Chronic renal failure, surgical management


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  • From - BAHAMAS INFORMATION SERVICES UPDATESGovernment spends $15 million annually on dialysis treatmentBy Matt MauraMar 10, 2011 - 3:46:02 PMNassau, The Bahamas - The Government of The Bahamas spends almost 15 million dollars annually to provide free dialysis treatment to 330 persons with kidney disease. This figure does not include costs associated with medications and/or hospitalisation as a result of associated complications.Dialysis treatment is predominantly used to manage kidney disease in The Bahamas and costs a whopping $45,000 per patient per year. Recent data confirms that there are more than 330 persons in The Bahamas receiving free dialysis treatment as a result of kidney disease. The total cost to treat those persons: $14,850,000.Public Health officials say the 330 figure does not include persons who “are unknown to nephrology services for whatever reason”. They say the number of persons with kidney disease is likely to increase as more and more Bahamians become more at-risk for the disease due to the high prevalence of chronic, non-communicable diseases such as diabetes and hypertension – two leading causes for kidney disease – in The Bahamas.Chronic, non-communicable diseases such as diabetes and hypertension or high blood pressure can be prevented through proper diet and exercise.Minister of Health, Dr. the Hon., Hubert A. Minnis said while the Government has implemented and will continue to implement new strategies to help battle kidney disease and reduce the heavy costs associated with the treatment and management of the disease, the onus is on “every single Bahamian, particularly those at-risk persons” to ensure that they adopt healthy lifestyles to prevent life threatening illnesses such as kidney disease.”Dr. Minnis said research has shown that “intensivecontrol” of diabetes and high blood pressure” can prevent the onset of kidney disease. â€œSimple choices like eating a balanced diet, engaging in regular exercise and having an annual physical examination are all necessary to help prevent the disease,” Dr. Minnis said.“It is also necessary for individuals who fall within high-risk groups for renal disease to get tested for the disease in order to facilitate early detection and prompt treatment and monitoring,” Dr. Minnis added.The Health Minister said conditions such as diabetes and hypertension have contributed to a rise in renal diseases in The Bahamas. The two are prevalent among Bahamians.He said public health officials have launched a series of education and awareness programmes designed to educate members of the public on the implications of the incidence of chronic kidney disease in the country and to ensure that the disease may be prevented, where possible, or to ensure early detection, timely referral and safe and effective client care.“As knowledge and understanding of the causes of kidney failure increases, so does the ability to predict and prevent kidney disease increases,” Dr, Minnis added.© Copyright 2011 by - 
  • ABO incompatibility.Cystoxic antibodies against HLA antigens of donor.Recent or metastatic malignancy.Active infection.AIDS.Severe extrarenal disease (cardiac, pulmonary, hepatic).Active vasculitis or glomeulonephritis.Uncorrectable lower urinary tract disease.Noncompliance.Psychiatric illness including alcoholism and drug addiction.Morbid obesity.Age > 70 years.Primary oxalosis.Persistent coagulation disorder.
  • Transplanted kidney is placed in the R or L lower quadrant of the abdomen in an extraperitoneal position. On examination, the transplant is easily palpable.The transplant renal a is anastomosed to the ipsilateral internal or external iliac a, the renal v to internal or external iliac v and the transplant ureter to the bladder.Generally a single kidney is transplanted.When small, paediatric or older cadaveric donor kidneys with age-related loss of renal fxn are transplanted, both kidneys from the donor might be placed in a single recipient to provide adequate fxnal renal mass.
  • Chronic renal failure, surgical management

    3. 3.  Chronic renal failure (CRF) is a progressivedecrease in renal function (CFR <60 ml/minfor ≥3 mo) with subsequent accumulation ofwaste products in the blood, electrolyteabnormalities, and anemia.Ferri: Ferris Clinical Advisor 2008, 10th ed.
    4. 4.  Number of patients with ESRD is increasing atthe rate of 7% to 9%/yr in the U.S. Each year 2/10,000 persons develop end-stageCRF. In the U.S., >250,000/yr receive dialysistreatment for ESRD.
    5. 5.  15 million dollars annually to provide free dialysistreatment to 330 persons with kidney disease. costs a whopping $45,000 per patient per year. Recent data confirms that there are more than 330persons in The Bahamas receiving free dialysistreatment as a result of kidney disease. The total cost to treat those persons: $14,850,000.
    6. 6.  Estimated figures will increase by some 60 % to 80% above current levels in all countries by the year2020. Diabetes is by far the single largest contributor tocauses of kidney failure, accounting for some 47%of diagnoses in the United States as reflected in theUSRDS statistics for 2011. Hypertension (high blood pressure) issecond, accounting for some 25-30%.
