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Renal Failure and Treatment

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Title: Renal Failure and Treatment


1
Renal Failure andTreatment
  • Vicky Jefferson, RN, CNN
  • Capital Dialysis of Texas

2
  • Bones can break, muscles can atrophy, glands can
    loaf, even the brain can go to sleep without
    immediate danger to survival. But -- should
    kidneys fail.... neither bone, muscle, nor brain
    could carry on.
  • Homer Smith, Ph.D.

3
Functions of the Kidneys
  • Renin secretion and the regulation of volume and
    composition of extracellular fluid.
  • Excretion
  • Blood pressure control
  • Vitamin D activation
  • Acid-base balance regulation.
  • Erythropoietin production
  • Urine formation

4
Renin
  • Renin is important in the regulation of blood
    pressure.
  • It is released from the granular cells of the
    efferent arteriole in response to decreased
    arteriole blood pressure, renal ischemia,
    extracellular fluid depletion, increased
    norepinephrine, and increased urinary Na
    concentration.

5
Blood Pressure Regulation
  • 4 mechanisms are involved
  • Volume control
  • Aldosterone effect
  • Renin-angiotensin-aldosterone
  • Renal prostaglandin

6
Prostaglandin
  • Prostoglandins (PGs)- synthesized by most body
    tissues. In the kidney, PGs are synthesized in
    the medulla and have a vasodilating action and
    promote Na excretion. PGs counteract the
    vasoconstrictor effect of angiotensin and
    norepinephrine. Renal PGs systemically lower
    blood pressure by decreasing systemic vascular
    resistance.

7
Vitamin D
  • Acquired by the body through diet or through
    synthesis by ultraviolet radiation on the
    cholesterol in the skin.
  • The liver and the kidney make the vitamin active
    in the body.

8
Erythropoietin
  • Erythropoietin is produced and released by the
    kidneys in response to decreased oxygen tension
    in the renal blood supply that is created by the
    loss of red blood cells.
  • Erythropoietin stimulates the production of RBCs
    in the bone marrow.
  • Erythropoietin deficiency leads to anemia in
    renal failure.

9
RBC Synthesis Maturation
  • Kidney secrete Erythropoietin, it stimulates
    the bone marrow to produce RBCs
  • ? in oxygen delivery simulates release
  • in response the RBC count rises in 3 - 5 days
  • speeds the maturation of RBCs

10
Acid Base Balance
  • Kidneys regulate acid-base balance by
    stabilizing body fluid volume flow rate to
    enhance the reabsorption or excretion of
    bicarbonate hydrogen ions

11
Electrolyte Regulation
  • Sodium
  • Potassium
  • Calcium Need to Know
  • Phosphate Normal Values
  • Magnesium Functions
  • Chloride Factors affect

12
Excretion of Metabolic Waste
  • Over 200 waste products excreted
  • Only 2 are used for clinical assessment
  • BUN
  • Creatinine

13
Excretion of Metabolic Waste
  • Over 200 waste products excreted
  • Only 2 are used for clinical assessment
  • BUN
  • Creatinine

14
BUN
  • Normal 8 - 20 mg/dl
  • Nitrogenous waste product of protein metabolism
  • Unreliable in measurement of renal function
  • Relevance is assessed in conjunction with
    Creatinine

15
Factors Affecting BUN
  • Urine flow
  • low renal perfusion
  • Volume depletion
  • Metabolic rate
  • Protein metabolism
  • Drugs

16
Creatinine
  • A waste product of muscle metabolism
  • Normal value0.6 - 1.5 mg/dl
  • 2 times normal 50 damage
  • 8 times normal 75 damage
  • 10 times normal 90 damage
  • Exception - severe muscular disease can greatly ?
    Creatinine levels

17
Diagnostic Tools for Assessing Renal Failure
  • Blood Tests
  • BUN elevated (norm 10-20)
  • Creatinine elevated (norm 0.7-1.3)
  • K elevated
  • PO4 elevated
  • Ca decreased
  • Urinalysis
  • Specific gravity
  • Protein
  • Creatinine clearance

18
Diagnostic Tools
  • Biopsy
  • Ultrasound
  • X-Rays

19
Acute Renal Failure (ARF)
  • Sudden onset - hours to days
  • Often reversible
  • Severe - 50 mortality rate overall generally
    related to infection.

