41 rcs renal failure


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  • Diabetic nephropathy is the kidney disease that occurs as a result of diabetes. It is a leading cause of kidney failure in Europe and the USA. After many years of diabetes the delicate filtering system in the kidney becomes destroyed, initially becoming leaky to large blood proteins such as albumin which are then lost in urine. This is more likely to occur if the blood sugar is poorly controlled. The overall risk of developing diabetic nephropathy varies between about 10% of type II diabetics (diabetes of late onset) to about 30% of type I diabetics (diabetes of early onset). Black men have a 3.5-4 fold increased risk of CFR compared to white men. Blood pressure and SES correlated with CFR in whites and blacks. Unclear if Blacks have increased risks when blood pressure and income are similar. Analgesic nephropathy: slow progression of disease due to chronic daily ingestion of analgesics Associated with long-term use of of NSAIDs and Acetaminophen. Chronic interstitial nephritis, renal papillary necrosis and renal calcifications seen
  • Good blood glucose control can prevent the development and slow the progression of diabetic nephropathy, as well as preventing the other complications of diabetes, even if kidney failure has developed. This can not be achieved by tablets and/or insulin alone, but requires a good diet too. Achieving these things will involve discussion with doctors, nurses and dieticians. The recommended target blood pressure is 125/75 mmHg in diabetic patients. This usually requires more than one type of tablet to achieve. If you are overweight, losing weight will help too. Two classes of drug used to control blood pressure deserve special mention. These are the A ngiotensin- C onverting E nzyme ( ACE ) inhibitors and a ngio t ensin II ( AT II ) receptor antagonists. Many studies have documented the greater potency of ACE inhibitors at reducing proteinuria and the progression of kidney disease compared to other classes of drug. These drugs not only reduce blood pressure in the large blood vessels, but also directly in the kidneys' filtering system (called glomeruli). Although these drugs tend to be preferentially used, they need to be monitored as they may have a detrimental effect on some people. It is thought that AT II receptor antagonists will have a similar effect, and these are often used in those unable to tolerate ACE inhibitors. A modest reduction in dietary protein intake may be of benefit in those who already have kidney impairment. However this is a controversial and uncertain area, because the effect may be small if other things are well controlled, and low protein diets can be hazardous. Many (eg the American Diabetic Association) recommend moderate restriction of dietary protein. Other aspects of diet (including energy, calcium and phosphate intake) are important in renal failure, and the assistance of a renal dietitian is usually required. Although the role of lipid-lowering is unclear in the course of diabetic nephropathy, it helps to prevent heart disease and possibly strokes. Lowering blood lipids requires both dietary and drug treatment, with the current available data pointing towards a target cholesterol of 5.2mmol/l. You really shouldn't smoke, not only for the sake of your kidneys, but also for the sake of your heart and brain blood vessels. Smokers die earlier than non-smokers, but diabetic smokers die much earlier and often develop serious circulation problems at a young age.
  • Albumin is a protein which is present in the blood. The kidneys act as a filter for waste products in the blood. Protein is not allowed to spill over into the urine unless the filter system is ‘leaky’. Microalbuminuria refers to the appearance of small but abnormal amounts of albumin in the urine. If measured, this protein excretion is between 30 and 300 mg during a 24 hour period
  • The symptoms and signs which constitute the uremic syndrome are summarized below:   Neurological Disorders: Fatigue, lethargy, sleep disturbances, headache, seizures, encephalopathy, peripheral neuropathy including restless leg syndrome, paraesthesia, motor weakness, paralysis.   Hematologic Disorders: Anemia, bleeding tendency – due in part to platelet dysfunction.   Anemia is universal as GFR falls below 25 ml/min.; in certain disorders it may occur with mild renal insufficiency Cardiovascular Disorders: Pericarditis, hypertension, congestive heart failure, coronary artery disease, myocardiopathy.   Hypertension occurs in 80% to 90% of patients with renal insufficiency Pulmonary Disorders: Pleuritis, uremic lung.   Gastrointestinal Disorders: Anorexia, nausea, vomiting gastroenteritis, GI bleeding, peptic ulcer.   Metabolic-Endocrine Disorders: Glucose intolerance, hyperllipidemia, hyperuricemia, malnutrition, sexual dysfunction and infertility.   Bone, Calcium, Phosphorus Disorders: Hyperphosphatemia, hypocalcemia, tetany, metastatic calcification, secondary hyperparathyroidism, 1,25-dihydroxy vitamin D deficiency, osteomalacia, osteitis fibrosa, osteoporosis, osteosclerosis.   Skin Disorders: Pruritus, pigmentation, easy bruising, uremic frost.   Psychological Disorders: Depression, anxiety, denial, psychosis.   Fluid and Electrolyte Disorders: Hyponatremia, hyperkalemia, hypermagnesemia, metabolic acidosis, volume expansion or depletion.
