ESRD: Dialysis & Transplantation Flashcards Preview

CVPR: Renal > ESRD: Dialysis & Transplantation > Flashcards

Flashcards in ESRD: Dialysis & Transplantation Deck (18)
Loading flashcards...
1
Q

Indications for dialysis

A
  • general: life-threatening conditions (e.g. severe hyperkalemia, severe volume overload, etc)
  • uremic encephalopathy/neuropathy
  • pericarditis or pleuritis
  • bleeding due to uremia
  • fluid overload despite diuretics
  • unresponsive HTN
  • persitent hyperkalemia, met acidosis, hyper/hypocalcemia or hypophosphatemia unresponsive to therapy
  • malnutrition/weight loss
  • persisent nausea/vomiting
2
Q

Major types of dialysis

A
  • hemodialysis
  • peritoneal dialysis
3
Q

Characteristics of hemodialysis

A
  • outpatient unit or @ home
  • 3x/week
  • blood is moved through an extracorporeal circuit via needle or catheter port and enters semi-permeable membrane
  • dialysate moves counter-currently on opposite side of membrane
  • solutes move into dialysate by diffusion
  • blood returned via needle or separate port
  • must have access to blood
4
Q

Types of dialysis access

A
  • preferred: arteriovenous fistula (AVF) = surgically made artery-vein anastamosis; usually @ arm
    • pro: lowest infection rate, last longest
    • con: take time to form, may not work
  • arteriovenous graft (AVG) = synthetic graft anastamosis
    • pro: quicker, more initial success
    • con: fail more quickly, more infections
  • Dual lumen catheters=@ IJ vein
    • pro: can be used immeadiately
    • con: highest rate of infection, high rate of dysfxn
5
Q

Conventional dialysis advantages/disadvantages

A
  • Advantages:
    • rapid, good at removing small mlx
    • control fluid removal
    • w/health care professionals
  • Disadvantages:
    • not physiologic, usually remove large volumes
    • not good at removing large mlx
    • complications
6
Q

Complications of dialysis

A
  • infections/sepsis
  • hypotension, angina, myocardial ischemia
  • disequilibrium syndrome:
    • headache
    • somnolence
    • seizures, coma (rare)
  • rare/dangerous:
    • air emboli
    • anaphylaxis
7
Q

Characteristics of peritoneal dialysis

A
  • coiled catheter @ peritoneal cavity w/exit site
  • dialysate infused into peritoneal cavity => fluid + solutes move into peritoneal cavity by osmosis => fluid drained and replaced
  • continuous ambulatory peritoneal dialysis (CAPD)
    • manual exchange of dialysate daily
  • continuous cycling peritoneal dialysis (CCPD)
    • automatic: noctural cycling by machine
8
Q

Peritoneal dialysis advantages/disadvantages

A
  • advantages:
    • cheaper
    • more freedom, easier to continue job
    • gradual, continous fluid removal
    • no vascular access
  • disadvantages/complications
    • hernias
    • difficult in large patients
    • peritonitis
    • additional carb load from dextrose
    • catheter problems
9
Q

Kidney Transplant vs. Dialysis

A
  • transplant improves patient survival vs. dialysis (not compared to general population)
  • more risk/mortality in peri-operative/immediate post-operative period
  • significant quality of life improvements + financial benefit (cheaper)
10
Q

HLA characteristics

A
  • HLA = products of MHC genes
  • Class I HLA antigents = HLA-A, HLA-B, HLA-C
    • all nucleated cells
    • present cytosolic peptides to CD8+ cytotoxic T cells
  • Class II HLA antigens = HLA-DR, HLA-DP, HLA-DQ
    • on antigen presenting cells
    • present extracellular proteins to CD4+ helper T cells
  • Donor HLA antigens will be recognized by recepient as “non-self” => rejection w/out immunosuppresion
11
Q

HLA matching in kidney transplants

A
  • 6 HLA matches taken into account
    • HLA-A, HLA-B, HLA-DR loci
  • matching does not impact actue rejection, but does impact long term graft survival
12
Q

Standard pharmacologic approach to kidney transplantation

A
  • calcineurin inhibitor
  • proliferation signal inhibitor
  • prednisone
13
Q

Clacineurin inhibitors

A
  • e.g. cyclosporine and tacrolimus
  • inhibits cytokine production/helps prevent graft rejection
  • dose: 2x/day w/variations based on transplant timing and immunologic risk
14
Q

Characteristics of proliferation inhibitors

A
  • mycophenolate mofetil
    • MOA: inhibits purine synthesis
  • mTOR inhibitors
    • MOA: inhibits mTOR proliferation signlaing
15
Q

Characteristics of prednisone

A
  • MOA: multiple, including reduced inflammation
16
Q

Pre-renal AKI DDx in kidney transplants

A
  • Volume depletion from post-operative fluid shifts, blood loss, etc.
  • Thrombosis of the transplanted renal artery or vein (surgical emergency)
  • Calcineurin inhibitor effects on the afferent arteriole
17
Q

Post-renal AKI DDx in kidney transplants

A
  • Transplant ureter obstruction due to fluid collection: requires surgical drainage
    • Lymphocele
    • Hematoma
  • Urine leak: most commonly due to break down of transplant ureter to bladder anastomosis. Creatine will rise.
18
Q

Intra-renal AKI DDx in kidney transplants

A
  • recurrence of primary renal disease:
    • FSGS
    • MPGN II
    • atypical HUS
  • infection
    • UTI/pyelonephritis
    • CMV virus
    • BK virus nephropathy
  • rejection: T-cell or B-cell/Ab mediated
    • T-cell = tubular or large vessel inflammation <=steroids and thymoglobulin
    • B-cell = small-vessel/glomerular inflammation <=plasmapheresis, Ab suppression