MANAGEMENT OF CHRONIC RENAL FAILURE

1.Conservative therapy

2.Renal replacement therapy

1.CONSERVATIVE THERAPY

Elimination of symptoms and prevention of further deterioration1. Aim

2.Initiated

When patient becomes azotemic

3.What we do?

Manage diet,fluid,electrolytes and calcium phosphate balance

Dietary

Modifications

(A)DIETARY MODIFICATIONS

Includes

1.Dietary regulation of protein

2.Nutritional supplements,if needed(20 -40 g/day)

(a)Improves acidosis,azotemia and nausea

(b)Reduces the excretory load of the kidney &

Thereby intraglomerular pressure and secondary injury to nephrons

(a)Multivitamin supplements

(b) Patients with early renal insufficiency,supplement diet with CaCO3 along with limited intake of phosphate containing foods

Take Care of “BEANS”

(Practical clinical approach to the management of patients with chronic renal failure)

1. Blood pressure should be maintained in a target range lower than 130/80 mm Hg

2.Haemoglobin levels should be maintained at 10-12 g/dL

3.Hyperlipidemia should be treated with a “statin” lipid lowering medication

4.Smoking cessation should also be encouraged

(B) DIALYSIS (DIA-THROUGH , LYSIS –LOOSENING)

*When the access should be created???

Serum creatinine> 4.0g/dL

GFR falls to <20 mL/min

*Close monitoring of nutritional status is important

The decision to initiate dialysis  renal failure depends on several factors. divided into acute or chronic indications.

in the patient with acute kidney injury -vowel acronym of "AEIOU":

1.Acidemia from metabolic acidosis 2.Electrolyte abnormality, such as severe hyperkalemia, 3.Intoxication, that is, acute poisoning with a dialyzable substance. 4.Overload of fluid5.Uremia complications, such as pericarditis, encephalopathy, or gastrointestinal bleeding.

Chronic indications for dialysis:1.Symptomatic renal failure2.Low glomerular filtration rate (GFR) In diabetics, dialysis is started earlier <15cc/min3.Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low

INDICATIONS:

Dialysis(a)Haemodialysis

(b)Peritoneal dialysis

(a)Haemodialysis is the removal of nitrogenous and toxic products of metabolism from the blood by means of a haemodialyzer system#Exchange occurs between the patient’s plasma and dialysate (electrolyte composition of which mimics that of extracellular fluid) across a semi permeable membrane that allows uremic toxins to diffuse out of the plasma while retaining the formed components and protein composition of blood

NOT provides the same degree of health as renal function provides because there is no resorptive capability in the dialysis membrane.

COMPONENTS of dialysis unit

1.Dialyzer2.Dialysate production unit3.Roller blood pump4.Heparin infusion pump5.Devices to monitor the conductivity,temperature,flow rate and pressure of dialysate

The frequency and duration of dialysis treatment are related to1. Body size2. residual renal function3.Protein intake4.Tolerance to fluid removal

#The typical patient undergoes haemodialysis 3 times/week with each treatment lasting approximately 3-4 hours on standard dialysis units and slightly less time on high efficiency/high flux dialysis units

NEWER FORMS :Nocturnal and daily dialysis with improved control of1.Biochemical abnormalities2.Blood pressure and volume status

1. In hemodialysis, the patient's blood is pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane.

2.Blood flows through the fibers, dialysis solution flows around the outside of the fibers, and water and wastes move between these two solutions.

3.The cleansed blood is then returned via the circuit back to the body.

***. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer.

4.This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several liters of excess fluid during a typical 3- to 5-hour treatment

Types of vascular access foe maintenance haemodialysis**Classic construction is side to side anastomosis b/w the radial artery and cephalic vein at the forearm

1.Primary arteriovenous(AV) fistula/shunt/external cannula system: Preferred for long term treatment.

2. Synthetic AV graft: Fistulae are created by means of autografts,PTFE grafts ,Dacron etc.A fistula is an enlarged vein (usually in your arm), created by connecting an artery directly to a vein.

3.Double lumen4.Cuffed tunneled catheters: indwelling central venous catheters used

(B) Peritoneal dialysis(accounts for10% of dialysis t/t)

1. access is achieved via a catheter through the abdominal wall into the peritoneum

2. 1-2 liters of dialysate is placed in the peritoneal cavity and is allowed to remain for varying intervals of time

3. Substances diffuse across the semipermeable peritoneal membrane to dialysate

4. #Tenckhoff Silastic catheter has made peritoneal puncture for each dialysis unnecessary

**little baby who needed dialysis. You can see his Tenckhoff Catheter coming out of his tummy. This type of catheter is used for peritoneal dialysis.

#

Hookup Infusion Diffusion (fresh)

Diffusion (waste)

Drainage

Various Regimens for peritoneal dialysis:

1.Chronic ambulatory patients..:2 L of dialysis fluid instilled in the peritoneal cavity, allowed to remain for 30 mins and drained out2.Continuous cyclic peritoneal dialysis,in which 2-3 L of dialysate is exchanged every hour over a 6-8 hour period overnight,7days /week

*** as it allows (a)great deal of personal freedom(b)No risk of air embolism and blood leaks(c) Hepariniztion unnecessarySO used as PRIMARY therapy/as a TEMPORARY MEASURE

2.RENAL TRANSPLANTATION

Treatment of choice for patients with irreversible kidney failureHowever the use of transplantation is limited by organ availability

INDICATIONS:1. ESRD2. Glomerulonephritis3.Pyelonephritis4.Congenital abnormalities5.Nephrotic syndrome

Other Approaches:

1.Hemofilteration

a) based on the principle of convection and physiologic function of glomerulusb) Standard dialysis technique is modified prediluting the blood with an electrolyte sol’n and ‘ultrafiltering’ it under high hydraulic pressure2.Adjunctive techniques used with maintenance dialysis include the use of ABSORBENT materials for solute removal

The Recirculating DialYsis System( REDY 2000, REDY Sorbent system)

Differs from regular single- pass dialysis in that after passing through dialyzer, the REDY dialysate fluid is regenerated, rather than discarded, by passing through a sorbent cartridge.