20
Characteristics of ARF
  • Homeostatic functions affected most
  • Electrolyte imbalances
  • Volume regulation
  • Blood pressure control
  • Endocrine functions affected lease
  • Require time to evolve
  • Renal size is preserved
  • Evidence of acute illness or insult exists

21
Chronic Renal Failure
  • Slow progressive renal disorder related to
    nephron loss, occurring over months to years
  • Culminates in End Stage Renal Disease

22
Characteristics of Chronic Renal Failure
  • Cause onset often unknown
  • Loss of function precedes lab abnormalities
  • Lab abnormalities precede symptoms
  • Symptoms (usually) evolve in orderly sequence
  • Renal size is usually decreased

23
Causes of Chronic Renal Failure
  • Diabetes
  • Hypertension
  • Glomerulonephritis
  • Cystic disorders
  • Developmental - Congenital
  • Infectious Disease

24
Causes of Chronic Renal Failure
  • Neoplasms
  • Obstructive disorders
  • Autoimmune diseases
  • Lupus
  • Hepatorenal failure
  • Scleroderma
  • Amyloidosis
  • Drug toxicity

25
Stages of Chronic Renal FailureOld System
  • Reduced Renal Reserve
  • Renal Insufficiency
  • End Stage Renal Disease (ESRD)

26
Stages of Chronic Renal FailureNKF
Classification System
  • Stage 1 GFR gt 90 ml/min despite kidney
    damage

27
Stages of Chronic Renal FailureNKF
Classification System
  • Stage 2 Mild reduction (GFR 60 89 ml/min)
  • 1. GFR of 60 may represent 50
    loss in function.
  • 2. Parathyroid hormones starts to
    increase.

28
During Stage 1 - 2
  • No symptoms
  • Serum creatinine doubles
  • Up to 50 nephron loss

29
Stages of Chronic Renal FailureNKF
Classification System
  • Stage 3 Moderate reduction (GFR 30 59
    ml/min)
  • 1. Calcium absorption decreases
  • 2. Malnutrition onset
  • 3. Anemia secondary to Erythropoietin
    deficiency
  • 4. Left ventricular hypertrophy

30
Stages of Chronic Renal FailureNKF
Classification System
  • Stage 4 Sever reduction (GFR 15 29 ml/min)
  • 1. Serum triglycerides increase
  • 2. Hyperphosphatemia
  • 3. Metabolic acidosis
  • 4. Hyperkalemia

31
During Stage 3 - 4
  • Signs and symptoms worsen if kidneys are stressed
  • Decreased ability to maintain homeostasis

32
During stages 3 - 4
  • 75 nephron loss
  • Decreased glomerular filtration rate, solute
    clearance, ability to concentrate urine and
    hormone secretion
  • Symptoms elevated BUN Creatinine, mild
    azotemia, anemia

33
Stages of Chronic Renal FailureNKF
Classification System
  • Stage 5 Kidney failure (GFR lt 15 ml/min)
  • 1. Azotemia

34
During Stage 5
  • Residual function lt 15 of normal
  • Excretory, regulatory and hormonal functions
    severely impaired.
  • metabolic acidosis
  • Marked increase in BUN, Creatinine, Phosphorous
  • Marked decrease in Hemoglobin, Hematocrit,
    Calcium
  • Fluid overload

35
During Stage 5
  • Uremic syndrome develops affecting all body
    systems
  • can be diminished with early diagnosis
    treatment
  • Last stage of progressive CRF
  • Fatal if no treatment

36
What happens when the kidneys dont function
correctly?
37
Manifestations of CRF -Nervous System
  • Mood swings
  • Impaired judgment
  • Inability to concentrate and perform simple math
    functions
  • Tremors, twitching, convulsions
  • Peripheral Neuropathy
  • restless legs
  • foot drop

