Rena;: Dialysis and Transplant

• Dialysis: Choosing a Treatment for Kidney Failure | Haemodialysis | Dialysis Access | Haemodialysis Problems | Peritoneal Dialysis | Peritoneal Dialysis Problems | The Dialysis Patient on Your Ward | Long-term Health on Dialysis
• Transplantation: Kidney Transplant Basics | The Operation and Early Weeks | Immunosuppression | Rejection | Infection After Transplant | Long-term Transplant Care | The Transplant Patient on Your Ward
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🫘 Kidney replacement therapy — dialysis or a transplant — keeps people alive when the kidneys fail. Around 70,000 people in the UK have kidney replacement therapy, roughly half with a working transplant. You will meet these patients on every ward, so you need to know how to protect their access, which drugs to avoid or adjust, and the complications that need urgent action (line sepsis, PD peritonitis, hyperkalaemia, transplant rejection and infection).
Your four questions for every patient: What kind of kidney replacement do they have (HD, PD, transplant)? When was their last dialysis — or what are their immunosuppressant levels? What is their fluid and potassium status? Have I spoken to the renal team before changing their treatment?

Choosing a Treatment for Kidney Failure

• Options:
  • Kidney transplant — best survival and quality of life for those fit enough; ideally pre-emptive (before dialysis).
  • Peritoneal dialysis (PD) — at home; good for preserving remaining kidney function and independence.
  • Home haemodialysis — flexible, more frequent sessions.
  • Hospital or satellite unit haemodialysis — the most common in the UK.
  • Conservative kidney management — see the CKD chapter.
• The choice depends on:
  • The patient's wishes, lifestyle and work.
  • Home circumstances and ability to self-care.
  • Previous abdominal surgery (may rule out PD).
  • Vascular access options.
  • Frailty and other illnesses.
• Start dialysis on symptoms and complications, not a number — typically eGFR 5–10 (see the CKD chapter).

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Haemodialysis

• How it works:
  • Blood is pumped through a dialyser (artificial kidney) — a semi-permeable membrane with dialysis fluid flowing the other way.
  • Diffusion removes urea, creatinine and potassium, and corrects acidosis (bicarbonate moves in).
  • Ultrafiltration (a pressure gradient) removes fluid.
  • Heparin is used to stop the circuit clotting.
• Schedule: Usually 4 hours, 3 times a week (e.g. Monday–Wednesday–Friday). The long weekend gap carries the highest risk of hyperkalaemia, fluid overload and sudden death.
• Haemodiafiltration (HDF) — adds convection to clear larger molecules; increasingly used in the UK.
• Measuring adequacy: Urea reduction ratio (target 65% or more) or Kt/V.
• "Dry weight" — the target weight after dialysis, with no fluid overload and no low BP.
• Patient advice:
  • Fluid restriction (often 500 mL–1 L/day plus urine output).
  • Low potassium and low phosphate diet; salt restriction.
  • Phosphate binders with meals.

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Dialysis Access

• Arteriovenous fistula (AVF) — the best access:
  • A surgical join between an artery and a vein (radiocephalic at the wrist, or brachiocephalic at the elbow).
  • Needs 6–12 weeks or more to mature before use.
  • Lowest infection and clotting rates; lasts longest.
  • Check for a thrill (feel) and bruit (listen) — if absent, suspect thrombosis (urgent surgical or radiology review).
• Arteriovenous graft (AVG) — a synthetic tube between artery and vein; usable sooner but clots and gets infected more.
• Tunnelled central venous catheter ("line"):
  • Usually in the internal jugular vein, tunnelled under the skin with a cuff.
  • Usable immediately.
  • Highest infection risk; causes central vein narrowing.
• Non-tunnelled (temporary) catheter — for urgent dialysis (femoral or jugular); short-term only.

⚠️ Safety Pearl: Never take blood, insert a cannula, or measure BP in an arm with a fistula or graft — and don't use dialysis lines for blood tests or drugs unless you are trained and it's agreed with the renal team. Protect the veins of people who may need a fistula in future.

