Approach to chronic renal failure

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Evaluation and management of chronic kidney disease:

Evaluation and management of chronic kidney disease Drjayaprakash

Definition::

Definition: K/DOQI criteria for definition of chronic kidney disease in children : A patient has CKD if either of the following criteria are present: 1. Kidney damage for ≥3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, indicated by one or more of the following: Abnormalities by kidney biopsy Abnormalities based on imaging tests Abnormalities in the composition of the blood or urine. 2. GFR <60 ml/min/1.73m² for ≥3 month, with or without the signs of kidney damage listed above

Children at risk of development of CKD::

Children at risk of development of CKD : Family history of renal disease Antenatally detected renal anomalies Neonatal acute renal failure Low birth weight babies History of urinary tract infection with reflux History of nephritis or nephrotic syndrome Lower urinary tract obstruction Diabetes Autoimmune disease Renal rickets Hypertension Long term use of non steroidal anti inflammatory drugs

Evaluation ::

Evaluation : To determine: Diagnosis Co-morbid conditions Severity based on GFR Complications related to level of GFR Risk factors for loss of kidney function Risk factors for cardiovascular disease

History and physical examination::

History and physical examination : CKD is asymptomatic in Stage I and II Earliest symptoms in obstructive uropathy or tubulo interstitial disorders – polyuria and polydipsia Evaluation of growth, pubertal development and nutritional status Physical findings vary depending on severity of kidney failure

Physical examination::

Physical examination: Serial measurements of growth parameters (height, weight, and head circumference for patients under three years of age). Blood pressure measurement which should be compared to normative blood pressure centiles based upon data on gender, age, and height. Pallor Signs of vasculitis

Physical examination contd…:

Physical examination contd … Evidence of renal osteodystrophy: deformities of the forearms and posterior bowing of the distal tibia are found more commonly in the infant genu varum is a characteristic finding in the toddler. In the older child, valgus deformities of the legs or a windswept deformity Assessment for the presence and severity of peripheral oedema . Assessment for any sign of hypervolemia by noting the presence of oedema , rales , hepatic enlargement and/or tenderness and cardiac gallop

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Initial testing in a child with suspected chronic kidney disease (CKD) must include: an examination of the urine estimation of the glomerular filtration rate (GFR) determination of disease duration- is best performed by comparing the current urinalysis or plasma creatinine concentration ( PCr ) with previous results

Laboratory evaluation::

Laboratory evaluation: Complete blood counts for anemia Blood urea nitrogen (BUN) Serum creatinine Estimation of the serum sodium, potassium, calcium, phosphorus, bicarbonate, Estimation of alkaline phosphatase , parathyroid hormone (PTH), Estimation of cholesterol and fractionated lipid levels

Urine examination::

Urine examination: Urine dipstick and microscopy : Dipstick is a quick method of screening and detecting proteinuria , hematuria , and pyuria and provides an estimate of the specific gravity Urine microscopy is performed on a centrifuge-spun urine specimen to look for red blood cells (RBCs), white blood cells (WBCs), and casts. Most children with chronic kidney disease have broad hyaline casts. Estimation of proteinuria by urine spot protein to creatinine ratio

Estimation of GFR:

Estimation of GFR GFR is equal to the sum of the filtration rates in all of the functioning nephrons Estimation of the GFR gives a rough measure of the number of functioning nephrons . GFR is directly proportional to body surface area and indirectly proportional to plasma creatinine GFR can be estimated by Counahan - Barratt formula or Schwartz formula

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eGFR ranges that are used to define the 5 CKD stages apply only to children aged 2 years and older The GFR can be estimated from the constant k, plasma creatinine concentration ( PCr ) (in mg/ dL ), and body length (L) (in cm) according to the Schwartz formula , as follows: GFR = (k X L) / PCr The value of k is different at different ages: k = 0.34 for preterm infants k = 0.45 for full-term infants k = 0.55 for those aged 2-12 years in children and adolescent girls k = 0.7 in adolescent boys