38
Manifestations of CRFSkin
  • Pale, grayish-bronze color
  • Dry scaly
  • Severe itching
  • Bruise easily
  • Uremic frost

39
Manifestations of CRFEyes
  • Visual blurring
  • Occasional blindness

40
Manifestations of CRF Fluid - Electrolyte - pH
  • Volume expansion and fluid overload
  • Metabolic Acidosis
  • Electrolyte Imbalances
  • Hyperkalemia

41
Manifestations of CRFGI Tract
  • Uremic fetor
  • Anorexia, nausea, vomiting
  • GI bleeding

42
Manifestations of CRF Hematologic
  • Anemia
  • Platelet dysfunction

43
Manifestations of CRF Musculoskeletal
  • Muscle cramps
  • Soft tissue calcifications
  • Weakness
  • Related to calcium phosphorous imbalances

44
Calcium-Phosphorous Balance
45
Manifestations of CRFHeart - Lungs
  • Hypertension
  • Congestive heart failure
  • Pericarditis
  • Pulmonary edema
  • Pleural effusions

46
Manifestations of CRF Endocrine - Metabolic
  • Erythropoietin production decreased
  • Hypothyroidism
  • Insulin resistance
  • Growth hormone decreased
  • Gonadal dysfunction
  • Parathyroid hormone and Vitamin D3
  • Hyperlipidemia

47
Treatment Options
  • Hemodialysis
  • Peritoneal Dialysis
  • Transplant
  • Nothing

48
Hemodialysis
  • Removal of soluble substances and water from
    the blood by diffusion through a semi-permeable
    membrane.

49
History
  • Early animal experiments began 1913
  • 1st human dialysis 1940 by Dutch physician Willem
    Kolff (2 of 17 patients survived)
  • Considered experimental through 1950s, No
    intermittent blood access for acute renal
    failure only.

50
History contd
  • 1960 Dr. Scribner developed Scribner Shunt
  • 1960s Machines expensive, scarce, no funding.
  • Death Panels panels within community decided
    who got to dialyze.

51
Hemodialysis Process
  • Blood removed from patient into the
    extracorporeal circuit.
  • Diffusion and ultrafiltration take place in the
    dialyzer.
  • Cleaned blood returned to patient.

52
Extracorporeal Circuit
53
How Hemodialysis Works
54
Vascular Access
  • Arterio-venous shunt (Scribner External Shunt)
  • Arterio-venous (AV) Fistula
  • PTFE Graft
  • Temporary catheters
  • Permanent catheters

55
Scribner Shunt
  • External- one end into artery, one into vein.
  • Advantages
  • place at bedside
  • use immediately
  • Disadvantages
  • infection
  • skin erosion
  • accidental separation
  • limits use of extremity

56
Arterio-venous (AV) FistulaPrimary Fistula
  • Patients own artery and vein surgically
    anastomosed.
  • Advantages
  • patients own vein
  • longevity
  • low infection and thrombosis rates
  • Disadvantages
  • long time to mature, 1- 6 months
  • steal syndrome
  • requires needle sticks

57
PTFE (Polytetraflourethylene) Graft
  • Synthetic vessel anastomosed into an artery and
    vein.
  • Advantages
  • for people with inadequate vessels
  • can be used in 7-14 days
  • prominent vessels
  • Disadvantages
  • clots easily
  • steal syndrome more frequent
  • requires needle sticks
  • infection may necessitate removal of graft

58
Temporary Catheters
  • Dual lumen catheter placed into a central
    vein-subclavian, jugular or femoral.
  • Advantages
  • immediate use
  • no needle sticks
  • Disadvantages
  • high incidence of infection
  • subclavian vein stenosis
  • poor flow-inadequate dialysis
  • clotting

59
Cuffed Tunneled Catheters
  • Dual lumen catheter with Dacron cuff surgically
    tunneled into subclavian, jugular or femoral
    vein.
  • Advantages
  • immediate use
  • can be used for patients that can have no other
    permanent access
  • no needle sticks
  • Disadvantages
  • high incidence of infection
  • poor flows result in inadequate dialysis
  • clotting