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Haemodialysis Problems

• During dialysis:
  • Low BP (the commonest) — from fast fluid removal; reduce ultrafiltration, give saline, review BP drugs and dry weight.
  • Cramps.
  • Nausea, headache.
  • Dialysis disequilibrium syndrome — headache, confusion and seizures from brain swelling when very high urea is lowered too fast; prevent with short, gentle first sessions.
  • Arrhythmias (potassium shifts); allergic reactions (rare).
  • Air embolism; circuit clotting; bleeding.
• Line infection — the commonest serious infection:
  • Fever or rigors at the start of dialysis; exit site redness or pus.
  • Usually Staphylococcus aureus (including MRSA) or coagulase-negative staphylococci.
  • Blood cultures from the line and peripherally.
  • IV antibiotics per local policy — often vancomycin (plus gentamicin for Gram-negative cover), given after dialysis.
  • Remove the line for S. aureus, persistent bacteraemia, tunnel infection or septic shock.
  • Look for complications — endocarditis, discitis, septic arthritis.
• Fistula problems:
  • Thrombosis (no thrill or bruit) — urgent referral; often after low BP or dehydration.
  • Stenosis — poor flow, prolonged bleeding after needles, arm swelling.
  • Steal syndrome — hand pain, coldness or numbness from blood being "stolen" from the hand.
  • Aneurysm; infection; bleeding (a ruptured fistula can be fatal — firm direct pressure).
• Missed or shortened dialysis:
  • Hyperkalaemia.
  • Pulmonary oedema.
  • Treat emergencies, then arrange urgent dialysis.

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Peritoneal Dialysis

• How it works:
  • The peritoneum acts as the dialysis membrane.
  • Dialysis fluid is run into the abdomen through a Tenckhoff catheter, left to "dwell", then drained.
  • Waste diffuses into the fluid; glucose (or icodextrin) in the fluid draws water out by osmosis.
• Types:
  • CAPD (continuous ambulatory PD) — about 4 manual exchanges a day, each taking about 30 minutes.
  • APD (automated PD) — a machine does exchanges overnight.
• Advantages:
  • Done at home; more freedom; fewer hospital visits.
  • Gentler on the heart and BP.
  • Preserves remaining kidney function longer.
  • No needles; saves arm veins.
• Disadvantages:
  • Daily commitment; needs space and dexterity (or a carer).
  • Peritonitis risk.
  • Glucose absorption (weight gain, high glucose and lipids).
  • The peritoneum fails over years.
  • Not possible with some previous abdominal surgery, hernias or stomas.
• Assisted PD — trained carers help frail patients at home.

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Peritoneal Dialysis Problems

• PD peritonitis:
  • Features: Cloudy drained fluid (often the first sign), abdominal pain, fever.
  • Diagnosis (ISPD):
    • PD fluid white cell count over 100/µL with more than 50% neutrophils.
    • Gram stain and culture of the fluid.
  • Common organisms: Skin bacteria (coagulase-negative staphylococci, S. aureus — touch contamination); Gram-negative bacteria (bowel); fungi (rare, serious).
  • Treatment:
    • Intraperitoneal antibiotics (added to the PD bags) — usually better than IV.
    • Cover both Gram-positives (vancomycin or a cephalosporin) and Gram-negatives (ceftazidime or an aminoglycoside), as per local policy.
    • Adjust when culture results come back; usually 2–3 weeks.
    • Remove the catheter for fungal peritonitis, relapsing or refractory infection.
    • Multiple bowel organisms — think bowel perforation (surgical review).
• Exit site and tunnel infection — redness, pus at the catheter exit; swab, topical and oral antibiotics.
• Catheter problems — poor drainage from constipation (laxatives), catheter migration, or fibrin.
• Fluid leaks — hernias, genital oedema, hydrothorax (pleural effusion with high glucose — fluid tracks through the diaphragm).
• Fluid overload — falling ultrafiltration as the peritoneum changes.
• Encapsulating peritoneal sclerosis — rare, after years of PD: thickened peritoneum wraps the bowel, causing bowel obstruction, weight loss and bloody fluid.

