Antihypertensive drugs should be given only to those with renin-angiotensin hypertension, after reducing fluid overload. 5. Anemia
- is a complication of uremia which is partly corrected by dialysis. Recombinant human erythropoietin can be given but is ineffective in presence of iron deficiency, severe deficiency of other erythropoietic factors, chronic or acute infections, aluminium intoxication, bone marrow suppression or uncontrolled hyperparathyroidism. G. Osteodystrophy and derangement of calcium and phosphate metabolism - Main cause of osteodystrophy is failure of hydroxylation of vitamin D in the kidneys. Low vitamin D activity associated with hypocalcemia and increased phosphate concentration. High doses of 1,25-dihydroxycalciferol 1-3g as bolus two to three times a week are more effective than daily small doses to prevent and reverse advanced hyperparathyroidism 7 Dialysis amyloidosis - is a common complication of long-term dialysis but may also occur with conservative treatment Clinical features are carpal tunnel syndrome and osteo-arthropathy. 8. Type II hypehipedemia - is a feature of chronic renal failure and often persists in dialysis patients. If diet is not effective, HMG CoA reductase inhibitors may be given . 9. Cardiovascular complications - Myocardial infarction, cardiac failure and CVAcan occur. 'Uremic'cardiomyopathy is characterised by concentric or more often, septal asymmteric LV hypertrophy, hyperparathyroidism may contribute to its development. 10. Infections - are generally the result of impaired immune response caused by uremia and malnutrition, associated with the risk of microbial contamination of the vascular access and extracorporeal circuit. Hepatitis B and C infection are not uncommon. 11. Malnutrition -due to Gl tract changes, loss of amino acids and peptides in the dialysate, sodium restriction, poor payability of the diet land hypercatabolism induced by the dialysis. Peritoneal dialysis Here the patiens peritoneum is used as the semipermeable membrane between capillary blood and dialysis fluid which is introduced into the peritoneal cavity through a permanent catheter Methods of peritoneal dialysis : 1. CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) is the most common technique Three or four exchanges of about 2 litres dialysis fluid are required every day. Complications - (a) Mechanical effects of increased abdominal pressure and leakage of dialysis fluid - abdominal hernia, hemorrhoids, back pain, oedema of external genitalia, hydrothorax. (b) Infections - peritonitis, infection of skin at exit site. (c) Metabolic complications - Obesity, hypertriglyceridemia and diabetes following glucose loading from dialysis fluid, protein and amino acid losses. Advantages - Can be performed at home without any specific equipment, lower cost than hemodialysis, continuous fluid removal with better hemodynamic stability. Disadvantages - Complications as stated above, high failure rate, psychological problems related to indwelling catheter, fatigue from continuous treatment. 2. INTERMITTENT (PERIODIC) DIALYSIS - 8-12 hrs of dialysis with 12-16 hrs of interdialytic phase. 3. CONTINUOUS CYCLIC PERITONEAL DIALYSIS - A single day of exchange, plus 4-6 exchanges during the night using automatic equipment. Renal transplantation - is the treatment of choice for ESRD, as it enables the patient to resume a normal life, with no restrictions in diet and fluid intake. Types of renal transplantation - (a) LIVING DONOR TRANSPLANTATION - Renal transplantation between identical twins is the only situation where immunosuppression is not required , following grafting. First degree blood relatives may be suitable donors but most transplant units require the donor to be both ABO compatible and to have close matching particularly of HLA class II loci. (b) CADAVERIC TRANSPLANTATION Contraindications - (a) Old age. (b) Associated conditions that might deteriorate with immunosuppression e g bronchiectasis or severe cardiovascular disease. (c) Presence of high titres of cytotoxic antibodies to transplant antigens Immunosuppression -Cyclosporin is the drug of choice. Immunosuppression with cyclosporine can be achieved without long-term steroid treatment Many immunosuppressive drugs produce side-effects. Complications of transplantation - (1) Rejection - Identification of rejection -(a) Serum creatinine is the most common marker. (b) Renal biopsy - may also be used to detect rejection and to assist in determining presence of cyclosporin toxicity. Cl.Fs. - (i) Acute cellular or vascular rejection occurring in first 3 months may be reversible by short-term high-dose corticosteroids. Additional regimens such as ant i lymphocyte immunoglobulin and plasmapheresis may be necessary. (ii) Chronic vascular rejection is usually unresponsive to treatment and may lead to progressive graft deterioration (2) Complications of immunosuppression - Side-effects associated with immunosuppressive drugs - (i) General - Susceptibility to infection, increased risk of neoplasia (ii) Corticosteroids - Hyperglycemia, Gl bleeding, cataracts, avascular necrosis of bone, Cushings habitus. (Complications now reduced with low dose regimens). (iii) Azathioprine
- Generalised or selective marrow hypoplasia, jaundice (iv) Cyclosporin - Nephrotoxicity, hirsutism, gingival hyperplasia, tremor..
