41 rcs renal failure

RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Renal Failure

Function of Kidneys
Remove toxic waste products
Remove excess water and salts
Play a part in controlling blood pressure
Produce erythropoetin (epo) which stimulates red cell production
Helps to keep calcium and phosphate in balance for healthy bones
Maintains proper pH for the blood

Definitions
Azotemia: Elevated blood urea nitrogen
(BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL)
Uremia: azotemia with symptoms or signs of renal failure
End Stage Renal Disease (ESRD): uremia requiring transplantation or dialysis
Chronic Renal Failure (CRF): irreversible kidney dysfunction with azotemia >3 mos.
Creatinine Clearance (CCr): rate of filtration of creatinine by the kidney (marker for GFR)
Glomerular Filtration Rate (GFR): the total rate of filtration of blood by the kidney.

Nephrons
Nephrons are the units in the kidney that transfer waste products from the blood to urine.
A human kidney has approximately one million nephrons.
Glomeruli are the filtration units of the nephron.
The Glomerulus (first structure of the nephron) is a tuft of capillaries. Blood enters the glomerulus by the afferent arteriole and exits by the efferent arteriole
Bowman’s capsule is a tough layer of epithelial cells that surrounds the glomerulus ;there is a small holding area for the initial filtrate in between the capillary walls of the glomerulus and the inner layer of Bowman’s capsule; this area is called Bowman’s space. Fluid and solutes filtered by the glomerulus collect in this space. The space connects to the proximal convoluted tubule, which is the first section of the nephron’s tube system
a network of tubules extends from Bowman’s capsule:
proximal convoluted tubule (PCT)
Loop of Henle—has a descending and ascending limb
distal convoluted tubule
Collecting duct

Renal Failure
Acute Renal Failure
Prerenal azotemia
An abnormally high level of nitrogen-type wastes in the bloodstream. It is caused by conditions that reduce blood flow to the kidneys.
Postrenal azotemia
An obstruction of some kind (i.e., bladder cancer, uric acid crystals, urethral stricture etc)
Intrinsic Renal Disease
Usually glomerular disease
Usually leads to End Stage Renal Disease

Chronic Renal Failure
Diabetic Nephropathy
50K cases of DN ESRD annually
Diabetes most common contributor to ESRD
>30% of ESRD cases attributed to Diabetes
Hypertension
CFR with Hypertension causes 23% of ESRD annually
Glomerulonephretis: 10%
Polycystic Kidney Disease: 5%
Rapidly progressive glomerulonephrities (vasculitis): 2%
Renal Vascular Disease (i.e., renal artery stenosis)
Medications
Analgesic Nephropathy (progression after many years)
Pregnancy: high incidence of increased creatitine and HTN during pregnancy associated with CRF

CRF is defined as a permanent reduction in glomerular filtration rate (GFR) sufficient to produce detectable alterations in well-being and organ function. This usually occurs at GFR below 25 ml/min.
About 100 to 150 per million persons in the U.S. develop CRF annually
Average annual cost is $25,000 – 35,000 per patient per year

Stages of Chronic Renal Failure
Silent – GFR up to 50 ml/min.
Renal insufficiency – GFR 25 to 50 ml/min.
Renal failure – GFR 5 to 25 ml/min
End-stage renal failure – GFR less than 5 ml/min.

Diabetic Nephropathy
What can be done to reduce the risk of problems?
Blood glucose control
Blood pressure control
Using ACE inhibitors and AT II antagonists
Diet
Controlling blood lipids and cholesterol
Smoking

Treatment for Diabetic Nephropathy Stage Assessment Treatment No Proteinuria Monitor BP & Glucose Screen for micoalbumininuria Hypertension drugs if needed (BP should be 130/85 or lower). Dietary advice for sugar and fat, stop smoking Microalbuminuria Close monitoring of BP, Glucose and blood lipids, monitor urinary proteins & CCr Add more Hypertension drugs if needed needed. Monitor cholesterol and add ACE inhibitor if needed Proteinuria Close monitoring of BP, glucose and blood lipids, monitor urinary protein and 24 CCr BP should be lower than 125/75, low protein diet Declining kidney function Prepare for dialysis &/or transplant

Metabolic changes
Na+ excretion initially increased
Edema occurs when GFR continues to diminish.
NH4+ excretion declines adding to metabolic acidosis.
Bone CaCO3 begins to act as a buffer for the acidosis and leading to chronic bone loss and bone lesions develop (renal osteodystrophy).
Accumulations of normally secreted uremic toxins

Uremic Syndrome
Uremia occurs in stage 3 & 4 of CRF. It means literally “urine in the blood”
Symptomatic azotemia
Fever, Malaise
Anorexia, Nausea
Mild neural dysfunction
Uremic pruritus (itching)

Associated problems with CFR
Immunosuppression
Increased risk of infection
People with CFR should be vaccinated regularly
Anemia
Due to reduced erythropoietin production by kidney. Usually doesn’t occur until 6-12 mos prior to dialysis
Hyperuricemia (Gout)
Increased uric acid in system
Pain in joints, may contribute to renal dysfunction
Hyperphosphatemia
Increased parathyroid hormone levels
Increased phosphate load from bone metabolism
Hypertension
Poor coagulation
Proteinuria

Chronic Renal Failure and Its Progression
Functional Adaptation to Nephron Loss
Increased amount of sodium that escapes reabsorption
Excessive amount of potassium in blood
Increased ammonia concentration
Calcium and phosphorus metabolism are markedly altered

Treatment of Chronic Renal Failure
Hypertension
Metabolic Acidosis
Anemia
Renal Osteodystrophy
Uremic Neuropathy
Sexual Dysfunction

Conservative Treatment Dialysis Transplant Hemodialysis Peritoneal Related Donor Cadaver Donor Home Center

Treatment of End Stage Renal Failure
Hemodialysis
Uses a mechanized filter to remove impurities from the blood system
Essentially replaces kidney with a machine
Dialysis usually occurs a couple times per week.

Hemodialysis
Vascular preparation
Surgical procedures usually completed weeks before beginning hemodialysis

Peritoneal Dialysis
Uses the abdominal cavity as a filter

Transplantation

Treatment of End Stage Renal Disease
Survival of People with ESRD
Data show a mean expected remaining life span of just under 8 years for people 40-44 beginning dialysis and just over 4 years for people 60-64
Adequacy of Dialysis
Nutrition

Physical Rehabilitation – benefits of exercise
Vocational Rehabilitation
The goal should be to help the person with chronic renal failure to resume all the duties, responsibilities and benefits he or she enjoyed prior to the illness
Gainful employment is extremely important for an adult in the earning period of his or her life, to regain self-esteem and to interact with society confidently
Fear of losing financial benefits may deter some people
Some research has shown that multidisciplinary predialysis intervention leads to maintenance of job

Additional Resources and Information from the Web
Florida End Stage Renal Disease Network ( http://www.fmqai.com/ESRD/esrd.htm )
University Renal Research and Education Association ( www.urrea.org )
National Institute of Diabetes & Digestive & Kidney Diseases ( www.niddk.nih.gov )
National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC) ( http://kidney.niddk.nih.gov/ )
Life Options Rehabilitation Program ( www.lifeoptions.org )
United Network for Organ Sharing (UNOS) ( http://www.unos.org )
American Society of Nephrology ( www.asn-online.org )
National Kidney Foundation ( www.kidney.org )
JAN’s webpage ( www.jan.wvu.edu/soar/other/renal.html )

41 rcs renal failure

by Dang Thanh Tuan

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