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The Dialysis Patient on Your Ward

• Contact the renal team early — to arrange dialysis and agree fluid and drug plans.
• Check:
  • Type of dialysis, schedule, and when the last session was.
  • Dry weight and today's weight.
  • Daily urine output (many still pass some urine).
  • Potassium (urgent if they missed dialysis).
  • Access — thrill and bruit of the fistula; line exit site.
• Fluids:
  • Avoid routine IV fluids — they cause pulmonary oedema.
  • Give fluid only for clear volume loss (bleeding, sepsis, vomiting), in small boluses with review.
  • Keep to their fluid restriction.
• Drugs:
  • Check every drug against the BNF or Renal Drug Database.
  • Avoid — NSAIDs (they can destroy remaining kidney function), morphine and codeine, LMWH at treatment doses (use unfractionated heparin or dose-adjust), metformin, nitrofurantoin.
  • Many drugs are removed by dialysis — give after dialysis (e.g. vancomycin, gentamicin).
  • Continue phosphate binders, ESAs and vitamin D.
• Diet: Renal diet (low potassium, phosphate and salt) — involve a renal dietitian.
• Itch (CKD-associated pruritus):
  • Optimise dialysis, phosphate and PTH; emollients.
  • Gabapentin (low dose, after dialysis).
  • Difelikefalin IV after dialysis (NICE TA890) for moderate to severe itch in adults on in-centre haemodialysis.
• Surgery and procedures — dialyse the day before; check potassium before theatre; avoid the fistula arm.

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Long-term Health on Dialysis

• Survival: Much lower than the general population — especially in older people and those with diabetes. Cardiovascular disease is the main cause of death (with infection).
• Cardiovascular:
  • Left ventricular hypertrophy; vascular calcification.
  • Sudden cardiac death (potassium shifts, long gaps between sessions).
  • Valve calcification.
  • Atrial fibrillation — anticoagulation decisions are complex (high bleeding risk).
• CKD–mineral and bone disorder — phosphate binders, vitamin D, cinacalcet or etelcalcetide, parathyroidectomy; calciphylaxis.
• Anaemia — IV iron and ESAs (target Hb 100–120 g/L).
• Dialysis-related amyloidosis — beta-2 microglobulin deposits after many years: carpal tunnel syndrome, joint pain, bone cysts.
• Acquired cystic kidney disease — raised risk of kidney cancer.
• Malnutrition and muscle wasting.
• Depression, poor sleep, restless legs, sexual dysfunction.
• Infection — line infections; vaccinate against hepatitis B, flu, pneumococcus, COVID-19.
• Advance care planning — including the option of stopping dialysis.

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Kidney Transplant Basics

• Why: Compared with staying on dialysis, a transplant gives longer survival, better quality of life, and no dietary or fluid restriction.
• Donor types:
  • Living donor — the best outcomes; can be planned pre-emptively. Kidneys last longest (often 15–20 years or more).
  • Deceased donor after brain stem death (DBD).
  • Deceased donor after circulatory death (DCD) — more delayed graft function, but similar long-term results.
• Matching:
  • ABO blood group compatibility.
  • HLA matching (especially HLA-DR) — better matches last longer.
  • Crossmatch — checks the recipient has no antibodies against the donor (prevents hyperacute rejection).
  • Sensitised patients — antibodies from previous transplants, pregnancy or blood transfusions make matching harder.
  • UK Living Kidney Sharing Scheme — paired or pooled exchanges between incompatible donor–recipient pairs.
  • Blood group- or HLA-incompatible transplants are possible with desensitisation (plasma exchange, rituximab, IVIG).
• Who can have one:
  • Anyone with kidney failure who is fit enough for surgery and will benefit.
  • Work-up — cardiac assessment, cancer screening, infection screening (HIV, hepatitis B and C, CMV, EBV, TB), vascular imaging, dental check.
• Contraindications:
  • Active cancer (wait times after treatment vary by type).
  • Active infection.
  • Severe uncorrectable heart or lung disease.
  • Short life expectancy.
  • Ongoing non-adherence or active substance misuse.
• Combined transplants — kidney and pancreas (type 1 diabetes); kidney and liver.

