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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
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Incident rates of ESRD in the World
2USRDS 2014
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Incident rates of ESRD
32017 Annual Data Report of USRDS
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Prevalence of treated ESRD
4USRDS 2017
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5
~19 billion USD
Dialysis~7.17% budget(40 billion NT;1.33 billion USD)
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Cardiovascular Mortality in the General
Population and in ESRD
KDOQI CKD Guidelines
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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, …
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ESRD Treatment Options
Hemodialysis
Kidney Transplant
Peritoneal Dialysis
Hospice
ESRD
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Incident Patient Counts (USRDS)
by 1st Modality
USRDS 2013 ADR
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CAUSES OF RENAL FAILURE
◆ Diabetes
◆ Untreated high blood pressure
◆ Inflammation
◆ Heredity
◆ Chronic infection
◆ Obstruction
◆Accidents
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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
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Types
Haemodialysis (HD)
Peritoneal Dialysis (PD)
They work on similar principles:
Movement of solute or water
across a semipermeable
membrane (dialysis membrane)
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Diffusion
Movement of solute
Across
semipermeable
membrane
From region of high
concentration to one
of low concentration
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Convection
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Selection for HD/PD
Clinical condition
Lifestyle
Patient competence/hygiene (PD -
high risk of infection)
Affordability / Availability
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Haemodialysis (HD)
Dialysis machine
Dialysis Access
HD Tube
Dialyser
HD 3-6 hrs/session
HD Frequency
:QW to TIW to QD
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Requirements for HD
Good access to patients circulation
Good cardiovascular status (dramatic
changes in BP may occur)
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Performing HD
HD may be carried out:
In a HD Unit
At a Minimal Care / Self-Care Centre
At Home
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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
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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
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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
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HD Access
2 types of access for HD:
◦ Must provide good flow
◦ Reliable access
A fistula: arterio-venous (AV)
Vascular Access Catheter
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Hemodialysis Vascular Access
Polytetrafluoroethylene
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N Engl J Med 2012; 367:2505-2514
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Changes in brain urea transporter (UT) and
aquaporin channel (AQP) expression in DDS.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Peritoneal Dialysis
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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
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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
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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%
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Types
Continuous Ambulatory Peritoneal
Dialysis (CAPD)
Automated peritoneal Dialysis (APD)
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Principle of PD Treatment
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• 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
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Types of PD Catheters
• Overall PD catheter survival : +/- 90% at 1 year
• No particular catheter is superior
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Placement of Peritoneal Dialysis
Catheter
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Placement of PD Catheter
Exit Site
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PD Catheter
Exit Site
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Fluid removal by PD
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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
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CAPD Exchange
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Automated peritoneal dialysis (APD)
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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
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PD Access
Done under
LA or GA
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Wearable Artificial Kidney
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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
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Principle of Kidney
Transplantation
Iliac Fossa