34 chronic renal failure & dialysis

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34 chronic renal failure & dialysis

  1. 1. Objectives <ul><li>Anatomy </li></ul><ul><li>Function </li></ul><ul><li>Chronic Renal Failure (CRF) </li></ul><ul><ul><li>Causes </li></ul></ul><ul><ul><li>Symptoms </li></ul></ul><ul><li>Dialysis </li></ul>
  2. 2. Anatomy and Physiology <ul><li>The Kidneys </li></ul><ul><ul><li>Hilum </li></ul></ul><ul><ul><li>Medulla </li></ul></ul><ul><ul><li>Pyramids </li></ul></ul><ul><ul><li>Papilla </li></ul></ul><ul><ul><li>Renal Pelvis </li></ul></ul>
  3. 3. Anatomy <ul><li>2 Kidneys </li></ul><ul><li>2 Ureters </li></ul><ul><li>Bladder </li></ul><ul><li>Urethra </li></ul>
  4. 5. Kidney Function <ul><li>Detoxify blood </li></ul><ul><li>Increase calcium absorption </li></ul><ul><ul><li>calcitriol </li></ul></ul><ul><li>Stimulate RBC production </li></ul><ul><ul><li>erythropoietin </li></ul></ul><ul><li>Regulate blood pressure and electrolyte balance </li></ul><ul><ul><li>renin </li></ul></ul>
  5. 6. <ul><li>Formation of Urine </li></ul><ul><ul><li>Glomerular Filtration </li></ul></ul><ul><ul><ul><li>GFR </li></ul></ul></ul><ul><ul><li>Reabsorption and Secretion </li></ul></ul><ul><ul><ul><li>Simple diffusion and osmosis </li></ul></ul></ul><ul><ul><ul><li>Facilitated diffusion </li></ul></ul></ul><ul><ul><ul><ul><li>Active transport </li></ul></ul></ul></ul>
  6. 7. Azotemia : elevated blood urea nitrogen not from an intrinsic renal disease <ul><li>Oliguria : urine output less than 500cc/24hr. </li></ul><ul><li>Nonoliguria : urine output greater than 500cc/24hr. </li></ul><ul><li>Anuria : urine output less than 50cc/24hr. </li></ul>
  7. 8. Acute Versus Chronic <ul><li>Acute </li></ul><ul><ul><li>sudden onset </li></ul></ul><ul><ul><li>rapid reduction in urine output </li></ul></ul><ul><ul><li>Usually reversible </li></ul></ul><ul><ul><li>Tubular cell death and regeneration </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Progressive </li></ul></ul><ul><ul><li>Not reversible </li></ul></ul><ul><ul><li>Nephron loss </li></ul></ul><ul><li>75% of function can be lost before its noticeable </li></ul>
  8. 9. ARF versus CRF <ul><li>Neuropathy </li></ul><ul><li>Renal osteodystrophy </li></ul><ul><li>Small size Kidney </li></ul><ul><li>Past history of CKD </li></ul><ul><li>Broad cast </li></ul>
  9. 10. Chronic renal failure <ul><li>Chronic renal failure: slowly progressive and non- reversible loss of kidney function </li></ul><ul><li>Uraemia: metabolic outcome of chronic renal failure </li></ul><ul><li>End-stage renal disease: requirement for renal replacement therapy </li></ul>
  10. 13. ETIOLOGY <ul><li>Diabetes mellitus (28%) </li></ul><ul><li>Hypertension (25%) </li></ul><ul><li>Glomerulonephritis (21%) </li></ul><ul><li>Polycystic Kidney Diease (4%) </li></ul><ul><li>Other (23%): Obstruction, infection, etc. </li></ul>
  11. 16. Progression of chronic renal failure <ul><li>Factors causing progression </li></ul><ul><ul><ul><li>sustaining primary disease </li></ul></ul></ul><ul><ul><ul><li>systemic hypertension </li></ul></ul></ul><ul><ul><ul><li>Intraglomerular hypertension </li></ul></ul></ul><ul><ul><ul><li>Proteinuria </li></ul></ul></ul><ul><ul><ul><li>Nephrocalcinosis </li></ul></ul></ul><ul><ul><ul><li>Dyslipidaemia </li></ul></ul></ul><ul><ul><ul><li>Imbalance between renal energy demands and supply </li></ul></ul></ul>
