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Renal replacement therapy 

Renal replacement therapy
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date: 25 February 2021

Maintenance haemodialysis (HD) is a highly successful treatment for patients with established renal failure and is the default therapy when other renal replacement therapy options are not available. HD uses the countercurrent flow of blood and dialysate through a hollow fibre dialyser to maximize the concentration gradient for diffusive transport of solutes. A hydrostatic gradient across the dialyser membrane induces ultrafiltration (UF) of water and convective transport of solutes by solvent drag. High-flux membranes are standard in most HD centres and are needed to achieve significant removal of middle molecules, of which β2-microglobulin (the cause of dialysis-related amyloid) is the prime example. The technique of haemodiafiltration contributes additional convective removal of fluid and better clearance of middle molecules. The need to secure and maintain reliable vascular access is fundamental to achieving adequate dialysis and maintaining health. An arteriovenous fistula is the preferred option, with fewer complications and longer survival than other access options. For historical and pragmatic reasons, HD is normally provided three times per week. Working definitions of adequacy are based on small-solute—typically urea—removal. The optimal dialysis dose has not been well defined, but minimum targets of delivered dose measured by urea reduction ratio and normalized urea clearance (Kt/V) have been established. The main acute complication of HD is intradialytic hypotension, resulting from an imbalance between the UF rate and the rate of vascular refill. Underlying cardiovascular disease, antihypertensive drugs, autonomic dysfunction, shortened dialysis times, large interdialytic fluid gains, and inaccurate dry-weight assessment all predispose. In the longer term, dialysis-related amyloidosis is a disabling, progressive condition caused by the polymerization of β2-microglobulin within tendons, synovium, and other tissues.

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