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Counahan – Baarratt formula : GFR = 38 * HEIGHT (cm) / plasma creatinine (µmol/L) Cystatin C : a low–molecular-weight protein that is a member of the cystatin superfamily of cysteine protease inhibitors. Cystatin C is produced in a constant rate by all nucleated cells Its rate of production is relatively constant and is unaltered by inflammatory conditions or changes in diet Freely filtered by glomeruli and not secreted Independent of age, gender, body composition and muscle mass The plasma cystatin C concentration may correlate more closely with the GFR than with the Plasma creatinine

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Other markers have been used to estimate clearance include : inulin , iohexol – non radioactive, measured by HPLC radioisotopic markers such as : 51Cr-ethylene diamine tetra acetic acid (EDTA) 99mTc-diethylene triamine penta acetic acid (DTPA) 125I-iothalamate

Ultrasonography ::

Ultrasonography : The modality of choice to assess possible obstructive disease Useful in differentiating a simple benign cyst from a more complex cyst or a solid tumor This technique is also commonly used to screen for and to diagnose types of polycystic kidney disease To assess renal structure for underlying abnormalities Measure length of kidneys serial follow up of renal growth

Radionuclide studies::

Radionuclide studies: Early detection of renal scarring is possible with radioisotope scanning with 99m ( 99m )-technetium dimercaptosuccinic acid (DMSA). Voiding cystourethrography - used to detect vesicoureteral reflux. Retrograde or anterograde pyelography : used to better diagnose and relieve urinary tract obstruction Nuclear imaging has limited role when GFR falls below 20-30ml/min/1.73m²

Treatment ::

Treatment : Specific therapy based on diagnosis Evaluation and management of reversible causes of renal dysfunction Prevention and treatment of complications of decreased kidney function Evaluation and management of co-morbid conditions Slowing the loss of kidney function Preparation for kidney failure therapy Replacement of kidney function with dialysis and transplantation if signs and symptoms of uremia are present Management of complications

Factors hastening the progression of CKD:

Factors hastening the progression of CKD Obstruction to the urinary tract Ongoing active glomerular disease Hypertension Proteinuria Infections of the urinary tract Hyperlipidemia Use of nephrotoxic medications

Evaluation of reversible causes of renal failure:

Evaluation of reversible causes of renal failure The common reversible causes include: Volume depletion, Nephrotoxic drugs, Infection, Congestive heart failure Urinary tract obstruction Ischemic nephropathy Metabolic and electrolyte disturbances

Retarding progression of renal disease::

Retarding progression of renal disease: The progression of CKD is greatest during the two periods of rapid growth: infancy and puberty Measures include : Strict blood pressure control Angiotensin -converting enzyme (ACE) inhibitor or Angiotensin II receptor–blocker (ARB) therapy Ramipril in a dose of 0.1-0.2 mg/kg/ day has been shown to lower blood pressure significantly, decrease proteinuria and significantly decelerate GFR Lipid lowering therapy Correction of anemia

Retarding progression contd…:

Retarding progression contd … Attention to UTI Efforts to reduce intravesical pressure Reduction in urinary protein excretion Dietary protein adjustments Monitoring of drug dosage and toxicity Management of urinary obstruction Avoid dehydration

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Targeting a reduction in proteinuria of 1g/day or more has shown renoprotective effects Goal of anti- proteinuric strategy should be to reduce proteinuria to <300mg/m²/day

Devise action plan for each stage of kidney disease:

Devise action plan for each stage of kidney disease Stage 1 CKD : treatment of the primary and co-morbid conditions with measures to slow the progression and reduce the cardiovascular disease risk factors. Stage 2 and 3 it is important to regularly estimate the rate of progression of CKD while ensuring a constant evaluation and treatment for co-morbid conditions. Stage 4 : preparations for renal replacement therapy are initiated Stage 5 : provide renal replacement therapy.