    7. 7. MONTH NEWPTSACUTEPTSTRANSIENT PTSTOTPTSTOTRxDEATHSJAN 11 1 3 139 1569 2FEB 3 5 5 139 1628 5MARCH 4 0 1 142 1722 3APRIL 3 3 7 142 1527 3MAY 6 2 3 150 1698 2JUNE 2 0 5 157 1754 0JULY 3 2 4 159 1750 2AUG 7 0 7 163 1902 3SEP 9 0 10 153 1624 0OCT 3 2 6 156 1814 0NOV 1 0 8 157 1611 0DEC 3 0 2 155 1503 6
    8. 8.  Diabetes (37%) Hypertension (30%) Chronic glomerulonephritis (12%) Polycystic kidney disease Tubular interstitial nephritis (e.g., drug hypersensitivity, analgesicnephropathy) Obstructive nephropathies (e.g., nephrolithiasis, prostatic disease) Vascular diseases (renal artery stenosis, hypertensivenephrosclerosis)
    9. 9.  The clinical presentation varies with the degree of renalfailure and its underlying etiology. Skin pallor, Ecchymoses Edema Hypertension Emotional lability depression Common symptoms are generalized fatigue, nausea,anorexia, pruritus, insomnia, taste disturbances
    11. 11.  LABORATORY EVALUATION Urinalysis: may reveal proteinuria, RBC casts Serum chemistry: elevated BUN andcreatinine, hyperkalemia, hyperuricemia, hypocalcemia, hyperphosphatemia, hyperglycemia, decreased bicarbonate Urinary protein excretion. Ratio of protein to creatinine of >1000mg/g suggests the presence of glomerular disease Cystatin C is a cysteine proteinase inhibitor produced by allnucleated cells, freely filtered at the glomerulus but not secretedby tubular cells. Given these characteristics, it may be superior tocreatinine concentration both in kidney disease and as a marker ofacute kidney injury.
    13. 13. People with chronic kidney failure have threetreatment choices. DIALYSIS RENAL TRANSPLANT CONSERVATIVE TREATMENT
    14. 14.  a method of removing toxic substances (impuritiesor wastes) from the blood when the kidneys areunable to do so. most frequently used for patients who havekidney failure, but may also be used to quicklyremove drugs or poisons in acute situations. This technique can be life saving in people withacute or chronic kidney failure. 2 methods: hemodialysis and peritoneal dialysis
    15. 15. Hemodialysis Peritoneal Dialysis
    16. 16.  A dialysis processwhich requires amachine to transportthe blood anddialysing fluid oneither side of a semi-permeable membraneto effect the removalof toxic metabolitesand excess water
    17. 17. Hemodialysis Treatment with the newdialysis machine
    18. 18. 1. blood6. dialysate7. body2. access3. tx w/ heparin4. dialyser5. solute exchange4-6 hours
    19. 19.  may be inserted forshort term or temporaryuse in acute renalfailure usually filled w/heparin & capped tomaintain patencybetween dialysistreatments may be left in place forup to 6 wks ifcomplications do notoccur
    20. 20.  may be inserted for shortterm or temporary use inacute renal failure client should not sit upmore than 45 or leanforward, or the cathetermay kink & occlude. an IV infusion pump w/microdrip tubing shouldbe used if a heparininfusion through thecatheter is prescribed
    21. 21.  Assess insertion site forhematoma, bleeding, dislodging, and infection. Do not use these catheters for any reason otherthan dialysis. Maintain an occlusive dressing.
    22. 22.  Access is formed bythe surgical insertionof 2 silastic cannulasinto an artery or veinin the forearm or legto form an externalblood path.
    23. 23. ADVANTAGES DISADVANTAGES Can be used immediatelyafter insertion No venipuncturenecessary for dialysis External danger ofdisconnecting or dislodgingthe shunt Risk of hemorrhage,infection or clotting Skin erosion around thecatheter site
    24. 24.  Avoid wetting the shunt. A dressing is wrapped completely around the shunt & keptdry & intact. Cannula clamps need to be available at the client’s bedside. Do not take BP, draw blood, place an IV line, or administerinjections in the shunt extremity. Monitor for hemorrhage, infection and clotting. Monitor skin integrity around the insertion site. Note that the shunt is patent if it is warm to touch. Auscultate & palpate for a bruit, although a bruit may notbe heard & is not always with the shunt. Notify the physician immediately if signs ofclotting, hemorrhage, or infection occur.
