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Renal Failure and Treatment

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Title: DIALYSIS Subject: Slide Show Presentation Author: Vicky Jefferson Last modified by: Preferred Customer Created Date: 4/14/1998 8:23:04 AM Document presentation ... – PowerPoint PPT presentation

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Title: Renal Failure and Treatment


1
Renal Failure andTreatment
  • Vicky Jefferson, RN, CNN

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, PhD

3
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.

4
History contd
  • 1960 Dr. Scribner developed Scribner Shunt
  • 1960s Machines expensive, scarce, no funding.
  • Death Panels panels within community decided
    who got to dialyze.

5
Normal Kidney Function
  • Fluid balance
  • Electrolyte regulation
  • Control acid base balance
  • Waste removal
  • Hormonal function
  • Erythropoietin
  • Renin
  • Active Vitamin D3
  • Prostaglandins

6
Acute Renal Failure (ARF)
  • Sudden onset - hours to days
  • Often reversible
  • Severe - 50 mortality rate overall generally
    related to infection.

7
Chronic Renal Failure (CRF)
  • Slow onset - years
  • Not reversible

8
Causes of Chronic Renal Failure
  • Diabetes
  • Hypertension
  • Glomerulonephritis
  • Cystic disorders
  • Developmental - Congenital
  • Infectious Disease

9
Causes of Chronic Renal Failure contd
  • Neoplasms
  • Obstructive disorders
  • Autoimmune diseases
  • Lupus
  • Hepatorenal failure
  • Scleroderma
  • Amyloidosis
  • Drug toxicity

10
Stages of Chronic Renal Failure
  • Reduced Renal Reserve
  • Renal Insufficiency
  • End Stage Renal Disease (ESRD)

11
Stage 1 Reduced Renal Reserve
  • Residual function 40 - 75 of normal
  • BUN and Creatinine normal (early)
  • No symptoms

12
Stage II Renal Insufficiency
  • Residual function 20 - 40 normal
  • Decreased glomerular filtration rate, solute
    clearance, ability to concentrate urine and
    hormone secretion
  • Symptoms elevated BUN Creatinine, mild
    azotemia, anemia

13
Stage II Renal Insufficiency contd
  • Signs and symptoms worsen if kidneys are stressed
  • Decreased ability to maintain homeostasis

14
Stage III End Stage Renal Disease (ESRD)
  • Residual function lt 15 of normal
  • Excretory, regulatory and hormonal functions
    severely impaired.
  • metabolic acidosis

15
Stage III End Stage Renal Disease (ESRD) contd
  • Marked increase in BUN, Creatinine, Phosphorous
  • Marked decrease in Hemoglobin, Hematocrit,
    Calcium
  • Fluid overload

16
Stage III End Stage Renal Disease (ESRD) contd
  • Uremic syndrome develops affecting all body
    systems
  • Last stage of progressive CRF
  • Fatal if no treatment

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 contd
  • Biopsy
  • Ultrasound
  • X-Rays

19
Manifestations of Chronic Renal Failure
20
Nervous System
  • Mood swings
  • Impaired judgment
  • Inability to concentrate and perform simple math
    functions
  • Tremors, twitching, convulsions
  • Peripheral Neuropathy
  • restless legs
  • foot drop

21
Integumentary
  • Pale, grayish-bronze color
  • Dry scaly
  • Severe itching
  • Bruise easily
  • Uremic frost

22
Eyes
  • Visual blurring
  • Occasional blindness

23
Fluid - Electrolyte - PH
  • Volume expansion and fluid overload
  • Metabolic Acidosis
  • Electrolyte Imbalances
  • Hyperkalemia

24
GI Tract
  • Uremic fetor
  • Anorexia, nausea, vomiting
  • GI bleeding

25
Hematologic
  • Anemia
  • Platelet dysfunction

26
Musculoskeletal
  • Muscle cramps
  • Soft tissue calcifications
  • Weakness
  • Related to calcium phosphorous imbalances

27
Heart Lungs
  • Hypertension
  • Congestive heart failure
  • Pericarditis
  • Pulmonary edema
  • Pleural effusions

28
Endocrine/Metabolic
  • Erythropoietin production decreased
  • Hypothyroidism
  • Insulin resistance
  • Growth hormone decreased
  • Gonadal dysfunctions
  • Parathyroid hormone and Vitamin D3
  • Hyperlipidemia

29
Treatment Options
  • Hemodialysis
  • Peritoneal Dialysis
  • Transplant

30
Hemodialysis
  • Removal of soluble substances and water from
    the blood by diffusion through a semi-permeable
    membrane.

31
Hemodialysis Process
  • Blood removed from patient into the
    extracorporeal circuit.
  • Diffusion and ultrafiltration take place in the
    dialyzer.
  • Cleaned blood returned to patient.