Evaluation and treatment of comorbid conditions::

Evaluation and treatment of comorbid conditions: Anemia Renal osteodystrophy Growth failure Electrolyte imbalance Acidosis

Anemia ::

Anemia : Anemia due to reduced kidney erythropoietin production generally develops when the GFR falls below 30ml/min/1.73m² Children in the early stages of CKD should have their hemoglobin tested at least annually with the frequency of monitoring increasing as the disease progresses into more advanced stages. A diagnosis of anemia is made when the observed hemoglobin result is below the 5th percentile of normal for age and sex

Anemia contd…:

Anemia contd … Initial investigation should at least include: Red blood cell indices Reticulocyte count Iron parameters (serum iron, total iron binding capacity, transferrin saturations [TSAT] and serum ferritin ) Occult blood in stool The recommended target hemoglobin-to- hematocrit ( Hgb / Hct ) ratio is 11-12 g/ dL / 33-36%

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Iron therapy at 3-6 mg/kg/day should be initiated to maintain : Transferrin saturation level of 20% or higher Serum ferritin level of 100 ng / dL or higher in children with chronic kidney disease. Optimal response to erythropoietin therapy

Erythropoietin therapy::

Erythropoietin therapy: EPO can be administered either subcutaneously, intravenously, or intraperionteally Subcutaneous use of EPO prolongs its half-life, and a decrease in total weekly dose In hemodialysis patients,EPO is administered via intravenous route during dialysis The initial rHuEPO dose in older children not receiving dialysis is 80 to 120 Units/kg/ week Children younger than five years of age or children receiving dialysis frequently require higher doses - 300Units/kg/week Maintenance dose of EPO varies between 60 and600 units/kg/week – based on monthly haemoglobin values

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It takes 3–4 weeks for EPO to commence an improvement in haemoglobin at the initiation phase. In case of a suboptimal response to therapy by 4 weeks, the dose of EPO should be increased. During the initial 3 months of EPO therapy, the TSAT and the serum ferritin should be checked every month Following attainment of the target hemoglobin / hematocrit , TSAT and serum ferritin evaluation should be determined at least every 3 months

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Failure to mount a good hemoglobin response to Erythropoietin can be due to : Iron deficiency Persistent infection or inflammation Severe hyperparathyroidism Chronic blood loss Malnutrition Folate or Vitamin B12 deficiency Presence of haemoglobinopathies .

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Novel erythropoietic stimulatory proteins (NESP) : DARBEPOETIN Long acting protein 2-3 fold increased half life which allows once weekly administration If hemoglobin is <6g/dl – 10ml/kg leukocyte depleted packed cells should be given slowly

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Anemia ( Hb < 11g/dl) yes no CKD 3 or higher, start oral iron and folic acid Evaluate for cause of anemia Iron deficiency Oral iron ( predialysis ) Intravenous iron ( hemodialysis ) Anemia of chronic disease Refractory Erythropoietin No improvement Continue maintenance therapy refractory Check : compliance –iron studies,PTH Further evaluation: Hb electrophoresis, bone marrow aspiration, Coombs test

Management of bone disease::

Management of bone disease: Stage II chronic kidney disease: usually will have no signs or symptoms of bone abnormalities may have evidence of abnormalities on laboratory testing - decreased serum calcitriol and elevated serum parathyroid hormone Subtle signs of renal osteodystrophy begin to be observed when GFR decreases to 50% of the reference range (stage III disease) 2 major types of bone disease commonly encountered in patients with chronic kidney disease include : enhanced bone resorption - osteitis fibrosa osteomalacia /rickets. adynamic bone disease in ESRD

Bone disease contd…:

Bone disease contd … the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend: monthly measurements for calcium and phosphorus in stage 5 whereas PTH measurements should be obtained at least every 3 months Serum PTH concentration is inversely correlated with renal function and is almost always elevated when the GFR falls below 60 mL /min per 1.73 m 2 Phosphate binders are recommended if phosphorus or intact PTH levels cannot be controlled within the target range despite dietary phosphorus restriction

