5th July 2024

Dialysis and Transplantation

Haemodialysis

Overview

Haemodialysis involves filtering waste by passing blood through an artificial kidney machine. Haemodialysis is the most common form of kidney replacement therapy for patients with end stage kidney disease in the world. In the UK 35.4% have hospital based or in-centre haemodialysis. Home haemodialysis forms 2%, as per the latest figures. (UK Renal Registry 2020).

Image Source: Wikimedia Commons (2008). Hemodialysis-en, Licensed under a creative commons licence. Available for free at: https://en.m.wikipedia.org/wiki/File:Hemodialysis-en.svg (Accessed: 5 February 2024).

Practical Points

Acute Indications for Dialysis

• Refractory Hyperkalaemia
• Refractory metabolic acidosis
• Refractory pulmonary oedema
• Uremic end organ damage (i.e. encephalopathy, pericarditis)

In this instance, treatment is usually initiated in an intensive care unit using a temporary internal jugular or femoral vein dialysis line or vascath.

Maintenance Treatment

Vascular Access for Dialysis

• Tunnelled dialysis catheter. The tip of the line should sit just above the right atrium. Access can be gained via the right internal jugular vein (most common), left IJV, or Subclavian vein.
• Arterio-venous fistula or graft. This can be done by connecting a superficial vein to an artery (arteriovenous fistula) or using a synthetic graft which connects a vein to an artery.

Hospital or in-centre dialysis (ICHD) tends to take place 3 times a week in 3.5-4 hour sessions.

Home Haemodialysis (HHD) patients have more frequent dialysis sessions, up to 5 times a week.

Missed Treatment

Recording the last session of dialysis with verbal confirmation with the patient is essential.

Practical tip: Inform your renal unit promptly if a dialysis patient is admitted to hospital. They may require to be transferred in order to continue dialysis.

Complications

• Infections: Dialysis access related infection should be considered. Tissue invasive infections like endocarditis, visceral abscesses are not uncommon.
• Inadequate dialysis: Patients may have been unable to complete dialysis sessions. Non-compliance may also be a factor.
• Acute deterioration precipitated by illness or intervention: Dialysis prior to and following an intervention requiring general or regional anaesthesia is vital. When unwell, they may need shorter and more frequent sessions. This is best managed in a tertiary care unit.

References

• Kidney Care UK 2020. https://www.kidneycareuk.org/about-kidney-health/treatments/dialysis/

Peritoneal Dialysis

Overview

Peritoneal dialysis (PD) uses a catheter in the abdominal cavity for dialysis. It is a home based therapy. Patients usually carry out the treatment themselves or have carers for support. Almost all patients have residual kidney function, i.e. are not anuric.

Maintenance Treatment

There are 2 ways of administering PD treatment.

1. Continuous Ambulatory peritoneal dialysis (CAPD). Dialysis prescriptions are individualised and usually, patients have 2-3 exchanges a day, 5-6 days a week. 1.5- 2 litres of fluid is infused into the peritoneal cavity, then drained out 30-90 mins later. This is 1 exchange. When a carer administers this treatment, it is called assisted-CAPD (aCAPD)
2. Automated PD(APD)- A machine is used to administer 6-8 exchanges over 10-12 hours. Most patients on APD will dialyse overnight

Some patients may also use a combination of CAPD and APD for a short duration for symptom control, e.g., Fluid overload.

Missed Treatment

Patients on peritoneal dialysis admitted to hospital should be discussed with the local nephrology team for support.

Complications

• PD Peritonitis – Usually associated with exit site infections but can occur without this too. Patients report abdominal pain and discomfort. Gram positive organisms are most commonly isolated from fluid cultures. Treatment is intraperitoneal antibiotics, via PD fluid and/or oral antibiotics. Parenteral antibiotics are generally not required, unless there are concomitant systemic infections.
• PD catheter issues – inform the nephrology team ASAP.
  • Exit site infection
  • Catheter dislodged
  • Catheter cut accidentally

Transplantation

Overview

Kidney transplantation is the most prevalent form of renal replacement therapy in the UK. Deceased donor kidney transplants are more common than living kidney donor transplants, with around 2000-3000 a year of the former and 500-1000 a year of the latter. The waiting list for kidney transplants in late 2022 was 3408 people.

Practical Points

Complications

• Immediate post-operative: Vascular thrombosis, bleeding, infected collections
• Early post-transplant (up to 6 months): Infections, rejection
• Late post-transplant: Infections, rejection, malignancy including post-transplant lymphoproliferative disease

Opportunistic Infections

Common infections to be aware of:

• Cytomegalovirus infection
• Pneumocystis jirovecii Pneumonia
• Reactivation of Tuberculosis, Varicella Zoster infection, Hepatitis B
• This list is limited, and doesn’t include community acquired, hospital acquired infections and tropical infections in those with relevant travel history

Immunosuppression

Induction immunosuppression, given at time of the kidney transplantation in the UK, is likely to be one of the following: Basiliximab, Anti -thymocyte Globulin(ATG) or Alemtuzumab.

Commonly used maintenance immunosuppression includes a Calcineurin inhibitor alone or in combination in mycophenolate mofetil and prednisolone.

References

• UK Renal Registry. 24ᵗʰ UK Renal Registry Annual report, 2021 https://ukkidney.org/sites/renal.org/files/publication/file-attachments/24th_UKRR_ANNUAL_REPORT_BOOK%20version%203.pdf
• NHS Blood and Transplant. 24ᵗʰ Annual Report, 2021. https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/24212/annual-stats.pdf