Renal Replacement Therapy (RRT)

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Renal Replacement Therapy(RRT)

• Types of therapy available to patients who have
  failing kidneys
• Debbie Jones RN CNeph(C)

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Objectives

• At the end of this presentation you will be
  familiar with
• The stages of progressive renal failure or
  (Chronic Kidney Disease or CKD)
• Causes Acute vs Chronic Kidney Disease
• The renal replacement therapies available to
  patients in North Bay and surrounding district
  who have either acute or chronic kidney failure
• The types of accesses required for peritoneal and
  hemodialysis

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Primary Functions of the Kidney

• Removal of metabolic wastes, drugs and other
  toxins
• Fluid Balance
• Electrolyte Balance
• Acid-Base Regulation
• Blood Pressure Control
• Hormone Production Erythropoietin, Vitamin D
  (Calcitriol), Renin
• Master Chemists of the Body

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Acute Kidney Failure

• Pre-renal factors
• Intra-renal Nephrotoxic factors
• Post-renal factors

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Chronic Kidney Disease Caused by

• Diabetes
• Hypertension
• Renal vascular disease (also generalized vascular
  disease)
• Nephritis
• Pyelonephritis chronic UT I
• Polycystic kidney disease
• Renal Neoplasms
• Analgesic nephropathy
• Immunological disorders such as Lupus,
  Scleroderma,
• Goodpasture syndrome
• Metabolic disorders gout
• Nephrotic Syndrome ?primary or secondary

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NEPHRON and GLOMERULUS
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Stages Of Chronic Kidney Disease?GFR
Glomerular Filtration Rate Volume of plasma
filtered from the glomerular capillaries into the
Bowmans capsule each minute, expressed in
mL/min. Average GFR for a young adult is 100 to
125 mL/min.
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Does everyone understand how important we
are?Kidneys Urine
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Types of Dialysis

• Dialysis is a way to clean blood of wastes,
  fluids and salts that build up in the body when
  the kidneys fail.
• There are two types of dialysis, the first type
  we will talk about is
• Peritoneal Dialysis
• Uses the peritoneal membrane as the filter. The
  membrane covers the abdominal organs and lines
  the abdominal wall. This treatment takes place
  inside the body and requires surgical placement
  of a catheter in the peritoneal cavity to allow
  fluid to be instilled and drain out.

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Peritoneal Dialysis
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Peritoneal Dialysis

• Uses the peritoneal membrane as the filter. The
  membrane covers the abdominal organs and lines
  the abdominal wall. The membrane size is 1 2 m2
  and approximates the body surface area. Uses the
  following principles
• Diffusion movement of solutes across the
  peritoneal membrane from an area of higher
  concentration (in the blood) to an area of lower
  concentration (the fluid within the peritoneal
  cavity)
• Osmosis movement of water across the peritoneal
  membrane from an area of lower solute
  concentration to an area of higher solute
  concentration.
• Ultrafiltration water removal related to an
  osmotic pressure gradient with the use of various
  concentrations of dialysate fluid. Glucose is the
  main ingredient in the solution that aids in the
  fluid removal.

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How does PD work?

• Fluid called DIALYSATE is put into the abdomen
  through a PD catheter. This fluid is left to
  dwell in the peritoneum for several hours.
• While in the abdomen, the fluid collects wastes
  that have been filtered through the peritoneal
  membrane. These wastes pass from the body when
  the fluid is drained.

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Peritoneal Dialysis

• Performed daily, by the patient at home,
  therefore more physiological
• Allows for independence, patients can work or
  travel
• Fewer fluid and dietary restrictions
• Often fewer medications or lower doses required
• Residual renal function preserved
• Ministry of Health funded home therapy

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Peritoneal Dialysis

• Patient responsibilities
• must have a clean room to perform exchanges and a
  large enough area to store all supplies no pets
  allowed in the room
• must learn to monitor their own weight and blood
  pressures
• must be able to follow important instructions to
  prevent infection in the peritoneum
• must also be able to determine the choice of
  dialysate fluid and when to use it

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Peritoneal Dialysis Catheter
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Peritoneal Dialysis 2 Types of Delivery

• Continuous Ambulatory Peritoneal Dialysis or CAPD
• The blood is cleaned constantly by dialysate
  fluid while it is in the abdomen.
• CAPD does not require the use of a machine, the
  exchanges are completed manually. Usually 4 times
  daily.
• Automated Peritoneal Dialysis or APD
• Requires the use of a machine called a CYCLER
• The CYCLER is used during the night and is set to
  deliver the fluid in and out of the abdomen.

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Automated Peritoneal Dialysis

• Cycler

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Second Type of Dialysis

• Hemodialysis
• Uses a dialyzer or artificial kidney to filter
  the blood. This takes place outside the body and
  requires some form of access to the circulatory
  system.
• Hemodialysis is accomplished with the use of a
  computerized control unit or dialysis machine.

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Hemodialysis

• Blood is circulated through an artificial kidney
  which has two compartments Blood Dialysate,
  which are separated by a thin semi-permeable
  membrane
• Waste and excess water pass from the blood side
  to the dialysate side and is discarded in the
  drain. The cleaned blood is returned to the
  patient. During the treatment, about 200 to 300
  mL of blood is out of the body at any given time.
• Hemodialysis results in mass transfer based on
  diffusion (changing the levels of BUN, Creat,
  lytes) fluid removal by the exertion of
  pressure within the system (ultrafiltration)
  usually done 3x /week 3 to 4hrs

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Hemodialysis

• Hemodialysis treatments every other day are not
  as physiological as peritoneal dialysis
• Requires a trip to the hospital up to 3 times
  weekly
• Patients can travel to other units but this must
  be pre-arranged and space is not always available
• Patients are more restricted in dietary and fluid
  intake between treatments
• Medication requirements different than for those
  on peritoneal dialysis e.g. require more
  antihypertensive meds, higher doses of
  Erythropoietin

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Hemodialysis The Integra
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Hemodialysis

• Requires access to the blood stream
• Arterio venous fistula
• Arterio venous graft
• Or central venous access devices
• Temporary catheter
• Long term catheter

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Hemodialysis fistula
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Hemodialysis Graft
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Temporary Hemodialysis Catheter
Exit site at surface of the skin
Tip located at junction of SVC and right Atrium
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Tunneled Hemodialysis Catheter
Catheter tunnel
Exit site
Tip located at junction of SVC and right Atrium
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Other choices of treatment for kidney failure

• kidney transplantation
• To be placed on a transplant list the patient
  must be on some form of renal replacement
  therapy, whether it is peritoneal dialysis or
  hemodialysis
• Once a patient is accepted for transplant, the
  date of start of dialysis is the date they are
  active on the list
• If the patient has a living donor who has been
  accepted as healthy donor, it is possible to have
  a pre-emptive transplant, bypassing dialysis.
• No treatment or palliative care

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Transplantation
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THATS ALL FOLKS! QUESTIONS?