Bone disease contd…:

Bone disease contd … The serum calcium-phosphorus product should be maintained at less than 55 mg 2 / dL in adolescents Extra skeletal calcification occurs if product in more than 72 KDOQI guidelines recommend targeted levels of serum PTH in stage 5 disease to be 200-300 pg/ mL Patients with serum levels of PTH of more than 300 pg/ mL may be treated with active vitamin D sterols to maintain PTH levels at about 2-4 times the reference range

Bone disease contd…:

Bone disease contd … Calcium-containing salts are the mainstay in phosphorus binding therapy. Calcium salts are: calcium carbonate calcium acetate calcium citrate. Calcium carbonate is the most commonly used compound.

Vitamin D therapy::

Vitamin D therapy: Controls serum PTH levels and heals the changes of osteitis fibrosa Ergocalciferol treatment should be initiated in patients with CKD when 25(OH)D3 levels fall below 30 ng /ml. Serum 25(OH)D3 levels should be rechecked after completion of the 3-month course of therapy. Serum calcium and phosphorus levels should be measured after 1 month of therapy, then every 3 months Supplementation discontinued if serum calcium levels exceed 10.2 mg/dl or if serum 25(OH)D3 levels exceed 30 ng /ml

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Three of these new vitamin D analogues are available for use in patients with chronic kidney disease: 22-oxacalcitriol 19-nor-1α-25-dihydroxyvitamin D2 ( paricalcitol ) 1α-hydroxyvitamin D2 ( doxercalciferol ) Dose of ergocalciferol in vit D deficiency:

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Renal osteodystrophy Stage II CKD – no signs Decreased S.calcitriol , Increased S.PTH Stage III CKD – signs appear when GFR <50% Monitor S.Ca , phosphate – monthly Monitor S.PTH- 3 monthly (Target PTH 200-300 pg/ml) PTH > 300 pg/ml Dietary phosphate restriction Phosphate binders – calcium containing salts Vitamin D therapy

Management of cardiovascular complications ::

Management of cardiovascular complications :

Hypertension management::

Hypertension management: The optimal target blood pressure for children with chronic renal failure is recommended to be below the 90th percentile for age Treatment of hypertension in children, with and without chronic kidney disease, is based on 3 factors: (1) degree of blood pressure elevation (2) the presence of cardiovascular risk factors, (3) the presence of end-organ damage

Hypertension contd…:

Hypertension contd … Non pharmacologic intervention includes: weight reduction, exercise, dietary salt reduction recommended daily sodium intake is 1.2 g/day for four to eight year olds and 1.5 g/day for older children Commonly used anti- hypertensives : ACE inhibitors, calcium channel blockers, prazosin , clonidine and alpha, beta blockers

Hypertension contd…:

Hypertension contd … ACE inhibitors or ARBs are often the preferred agent as they have a dual action : anti-hypertensive, reducing proteinuria . In addition they have anti-fibrotic activity ACE inhibitors and ARBs should be used cautiously if the GFR is less than 60ml/min/1.73m2 ACE inhibitors should be avoided when GFR <30ml/min/1.73m² Decline in GFR induced by an ACE inhibitor typically occurs within the first few days after the onset of therapy Serum creatinine and Potassium concentrations should be rechecked within a week

Hypertension contd…:

Hypertension contd … Calcium channel blockers are used as monotherapy in non – proteinuric patients Combination of ACE inhibitors and ARB increase anti- proteinuric effect by 30-40% Long acting ACEI or CCB at bed time reduce night time blood pressure more than diurnal blood pressure Hypertensive emergencies should be treated with sublingual nifedipine or IV sodium nitroprusside

Management of dyslipidemia::

