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  1. 1. Renal Failure and Treatment Vicky Jefferson, RN, CNN Satellite Dialysis
  2. 2. 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, Ph.D.
  3. 3. Renal Hemodynamics  Renal circulation receives 20 - 25 % of cardiac output under normal physiologic conditions.  The bodies blood volume circulates through the kidney every 6 minutes (12 times/hour).
  4. 4. Functions of the Kidneys  Renin secretion and the  Vitamin D activation regulation of volume and  Acid-base balance composition of regulation. extracellular fluid.  Erythropoietin  Excretion production  Blood pressure control  Urine formation
  5. 5. Renin  Renin is important in the regulation of blood pressure.  It is released from the granular cells of the efferent arteriole in response to decreased arteriole blood pressure, renal ischemia, extracellular fluid depletion, increased norepinephrine, and increased urinary Na+ concentration.
  6. 6. Blood Pressure Regulation 4 mechanisms are involved  Volume control  Aldosterone effect  Renin-angiotensin-aldosterone  Renal prostaglandin
  7. 7. Prostaglandin Prostoglandins (PGs)- synthesized by most body tissues. In the kidney, PGs are synthesized in the medulla and have a vasodilating action and promote Na+ excretion. PGs counteract the vasoconstrictor effect of angiotensin and norepinephrine. Renal PGs systemically lower blood pressure by decreasing systemic vascular resistance.
  8. 8. Vitamin D  Acquired by the body through diet or through synthesis by ultraviolet radiation on the cholesterol in the skin.  The liver and the kidney make the vitamin active in the body.
  9. 9. Erythropoietin  Erythropoietin is produced and released by the kidneys in response to decreased oxygen tension in the renal blood supply that is created by the loss of red blood cells.  Erythropoietin stimulates the production of RBCs in the bone marrow.  Erythropoietin deficiency leads to anemia in renal failure.
  10. 10. RBC Synthesis & Maturation Kidney secrete Erythropoietin, it stimulates the bone marrow to produce RBC’s   in oxygen delivery simulates release  in response the RBC count rises in 3 - 5 days  speeds the maturation of RBC’s
  11. 11. Acid Base Balance Kidneys regulate acid-base balance by stabilizing body fluid volume & flow rate to enhance the reabsorption or excretion of bicarbonate & hydrogen ions
  12. 12. Electrolyte Regulation  Sodium  Potassium  Calcium Need to Know:  Phosphate Normal Values  Magnesium Functions  Chloride Factors affect
  13. 13. Excretion of Metabolic Waste  Over 200 waste products excreted  Only 2 are used for clinical assessment  BUN  Creatinine
  14. 14. Excretion of Metabolic Waste  Over 200 waste products excreted  Only 2 are used for clinical assessment  BUN  Creatinine
  15. 15. BUN  Normal 8 - 20 mg/dl  Nitrogenous waste product of protein metabolism  Unreliable in measurement of renal function  Relevance is assessed in conjunction with Creatinine
  16. 16. Factors Affecting BUN  Urine flow  low renal perfusion  Volume depletion  Metabolic rate  Protein metabolism  Drugs
  17. 17. Creatinine  A waste product of muscle metabolism  Normal value 0.6 - 1.2 mg/dl  2 times normal = 50% damage  8 times normal = 75% damage  10 times normal = 90% damage  Exception - severe muscular disease can greatly  Creatinine levels
  18. 18. Diagnostic Tools for Assessing Renal Failure  Blood Tests  BUN elevated (norm 10-20)  Creatinine elevated (norm 0.6 - 1.2)  K elevated  PO4 elevated  Ca decreased  Urinalysis  Specific gravity  Protein  Creatinine clearance
  19. 19. Diagnostic Tools  Biopsy  Ultrasound  X-Rays
  20. 20. Acute Renal Failure (ARF)  Sudden onset - hours to days  Often reversible  Severe - 50% mortality rate overall; generally related to infection.
