Renal Failure and Treatment - PowerPoint by duw14213

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									Renal Failure
and
Treatment
     Vicky Jefferson, RN, CNN
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
History
• Early animal experiments began 1913
• 1st human dialysis 1940 by Dutch physician
  Willem Kolff (2 of 17 patients survived)
• Considered experimental through 1950’s,
  No intermittent blood access; for acute renal
  failure only.
History cont’d
• 1960 Dr. Scribner developed Scribner Shunt
• 1960’s Machines expensive, scarce, no
  funding.
• “Death Panels” panels within community
  decided who got to dialyze.
Normal Kidney Function
•   Fluid balance
•   Electrolyte regulation
•   Control acid base balance
•   Waste removal
•   Hormonal function
     – Erythropoietin
     – Renin
     – Active Vitamin D3
     – Prostaglandins
Acute Renal Failure (ARF)
• Sudden onset - hours to days
• Often reversible
• Severe - 50% mortality rate overall;
  generally related to infection.
Chronic Renal Failure (CRF)
• Slow onset - years
• Not reversible
Causes of Chronic Renal Failure
•   Diabetes
•   Hypertension
•   Glomerulonephritis
•   Cystic disorders
•   Developmental - Congenital
•   Infectious Disease
Causes of Chronic Renal Failure
cont’d
• Neoplasms
• Obstructive disorders
• Autoimmune diseases
    – Lupus
•   Hepatorenal failure
•   Scleroderma
•   Amyloidosis
•   Drug toxicity
Stages of Chronic Renal Failure
• Reduced Renal Reserve
• Renal Insufficiency
• End Stage Renal Disease (ESRD)
Stage 1: Reduced Renal Reserve
• Residual function 40 - 75% of normal
• BUN and Creatinine normal (early)
• No symptoms
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
Stage II: Renal Insufficiency
cont’d
• Signs and symptoms worsen if kidneys are
  stressed
• Decreased ability to maintain homeostasis
Stage III: End Stage Renal
Disease (ESRD)
• Residual function < 15% of normal
• Excretory, regulatory and hormonal
  functions severely impaired.
• metabolic acidosis
Stage III: End Stage Renal
Disease (ESRD) cont’d
• Marked increase in: BUN, Creatinine,
  Phosphorous
• Marked decrease in: Hemoglobin,
  Hematocrit, Calcium
• Fluid overload
Stage III: End Stage Renal
Disease (ESRD) cont’d
• Uremic syndrome develops affecting all
  body systems
• Last stage of progressive CRF
• Fatal if no treatment
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
Diagnostic Tools cont’d
• Biopsy
• Ultrasound
• X-Rays
Manifestations of Chronic Renal
Failure
Nervous System
• Mood swings
• Impaired judgment
• Inability to concentrate and perform simple
  math functions
• Tremors, twitching, convulsions
• Peripheral Neuropathy
  – restless legs
  – foot drop
Integumentary
•   Pale, grayish-bronze color
•   Dry scaly
•   Severe itching
•   Bruise easily
•   Uremic frost
Eyes
• Visual blurring
• Occasional blindness
Fluid - Electrolyte - PH
• Volume expansion and fluid overload
• Metabolic Acidosis
• Electrolyte Imbalances
  – Hyperkalemia
GI Tract
• Uremic fetor
• Anorexia, nausea, vomiting
• GI bleeding
Hematologic
• Anemia
• Platelet dysfunction
Musculoskeletal
•   Muscle cramps
•   Soft tissue calcifications
•   Weakness
•   Related to calcium phosphorous imbalances
Heart Lungs
•   Hypertension
•   Congestive heart failure
•   Pericarditis
•   Pulmonary edema
•   Pleural effusions
Endocrine/Metabolic
•   Erythropoietin production decreased
•   Hypothyroidism
•   Insulin resistance
•   Growth hormone decreased
•   Gonadal dysfunctions
•   Parathyroid hormone and Vitamin D3
•   Hyperlipidemia
Treatment Options
• Hemodialysis
• Peritoneal Dialysis
• Transplant
Hemodialysis
•   Removal of soluble substances and
    water from the blood by diffusion
    through a semi-permeable membrane.
Hemodialysis Process
• Blood removed from patient into the
  extracorporeal circuit.
• Diffusion and ultrafiltration take place in
  the dialyzer.
• Cleaned blood returned to patient.