  12. 17. Slowing the Progression of Chronic Renal Failure <ul><li>Control BP to <130 /80 </li></ul><ul><li>Diet </li></ul><ul><li>Anaemia </li></ul><ul><li>Calcium and Phosphate </li></ul><ul><li>Dyslipidaemia </li></ul><ul><li>Obesity </li></ul><ul><li>Smoking Cessation </li></ul>
  13. 18. Old Chinese saying……. <ul><li>Good doctor relieve disease </li></ul><ul><li>Better doctor cure disease </li></ul><ul><li>Superior doctor prevent disease </li></ul>
  14. 19. Symptoms of chronic renal failure <ul><li>Many are symptom free until 2/3 of renal mass lost. Often no physical examination findings or history. Several common modes of presentation: </li></ul><ul><li>progressive lethargy, anorexia, (and later vomiting) </li></ul><ul><li>hypertension, and /or heart failure </li></ul><ul><li>unexplained anaemia </li></ul><ul><li>serendipitous findings on biochemistry </li></ul>
  15. 20. The Medical Burden Of Chronic Renal Failure <ul><li>Prevention of ESRD may prevent other co-morbid conditions from developing </li></ul><ul><li>In particular, there is a high prevalence of Cardiovascular diseases in patients with Chronic kidney disease </li></ul>
  16. 21. CHRONIC RENAL FAILURE: CLINICAL MANIFESTATIONS <ul><li>Sodium and water retention </li></ul><ul><li>Hyperkalemia </li></ul><ul><li>Metabolic Acidosis </li></ul><ul><li>Mineral and Bone metabolism </li></ul><ul><li>Cardiovascular and Pulmonary Disorders </li></ul><ul><li>Hematologic Abnormalities </li></ul><ul><li>Neuromuscular Abnormalities </li></ul><ul><li>Gastrointestinal Abnormalities </li></ul><ul><li>Endocrine Abnormalities </li></ul><ul><li>Dermatologic Abnormalities </li></ul>
  17. 22. Sodium and Volume Balance <ul><li>Sodium and water retention: </li></ul><ul><ul><li>CHF, Hypertension, ascites, edema </li></ul></ul><ul><li>Enhanced sensitivity to extra-renal sodium and water loss </li></ul><ul><ul><li>vomiting, diarrhea, fever, sweating </li></ul></ul><ul><ul><li>Symptoms: dry mouth, dizziness, tachycardia, etc. </li></ul></ul><ul><li>Recommendations </li></ul><ul><ul><li>Avoid excess salt and water intake </li></ul></ul><ul><ul><li>Diuretics or dialysis </li></ul></ul>
  18. 23. Potassium Balance <ul><li>Hyperkalemia (GFR below 5 mL/min) </li></ul><ul><ul><li>GFRs >5 mL/min: compensatory aldosterone-mediated K transport in the DCT </li></ul></ul><ul><ul><li>K-sparing diuretics, ACEis, beta-blockers impair Aldosterone-mediated actions </li></ul></ul><ul><ul><li>Exacerbation of hyperkalenia: </li></ul></ul><ul><ul><ul><li>Exogenous factors: K-rich diet, etc. </li></ul></ul></ul><ul><ul><ul><li>Endogenous factors: infection, trauma, etc. </li></ul></ul></ul>
  19. 24. Hyperkalemia & EKG <ul><li>K > 5.5 -6 </li></ul><ul><li>Tall, peaked T’s </li></ul><ul><li>Wide QRS </li></ul><ul><li>Prolong PR </li></ul><ul><li>Diminished P </li></ul><ul><li>Prolonged QT </li></ul><ul><li>QRS-T merge – sine wave </li></ul>
  20. 25. Hyperkalemia Symptoms <ul><li>Weakness </li></ul><ul><li>Lethargy </li></ul><ul><li>Muscle cramps </li></ul><ul><li>Paresthesias </li></ul><ul><li>Hypoactive DTRs </li></ul><ul><li>Dysrhythmias </li></ul>EKG?
