NP37 Nephrology

Renal Replacement Therapy

Essential Med Notes 2015

Table 15. Peritoneal Dialysis vs. Hemodialysis

Rate

Peritoneal Dialysis
Slow

Hemodialysis
Fast

Location

Home

Hospital (usually)

Ultrafiltration

Osmotic pressure via dextrose dialysate

Hydrostatic pressure

Solute Removal

Concentration gradient and convection

Concentration gradient and convection

Membrane

Peritoneum

Semi-permeable artificial membrane

Method

Indwelling catheter in peritoneal cavity

Line from vessel to artificial kidney

Complications

Infection at catheter site

Bacterial peritonitis
Metabolic effects of glucose
Difficult to achieve adequate clearance in
patients with large body mass

Preferred When

Vascular access (clots, collapse)

Bacteremia
Bleeding due to heparin
Hemodynamic stress of extracorporeal circuit
Disequilibrium syndrome (headache, cerebral
edema, hypotension, nausea, muscle cramps
related to solute/water flux over short time)
Young, high functioning, residual renal function
Bed-bound, comorbidities, no renal function
Success depends on presence of residual renal function Residual renal function not as important

Renal Transplantation
provides maximum replacement of GFR
preferred modality of RRT in CKD, not AKI
best way to reverse uremic signs and symptoms
only therapy shown to improve survival in CKD patients with ESRD
native kidneys usually left in situ
2 types: deceased donor, living donor (related or unrelated)
kidney transplanted into iliac fossa, transplant renal artery anastomosed to external iliac artery
of recipient
1 yr renal allograft survival rates 90%
Complications
leading causes of late allograft loss: interstitial fibrosis/tubular atrophy (IFTA) and death with
functioning graft
#1 cause of mortality in transplanted patients is cardiovascular disease
immunosuppressant drug therapy: side effects include infections, malignancy (skin, Kaposis
sarcoma, post-transplant lymphoproliferative disorder)
acute rejection: graft site tenderness, rise in Cr, oliguria, fever, although symptoms are
uncommon
de novo GN (usually membranous)
new-onset DM (often due to prednisone use)
cyclosporine or tacrolimus nephropathy (refer to Small Vessel Disease, NP18)
chronic allograft nephropathy
early allograft damage caused by episodes of acute rejection and acute peritransplant injuries
immunologic and nonimmunologic factors (HTN, hyperlipidemia, age of donor, quality of
graft, new onset DM)
transplant glomerulopathy from antibody injury causes nephrotic proteinuria
CMV (cytomegalovirus) infection and other opportunistic infections usually occur between
1 and 6 mo post-transplant
BK virus (polyoma virus) nephropathy can result from over-immunosuppression and lead to
graft loss

When to Initiate Dialysis

CrCl <20 mL/min
Educate patient regarding dialysis; if
not a candidate for peritoneal dialysis,
make arrangements for AV fistula
CrCl <15 mL/min
Weigh risk and benefits for initiating
dialysis
CrCl <10 mL/min
Dialysis should be initiated
NOTE
Cockcroft-Gault equation (or MDRD
equation) should be used to measure
kidney function
Monitor for uremic complications
Significant benefits in quality of life
can occur if dialysis started before
CrCl <15 mL/min
It is unclear whether patients who
start dialysis early have increased
survival
A preemptive transplant can be
considered if patient is stable, in order
to avoid dialysis
Source: National Kidney Foundation Kidney Disease
Outcomes Quality Initiative.

Commonly Used Immunosuppressive

Drugs
Calcineurin inhibitors
Cyclosporine
Tacrolimus
Antiproliferative medications
Mycophenolate mofetil
Azathioprine
Other agents
Sirolimus
Prednisone
Anti-lymphocyte antibodies
Thymoglobulin
Basiliximab

Survival Among Nocturnal Home Haemodialysis

Patients Compared to Kidney Transplant
Recipients
Nephrol Dial Transplant 2009;24:2915-2919
Study: Retrospective, matched cohort with 4-5 yr
average follow up.
Population: 177 nocturnal home dialysis (NHD)
patients (mean age 46, 68% white) were matched
to 533 deceased donor transplant (DTX) patients
and 533 live donor (LTX) transplant patients (1:3:3
ratio).
Intervention: Nocturnal home dialysis vs. live or
deceased donor transplant.
Outcome: Primary outcome was all cause
mortality.
Results: No significant difference in survival or
hazard ratio between NHD and DTX. Significant
survival benefit for patients undergoing LTX vs.
NHD. Significant mortality hazard ratio reduction
with LTX (0.51) with no difference in hazard ratio
for DTX vs. NHD reference.
Conclusion: NHD has comparable mortality to DTX,
but is inferior to LTX.