  • Various social or medical factors influence decisions about peritoneal or hemodialysis, and transplantation in the treatment of end-stage renal failure
  • 41 rcs renal failure

    1. 1. RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Renal Failure
    2. 2. Function of Kidneys <ul><li>Remove toxic waste products </li></ul><ul><li>Remove excess water and salts </li></ul><ul><li>Play a part in controlling blood pressure </li></ul><ul><li>Produce erythropoetin (epo) which stimulates red cell production </li></ul><ul><li>Helps to keep calcium and phosphate in balance for healthy bones </li></ul><ul><li>Maintains proper pH for the blood </li></ul>
    3. 3. Definitions <ul><li>Azotemia: Elevated blood urea nitrogen </li></ul><ul><ul><li>(BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL) </li></ul></ul><ul><li>Uremia: azotemia with symptoms or signs of renal failure </li></ul><ul><li>End Stage Renal Disease (ESRD): uremia requiring transplantation or dialysis </li></ul><ul><li>Chronic Renal Failure (CRF): irreversible kidney dysfunction with azotemia >3 mos. </li></ul><ul><li>Creatinine Clearance (CCr): rate of filtration of creatinine by the kidney (marker for GFR) </li></ul><ul><li>Glomerular Filtration Rate (GFR): the total rate of filtration of blood by the kidney. </li></ul>
    4. 4. Nephrons <ul><li>Nephrons are the units in the kidney that transfer waste products from the blood to urine. </li></ul><ul><li>A human kidney has approximately one million nephrons. </li></ul><ul><li>Glomeruli are the filtration units of the nephron. </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>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 </li></ul><ul><li>a network of tubules extends from Bowman’s capsule: </li></ul><ul><ul><li>proximal convoluted tubule (PCT) </li></ul></ul><ul><ul><li>Loop of Henle—has a descending and ascending limb </li></ul></ul><ul><ul><li>distal convoluted tubule </li></ul></ul><ul><ul><li>Collecting duct </li></ul></ul>
    5. 5. Renal Failure <ul><li>Acute Renal Failure </li></ul><ul><ul><li>Prerenal azotemia </li></ul></ul><ul><ul><ul><li>An abnormally high level of nitrogen-type wastes in the bloodstream. It is caused by conditions that reduce blood flow to the kidneys. </li></ul></ul></ul><ul><ul><li>Postrenal azotemia </li></ul></ul><ul><ul><ul><li>An obstruction of some kind (i.e., bladder cancer, uric acid crystals, urethral stricture etc) </li></ul></ul></ul><ul><ul><li>Intrinsic Renal Disease </li></ul></ul><ul><ul><ul><li>Usually glomerular disease </li></ul></ul></ul><ul><ul><ul><li>Usually leads to End Stage Renal Disease </li></ul></ul></ul>
    6. 6. Chronic Renal Failure <ul><li>Diabetic Nephropathy </li></ul><ul><ul><li>50K cases of DN ESRD annually </li></ul></ul><ul><ul><li>Diabetes most common contributor to ESRD </li></ul></ul><ul><ul><li>>30% of ESRD cases attributed to Diabetes </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>CFR with Hypertension causes 23% of ESRD annually </li></ul></ul><ul><li>Glomerulonephretis: 10% </li></ul><ul><li>Polycystic Kidney Disease: 5% </li></ul><ul><li>Rapidly progressive glomerulonephrities (vasculitis): 2% </li></ul><ul><li>Renal Vascular Disease (i.e., renal artery stenosis) </li></ul><ul><li>Medications </li></ul><ul><li>Analgesic Nephropathy (progression after many years) </li></ul><ul><li>Pregnancy: high incidence of increased creatitine and HTN during pregnancy associated with CRF </li></ul>
    7. 7. Chronic Renal Failure <ul><li>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. </li></ul><ul><li>About 100 to 150 per million persons in the U.S. develop CRF annually </li></ul><ul><li>Average annual cost is $25,000 – 35,000 per patient per year </li></ul>
    8. 8. Stages of Chronic Renal Failure <ul><li>Silent – GFR up to 50 ml/min. </li></ul><ul><li>Renal insufficiency – GFR 25 to 50 ml/min. </li></ul><ul><li>Renal failure – GFR 5 to 25 ml/min </li></ul><ul><li>End-stage renal failure – GFR less than 5 ml/min. </li></ul>
    9. 9. Diabetic Nephropathy <ul><li>What can be done to reduce the risk of problems? </li></ul><ul><ul><li>Blood glucose control </li></ul></ul><ul><ul><li>Blood pressure control </li></ul></ul><ul><ul><li>Using ACE inhibitors and AT II antagonists </li></ul></ul><ul><ul><li>Diet </li></ul></ul><ul><ul><li>Controlling blood lipids and cholesterol </li></ul></ul><ul><ul><li>Smoking </li></ul></ul>
    10. 10. 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