Management of dyslipidemia : The patients should be evaluated with a complete fasting lipid profile and triglycerides at presentation, and should be evaluated annually thereafter or 2-3 months after a change in treatment Options for individualized treatment: Hepatic 3-methylglutaryl coenzyme A reductase inhibitors ( statins ), fibrates , plant stanols , bile acid–binding resins, dietary manipulation

Management of Growth failure:

Management of Growth failure More prevalent among children with Stage 3, 4 and 5 CKD when GFR decreases to 50% of normal Disruption of the hypothalamic-pituitary growth hormone axis contributes to the growth hormone resistant state in uremia Based on the KDOQI guidelines, treatment with rhGH should be considered under the following conditions : Children whose height for chronologic age varies by more than 2 negative standard deviation scores (SDS) Children whose height velocity for chronologic age varies by more than 2 negative SDS Children with growth potential documented by open epiphyses No other contraindication for recombinant hGH use

Growth failure contd…:

Growth failure contd … Nutritional and metabolic imbalances should be corrected before use of recombinant hGH : Insufficient intake of energy, protein, and other nutrients Acidosis Anemia – Hb level 10 -11 g/dl Hyperphosphatemia - correct serum phosphorus level to < 1.5 times the upper limit for age Secondary hyperparathyroidism The initial dose of rHuGH in children with CKD is currently 0.05mg/kg per day subcutaneously

Growth failure contd…:

Growth failure contd … rHuGH is continued until : the child reaches the 50th centile for mid-parental height, achieves a final adult height with closed epiphyses, or receives a renal transplant Complications : Increased bone age Aseptic necrosis Slipped epiphysis Hypercalciuria Pseudotumor cerebri Glucose intolerance Diabetes mellitus Hypertension

Growth failure contd…:

Growth failure contd … Contraindications : Uncontrolled diabetes Severe osteodystrophy Active neoplasia Post transplant patients Monitoring : Anthropometry 6 monthly Urea, creatinine,calcium , phosphorus, parathormone,hemoglobin 3-6 monthly TSH, bone age by TW2 method, x ray pelvis

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Ht <5 th percentile or Ht velocity <25 th percentile yes Meeting nutritional needs Supplemental feeding no yes Serum Na,K,HCO3,PO₄,Ca- normal limits? Treat specific disorder no yes PTH < 2 times of normal ? Treat ROD no yes Baseline hip,knee,bone age xray Basline biochemical parameters Note parental height Begin GH 0.05mg/kg/day subcutaneously

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GH 0.05mg/kg/day subcutaneous Monitor Ht, Ca, Phosphorus, urea, creatinine - 3 monthly Monitor PTH 6 monthly Ht >50% of mid-parental height Stop GH therapy Yes No Monitor hip, knee, bone age x-ray yearly Look of epiphyseal closure Stop therapy Continue therapy No Yes

Management of metabolic acidosis:

Management of metabolic acidosis Overt acidosis is characteristically present when the estimated glomerular filtration rate ( eGFR ) is less than 30 mL /min per 1.73 m 2 (stage IV). The acidosis in CKD can be associated with an increased or normal anion gap. Guidelines recommend maintaining a serum bicarbonate level of 22 mmol /L Recommend supplementation with sodium bicarbonate, started at 1-2 mEq /kg/d in 2-3 divided doses

Dietary management::

Dietary management: Causes of malnutrition in CKD include poor appetite, decreased intestinal absorption of nutrients due to altered transit time, and metabolic acidosis Tools for evaluation for malnutrition include: Adequacy of dietary intake- 3day diet record Estimated dry weight Weight for age standard deviation score Height for age standard deviation score BMI for age Head circumference for age Height velocity for age

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Assessment of growth and nutritional status should be carried out 6 monthly in CKD And 1-3 monthly in children with polyuria , severe malnutrion , growth failure and dialysis dependence Serum albumin has been identified as a surrogate marker for nutritional status and morbidity/mortality in patients with end-stage renal failure (ESRF). Each fall of serum albumin by 1 g/dl at the start of dialysis was associated with a 54% higher risk of death

