferred and best)Pros• Last Longer(decades).• Less prone to infection.• Less chance of clotting.• Best dialysis performance.Cons• It takes time to mature.• Needles to be inserted every

Care of AVFistulasNo constrictive clothing.• Needles to be inserted every

time.• Bleeding after removing

needles.• Visible under the skin.• May require temporary access

while it develops. • Steal syndrome.• Aneurysms

No constrictive clothing.Avoid cuts and abrationsNo blood samples No Blood pressure No IV cannulasDo not sleep with your access arm under your head or body.Avoid dehydration

∗ ArterioVenous Fistula needles

Tunnelled Dialysis catheter

Pros

• Perform dialysis immediately.

• Avoids needle insertion each time.

Cons

• High infection rates.• High infection rates.

• May cause stenosis/ narrow central veins.

• Blood flow may not be sufficient to perform adequate dialysis.

• Difficult with shower or bath.

1.DiffusionThe movement of solutes from an area of high concentration to an area of low concentration; Clearance by diffusion targets small molecules.

Principles of Haemodialysis

DiffusionThe rate of movement of solutes is dependent upon blood and dialysate

flow rates, concentration gradient and the membrane characteristics.

Dialysate Out Blood In

ClearanceClearance

Dialysate In Blood Out

HIGH CONCHIGH CONCLOW CONCLOW CONC

ClearanceClearance

2.UltrafiltrationUltrafiltration is achieved by the creation of pressure within the dialyser, forcing fluid from the blood to the dialysate.

This is created by applying positive pressure in the blood compartment and negative

Blood In

Fluid VolumeFluid Volumecompartment and negative pressure in the dialysate compartment.

Filtered water is measured constantly.

Blood Out

POSITIVE POSITIVE PRESSPRESSNEGATIVE NEGATIVE PRESSPRESS

Fluid VolumeFluid Volume

ReductionReduction

3.Convection Solutes are dragged across a membrane with ultrafiltered fluid; the rate of transfer

is dependent on the ultrafiltrate volume. Clearance by convection targets middle molecular weight uremic toxins.

Blood In

ClearanceClearance

Blood Out

HIGH PRESSHIGH PRESSLOW PRESSLOW PRESS

ClearanceClearance

• Mortality rates are high with HD.

• Treatments are scheduled by the center and are relatively fixed. (12 hours weekly)

• Travel to the center for treatment.

• This treatment has the strictest diet and fluid limits of all.

Quality of life

all.

• Longer treatment times is more beneficial, however not liked by clients.

• Other endocrine functions: Anaemia management, Calcium phosphate management, BP management etc…

Best treatment option

Two types

∗ Cadaveric : From people that have died suddenly.

∗ Living donors: Living person usually a relative.

Average waiting time is more than 3years.

Renal Transplantation

Average waiting time is more than 3years.

More than 500 people waiting for transplant.

Demand is more supply is less.

ANY QUESTIONS?QUESTIONS?