Renal Failure:

Renal replacement therapy

Chih-Kang Chiang MD. PhD

姜至剛教授

20180409 16:30~17:20

國防醫學院2教室

Incident rates of ESRD in the World

2USRDS 2014

Incident rates of ESRD

32017 Annual Data Report of USRDS

Prevalence of treated ESRD

4USRDS 2017

5

~19 billion USD

Dialysis~7.17% budget(40 billion NT;1.33 billion USD)

Cardiovascular Mortality in the General

Population and in ESRD

KDOQI CKD Guidelines

Indications for Renal

Replacement Therapy Hyperkalemia

Metabolic acidosis

Fluid overload (recurrent CHF admissions)

Uremic pericarditis (rub)

Other non specific uremic symptoms: anorexia and nausea, impaired nutritional status, increased sleepiness, and decreased energy level, attentiveness, and cognitive tasking, …

ESRD Treatment Options

Hemodialysis

Kidney Transplant

Peritoneal Dialysis

Hospice

ESRD

Incident Patient Counts (USRDS)

by 1st Modality

USRDS 2013 ADR

CAUSES OF RENAL FAILURE

◆ Diabetes

◆ Untreated high blood pressure

◆ Inflammation

◆ Heredity

◆ Chronic infection

◆ Obstruction

◆Accidents

DialysisDefinition Artificial process that partially replaces

renal function

Removes waste products from blood by diffusion (toxin clearance)

Removes excess water by ultrafiltration (maintenance of fluid balance)

Wastes and water pass into a special liquid – dialysis fluid or dialysate

Types

Haemodialysis (HD)

Peritoneal Dialysis (PD)

They work on similar principles:

Movement of solute or water

across a semipermeable

membrane (dialysis membrane)

Diffusion

Movement of solute

Across

semipermeable

membrane

From region of high

concentration to one

of low concentration

Convection

Selection for HD/PD

Clinical condition

Lifestyle

Patient competence/hygiene (PD -

high risk of infection)

Affordability / Availability

Haemodialysis (HD)

Dialysis machine

Dialysis Access

HD Tube

Dialyser

HD 3-6 hrs/session

HD Frequency

:QW to TIW to QD

Requirements for HD

Good access to patients circulation

Good cardiovascular status (dramatic

changes in BP may occur)

Performing HD

HD may be carried out:

In a HD Unit

At a Minimal Care / Self-Care Centre

At Home

HD Unit

Specially designed Renal Unit within a

hospital

Patients must travel to the Unit 3x a week

Patients are unable to move around while on

dialysis; may chat, read, watch TV or eat

Nursing staff prepare equipment, insert the

needles and supervise the sessions

Minimal / Self-Care Dialysis

Patients take a more active role

Patients prepare the dialysis machine,

insert the needles, adjust pump speeds and

machine settings and chart their progress

under the supervision of dialysis staff

Patients must travel to the unit 3x / week

Patients need to be on a fixed schedule

Home Haemodialysis

Use of machines set up at home

Machines have many safety devices inbuilt

Thorough patient training

Requires the help of a partner at home every time

Suitability is assessed by the haemodialysis team

Ideal for patients who value their independence

and need to fit in their treatment around a busy

schedule

HD Access

2 types of access for HD:

◦ Must provide good flow

◦ Reliable access

A fistula: arterio-venous (AV)

Vascular Access Catheter

Hemodialysis Vascular Access

Polytetrafluoroethylene

N Engl J Med 2012; 367:2505-2514

Changes in brain urea transporter (UT) and

aquaporin channel (AQP) expression in DDS.

CRRT Modalities

• SCUF- Slow Continuous Ultrafiltration

◦ Ultrafiltration

• CVVH- Continuous Veno-Venous Hemofiltration

◦ Convection

• CVVHD- Continuous Veno-Venous Hemodialysis

◦ Diffusion

• CVVHDF- Continuous Veno-Venous Hemodiafiltration

◦ Diffusion and Convection

SCUF

Syringe pump

Return Pressure Air Detector

Blood Pump

Access Pressure Filter Pressure

BLD

Hemofilter

Patient

Effluent Pump

Return Clamp

Pre Blood Pump

Effluent Pressure

306100135

CVVHReturn Pressure Air Detector

Return Clamp Patient

Access Pressure

Effluent Pump

Syringe Pump

Filter Pressure

Hemofilter

Pre Post

Post

Replacement Pump Replacement Pump Pre Blood Pump

Effluent Pressure

306100135

CVVHD

Return Pressure Air Detector

Return Clamp

Access Pressure

Blood Pump Syringe Pump

Filter Pressure

Hemofilter

Patient

Effluent Pump Dialysate Pump Pre Blood Pump

BLD

Effluent Pressure

Conclusions of CRRT

in Critical ill patient

An increased treatment dose from 20 ml/h/kg to 35

ml/h/kg significantly improved survival.

A delivery of 45ml/kg/hr did not result in further

benefit in terms of survival, but in the septic patient

an improvement was observed.