Hemodialysis Process
Hemodialysis
Circuit
Extracorporeal
Circuit
Vascular Access
• Arterio-venous shunt (Scribner External
  Shunt)
• Arterio-venous (AV) Fistula
• PTFE Graft
• Temporary catheters
• “Permanent” catheters
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
External (Scribner) Shunt
Arterio-venous (AV) Fistula
Primary 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
AV Fistula
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
PTFE Graft
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
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
Cuffed Tunneled
Catheter
Complications of Hemodialysis
• During dialysis
   – Fluid and electrolyte related
      • hypotension
   – Cardiovascular
      • arrythmias
   – Associated with the extracorporeal circuit
      • exsanguination
   – Neurologic
      • seizures
   – other
      • fever
Complications of Hemodialysis
cont’d
• Between treatments
  –   Hypertension/Hypotension
  –   Edema
  –   Pulmonary edema
  –   Hyperkalemia
  –   Bleeding
  –   Clotting of access
Complications of Hemodialysis
cont’d
• Long term
   – Metabolic
      • hyperparathyroidism
      • diabetic complications
   – Cardiovascular
      • CHF
      • AV access failure
   – Respiratory
      • pulmonary edema
   – Neuromuscular
      • neuropathy
Complications of Hemodialysis
cont’d
• Long term cont’d
  – Hematologic
     • anemia
  – GI
     • bleeding
  – dermatologic
     • calcium phosphorous deposits
  – Rheumatologic
     • amyloid deposits
Complications of Hemodialysis
cont’d
• Long term cont’d
  – Genitourinary
     • infection
     • sexual dysfunction
  – Psychiatric
     • depression
  – Infection
     • bloodborne pathogens
Calcium-Phosphorous Balance
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
Peritoneal Dialysis
• Removal of soluble substances and water
  from the blood by diffusion through a semi-
  permeable membrane that is intracorporeal
  (inside the body).
Peritoneal
Dialysis
Types of Peritoneal Dialysis
• CAPD: Continuous ambulatory peritoneal dialysis
• CCPD: Continuous cycling peritoneal dialysis
• IPD: Intermittent peritoneal dialysis
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
Peritoneal Catheter Exit Site
Draining of Peritoneal Dialysate
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
Complications of Peritoneal
Dialysis
• Infection
   – peritonitis
   – tunnel infections
   – catheter exit site
• Hypervolemia
   – hypertension
   – pulmonary edema
• Hypovolemia
   – hypotension
• Hyperglycemia
• Malnutrition
Complications of Peritoneal
Dialysis cont’d
•   Obesity
•   Hypokalemia
•   Hernia
•   Cuff erosion
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
Peritoneal Dialysis Multi-bag
Prong Manifold
Medications Common to Dialysis
Patients
• Vitamins - water soluble
• Phosphate binder - (Phoslo, Calcium,
  Aluminum hydroxide) Give with meals
• Iron Supplements - don’t give with
  phosphate binder or calcium
• Antihypertensives - hold prior to dialysis
Medications Common to Dialysis
Patients cont’d
• 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
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
Patient Education
•   Alleviate fear
•   Dialysis process
•   Fistula/catheter care
•   Diet and fluid restrictions
•   Medication
•   Diabetic teaching
Transplantation
Treatment Not a Cure
Kidney Awaiting Transplant
Advantages
• Restoration of “normal” renal function
• Freedom from dialysis
• Return to “normal” life
Disadvantages
•   Life long medications
•   Multiple side effects from medication
•   Increased risk of tumor
•   Increased risk of infection
•   Major surgery
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
Function
• ATN? (acute tubular necrosis)
    – 50% experience
•   Urine output >100 <500 cc/hr
•   BUN, creatinine, creatinine clearance
•   Fluid Balance
•   Ultrasound
•   Renal scans
•   Renal biopsy
Fluid & Electrolyte Balance
• Accurate I & O
  – CRITICAL TO AVOID DEHYDRATION
  – Output normal - >100 <500 cc/hr, could be 1-2
    L/hr
  – Potential for volume overload/deficit
• Daily weights
• Hyper/Hypokalemia potential
• Hyponatremia
• Hyperglycemia
Prevention of Infection
• Major complication of transplantation due
  to immunosuppression
• HANDWASHING
• Crowds, Kids
• Patient Education
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
Rejection cont’d
• 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
Rejection cont’d
• Chronic - gradual process of graft
  dysfunction
  – Repeated rejection episodes that have not been
    completely resolved with treatment
  – Rx = return to dialysis or re-transplantation
Immunosuppressant Drugs
• Prednisone
  – Prevents infiltration of T lymphocytes
• Side effects
  –   cushnoid changes
  –   Avascular Necrosis
  –   GI disturbances
  –   Diabetes
  –   infection
  –   risk of tumor
Immunosuppressant Drugs cont’d
• Azathioprine (Imuran)
  – Prevents rapid growing lymphocytes
• Side Effects
  –   bone marrow toxicity
  –   hepatotoxicity
  –   hair loss
  –   infection
  –   risk of tumor
Immunosuppressant Drugs cont’d
• 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
Immunosuppressant Drugs cont’d
• Cytoxan - in place of Imuran less toxic
• FK506 - 100 x more potent than
  Cyclosporin
• Prograf
• Cellcept
• other in trials
Immunosuppressant Drugs cont’d
• 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
Immunosuppressant Drugs cont’d
• 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
Patient Education
• Signs of infection
• Prevention of infection
• Signs of rejection
   – decreased urine output
   – increased weight gain
   – tenderness over kidney
   – fever > 100 degrees F
• Medications
• time, dose, side effects

								
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