  21. 28. Metabolic Acidosis <ul><li>Decreased acid excretion and ability to maintain physiologic buffering capacity: </li></ul><ul><li>GFR < 20 mL/min: transient moderate acidosis </li></ul><ul><li>Treat with oral sodium bicarbonate </li></ul><ul><li>Increased susceptibility to acidosis </li></ul>
  22. 29. Mineral and Bone <ul><li>Bone disease (Figure 16-6) from: </li></ul><ul><li>Decreased Ca absorption from the gut </li></ul><ul><li>Over-production of PTH </li></ul><ul><li>Altered Vitamin D metabolism </li></ul><ul><li>Chronic metabolic acidosis </li></ul>
  23. 31. Cardiovascular and Pulmonary Abnormalities <ul><li>Volume and salt overload </li></ul><ul><ul><li>CHF and pulmonary edema </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><li>Hyperreninemia: Hypertension </li></ul><ul><li>Pericarditis: Remic toxin accumulation </li></ul><ul><li>Accelerated atherosclerosis: linked to factors above and metabolic abnormalities (Ca alterations, hyperlipidemia) </li></ul>
  24. 32. Hematological Abnormalities <ul><li>Anemia: lack of erythropoietin production </li></ul><ul><li>Bone marrow suppression: </li></ul><ul><ul><li>uremic poisons: leukocyte suppression - infection </li></ul></ul><ul><ul><li>bone marrow fibrosis: elevated PTH an aluminum toxicity from dialysis </li></ul></ul><ul><li>Increased bruising, blood loss (surgery) and hemorrhage </li></ul><ul><li>Lab Abnormalities: Prolonged bleeding time, abnormal platelet aggregation </li></ul>
  25. 33. Neuromuscular Abnormalites <ul><li>CNS Abnormalities: </li></ul><ul><ul><li>Mild-Moderate: Sleep disorders, impaired concentration and memory, irritability </li></ul></ul><ul><ul><li>Severe: Asterixis, myoclonus, stupor, seizures and coma </li></ul></ul><ul><li>Peripheral neuropathies: </li></ul><ul><ul><li>“ restless legs” syndrome </li></ul></ul><ul><li>Hemodialysis-related neuropathies </li></ul>
  26. 34. Gastrointestinal Abnormalities <ul><li>Peptic Ulcer disease: Secondary hyperparathyrodism? </li></ul><ul><li>Uremic gastroenteritis: mucosal alterations </li></ul><ul><li>Uremic Fetor: bad breath (ammonia) </li></ul><ul><li>Non-Specific abnormalities: </li></ul><ul><ul><li>anorexia, nausea, vomiting, diverticulosis, hiccoughs </li></ul></ul>
  27. 35. Endocrine Abnormalities <ul><li>Insulin: Prolonged half-life due to reduced clearance (metabolism) </li></ul><ul><li>Amenorrhea and pregnancy failure: low estrogen levels </li></ul><ul><li>Impotence, oligospermia and geminal cell dysplasia: Low testosterone levels </li></ul>
  28. 36. Dermatologic Abnormalities <ul><li>Pallor: anemia </li></ul><ul><li>Skin color changes: accumulation of pigments </li></ul><ul><li>Ecchymoses and hematomas: clotting abnormalities </li></ul><ul><li>Pruritus and Excoriations: Ca deposits from secondary hyperparathyroidism </li></ul>
  29. 37. Conclusion – chronic renal failure <ul><li>Progressive chronic disease leading to end-state renal failure </li></ul><ul><li>Different primary disease can cause chronic renal failure </li></ul><ul><li>Diabetic nephropathy is a frequent cause for chronic renal failure </li></ul><ul><li>Symptoms can be very different and depend on primary disease and stage of chronic renal failure </li></ul><ul><li>Stages of renal failure can be associated with a progressive decrease of GFR </li></ul><ul><li>The consequences are complex according to the different function of the kidney and involve many organ systems </li></ul>