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Energy – prescribed calories for children with CKD is based upon the estimated energy requirement (EER) for chronological age 125% of RDA should be provided to ensure catch up growth 55-60% calories from carbohydrates, 30% from fats and 10% from proteins Supplemental nutrition – naso gastric feeding or per gastrostomy is given in children whose expected weight gain are not met with oral intake

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Protein : Protein is required to maintain positive nitrogen balance for growth and maintain body protein turn over The diet should include 1.1-1.2 g/kg/d protein, with 60-70% protein from high biologic value origin. Protein intake should be between 100 to 140% of the RDA based upon age and gender for children with Stage III CKD Between 100 and 120% for those with Stages IV and V CKD Protein restriction is not recommended in children, because it has not been shown to influence the decrease in renal function in children with chronic kidney disease

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Fats – diet high in poly unsaturated fats such as corn oil, medium chain triglyceride oil are preferred Children with CKD should receive 100% of the RDA for the vitamins Requirements in CKD : B1,B2 and folic acid – 1mg each Pyridoxine and pantothenic acid – 10mg each Vitamin C – 50mg B12 – 5mg Biotin – 300mg

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Excess vit A intake is associated with hypercalcemia , anemia and hyperlipidemia Excess vit C causes oxalate deposition in kidney Supplementation of folic acid is recommended when GFR <40ml/min/1.73m² Infants: 250 μg /kg to maximum of 2.5 mg daily Children 1–5 years: 2.5 mg daily Children >5 years: 5 mg daily Children on peritoneal dialysis need supplementation with Vit C, folic acid and pyridoxine to compensate dialysis losses

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Phosphorus and Calcium: Dietary phosphate should be restricted when GFR <5oml/min/1.73m² Dietary phosphorus restriction to 80% of RDA Regular phosphate binders with the meals The elemental calcium intake recommended for pediatric patients with chronic kidney disease is as follows: Age 1-10 years: 500-600 mg/d Age 11-18 years: 800-1000 mg/d

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Potassium abnormalities : Management strategies for hyperkalemia includes: Restriction of potassium intake if GFR <10ml/min/1.7 3m² loop diuretic for increasing potassium excretion, correcting metabolic acidosis with oral sodium bicarbonate intake of potassium chelating agents like sodium polystyrene sulfonate to reduce potassium excretion Hypokalemia can occur with excess use of diuretics When S.Potassium is <3mEq/l supplements of food rich in potassium is given – oranges, almonds, green leafy vegetables

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Sodium and fluid management : No added salt (NAS) and restriction of salty snacks is recommended. Salt intake should be kept to less than 2400 mg/d Diuretic therapy includes : loop diuretics such as furosemide given at a dose of 0.5 - 2 mg/kg/day or thiazide diuretics such as hydrocholorothiazide at 1 - 3 mg/kg/day. Thiazide diuretics are used in early stages of CKD Loop diuretic in the more advanced stages when the thiazides are less effective

Uremic bleeding::

Uremic bleeding: Severe chronic uremia causes platelet dysfunction, particularly abnormalities in platelet adhesion and aggregation Desmopressin - intravenously or subcutaneously at a dose of 0.3mcg/kg with an onset of effect within one hour of administration and the effect lasts for six to eight hours Cryoprecipitate (1 - 2 units/10 kg); the effect lasts for 24 to 36 hours

Vaccination::

Vaccination: Hepatitis B vaccine : In all patients considered for dialysis A rapid schedule of 0,1,2 (months) with a booster at 12 months may be used. Once on dialysis the patients should be routinely screened for HBsAg . varicella vaccine : A two dose schedule is recommended to all children on conservative management for renal failure function. For babies born with renal failure, the aim is to complete all immunization by 17 months, so as to enable them to be ready for a possible transplant. No transplant should be considered for 3 months if any live vaccine was administered