60
Complications of Hemodialysis
  • During dialysis
  • Fluid and electrolyte related
  • hypotension
  • Cardiovascular
  • arrythmias
  • Associated with the extracorporeal circuit
  • exsanguination
  • Neurologic
  • seizures
  • other
  • fever

61
Complications of Hemodialysis contd
  • Between treatments
  • Hypertension/Hypotension
  • Edema
  • Pulmonary edema
  • Hyperkalemia
  • Bleeding
  • Clotting of access

62
Complications of Hemodialysis contd
  • Long term
  • Metabolic
  • hyperparathyroidism
  • diabetic complications
  • Cardiovascular
  • CHF
  • AV access failure
  • Respiratory
  • pulmonary edema
  • Neuromuscular
  • neuropathy

63
Complications of Hemodialysiscontd
  • Long term contd
  • Hematologic
  • anemia
  • GI
  • bleeding
  • dermatologic
  • calcium phosphorous deposits
  • Rheumatologic
  • amyloid deposits

64
Complications of Hemodialysis contd
  • Long term contd
  • Genitourinary
  • infection
  • sexual dysfunction
  • Psychiatric
  • depression
  • Infection
  • bloodborne pathogens

65
Dietary Restrictions on Hemodialysis
  • Fluid restrictions
  • Phosphorous restrictions
  • Potassium restrictions
  • Sodium restrictions
  • Protein to maintain nitrogen balance
  • too high - waste products
  • too low - decreased albumin, increased mortality
  • Calories to maintain or reach ideal weight

66
Peritoneal Dialysis
  • Removal of soluble substances and water from the
    blood by diffusion through a semi-permeable
    membrane that is intracorporeal (inside the body).

67
Types of Peritoneal Dialysis
  • CAPD Continuous ambulatory peritoneal dialysis
  • CCPD Continuous cycling peritoneal dialysis
  • IPD Intermittent peritoneal dialysis

68
CAPD
  • Catheter into peritoneal cavity
  • Exchanges 4 - 5 times per day
  • Treatment 24 hours 7 days a week
  • Solution remains in peritoneal cavity except
    during drain time
  • Independent treatment

69
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70
Phases of A Peritoneal Dialysis Exchange
  • Fill fluid infused into peritoneal cavity
  • Dwell time fluid remains in peritoneal cavity
  • Drain time fluid drains from peritoneal cavity

71
Complications of Peritoneal Dialysis
  • Infection
  • peritonitis
  • tunnel infections
  • catheter exit site
  • Hypervolemia
  • hypertension
  • pulmonary edema
  • Hypovolemia
  • hypotension
  • Hyperglycemia
  • Malnutrition

72
Complications of Peritoneal Dialysis contd
  • Obesity
  • Hypokalemia
  • Hernia
  • Cuff erosion

73
Advantages of CAPD
  • Independence for patient
  • No needle sticks
  • Better blood pressure control
  • Some diabetics add insulin to solution
  • Fewer dietary restrictions
  • protein loses in dialysate
  • generally need increased potassium
  • less fluid restrictions

74
Peritoneal Catheter Exit Site
75
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76
Medications Common to Dialysis Patients
  • Vitamins - water soluble
  • Phosphate binder - (Phoslo, Calcium, Aluminum
    hydroxide) Give with meals
  • Iron Supplements - dont give with phosphate
    binder or calcium
  • Antihypertensives - hold prior to dialysis

77
Medications Common to Dialysis Patients contd
  • Erythropoietin
  • Calcium Supplements - Between meals, not with
    iron
  • Activated Vitamin D3 - aids in calcium absorption
  • Antibiotics - hold dose prior to dialysis if it
    dialyzes out

78
Medications
  • Many drugs or their metabolites are excreted by
    the kidney
  • Dosages - many change when used in renal failure
    patients
  • Dialyzability - many removed by dialysis varies
    between HD and PD

79
Patient Education
  • Alleviate fear
  • Dialysis process
  • Fistula/catheter care
  • Diet and fluid restrictions
  • Medication
  • Diabetic teaching