    25. 25.  for chronic dialysisclients created surgically byanastomosis of a largeartery & a large veinin the arm Maturity: veinsbecome engorged dueto the flow of arterialblood into the venoussystem; takes 1-2 wks. Maturity is requiredbefore the fistula canbe used
    26. 26.  Preferred form of dialysis access Types Radiocephalic (first choice) Brachiocephalic (second choice) Brachiobasilic (third choice, requiressuperficialization of basilic vein, i.e. transposition) Lower extremity fistulae are rare
    27. 27. ADVANTAGES DISADVANTAGES Less danger of clottingand bleeding Can be used indefinitely Decreased incidence ofinfection No external dressingrequired Freedom of movement Cannot be usedimmediately after insertion Venipuncture is requiredfor dialysis Infiltration of needles →hematoma Aneurysm in the fistula Arterial steal syndrome Congestive heart failure
    28. 28.  for chronic dialysis clientswho do not have adequateblood vessels for thecreation of a fistula Gore-Tex or a bovine(cow) carotid artery asartificial vein for bloodflow Procedure involves theanastomosis of the graft tothe artery, a tunnelingunder the skin, andanastomosis to a vein. can be used 2 wks afterinsertion Complications: clotting,aneurysms and infection
    29. 29.  Synthetic conduit, usually polytetrafluoroethylene(PTFE, aka Gortex), between an artery and a vein Either straight or looped Common sites Straight forearm : Radial artery to cephalic vein Looped forearm : brachial artery to cephalic vein Straight upper arm : brachial artery to axillary vein Looped upper arm : axillary artery to axillary vein
    30. 30. ADVANTAGES DISADVANTAGES Less danger of clottingand bleeding Can be used indefinitely Decreased incidence ofinfection No external dressingrequired Freedom of movement Cannot be usedimmediately after insertion Venipuncture is requiredfor dialysis Infiltration of needles →hematoma Aneurysm in the fistula Arterial steal syndrome Congestive heart failure
    31. 31.  Do not measure BP, draw blood, place an IV line, oradminister injections in the fistula or graft extremity. Monitor for clotting. Monitor for arterial steal syndrome. Palpate or auscultate for bruit or thrill over the fistulaor graft. Palpate pulses below the fistula or graft, and monitorfor hand swelling as an indication of ischemia. Note temperature and capillary refill of the extremity. Monitor for infection. Monitor lung and heart sound for signs of CHF. Notify the physician immediately if sings of clotting,infection, or arterial steal syndrome occur.
    32. 32. Hemodialysis Peritoneal Dialysis
    33. 33.  A dialysis process which requires theintroduction of peritoneal dialysis solution(dialysate) into the peritoneal cavity via gravityor a cycler. A soft, elastic tube (catheter) inside theabdomen is inserted through a minor surgicaloperation.
    34. 34.  Peritoneum – semi-permeable; rich bloodsupply When a dialysate is put into the peritonealcavity, the dialysate gently pulls the smallpieces of waste products & water from theblood into the dialysate via the semi-permeablemembrane. (diffusion & osmosis)
    35. 35. 1. Urea &other toxic wastes6. Drained out2. Capillary blood3. Peritonealmembrane4. dialysate5. “effluent”
    36. 36.  Continuous Ambulatory Peritoneal Dialysis(CAPD) Automated Peritoneal Dialysis (APD)
    37. 37.  A dialysis treatmentcarried outcontinuously 24/7without the use of adialysis machine
    38. 38. CAPD Solution Baghas 2 short tubes at the bottom end:Shorter tube w/ aluminum cap: for adding medicationLonger tube w/ connector: for connection w/ the Y-SetAlways check the ff before use:Strength: 1.5 GLU to 4.25 GLUClarity: clear & w/o particlesAmount: 1L to 2LLeakage: no leaking bagsExpiry Date: do not use after expiry date
    39. 39.  CAPD Y-Set Connection for the patient line, new solution bag and empty bag Patient Line Attached to the catheter Reduces exit site infection White Caps Used to cover the end of the patient line after an exchange Braunoderm (Skin disinfectant) For disinfection Masks Protection for both the nurse and equipment
    40. 40. 1. The dialysate is instilledinto the peritoneal cavitythrough an implant catheterattached to atransferline, which isattached to a bag ofdialysate.2. Once the fluid has been instilledcompletely into the peritoneal cavity, theempty bag and transferline are folded upand worn in a cloth pouch beneath theclothing. Thus, the patient is free toambulate and resume his normal dailyactivities.