32
Hemodialysis Process


33
HemodialysisCircuit
34
ExtracorporealCircuit
35
(No Transcript)
36
Vascular Access
  • Arterio-venous shunt (Scribner External Shunt)
  • Arterio-venous (AV) Fistula
  • PTFE Graft
  • Temporary catheters
  • Permanent catheters

37
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

38
External (Scribner) Shunt
39
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

40
AV Fistula
41
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

42
PTFE Graft
43
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

44
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

45
Cuffed TunneledCatheter
46
Complications of Hemodialysis
  • During dialysis
  • Fluid and electrolyte related
  • hypotension
  • Cardiovascular
  • arrythmias
  • Associated with the extracorporeal circuit
  • exsanguination
  • Neurologic
  • seizures
  • other
  • fever

47
Complications of Hemodialysis contd
  • Between treatments
  • Hypertension/Hypotension
  • Edema
  • Pulmonary edema
  • Hyperkalemia
  • Bleeding
  • Clotting of access

48
Complications of Hemodialysis contd
  • Long term
  • Metabolic
  • hyperparathyroidism
  • diabetic complications
  • Cardiovascular
  • CHF
  • AV access failure
  • Respiratory
  • pulmonary edema
  • Neuromuscular
  • neuropathy

49
Complications of Hemodialysiscontd
  • Long term contd
  • Hematologic
  • anemia
  • GI
  • bleeding
  • dermatologic
  • calcium phosphorous deposits
  • Rheumatologic
  • amyloid deposits

50
Complications of Hemodialysis contd
  • Long term contd
  • Genitourinary
  • infection
  • sexual dysfunction
  • Psychiatric
  • depression
  • Infection
  • bloodborne pathogens

51
Calcium-Phosphorous Balance
52
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

53
Peritoneal Dialysis
  • Removal of soluble substances and water from the
    blood by diffusion through a semi-permeable
    membrane that is intracorporeal (inside the body).

54
PeritonealDialysis
55
Types of Peritoneal Dialysis
  • CAPD Continuous ambulatory peritoneal dialysis
  • CCPD Continuous cycling peritoneal dialysis
  • IPD Intermittent peritoneal dialysis

56
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

57
Peritoneal Catheter Exit Site
58
Draining of Peritoneal Dialysate
59
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

60
Complications of Peritoneal Dialysis
  • Infection
  • peritonitis
  • tunnel infections
  • catheter exit site
  • Hypervolemia
  • hypertension
  • pulmonary edema
  • Hypovolemia
  • hypotension
  • Hyperglycemia
  • Malnutrition

61
Complications of Peritoneal Dialysis contd
  • Obesity
  • Hypokalemia
  • Hernia
  • Cuff erosion

62
Advantages of CAPD
  • Independence for patient
  • No needle sticks
  • Better blood pressure control
  • Diabetics add insulin to solution
  • Fewer dietary restrictions
  • protein loses in dialysate
  • generally need increased potassium
  • less fluid restrictions

63
Peritoneal Dialysis Multi-bag Prong Manifold
64
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65
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

66
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

67
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

68
Patient Education
  • Alleviate fear
  • Dialysis process
  • Fistula/catheter care
  • Diet and fluid restrictions
  • Medication
  • Diabetic teaching

69
Transplantation
70
Treatment Not a Cure
71
Kidney Awaiting Transplant
72
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73
Advantages
  • Restoration of normal renal function
  • Freedom from dialysis
  • Return to normal life

74
Disadvantages
  • Life long medications
  • Multiple side effects from medication
  • Increased risk of tumor
  • Increased risk of infection
  • Major surgery

75
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

76
Function
  • ATN? (acute tubular necrosis)
  • 50 experience
  • Urine output gt100 lt500 cc/hr
  • BUN, creatinine, creatinine clearance
  • Fluid Balance
  • Ultrasound
  • Renal scans
  • Renal biopsy

77
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

78
Prevention of Infection
  • Major complication of transplantation due to
    immunosuppression
  • HANDWASHING
  • Crowds, Kids
  • Patient Education

79
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

80
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

81
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

82
Immunosuppressant Drugs
  • Prednisone
  • Prevents infiltration of T lymphocytes
  • Side effects
  • cushnoid changes
  • Avascular Necrosis
  • GI disturbances
  • Diabetes
  • infection
  • risk of tumor

83
Immunosuppressant Drugs contd
  • Azathioprine (Imuran)
  • Prevents rapid growing lymphocytes
  • Side Effects
  • bone marrow toxicity
  • hepatotoxicity
  • hair loss
  • infection
  • risk of tumor

84
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

85
Immunosuppressant Drugs contd
  • Cytoxan - in place of Imuran less toxic
  • FK506 - 100 x more potent than Cyclosporin
  • Prograf
  • Cellcept
  • other in trials

86
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

87
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

88
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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