80
Transplantation
  • Treatment not cure

81
Kidney Awaiting Transplant
82
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83
Advantages
  • Restoration of normal renal function
  • Freedom from dialysis
  • Return to normal life

84
Disadvantages
  • Life long medications
  • Multiple side effects from medication
  • Increased risk of tumor
  • Increased risk of infection
  • Major surgery

85
Care of the Recipient
  • Major surgery with general anesthesia
  • Assessment of renal function
  • Assessment of fluid and electrolyte balance
  • Prevention of infection
  • Prevention and management of rejection

86
Function
  • ATN? (acute tubular necrosis)
  • 50 experience
  • Urine output gt100 lt500 cc/hr
  • BUN, creatinine, creatinine clearance
  • Fluid Balance
  • Ultrasound
  • Renal scans
  • Renal biopsy

87
Fluid Electrolyte Balance
  • Accurate I O
  • CRITICAL TO AVOID DEHYDRATION
  • Output normal - gt100 lt500 cc/hr, could be 1-2
    L/hr
  • Potential for volume overload/deficit
  • Daily weights
  • Hyper/Hypokalemia potential
  • Hyponatremia
  • Hyperglycemia

88
Prevention of Infection
  • Major complication of transplantation due to
    immunosuppression
  • HANDWASHING
  • Crowds, Kids
  • Patient Education

89
Rejection
  • Hyperacute - preformed antibodies to donor
    antigen
  • function ceases within 24 hours
  • Rx removal
  • Accelerated - same as hyperacute but slower, 1st
    week to month
  • Rx removal

90
Rejection contd
  • Acute - generally after 1st 10 days to end of 2nd
    month
  • 50 experience
  • must differentiate between rejection and
    cyclosporine toxicity
  • Rx steroids, monoclonal (OKT3), or polyclonal
    (HTG) antibodies

91
Rejection contd
  • Chronic - gradual process of graft dysfunction
  • Repeated rejection episodes that have not been
    completely resolved with treatment
  • Rx return to dialysis or re-transplantation

92
Immunosuppressant Drugs
  • Prednisone
  • Prevents infiltration of T lymphocytes
  • Side effects
  • cushnoid changes
  • Avascular Necrosis
  • GI disturbances
  • Diabetes
  • infection
  • risk of tumor

93
Immunosuppressant Drugs contd
  • Azathioprine (Imuran)
  • Prevents rapid growing lymphocytes
  • Side Effects
  • bone marrow toxicity
  • hepatotoxicity
  • hair loss
  • infection
  • risk of tumor

94
Immunosuppressant Drugs contd
  • Cyclosporin
  • Interferes with production of interleukin 2 which
    is necessary for growth and activation of T
    lymphocytes.
  • Side Effects
  • Nephrotoxicity
  • HTN
  • Hepatotoxicity
  • Gingival hyperplasia
  • Infection

95
Immunosuppressant Drugs contd
  • Cytoxan - in place of Imuran less toxic
  • FK506 - 100 x more potent than Cyclosporin
  • Prograf
  • Cellcept
  • other in trials

96
Immunosuppressant Drugs contd
  • OKT3 - monoclonal antibody used to treat
    rejection or induce immunosuppression
  • decreases CD3 cells within 1 hour
  • Side effects
  • anaphylaxis
  • fever/chills
  • pulmonary edema
  • risk of infection
  • tumors
  • 1st dose reaction expected wanted, pre-treat
    with Benadryl, Tylenol, Solumedrol

97
Immunosuppressant Drugs contd
  • Atgam - polyclonal antibody used to treat
    rejection or induce immunosuppression
  • decreased number of T lymphocytes
  • Side effects
  • anaphylaxis
  • fever chills
  • leukopenia
  • thrombocytopenia
  • risk of infection
  • tumor

98
Patient Education
  • Signs of infection
  • Prevention of infection
  • Signs of rejection
  • decreased urine output
  • increased weight gain
  • tenderness over kidney
  • fever gt 100 degrees F
  • Medications
  • time, dose, side effects
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