RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling

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RCS 6080 Medical and Psychosocial Aspects of
Rehabilitation Counseling

• Renal Failure

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Function of Kidneys

• Remove toxic waste products
• Remove excess water and salts
• Play a part in controlling blood pressure
• Produce erythropoetin (epo) which stimulates red
  cell production
• Helps to keep calcium and phosphate in balance
  for healthy bones
• Maintains proper pH for the blood

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Definitions

• Azotemia Elevated blood urea nitrogen
• (BUNgt28mg/dL) Creatinine (Crgt1.5mg/dL)
• Uremia azotemia with symptoms or signs of renal
  failure
• End Stage Renal Disease (ESRD) uremia requiring
  transplantation or dialysis
• Chronic Renal Failure (CRF) irreversible kidney
  dysfunction with azotemia gt3 mos.
• Creatinine Clearance (CCr) rate of filtration of
  creatinine by the kidney (marker for GFR)
• Glomerular Filtration Rate (GFR) the total rate
  of filtration of blood by the kidney.

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Nephrons

• Nephrons are the units in the kidney that
  transfer waste products from the blood to urine.
• A human kidney has approximately one million
  nephrons.
• Glomeruli are the filtration units of the
  nephron.
• The Glomerulus (first structure of the nephron)
  is a tuft of capillaries. Blood enters the
  glomerulus by the afferent arteriole and exits by
  the efferent arteriole
• Bowmans capsule is a tough layer of epithelial
  cells that surrounds the glomerulus there is a
  small holding area for the initial filtrate in
  between the capillary walls of the glomerulus and
  the inner layer of Bowmans capsule this area is
  called Bowmans space. Fluid and solutes filtered
  by the glomerulus collect in this space. The
  space connects to the proximal convoluted tubule,
  which is the first section of the nephrons tube
  system
• a network of tubules extends from Bowmans
  capsule
• proximal convoluted tubule (PCT)
• Loop of Henlehas a descending and ascending limb
  
• distal convoluted tubule
• Collecting duct

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Renal Failure

• Acute Renal Failure
• Prerenal azotemia
• An abnormally high level of nitrogen-type wastes
  in the bloodstream. It is caused by conditions
  that reduce blood flow to the kidneys.
• Postrenal azotemia
• An obstruction of some kind (i.e., bladder
  cancer, uric acid crystals, urethral stricture
  etc)
• Intrinsic Renal Disease
• Usually glomerular disease
• Usually leads to End Stage Renal Disease

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Chronic Renal Failure

• Diabetic Nephropathy
• 50K cases of DN ESRD annually
• Diabetes most common contributor to ESRD
• gt30 of ESRD cases attributed to Diabetes
• Hypertension
• CFR with Hypertension causes 23 of ESRD annually
• Glomerulonephretis 10
• Polycystic Kidney Disease 5
• Rapidly progressive glomerulonephrities
  (vasculitis) 2
• Renal Vascular Disease (i.e., renal artery
  stenosis)
• Medications
• Analgesic Nephropathy (progression after many
  years)
• Pregnancy high incidence of increased creatitine
  and HTN during pregnancy associated with CRF

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Chronic Renal Failure

• CRF is defined as a permanent reduction in
  glomerular filtration rate (GFR) sufficient to
  produce detectable alterations in well-being and
  organ function. This usually occurs at GFR below
  25 ml/min.
• About 100 to 150 per million persons in the U.S.
  develop CRF annually
• Average annual cost is 25,000 35,000 per
  patient per year

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Stages of Chronic Renal Failure

1. Silent GFR up to 50 ml/min.
2. Renal insufficiency GFR 25 to 50 ml/min.
3. Renal failure GFR 5 to 25 ml/min
4. End-stage renal failure GFR less than 5 ml/min.