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The Operation and Early Weeks

• The operation:
  • The new kidney is placed in the iliac fossa (lower abdomen, right or left) — you can feel it.
  • Joined to the iliac artery and vein; the ureter is joined to the bladder, often with a temporary stent (removed at about 4–6 weeks).
  • The patient's own kidneys are usually left in place (removed only for infection, bleeding, very large polycystic kidneys, or cancer).
• Delayed graft function — dialysis needed in the first week (more common with DCD kidneys and long cold storage).
• Early surgical problems:
  • Bleeding.
  • Renal artery or vein thrombosis — sudden loss of function, graft pain (urgent Doppler).
  • Urine leak; ureteric obstruction.
  • Lymphocele (fluid collection).
  • Wound infection.
• Early follow-up — clinic visits two or three times a week at first, with creatinine and tacrolimus levels.

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Immunosuppression

• Induction (at the time of transplant):
  • Basiliximab (IL-2 receptor antibody) or alemtuzumab (anti-CD52, commonly used in the UK).
  • IV methylprednisolone.
• Maintenance — lifelong, usually a combination:
  • Tacrolimus (calcineurin inhibitor) — the cornerstone:
    • Check trough levels — a narrow therapeutic window.
    • Side effects: nephrotoxicity, tremor, new-onset diabetes, hypertension, high potassium, low magnesium, hair loss, headache, PRES (posterior reversible encephalopathy).
    • Don't switch between brands without specialist supervision.
  • Mycophenolate mofetil (MMF) — antiproliferative:
    • Diarrhoea, low white cells and anaemia.
    • Teratogenic — contraception needed; switch to azathioprine before pregnancy.
  • Prednisolone — low dose (some units stop it early).
• Alternatives:
  • Ciclosporin — gum overgrowth, hirsutism, hypertension, nephrotoxicity.
  • Azathioprine — bone marrow suppression; check TPMT; dangerous with allopurinol.
  • Sirolimus or everolimus (mTOR inhibitors) — poor wound healing, mouth ulcers, high lipids, proteinuria, pneumonitis; lower skin cancer risk.
  • Belatacept — IV infusion; avoids calcineurin inhibitor nephrotoxicity; higher PTLD risk if EBV-negative.
• Key drug interactions (tacrolimus and ciclosporin are metabolised by CYP3A4):
  • Raise levels (toxicity) — clarithromycin, erythromycin, fluconazole and other azoles, diltiazem, verapamil, grapefruit juice, some HIV drugs.
  • Lower levels (rejection) — rifampicin, carbamazepine, phenytoin, St John's wort.
  • Statins with ciclosporin — myopathy risk (use low doses).
  • Trimethoprim and ACE inhibitors — add to high potassium.

⚠️ Safety Pearl: Before prescribing any new drug for a transplant patient, check for interactions with tacrolimus or ciclosporin. A short course of clarithromycin can cause tacrolimus toxicity and AKI; rifampicin can trigger rejection.

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Rejection

• Non-adherence to immunosuppression is a major cause of graft loss — especially in teenagers and young adults.
• Diagnosis of rejection needs a transplant biopsy after excluding other causes (see "The Transplant Patient on Your Ward").