- is a complication of uremia which is partly corrected by dialysis. Recombinant human erythropoietin can be given but is ineffective in presence of iron deficiency, severe deficiency of other erythropoietic factors, chronic or acute infections, aluminium intoxication, bone marrow suppression or uncontrolled hyperparathyroidism. G. Osteodystrophy and derangement of calcium and phosphate metabolism - Main cause of osteodystrophy is failure of hydroxylation of vitamin D in the kidneys. Low vitamin D activity associated with hypocalcemia and increased phosphate concentration. High doses of 1,25-dihydroxycalciferol 1-3g as bolus two to three times a week are more effective than daily small doses to prevent and reverse advanced hyperparathyroidism 7 Dialysis amyloidosis - is a common complication of long-term dialysis but may also occur with conservative treatment Clinical features are carpal tunnel syndrome and osteo-arthropathy. 8. Type II hypehipedemia - is a feature of chronic renal failure and often persists in dialysis patients. If diet is not effective, HMG CoA reductase inhibitors may be given . 9. Cardiovascular complications - Myocardial infarction, cardiac failure and CVAcan occur. 'Uremic'cardiomyopathy is characterised by concentric or more often, septal asymmteric LV hypertrophy, hyperparathyroidism may contribute to its development. 10. Infections - are generally the result of impaired immune response caused by uremia and malnutrition, associated with the risk of microbial contamination of the vascular access and extracorporeal circuit. Hepatitis B and C infection are not uncommon. 11. Malnutrition -due to Gl tract changes, loss of amino acids and peptides in the dialysate, sodium restriction, poor payability of the diet land hypercatabolism induced by the dialysis. Peritoneal dialysis Here the patiens peritoneum is used as the semipermeable membrane between capillary blood and dialysis fluid which is introduced into the peritoneal cavity through a permanent catheter Methods of peritoneal dialysis : 1. CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) is the most common technique Three or four exchanges of about 2 litres dialysis fluid are required every day. Complications - (a) Mechanical effects of increased abdominal pressure and leakage of dialysis fluid - abdominal hernia, hemorrhoids, back pain, oedema of external genitalia, hydrothorax. (b) Infections - peritonitis, infection of skin at exit site. (c) Metabolic complications - Obesity, hypertriglyceridemia and diabetes following glucose loading from dialysis fluid, protein and amino acid losses. Advantages - Can be performed at home without any specific equipment, lower cost than hemodialysis, continuous fluid removal with better hemodynamic stability. Disadvantages - Complications as stated above, high failure rate, psychological problems related to indwelling catheter, fatigue from continuous treatment. 2. INTERMITTENT (PERIODIC) DIALYSIS - 8-12 hrs of dialysis with 12-16 hrs of interdialytic phase. 3. CONTINUOUS CYCLIC PERITONEAL DIALYSIS - A single day of exchange, plus 4-6 exchanges during the night using automatic equipment. Renal transplantation - is the treatment of choice for ESRD, as it enables the patient to resume a normal life, with no restrictions in diet and fluid intake. Types of renal transplantation - (a) LIVING DONOR TRANSPLANTATION - Renal transplantation between identical twins is the only situation where immunosuppression is not required , following grafting. First degree blood relatives may be suitable donors but most transplant units require the donor to be both ABO compatible and to have close matching particularly of HLA class II loci. (b) CADAVERIC TRANSPLANTATION Contraindications - (a) Old age. (b) Associated conditions that might deteriorate with immunosuppression e g bronchiectasis or severe cardiovascular disease. (c) Presence of high titres of cytotoxic antibodies to transplant antigens Immunosuppression -Cyclosporin is the drug of choice. Immunosuppression with cyclosporine can be achieved without long-term steroid treatment Many immunosuppressive drugs produce side-effects. Complications of transplantation - (1) Rejection - Identification of rejection -(a) Serum creatinine is the most common marker. (b) Renal biopsy - may also be used to detect rejection and to assist in determining presence of cyclosporin toxicity. Cl.Fs. - (i) Acute cellular or vascular rejection occurring in first 3 months may be reversible by short-term high-dose corticosteroids. Additional regimens such as ant i lymphocyte immunoglobulin and plasmapheresis may be necessary. (ii) Chronic vascular rejection is usually unresponsive to treatment and may lead to progressive graft deterioration (2) Complications of immunosuppression - Side-effects associated with immunosuppressive drugs - (i) General - Susceptibility to infection, increased risk of neoplasia (ii) Corticosteroids - Hyperglycemia, Gl bleeding, cataracts, avascular necrosis of bone, Cushings habitus. (Complications now reduced with low dose regimens). (iii) Azathioprine
- Generalised or selective marrow hypoplasia, jaundice (iv) Cyclosporin - Nephrotoxicity, hirsutism, gingival hyperplasia, tremor..
No comments:
Post a Comment