    41. 41. 3.When it is time to drain off the effluent, the bag isunfolded, placed on the floor and drainage is achieved bygravity. A new bag of dialysate is then attached to thetransferline and the process is repeated. Usually thesolution exchange procedure takes about 15 minutes.
    42. 42.  Continuous Ambulatory Peritoneal Dialysis(CAPD) Automated Peritoneal Dialysis (APD)
    43. 43.  Similar to CAPD Requires a peritonealcycling machinecalled a cycler Can be done asintermittentperitoneal dialysis,continuous cyclingperitoneal dialysis, ornightly peritonealdialysis
    44. 44.  Peritonitis Signs: cloudy bag, stomach pain, fever If suspected, obtain a culture of the outflow to determine the infective organism Abdominal Pain Pain during inflow is common during the 1st few exchanges & usuallydisappears 1 to 2 wks of dialysis treatments Place heating pad Insufficient Outflow Check for kinks and placement; refer to physician Encourage high-fiber diet Leakage around the catheter site May take up to 2 wks for client to tolerate a full 2L exchange w/o leakingaround the catheter site Bladder or Bowel Perforation
    45. 45.  Monitor vital signs. Monitor for signs of infection. Monitor for respiratory distress, pain, or discomfort. Monitor signs of pulmonary edema. Monitor for hypotension & hypertension. Monitor for malaise, nausea, vomiting. Assess the catheter sit dressing for wetness or bleeding. Monitor dwell time as prescribed by the physician & initiate flow. Do not allow dwell time to extend beyond the physician’s orderbecause this increases the risk for hyperglycemia. Turn the client from side to side if the outflow is slow to start. Monitor outflow, which should be a continuous stream after theclamp is opened. Monitor outflow for color & clarity. Monitor intake & output accurately. If outflow < inflow, inflow – outflow = amt absorbed/retained bythe client during dialysis andshould be counted as intake.
    46. 46.  Annual mortality rates for patients under dialysisrange from 21%-25%, but <8% with cadaveric and<4% with living-related transplant recipients. Healthier patients generally are selected fortransplantation. The benefit of transplantation is most notable inyoung people and in those with diabetes mellitus.Projected years of life for patients 20-39 years old:Dialysis TransplantNon diabetic 20 31 yearsDiabetic 8 25years
    47. 47. INDICATIONS CONTRAINDICATIONS All patients with ESRDare candidates for KTAbsolute : Severe vasculardisease.Relative : Recent malignancy. Coronary arterydisease. Activebacterial, fungal, orviral disease. HIV positivity. Social conditions.
    48. 48. - Blood relative.- Highly motivated.- ABO blood group-compatible.- HLA-identical or haploidentical with negativecross-match.- Excellent medical condition with normal renalfunction.
    49. 49. - Irreversible brain damage.- Normal renal function appropriate for age.- No evidence of preexisting renal disease.- No evidence of transmissible diseases.- ABO blood group-compatible.- Negative cross-match.- Best HLA match possible, particularly at the DRand B loci.
    50. 50.  Wet ischemia time (time from cessation ofcirculation to removal of organ and itsplacement in cold storage) should not exceed30 mins. Living donor transplants function immediatelyafter transplant, +/- 30% of cadaverictransplants have delayed graft functionbecause of more prolonged ischemic coldpreservation. These pts need continueddialysis support until the kidney starts tofunction.
    51. 51.  Directly related to source of donor kidney. Recipients of cadaveric kidneys have moreepisodes of rejection and lower graft survivalrates. Graft survival rates for kidneys from livingdonor is 95% @ 1 yr and 76% @ 5 yrs vs graftsurvival from a cadaveric kidney donor is 89%@ 1 yr and 61% @ 5 yrs.
    52. 52.  Usual postop generic complications: Atelectasis Pneumonia Haemorrhage Venous thromboembolism Transplant rejection (hyeracute,acute,chronic) Wound infection Fever
    53. 53. I. Acute occlusion of transplant renal a or v.II. Electrolyte imbalanceIII. Peritransplant haematomaIV. Urinary LeakV. Obstructive uropathyVI. Renal artery stenosis
    54. 54.  Chronic renal failure is a debilitatingcondition. Urgent appropriate intervention tends toprolong life and prevent a sequel ofcomplications Renal transplantation is superior compared todialysis Transplant tends to prolong life morecompared to dialysis
    55. 55.  Ferri: Ferris Clinical Advisor 2008, 10th ed. Principles of Surgical Patient Care, 2nd edition,CJ Mieny + V Mennen, 2003. Emedicine, Transplant, Renal, Richard Sinert +Mert Erogul. Special thanks to Dialysis Unit PMH Special thanks to Dr McPhee