  30. 38. <ul><li>Pre-Dialysis Treatment </li></ul><ul><li>Maintain normal electrolytes </li></ul><ul><li>Potassium, calcium, phosphate are major electrolytes affected in CRF </li></ul><ul><li>ACE inhibitors may be acceptable in many patients with creatinine >3.0mg/dL </li></ul><ul><li>ACE inhibitors may slow the progression of diabetic and non-diabetic renal disease [ 13 ] </li></ul><ul><li>Reduce or discontinue other renal toxins (including NSAIDS) </li></ul><ul><li>Diuretics (eg. furosemide) may help maintain potassium in normal range </li></ul><ul><li>Renal diet including high calcium and low phosphate </li></ul>
  31. 39. <ul><li>Reduce protein intake to <0.6gm/kg body weight </li></ul><ul><li>Appears to slow progression of diabetic and non-diabetic kideny disease </li></ul><ul><li>In type 1 diabetes mellitus, protein restriction reduced levels of albuminuria </li></ul><ul><li>Low protein diet did not slow progression in children with CRF </li></ul><ul><li>Underlying Disease </li></ul><ul><li>Diabetic nephropathy should be treated with ACE inhibitors until creatinine >2.5-3mg/dL </li></ul><ul><li>Hypertension should be aggressively treated (ACE inhibitors are preferred) </li></ul>
  32. 40. Dialysis <ul><li>½ of patients with CRF eventually require dialysis </li></ul><ul><li>Diffuse harmful waste out of body </li></ul><ul><li>Control BP </li></ul><ul><li>Keep safe level of chemicals in body </li></ul><ul><li>2 types </li></ul><ul><ul><li>Hemodialysis </li></ul></ul><ul><ul><li>Peritoneal dialysis </li></ul></ul>
  33. 41. Hemodialysis <ul><li>Indications </li></ul><ul><li>Uremia - azotemia with symptoms and/or signs </li></ul><ul><li>Severe Hyperkalemia </li></ul><ul><li>Volume Overload - usually with congestive heart failure (pulmonary edema) </li></ul><ul><li>Toxin Removal - ethylene glycol poisoning, theophylline overdose, etc. </li></ul><ul><li>An arterio-venous fistula in the arm is created surgically </li></ul><ul><li>Catheters are inserted into the fistula for blood flow to dialysis machine </li></ul>
  34. 42. Hemodialysis <ul><li>3-4 times a week </li></ul><ul><li>Takes 2-4 hours </li></ul><ul><li>Machine filters </li></ul><ul><li>blood and </li></ul><ul><li>returns it to </li></ul><ul><li>body </li></ul>
  35. 43. <ul><li>Procedure for Chronic Hemodialysis </li></ul><ul><li>Blood is run through a semi-permeable filter membrane bathed in dialysate </li></ul><ul><li>Composition of the dialysate is altered to adjust electrolyte parameters </li></ul><ul><li>Electrolytes and some toxins pass through filter </li></ul><ul><li>By controlling flow rates (pressures), patient's intravascular volume can be reduced </li></ul><ul><li>Most chronic hemodialysis patients receive 3 hours dialysis 3 days per week </li></ul>