    11. 11. Metabolic changes <ul><li>Na+ excretion initially increased </li></ul><ul><li>Edema occurs when GFR continues to diminish. </li></ul><ul><li>NH4+ excretion declines adding to metabolic acidosis. </li></ul><ul><li>Bone CaCO3 begins to act as a buffer for the acidosis and leading to chronic bone loss and bone lesions develop (renal osteodystrophy). </li></ul><ul><li>Accumulations of normally secreted uremic toxins </li></ul>
    12. 12. Uremic Syndrome <ul><li>Uremia occurs in stage 3 & 4 of CRF. It means literally “urine in the blood” </li></ul><ul><ul><li>Symptomatic azotemia </li></ul></ul><ul><ul><li>Fever, Malaise </li></ul></ul><ul><ul><li>Anorexia, Nausea </li></ul></ul><ul><ul><li>Mild neural dysfunction </li></ul></ul><ul><ul><li>Uremic pruritus (itching) </li></ul></ul>
    13. 13. Associated problems with CFR <ul><li>Immunosuppression </li></ul><ul><ul><li>Increased risk of infection </li></ul></ul><ul><ul><li>People with CFR should be vaccinated regularly </li></ul></ul><ul><li>Anemia </li></ul><ul><ul><li>Due to reduced erythropoietin production by kidney. Usually doesn’t occur until 6-12 mos prior to dialysis </li></ul></ul><ul><li>Hyperuricemia (Gout) </li></ul><ul><ul><li>Increased uric acid in system </li></ul></ul><ul><ul><li>Pain in joints, may contribute to renal dysfunction </li></ul></ul><ul><li>Hyperphosphatemia </li></ul><ul><ul><li>Increased parathyroid hormone levels </li></ul></ul><ul><ul><li>Increased phosphate load from bone metabolism </li></ul></ul><ul><li>Hypertension </li></ul><ul><li>Poor coagulation </li></ul><ul><li>Proteinuria </li></ul>
    14. 14. Chronic Renal Failure <ul><li>Chronic Renal Failure and Its Progression </li></ul><ul><li>Functional Adaptation to Nephron Loss </li></ul><ul><ul><li>Increased amount of sodium that escapes reabsorption </li></ul></ul><ul><ul><li>Excessive amount of potassium in blood </li></ul></ul><ul><ul><li>Increased ammonia concentration </li></ul></ul><ul><ul><li>Calcium and phosphorus metabolism are markedly altered </li></ul></ul>
    15. 15. Treatment of Chronic Renal Failure <ul><li>Hypertension </li></ul><ul><li>Metabolic Acidosis </li></ul><ul><li>Anemia </li></ul><ul><li>Renal Osteodystrophy </li></ul><ul><li>Uremic Neuropathy </li></ul><ul><li>Sexual Dysfunction </li></ul>
    16. 16. Conservative Treatment Dialysis Transplant Hemodialysis Peritoneal Related Donor Cadaver Donor Home Center
    17. 17. Treatment of End Stage Renal Failure <ul><li>Hemodialysis </li></ul><ul><ul><li>Uses a mechanized filter to remove impurities from the blood system </li></ul></ul><ul><ul><li>Essentially replaces kidney with a machine </li></ul></ul><ul><ul><li>Dialysis usually occurs a couple times per week. </li></ul></ul>
    18. 18. Hemodialysis <ul><li>Vascular preparation </li></ul><ul><ul><li>Surgical procedures usually completed weeks before beginning hemodialysis </li></ul></ul>
    19. 19. Treatment of End Stage Renal Failure <ul><li>Peritoneal Dialysis </li></ul><ul><ul><li>Uses the abdominal cavity as a filter </li></ul></ul>
    20. 20. Treatment of End Stage Renal Failure <ul><li>Transplantation </li></ul>
    21. 21. Treatment of End Stage Renal Disease <ul><li>Survival of People with ESRD </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>Adequacy of Dialysis </li></ul><ul><li>Nutrition </li></ul>
    22. 22. Chronic Renal Failure <ul><li>Physical Rehabilitation – benefits of exercise </li></ul><ul><li>Vocational Rehabilitation </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><ul><li>Fear of losing financial benefits may deter some people </li></ul></ul></ul><ul><ul><ul><li>Some research has shown that multidisciplinary predialysis intervention leads to maintenance of job </li></ul></ul></ul>
    23. 23. Additional Resources and Information from the Web <ul><li>Florida End Stage Renal Disease Network ( http://www.fmqai.com/ESRD/esrd.htm ) </li></ul><ul><li>University Renal Research and Education Association ( www.urrea.org ) </li></ul><ul><li>National Institute of Diabetes & Digestive & Kidney Diseases ( www.niddk.nih.gov ) </li></ul><ul><ul><li>National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC) ( http://kidney.niddk.nih.gov/ ) </li></ul></ul><ul><li>Life Options Rehabilitation Program ( www.lifeoptions.org ) </li></ul><ul><li>United Network for Organ Sharing (UNOS) ( http://www.unos.org ) </li></ul><ul><li>American Society of Nephrology ( www.asn-online.org ) </li></ul><ul><li>National Kidney Foundation ( www.kidney.org ) </li></ul><ul><li>JAN’s webpage ( www.jan.wvu.edu/soar/other/renal.html ) </li></ul>