Data suggest an early initiation of treatment and a

minimum dose delivery of 35 ml/h/kg (ex. 70 kg

patient = 2450 ml/h) improve patient survival rate.

Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet . july 00

Effects of HD on Lifestyle

Flexibility:

◦Difficult to fit in with school, work esp if unit is far from home. Home HD offers more flexibility

Travel:

◦Necessity to book in advance with HD unit of places of travel

Responsibility & Independence:

◦Home HD allows the greatest degree of independence

Effects of HD on Lifestyle

Sexual Activity:

◦Anxiety of living with renal failure affects relationship with partner

Sport & Exercise:

◦Can exercise and participate in most sports

Body Image:

◦Esp with fistula; patient can be very self conscious about it

Problems with HD

Rapid changes in BP◦ fainting, vomiting, cramps, chest pain,

irritability, fatigue, temporary loss of vision

Fluid overload ◦ esp in between sessions

Fluid restrictions◦ more stringent with HD than PD

Hyperkalaemia ◦ esp in between sessions

Problems with HD

Loss of independenceProblems with access ◦ poor quality, blockage etc. Infection

(vascular access catheters)

Pain with needlesBleeding ◦ from the fistula during or after dialysis

Infections◦ during sessions; exit site infections;

blood-borne viruses e.g. Hepatitis, HIV

Peritoneal Dialysis

Peritoneal Dialysis (PD)

Uses natural membrane (peritoneum) for

dialysis

Access is by PD catheter, a soft plastic tube

Catheter and dialysis fluid may be hidden

under clothing

Suitability

◦ Excludes patients with prior peritoneal scarring e.g.

peritonitis, laparotomy

◦ Excludes patients unable to care for self

Addendum to Principles (PD)

Fluid across the membrane faster than solutes; therefore longer dwell times are needed for solute transfer

Protein loss in PD fluid is significant ~ 8-9g/day

Protein loss ↑s during peritonitis

PD patients require adequate daily protein averaging 1.2 – 1.5g/kg/day

Other substances lost in the dialysate◦ Amino acids, water soluble vitamins, some

medications and hormones

Calcium and dextrose are absorbed from the dialysate fluid into the circulation

Addendum to Principles (PD) Standard dialysis solution contains:

Na+ – 132 mEq/l

Cl- – 96 -102 mEq/l

Ca2+ – 2.5 – 3.5 mEq/l

Mg2+ – 0.5 -1.5 mEq/l

Dialysis solution buffer:

◦ Sodium lactate

◦ Pure HCo3-

◦ HCo3- /Lactate combinations

Lactate is absorbed and converted to HCo3- by the

liver

Dextrose solution strengths: 1.5%, 2.5%, 4.25%

Types

Continuous Ambulatory Peritoneal

Dialysis (CAPD)

Automated peritoneal Dialysis (APD)

Principle of PD Treatment

• Abdominal cavity is lined by peritoneal

membrane which acts as a semi-permeable

membrane

• Diffusion of solutes (urea, creatinine, …) from

blood into the dialysate contained in the

abdominal cavity

• Removal of excess water (ultrafiltration) due to

osmotic gradient generated by glucose in

dialysate

Types of PD Catheters

• Overall PD catheter survival : +/- 90% at 1 year

• No particular catheter is superior

Placement of Peritoneal Dialysis

Catheter

Placement of PD Catheter

Exit Site

PD Catheter

Exit Site

Fluid removal by PD

CAPD

• Dialysis takes place 24hrs a day, 7 days a week

• Patient is not attached to a machine for treatment

• Exchanges are usually carried out by patient after training by a CAPD nurse

• Most patients need 3-5 exchanges a day i.e.

• 4-6 hour intervals (Dwell time) 30 mins per exchange

• May use 2-3 litres of fluid in abdomen

• No needles are used

• Less dietary and fluid restriction

CAPD Exchange

Automated peritoneal dialysis (APD)

Automated peritoneal dialysis (APD)

• Uses a home based machine to perform exchanges

• Overnight treatment whilst patient sleeps

• The APD machine controls the timing of exchanges, drains the used solution and fills the peritoneal cavity with new solution

• Simple procedure for the patient to perform

• Requires about 8-10 hrs

• Machines are portable, with in-built safety features and requires electricity to operate

PD Access

Done under

LA or GA

Wearable Artificial Kidney

Comparison of Dialysis Treatment OptionsPD Unit HD Home

HD

Home Dialysis √ × √

Convenient Sessions √ × √

Socializn with other CRF pats × √ ×

Home Equipment/Supplies √ × √

Special diet/fluid allowance √ √ √

Sports/exercises participation Most Most Most

Full day activity -work/school √ Not alwys √

Direct assist–partner/family × × √

Travel √ Delivery of

supplies to

most destins

easy. Some

notice required

√ Prior

arrangements

must be made

well in

advance

× Prior

arrangements

must be made

well in advance

Principle of Kidney

Transplantation

Iliac Fossa

Thanks !!

ckchiang@ntu.edu.tw