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Chronic Renal Failure

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Chronic Renal Failure Chronic Renal Failure Progressive, irreversible damage to the nephrons and glomeruli Causes: recurrent kidney infections, vascular changes ... – PowerPoint PPT presentation

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Title: Chronic Renal Failure


1
Chronic Renal Failure
2
Chronic Renal Failure
  • Progressive, irreversible damage to the nephrons
    and glomeruli
  • Causes recurrent kidney infections, vascular
    changes (Diabetes/Hypertension) etc. May
    be diffuse or limited to one kidney
  • Regardless of the cause Decreased GFR, tubular
    function tubular reabsorption capabilities.
    Dysfunction fluids electrolytes, acid base
    disturbances, systemic problems develops

3
Chronic Renal FailureEnd Stage Renal Disease
(ESRD)
  • Protein and waste metabolism accumulates in the
    blood (azotemia)
  • 90 of kidney function is lost (kidney cannot
    adequately function)
  • Hypothesis Nephrons remains intact, others
    progressively destroyed.
  • Adaptive response maintains function until ¾ are
    destroyed
  • Hypertrophy continues kidneys begin to lose
    their ability to concentrate the urine adequately

4
ESRD
  • Polyuria is perhaps early sign of ESRD
  • As the disease progress unable to rid the body
    of excess waste products via kidneys uremia
    results eventually other systems affected
  • When the creatinine clearance falls below 10
    ml/min (average), GFR lt 5ml/min (average)
    dialysis
  • Other symptoms Nocturia, oliguria/anuria,
    increased K, Mg, PO4 and decrease Ca,
    Neurological changes, CV changes, etc.

5
Stages of Chronic Renal Failure
  • Diminished Renal Reserve Normal BUN, and serum
    creatinine absence of symptoms
  • Renal Insufficiency GFR is about 25 of
    normal, BUN Creatinine levels increased
  • Renal Failure GFR lt25 of normal increasing
    symptoms
  • ESRD or Uremia GFR lt 5-10 normal, creatinine
    clearance lt5-10 ml/min
  • resulting in a cumulative effect

6
Treatment Modalities
  • Decrease fluid 1000ml/day
  • Decrease protein (.5-1kg body weight)
  • Decrease sodium (1-4gm variable)
  • Decrease potassium
  • Decrease phosphorous (lt1000mg/day)
  • Dialysis (periotoneal, hemodialysis)
  • RBC, Vitamin D (calcitrol replacement) etc.

7
Dialysis Hemodialyis(Hemo)Peritoneal (PD)
  • General Principal Movement of fluid and
    molecules across a semi permeable membrane from
    one compartment to another
  • Hemodialysis Move substances from blood through
    a semi permeable membrane and into a dialysis
    solution (dialysate bath) (synethetic membrane)
  • Peritoneal Peritoneal membrane is the semi
    permeable membrane

8
Osmosis-Diffusion-Ultrafiltration
Osmosis - movement fluid from an area of lt to gt
concentration of solutes (particles)
  • Diffusion - movement of solutes (particles)
    from an area of gt concentration to area of lt
    concentration Remove urea, creatinine, uric
    acid and electrolytes, from the blood to the
    dialystate bath RBC, WBC, Large plasma proteins
    do not go through
  • Ultrafiltration Water and fluid removed when
    the pressure gradient across the membrane is
    created, by increase pressure in the blood
    compartment decrease pressure in the dialysate
    compartment

9
Peritoneal Dialysis
  • Catheter placement anterior abdominal wall
  • Tenckoff (25cm length with cuff anchor and
    migration)
  • Dialysis solution (1-2 liters sometimes smaller)
  • Three phases of PD
  • Inflow (fill) approximately 10 minutes, could
    be in cycles)
  • Dwell (equilibration) (approximately 20-30 min
    or 8 hours)
  • Drain (approximately 15 minutes)
  • These 3 phases are called Exchanges

10
Peritoneal Dialysis
11
Hemodialysis
  • Vascular access for high blood flow
  • Shunts, (telfon, external)
  • Arteriovenous fistulas and grafts (AV)
  • Anastomosis between an artery and vein
  • Fistulas are native vessels (4-6 wks maturity)
  • Grafts are artificial/synthetic material

12
Hemodialysis
AV Fistula Communication
AV Graph Access
13
Hemodialysis
Hemodialysis Machine
Hemodialysis Circuit
14
PD Advantages and Disadvantages
Advantages
Disadvantages
  • Bacterial/chemical periotonitis
  • Protein loss
  • Exit site of catheter
  • Self image
  • Hyperglycemia
  • Surgical placement of catheter
  • Multiple abdominal surgery
  • Immediate initiation
  • Less complicated
  • Portable (CAPD)
  • Fewer dietary restrictions
  • Short training time
  • Less cardio stress
  • Choice for diabetics