  36. 44. <ul><li>Efficacy </li></ul><ul><li>Some acids, BUN and creatinine are reduced </li></ul><ul><li>Phosphate is dialyzed, but quickly released from bone </li></ul><ul><li>Very effective at reducing intravascular volume/potassium </li></ul><ul><li>Once dialysis is initiated, kidney function is often reduced </li></ul><ul><li>Not all uremic toxins are removed and patients generally do not feel &quot;normal&quot; </li></ul><ul><li>Response of anemia to erythropoietin is often suboptimal with hemodialysis </li></ul>
  37. 45. <ul><li>Chronic Hemodialysis Medications </li></ul><ul><li>Anti-hypertensives - labetolol, CCB, ACE inhibitors </li></ul><ul><li>Eythropoietin (Epogen®) for anemia in ~80% dialysis pts </li></ul><ul><li>Vitamin D Analogs - calcitriol given intravenously </li></ul><ul><li>Calcium carbonate or acetate to  phosphate and PTH </li></ul><ul><li>RenaGel, a non-adsorbed phosphate binder, is being developed for hyperphosphatemia </li></ul><ul><li>DDAVP may be effective for patients with symptomatic platelet problems </li></ul>
  38. 46. Types of Access <ul><li>Temporary site </li></ul><ul><li>AV fistula </li></ul><ul><ul><li>Surgeon constructs by combining an artery and a vein </li></ul></ul><ul><ul><li>3 to 6 months to mature </li></ul></ul><ul><li>AV graft </li></ul><ul><ul><li>Man-made tube inserted by a surgeon to connect artery and vein </li></ul></ul><ul><ul><li>2 to 6 weeks to mature </li></ul></ul>
  39. 47. Temporary Catheter
  40. 48. AV Fistula & Graft
  41. 49. Chronic Renal Failure <ul><li>Long-Term Management </li></ul><ul><ul><li>Renal Dialysis </li></ul></ul><ul><ul><ul><li>Hemodialysis </li></ul></ul></ul><ul><ul><ul><li>Common complications </li></ul></ul></ul>
  42. 50. What This Means For You <ul><li>No BP on same arm as fistula </li></ul><ul><li>Protect arm from injury </li></ul><ul><li>Control obvious hemorrhage </li></ul><ul><ul><li>Bleeding will be arterial </li></ul></ul><ul><ul><li>Maintain direct pressure </li></ul></ul><ul><li>No IV on same arm as fistula </li></ul><ul><li>A thrill will be felt – this is normal </li></ul>
  43. 51. Access Problems <ul><li>AV graft thrombosis </li></ul><ul><li>AV fistula or graft bleeding </li></ul><ul><li>AV graft infection </li></ul><ul><li>Steal Phenomenon </li></ul><ul><ul><li>Early post-op </li></ul></ul><ul><ul><li>Ischemic distally </li></ul></ul><ul><ul><li>Apply small amount of pressure to reverse symptoms </li></ul></ul>
  44. 52. Peritoneal Dialysis <ul><li>Abdominal lining filters blood </li></ul><ul><li>3 types </li></ul><ul><ul><li>Continuous ambulatory </li></ul></ul><ul><ul><li>Continuous cyclical </li></ul></ul><ul><ul><li>Intermittent </li></ul></ul>
  45. 53. Considerations <ul><li>Make sure the dressing remains intact </li></ul><ul><li>Do not push or pull on the catheter </li></ul><ul><li>Do not disconnect any of the catheters </li></ul><ul><li>Always transport the patient and bags/catheters as one piece </li></ul><ul><li>Never inject anything into catheter </li></ul>
  46. 54. Dialysis Related Problems <ul><li>Lightheaded –give fluids </li></ul><ul><li>Hypotension </li></ul><ul><li>Dysrhythmias </li></ul><ul><li>Disequilibration Syndrome </li></ul><ul><ul><li>At end of early sessions </li></ul></ul><ul><ul><li>Confusion, tremor, seizure </li></ul></ul><ul><ul><li>Due to decrease concentration of blood versus brain leading to cerebral edema </li></ul></ul>

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