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Infection After Transplant

Timing helps predict the cause:

• First month: Surgical and hospital infections — wound infection, UTI, line infection, pneumonia, C. difficile.
• 1–6 months (peak immunosuppression) — opportunistic infections:
  • Cytomegalovirus (CMV):
    • Highest risk if the donor is CMV-positive and recipient negative.
    • Fever, low white cells, hepatitis, colitis, pneumonitis.
    • Prevention — valganciclovir prophylaxis or regular PCR monitoring.
    • Treatment — valganciclovir or IV ganciclovir.
  • Pneumocystis pneumonia (PJP) — prevented by co-trimoxazole for 6–12 months.
  • BK polyomavirus — causes BK nephropathy (rising creatinine, mimics rejection) and ureteric stenosis. Screen blood BK PCR; treat by reducing immunosuppression.
  • EBV — risk of post-transplant lymphoproliferative disorder (PTLD).
  • Fungal infections; TB reactivation; hepatitis B reactivation.
• After 6 months: Mostly community infections (pneumonia, UTI, flu, COVID-19), but opportunistic infections remain possible, especially after rejection treatment.
• Graft pyelonephritis — fever, graft tenderness, rising creatinine; IV antibiotics.
• Vaccines:
  • No live vaccines (MMR, yellow fever, BCG, oral typhoid, live shingles vaccine).
  • Use Shingrix (non-live) for shingles.
  • Yearly flu; pneumococcal; COVID-19.
  • Give needed vaccines (including live ones) before transplant where possible.
  • Household contacts should be vaccinated.

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Long-term Transplant Care

• Cancer:
  • Skin cancer — the commonest; squamous cell carcinoma is many times more common than in the general population, and more aggressive.
    • Sun protection (high-factor sunscreen, hats).
    • Yearly skin checks; urgent review of new lesions.
    • Switching to an mTOR inhibitor may help with multiple skin cancers.
  • Post-transplant lymphoproliferative disorder (PTLD) — EBV-driven lymphoma; lymph nodes, fever, weight loss, graft or gut involvement. Reduce immunosuppression; rituximab; chemotherapy.
  • Cervical and anogenital (HPV), Kaposi sarcoma, kidney cancer.
  • Keep up with national screening programmes.
• Cardiovascular disease — the main cause of death with a working graft: BP, lipids (statins), smoking, weight.
• Post-transplant diabetes — from tacrolimus and steroids; check HbA1c and glucose regularly.
• Bone disease — steroids, persisting hyperparathyroidism (tertiary — may need parathyroidectomy).
• Gout — ciclosporin raises urate; avoid allopurinol with azathioprine.
• Recurrent disease in the graft — primary FSGS, C3 glomerulopathy, atypical HUS, IgA nephropathy, membranous, diabetes.
• Pregnancy — possible after about 1 year with stable function; switch MMF to azathioprine; high-risk obstetric care.
• Anaemia, polycythaemia (post-transplant erythrocytosis — ACE inhibitor helps).

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The Transplant Patient on Your Ward

• Contact the transplant team — always before stopping or changing immunosuppression.
• Don't stop immunosuppression without advice — even when unwell or nil by mouth (IV or alternative routes can be arranged). Stopping causes rejection.
• Steroids — patients on long-term prednisolone may need extra steroid cover when acutely unwell or for surgery (adrenal crisis risk).
• Causes of rising creatinine in a transplant patient:
  • Pre-renal — dehydration (diarrhoea from MMF is common), sepsis, ACE inhibitors, diuretics.
  • Tacrolimus toxicity — check the trough level; look for interacting drugs.
  • Rejection — especially with non-adherence or low levels.
  • Infection — graft pyelonephritis, BK virus, CMV.
  • Obstruction — ureteric stenosis, lymphocele, retention.
  • Vascular — transplant renal artery stenosis (hypertension, bruit over graft).
  • Recurrent disease.
  • Drugs — NSAIDs, trimethoprim, contrast.
• Investigate:
  • U&E, tacrolimus level, FBC, CRP.
  • Urine dipstick, culture and ACR.
  • BK and CMV PCR.
  • Transplant ultrasound with Doppler.
  • Biopsy (renal team) if no clear cause.
• Fever — may be blunted by immunosuppression; investigate early and thoroughly.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A haemodialysis patient missed Friday's session. On Monday he is breathless with potassium 7.2 mmol/L and crackles to the mid-zones.
Answer: Hyperkalaemia and pulmonary oedema from missed dialysis.