15
Hemo Advantages Disadvantages
Advantages
Disadvantages
  • Rapid fluid removal
  • Rapid removal of urea creatinine
  • Effective K removal
  • Less protein loss
  • Lower triglycerides
  • Home dialysis possible
  • Temporary access at the bedside
  • Vascular access problems
  • Dietary fluid restrictions
  • Heparinization
  • Extensive equipment
  • Hypotension
  • Added blood lost
  • Trained specialist

16
Disequalibrium Syndrome
  • Fluid removal and decrease in BUN during
    hemodilaysis which cause changes in blood
    osmolarity.These changes trigger a fluid shift
    from the vascular compartment into the cells. In
    the brain, this can cause cerebral edema,
    resulting in increase intracranial pressure and
    visible signs of decreasing level of
    consciousness. Symptoms Sudden onset of
    headache, nausea and vomiting, nervousness,
    muscle twitching, palpitation, disorientation and
    seizures
  • Treatment Hypertonic saline, Normal saline

17
Nursing Care Pre, Post Dialysis
  • Weigh before after
  • Assess site before after (bruit, thrill,
    infection, bleeding etc.)
  • Medications (precautions before after)
  • Vital signs before and after etc.

18
Renal Transplant
  • Living and Cadaveric donors
  • Predialysis obtain a dry weight free of excess
    fluids and toxins
  • More preparation time from a living donor vs.
    cadaveric transplant within 36 hours of
    procurement
  • Delay may increase ATN
  • Pre-transplant Immunotherapy (IV
    methylprednisolone sodium succinate, (A
    methaPred, Solu-Medrol), cyclosporine
    (Sandimmune and azathioprine ((Imuran)

19
Immunological Compatibility of Donor and
Recipient
  • Done to minimize the destruction (rejection) of
    the transplanted kidney
  • HUMAN LEUKOCYTE ANTIGEN (HLA)
  • This gives you your genetic identity (twins share
    identical HLA)
  • HLA compatibility minimizes the recognition of
    the transplanted kidney as foreign tissues.

20
Immunological Analysis
  • WHITE CELL CROSS MATCH (the recipient serum is
    mixed with donor lymphocytes to test for
    performed cytotoxic (anti-HLA) antibodies to the
    potential donor kidney
  • A positive cross match indicates that the
    recipient has cytotoxic antibodies to the donor
    and is an absolute contraindication to
    transplantation

21
Immulogical Analysis
  • MIXED LYMPHOCYTE CULTURE
  • The donor and recipient lymphocytes are
  • mixed. Result HIGH SENTIVITY, this is
    contraindicated for renal transplantation.
  • ABO BLOOD GROUPING
  • ABO blood group must be compatible

22
Surgery
  • LLQ of the abdomen outside of the peritoneal
    cavity
  • Renal artery and vein anastomosed to the
    corresponding iliac vessels
  • Donor ureters are tunneled into the recipients
    bladder.

23
Complications Post Transplant
  • Rejection is a major problem
  • Hyperacute rejection occurs within minutes to
    hours after transplantation
  • Renal vessels thrombosis occurs and the kidney
    dies
  • There is no treatment and the transplanted kidney
    is removed

24
Complications Post Transplant
  • Acute Rejection occurs 4 days to 4 months after
    transplantation
  • It is not uncommon to have at least one rejection
    episode
  • Episodes are usually reversible with additional
    immunosuppressive therapy (Corticosteroids,
    muromonab-CD3, ALG, or ATG)
  • Signs increasing serum creatinine, elevated BUN,
    fever, wt. gain, decrease output, increasing BP,
    tenderness over the transplanted kidneys

25
Complications Post Transplant
  • Chronic Rejection occurs over months or years
    and is irreversible.
  • The kidney is infiltrated with large numbers of T
    and B cells characteristic of an ongoing , low
    grade immunological mediated injury
  • Gradual occlusion renal blood vessels
  • Signs proteinuria, HTN, increase serum
    creatinine levels
  • Supportive treatment, difficult to manage
  • Replace on transplant list

26
Complications Post Transplant
  • Infection
  • Hypertension
  • Malignancies (lip, skin, lymphomas, cervical)
  • Recurrence of renal disease
  • Retroperiotneal bleed
  • Arterial stenosis
  • Urine leakage
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