Renal replacement therapy::

Renal replacement therapy: Renal replacement therapy is given when GFR <15ml/min/1.73m² 2 modalities: Dialysis : Peritoneal dialysis Hemodialysis Renal transplantation

Dialysis ::

Dialysis : Principle : Movement of fluid and molecules across a semi permeable membrane from one compartment to another against concentration gradient Solutes in high concentration in blood – urea, creatinine , potassium move into dialysis fluid Solutes in high concentration in dialysate – glucose, calcium,lactate move into blood

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Dialysis solutions : Dextrose solution Non- dextrose solution : Icodextrin , mixture of amino acids Contain low sodium and potassium Buffers commonly used are lactate and bicarbonate Electrolyte constitution: Na 135-140mEq/L K 2-3mEq/L Ionized Ca 2-2.5mEq/L Bicarbonate 35-45mEq/L Magnesium 1-1.5mEq/L

Peritoneal dialysis: :

Peritoneal dialysis: More commonly used in children Catheter placement – anterior abdominal wall Tenchkoff (25cm length) catheter 3 phases: Fill period: Lasts 5-10 min Time taken to infuse dialysate fluid into abdomen Dwell period: Lasts 30-45min During which dialysate is allowed to stay in contact with peritoneal membrane to allow ultrafiltration Drain phase: Lasts 5-10min During which abdomen is emptied of dialysate

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Advantages: Stable biochemistries and blood pressure Fewer restrictions on diet and fluid Can be done at home Reduced requirement of erythropoietin and blood transfusions No venepuncture required More suitable for patients with cardiovascular instability Can be carried out at night as CAPD – continuous ambulatory peritoneal dialysis CCPD- continuous cyclical peritoneal dialysis or automated peritoneal dialysis – (total 10hours exchanges during the night)

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Disadvantages: Not useful in emergency situations like pulmonary edema or severe hyperkalemia Contraindicated in : Peritoneal membrane failure Extensive adhesions in peritoneum Peritoneal leaks VP shunt IBD Complications: Bleeding at catheter insertion Perforation of gut Leakage around catheter Peritonitis Pulmonary complications – basal pneumonia, atelectasis , pleural effusions

Peritoneal Dialysis:

Peritoneal Dialysis

Hemodialysis :

Hemodialysis Fluid or toxins are removed by extracorporeal circulation of blood through dialysis Site of vascular access – femoral, subclavian , internal juglar Can be given through creation of fistulas between – radial artery and cephalic vein or brachial artery and cephalic vein Blood is drawn at rate of 3-5 upto maximum 10ml/kg/hr Duration is 3-4 hours per session, three times a week

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Trans membrane pressure and permeability of membrane regulate removal of fluid Dialysis disequilibrium syndrome : Due to rapid removal of solute causing fall in plasma osmolality Trigger a fluid shift from the vascular compartment into the cells Manifest as sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation, seizures during or immediately after dialysis Prevented by infusion of mannitol 0.5-1 g/kg as continuous infusion during first 1-2hours of dialysis

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Advantages: Rapid fluid removal Rapid removal of urea & creatinine Effective K + removal Less protein loss Lower triglycerides Home dialysis possible Temporary access at the bedside Disadvantages: Vascular access problems Dietary & fluid restrictions Heparinization Extensive equipment Hypotension Added blood lost Trained specialist

Hemodialysis:

Hemodialysis AV fistula access AV Graft access

Renal transplant::

Renal transplant: Living and Cadaveric donors Pre-transplant: Immunotherapy - methylprednisolone , cyclosporine , azathioprine Complications: Rejection is a major problem Hyper acute rejection: occurs within minutes to hours after transplantation Acute Rejection: occurs 4 days to 4 months after transplantation Chronic Rejection: occurs over months or years and is irreversible. Signs: increasing serum creatinine , elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys

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