• Cardiac monitoring; IV calcium gluconate; insulin–glucose; salbutamol.
• Oxygen; sit up; avoid IV fluids; IV nitrates or CPAP if needed.
• Urgent dialysis — the definitive treatment; contact the renal team now.

2. A PD patient has abdominal pain and cloudy fluid. Fluid white count is 850/µL with 90% neutrophils.
Answer: PD peritonitis.

• Fluid Gram stain and culture.
• Intraperitoneal antibiotics covering Gram-positives and Gram-negatives (per local policy).
• Review technique; remove the catheter if fungal or refractory.

3. A transplant patient on tacrolimus, MMF and prednisolone is prescribed clarithromycin for a chest infection. A week later creatinine has risen from 120 to 210 and she has a tremor.
Answer: Tacrolimus toxicity from a CYP3A4 interaction.

• Check the tacrolimus trough level; stop clarithromycin (use doxycycline or amoxicillin).
• Contact the transplant team to adjust the dose.
• Exclude other causes (dehydration, obstruction, rejection, infection).

4. Six weeks after a kidney transplant from a CMV-positive donor (recipient CMV-negative), a man has fever, diarrhoea and a white cell count of 2.1.
Answer: CMV disease (CMV colitis).

• CMV PCR in blood; colonoscopy and biopsy if needed.
• IV ganciclovir or oral valganciclovir; reduce immunosuppression with the transplant team.
• Check whether prophylaxis was taken.

5. A 19-year-old transplant recipient has creatinine rising from 110 to 250. Tacrolimus level is undetectable. He admits stopping his tablets.
Answer: Suspected rejection from non-adherence.

• Urgent transplant team review; donor-specific antibodies; ultrasound; biopsy.
• Treat according to the biopsy type (pulsed steroids, plasma exchange or IVIG).
• Explore barriers to adherence; transition-clinic support.

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Key Points

• Transplant (ideally pre-emptive) gives the best survival; living donor kidneys last longest.
• Haemodialysis is usually 4 hours, 3 times a week; the long weekend gap is the riskiest time.
• A fistula is the best access; protect it — no BP cuffs, cannulas or blood tests in that arm.
• Rigors at the start of dialysis via a line = line infection (often S. aureus): cultures, vancomycin, consider line removal.
• Cloudy PD fluid = peritonitis until proven otherwise: white count over 100 with over 50% neutrophils; intraperitoneal antibiotics.
• On the ward: avoid routine IV fluids in dialysis patients, check potassium, and dose drugs for dialysis.
• Maintenance immunosuppression is usually tacrolimus, MMF and prednisolone — never stop without the transplant team.
• Tacrolimus levels rise with clarithromycin, azoles, diltiazem and verapamil; fall with rifampicin, carbamazepine, phenytoin and St John's wort.
• Never combine azathioprine with allopurinol.
• Rejection: hyperacute (rare), acute cellular (steroids), antibody-mediated (plasma exchange, IVIG), chronic (slow scarring).
• Opportunistic infections peak at 1–6 months: CMV, PJP, BK virus, EBV/PTLD.
• No live vaccines after transplant.
• Skin cancer (SCC) is very common after transplant — sun protection and yearly checks.

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Guidelines and Further Reading

• NICE NG107: Renal replacement therapy and conservative management
• UK Kidney Association clinical practice guidelines: haemodialysis, peritoneal dialysis, vascular access, post-operative care of the kidney transplant recipient
• International Society for Peritoneal Dialysis (ISPD): peritonitis recommendations
• KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients
• NHS Blood and Transplant (NHSBT): kidney transplantation and the UK Living Kidney Sharing Scheme
• NICE TA890: Difelikefalin for treating pruritus in people having haemodialysis
• UK Renal Registry annual report
• BNF and Renal Drug Database — for current doses and interactions

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