Renal Procedures

Percutaneous nephrolithotomy (PCNL)

This is a procedure which is used to remove stones from the kidney

– It involves making an incision in the skin and then passing a tube into the renal pelvis.

– It is usually required when there are larger stones (>2cm) and Staghorn calculi which would be unable to pass spontaneously themselves or broken up using shockwave lithotripsy

Renal Replacement therapy (Dialysis)

Dialysis is common in patients who experience renal failure. This includes patients who are unable to control volume status, blood pressure and acid-base

– The GFR of these patients is usually 5-10 – dialysis provides just enough clearance in kidney failure

– There are two common types of dialysis – hemodialysis and peritoneal dialysis

Retroperitoneal Dialysis (PD)

This technique uses the peritoneum as a natural filter paper

– As it is partially permeable, fluid can be passed over it. As this happens, solutes will slowly diffuse through into the bloodstream

– In addition, by adding a hypertonic fluid solution, this means that water is drawn out of the bloodstream. This is used to mimic ultrafiltration.

– In this way, it mimics the role of the kidneys

Complications

– Catheter site infection giving peritonitis, usually with staphylococcus epidermidis or S.Aureus

– Hernias

– Loss of membrane function over time

Hemodialysis (HD)

This technique is where blood is taken from a an ateriovenous fistula

– It is passed over a partially-permeable membrane which has dialysis fluid on the other side flowing in the opposing direction.

– As this happens, solutes diffuse down their gradient removing waste from blood and water flows out mimicking ultrafiltration.

– Hemodialysis is needed a minimum of 3 times/week lasting 4hrs/session

Complications

The annual mortality of renal replacement therapy is high, due to a significant number of complications.

– Cardiovascular – poor renal function increases BP, vascular stiffness and inflammation

– Protein- calorie malnutrition – renal bone disease

– Amyloid – B2 microglobulin accumulate in long-term dialysis

– Access – AV fistula, stenosis, infection

– Renal cell carcinoma

– Dialysis disequilibrium – disequilibrium of cerebral + blood solutes can lead to cerebral oedema

Transplantation

This is considered in people reaching Grade 5 kidney disease

– It is never used in cancer with metastases or people with congestive heart failure

– Should not be undertaken whilst the patient has an active infection e.g. active HIV

 

A combination of drugs is used to reduce the risk of immunological rejection:

– Initial: Ciclosporin/Tacrolimus + Monoclonal antibody (daclizumab/basiliximab)

– Maintenance: Ciclosporin/Tacrolimus + Mycophenolate or Sirolimus

Transurethral resection of prostate (TURP)

This is a procedure used for the surgical removal of the prostate gland

– It uses a resectoscope, a thin metal tube with camera and a loop of wire

– It is passed up urethra and the wire is heated to cut away sections of the prostate.

– The catheter is then used to pump fluid and flush away fragments.

Complications

– Infection

– Incontinence

– Retrograde ejaculation (common)

– TURP syndrome –> hyponatreamia + fluid overload + glycine toxicity