DR MARIA FATIMA
PGT, GMT-1

 Renal replacement therapy (RRT) replaces the
normal blood filtering functions of the kidney
in patients with renal failure.

 Refractory hyperkalemia
 Refractory metabolic acidosis
 Signs of uremia
 Fluid overload unresponsive to diuresing
agents
 Anuria
 Overdose of dialysable toxin e.g Lithium

 GFR <15ml/min/1.73m2
 Severe hyperkalemia
 Severe metabolic acidosis
 Intractable intravascular fluid overload
 Urine output <200ml in 12 hours
 Uremic Pericarditis/Encephalopathy
 Failure to thrive

 HEMODIALYSIS
 HEMOFILTRATION
 HEMODIAFILTRATION
 PERITONEAL DIALYSIS
 KIDNEY TRANSPLANT

 Diffusion
 Ultrafiltration

 Hemodialysis:
Solute passively moves down a concentration
gradient between the dialysate and the
capillaries.
 Hemofiltration
Plasma water and solute move down a
concentration gradient by ultrafiltration and
convection induced by hydrostatic pressure,

 3 essential components:
 Dialyser
 Dialysate
 Blood filtering system

 Hollow fiber dialyser, most commonly used.
 Contains bundles of capillary tubes through
which blood flows, while the dialysate
circulates outside it.

 Dialysate flows countercurrent to the blood,
 Urea, Creatinine and Potassium flow from
Blood to Dialysate.
 Calcium and Bicarbonate flow from Dialysate
to Blood.

 Easy access to blood
 Prevention of stenosis and thrombosis
 Low risk of infection
 Sites:
 Internal Jugular vein
 Subclavian vein
 Femoral vein

• Vein cross cut and
attached end to side
with artery.
• Takes 2-4 months to
mature.
• Low infectious risk,
durable.

 Biocompatible tube
attached from end to
side on artery and vein.
 Requires 2 weeks till
swelling resolves.
 Higher risk of
stenosis/thrombosis,
high infection risk.

 Tunelled under skin to
reduce contamination.
 Can be used
immediately.
 High risk of
thrombosis, infection.

• Arm veins suitable for access should be
preserved.
• Wear Medic bracelet.
• Save the non-dominant arm
 No B.P measurement
 No I/V cannula
 No blood draws
• Place vascular access within ayear of
hemodialysis anticipation.

 To maintain patency of vascular access.
 Unfractionated/LMW Heparin may be used
@40-70U/Kg bolus dose follwed by 0.5-
1.0U/kg/hour in infusion.
 C/I to anticoagulation in dialysis?

• Line sepis
• Air emboli
• Blood loss
• Platelet consumption
• Hemodynamic instability
• Electrolyte imbalance
• Hypothermia
• Heparin induced thrombocytopenia

 Dialysate infused into peritoneal cavity,
followed by slow diffusion of solutes e.g
urea, creatinine.
 The vascular peritoneal membrane acts as a
semi-permeable membrane.
 Ultrafiltration due to osmotic gradient
generated by glucose in dialysate.

 Peritonitis
 Catheter associated infections
 Protein loss
 Residual uremia
 Interference with diaphragm function

• Low dialysate & blood flow rates.
• Small molecule detoxification
• Reduced anti-coagulant requirement
• 11 hours SLED equally efficient to CRRT
• Reduced cost

 During or immediately after dialysis.
 Caused by acute rapid increase in water
content in the brain cells and change in pH of
CSF.
 Anorexia, vomiting, headache, hypotension,
blurred vision, cramps, tremors.
 May cause psychosis, confusion, seizures

 Stop dialysis
 Protect airway
 Correct hypoglycemia
 Inj Valium/Phenytoin for seizures
 May be avoided by short dialysis session, low
sodium dialysate.

 GFR < 20ml/kg/min
 GFR 15-19ml/kg/min: live donor with 6
antigen matches
 GFR <15ml/kg/min: any donor

 Active malignancy
 Advanced lung disease
 Liver Cirrhosis
 Ongoing infection
 Life expectancy <2 years
 Ischemic cardiac disease
 Severe peripheral vascular disease
 BMI >40

 Acute transplant rejection
 Graft vs host disease
 Post transplant malignancy
 Diabetes
 Recurrent infections

 Anemia
 Hypocalcemia
 Serum Vit D deficiency
 Hyperphosphatemia
 Metabolic acidosis

 Caused due to decreased erythropoietin
production.
 Erythropoietin stimulating agents e.g Epoietin
alfa or Darbepoietin alfa may be used if Hb
<10g/dL.

 Calcium salts e.g Calcium acetate, Calcium
carbonate may be given with or without
Calcitriol.
 Vitamin D analogues e.g Calcitriol (1,25
dihydroxycholecalciferol) or Doxercalciferol
(1-alphahydroxyergocalciferol) may be given
in case of elevated or rising PTH levls.

 Calcium salts
 Calcimimetics e.g
 Cinacalcet by increasing sensitivity of calcium
receptors on parathyroid gland to
extracellular calcium
 Etelcalcitide by enhancing calcium receptor
activation by extracellular calcium.

 Phosphate binders e.g calcium acetate,
lanthanum carbonate, Sevelamer.
 Insoluble salts excreted in feces.

 Oral alkali supplements