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Diabetic Nephropathy

• What can be done to reduce the risk of problems?
• Blood glucose control
• Blood pressure control
• Using ACE inhibitors and AT II antagonists
• Diet
• Controlling blood lipids and cholesterol
• Smoking

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Treatment for Diabetic Nephropathy
Stage Assessment Treatment
No Proteinuria Monitor BP Glucose Screen for micoalbumininuria Hypertension drugs if needed (BP should be 130/85 or lower). Dietary advice for sugar and fat, stop smoking
Microalbuminuria Close monitoring of BP, Glucose and blood lipids, monitor urinary proteins CCr Add more Hypertension drugs if needed needed. Monitor cholesterol and add ACE inhibitor if needed
Proteinuria Close monitoring of BP, glucose and blood lipids, monitor urinary protein and 24 CCr BP should be lower than 125/75, low protein diet
Declining kidney function Prepare for dialysis /or transplant
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Metabolic changes

• Na excretion initially increased
• Edema occurs when GFR continues to diminish.
• NH4 excretion declines adding to metabolic
  acidosis.
• Bone CaCO3 begins to act as a buffer for the
  acidosis and leading to chronic bone loss and
  bone lesions develop (renal osteodystrophy).
• Accumulations of normally secreted uremic toxins

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Uremic Syndrome

• Uremia occurs in stage 3 4 of CRF. It means
  literally urine in the blood
• Symptomatic azotemia
• Fever, Malaise
• Anorexia, Nausea
• Mild neural dysfunction
• Uremic pruritus (itching)

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Associated problems with CFR

• Immunosuppression
• Increased risk of infection
• People with CFR should be vaccinated regularly
• Anemia
• Due to reduced erythropoietin production by
  kidney. Usually doesnt occur until 6-12 mos
  prior to dialysis
• Hyperuricemia (Gout)
• Increased uric acid in system
• Pain in joints, may contribute to renal
  dysfunction
• Hyperphosphatemia
• Increased parathyroid hormone levels
• Increased phosphate load from bone metabolism
• Hypertension
• Poor coagulation
• Proteinuria

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Chronic Renal Failure

• Chronic Renal Failure and Its Progression
• Functional Adaptation to Nephron Loss
• Increased amount of sodium that escapes
  reabsorption
• Excessive amount of potassium in blood
• Increased ammonia concentration
• Calcium and phosphorus metabolism are markedly
  altered

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Treatment of Chronic Renal Failure

• Hypertension
• Metabolic Acidosis
• Anemia
• Renal Osteodystrophy
• Uremic Neuropathy
• Sexual Dysfunction

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Treatment of End Stage Renal Failure

• Hemodialysis
• Uses a mechanized filter to remove impurities
  from the blood system
• Essentially replaces kidney with a machine
• Dialysis usually occurs a couple times per week.

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Hemodialysis

• Vascular preparation
• Surgical procedures usually completed weeks
  before beginning hemodialysis

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Treatment of End Stage Renal Failure

• Peritoneal Dialysis
• Uses the abdominal cavity as a filter

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Treatment of End Stage Renal Failure

• Transplantation

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Treatment of End Stage Renal Disease

• Survival of People with ESRD
• Data show a mean expected remaining life span of
  just under 8 years for people 40-44 beginning
  dialysis and just over 4 years for people 60-64
• Adequacy of Dialysis
• Nutrition

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Chronic Renal Failure

• Physical Rehabilitation benefits of exercise
• Vocational Rehabilitation
• The goal should be to help the person with
  chronic renal failure to resume all the duties,
  responsibilities and benefits he or she enjoyed
  prior to the illness
• Gainful employment is extremely important for an
  adult in the earning period of his or her life,
  to regain self-esteem and to interact with
  society confidently
• Fear of losing financial benefits may deter some
  people
• Some research has shown that multidisciplinary
  predialysis intervention leads to maintenance of
  job

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Additional Resources and Information from the Web

• Florida End Stage Renal Disease Network
  (http//www.fmqai.com/ESRD/esrd.htm)
• University Renal Research and Education
  Association (www.urrea.org)
• National Institute of Diabetes Digestive
  Kidney Diseases (www.niddk.nih.gov)
• National Kidney Urologic Diseases Information
  Clearinghouse (NKUDIC) (http//kidney.niddk.nih.go
  v/)
• Life Options Rehabilitation Program
  (www.lifeoptions.org)
• United Network for Organ Sharing (UNOS)
  (http//www.unos.org)
• American Society of Nephrology (www.asn-online.org
  )
• National Kidney Foundation (www.kidney.org)
• JANs webpage (www.jan.wvu.edu/soar/other/renal.ht
  ml)