  21. 21. Characteristics of ARF  Homeostatic functions affected most  Electrolyte imbalances  Volume regulation  Blood pressure control  Endocrine functions affected lease  Require time to evolve  Renal size is preserved  Evidence of acute illness or insult exists
  22. 22. Acute Renal Failure (ARF)  Sudden fall in glomerular filtration rate (GFR)  Retention of nitrogenous (BUN and creatinine) and other wastes  Hours to days  About 5% of all hospitalizations  About 20% of ICU admissions  Mortality 50 – 80%  Independent risk factor for death – 5x increase risk
  23. 23. Chronic Renal Failure  Slow progressive renal disorder related to nephron loss, occurring over months to years  Culminates in End Stage Renal Disease
  24. 24. Characteristics of Chronic Renal Failure  Cause & onset often unknown  Loss of function precedes lab abnormalities  Lab abnormalities precede symptoms  Symptoms (usually) evolve in orderly sequence  Renal size is usually decreased
  25. 25. Causes of Chronic Renal Failure  Diabetes  Hypertension  Glomerulonephritis  Cystic disorders  Developmental - Congenital  Infectious Disease
  26. 26. Causes of Chronic Renal Failure  Neoplasms  Obstructive disorders  Autoimmune diseases  Lupus  Hepatorenal failure  Scleroderma  Amyloidosis  Drug toxicity
  27. 27. Glomerular Filtration Rate GFR  24 hour urine for creatinine clearance  Can estimate creatinine clearance by: 140 – {age x weight (kg)} 72 x serum creatinine
  28. 28. Stages of Chronic Renal Failure Old System  Reduced Renal Reserve  Renal Insufficiency  End Stage Renal Disease (ESRD)
  29. 29. Stages of Chronic Renal Failure NKF Classification System Stage 1: GFR > 90 ml/min despite kidney damage
  30. 30. Stages of Chronic Renal Failure NKF Classification System Stage 2: Mild reduction (GFR 60 – 89 ml/min) 1. GFR of 60 may represent 50% loss in function. 2. Parathyroid hormones starts to increase.
  31. 31. During Stage 1 - 2  No symptoms  Serum creatinine doubles  Up to 50% nephron loss
  32. 32. Stages of Chronic Renal Failure NKF Classification System Stage 3: Moderate reduction (GFR 30 – 59 ml/min) 1. Calcium absorption decreases 2. Malnutrition onset 3. Anemia secondary to Erythropoietin deficiency 4. Left ventricular hypertrophy
  33. 33. Stages of Chronic Renal Failure NKF Classification System Stage 4: Sever reduction (GFR 15 – 29 ml/min) 1. Serum triglycerides increase 2. Hyperphosphatemia 3. Metabolic acidosis 4. Hyperkalemia
  34. 34. During Stage 3 - 4  Signs and symptoms worsen if kidneys are stressed  Decreased ability to maintain homeostasis
  35. 35. During stages 3 - 4  75% nephron loss  Decreased: glomerular filtration rate, solute clearance, ability to concentrate urine and hormone secretion  Symptoms: elevated BUN & Creatinine, mild azotemia, anemia
  36. 36. Stages of Chronic Renal Failure NKF Classification System Stage 5: Kidney failure (GFR < 15 ml/min) 1. Azotemia
  37. 37. During Stage 5  Residual function < 15% of normal  Excretory, regulatory and hormonal functions severely impaired.  metabolic acidosis  Marked increase in: BUN, Creatinine, Phosphorous  Marked decrease in: Hemoglobin, Hematocrit, Calcium  Fluid overload
  38. 38. During Stage 5  Uremic syndrome develops affecting all body systems  can be diminished with early diagnosis & treatment  Last stage of progressive CRF  Fatal if no treatment
  39. 39. What happens when the kidneys don’t function correctly?
  40. 40. Manifestations of CRF - Nervous System  Mood swings  Impaired judgment  Inability to concentrate and perform simple math functions  Tremors, twitching, convulsions  Peripheral Neuropathy  restless legs  foot drop
  41. 41. Manifestations of CRF Skin  Pale, grayish-bronze color  Dry scaly  Severe itching  Bruise easily  Uremic frost
  42. 42. Manifestations of CRF Eyes  Visual blurring  Occasional blindness
  43. 43. Manifestations of CRF Fluid - Electrolyte - pH  Volume expansion and fluid overload  Metabolic Acidosis  Electrolyte Imbalances  Hyperkalemia
  44. 44. Manifestations of CRF GI Tract  Uremic fetor  Anorexia, nausea, vomiting  GI bleeding
  45. 45. Manifestations of CRF Hematologic  Anemia  Platelet dysfunction
  46. 46. Manifestations of CRF Musculoskeletal  Muscle cramps  Soft tissue calcifications  Weakness  Related to calcium phosphorous imbalances
  47. 47. Calcium-Phosphorous Balance
  48. 48. Manifestations of CRF Heart - Lungs  Hypertension  Congestive heart failure  Pericarditis  Pulmonary edema  Pleural effusions
  49. 49. Manifestations of CRF Endocrine - Metabolic  Erythropoietin production decreased  Hypothyroidism  Insulin resistance  Growth hormone decreased  Gonadal dysfunction  Parathyroid hormone and Vitamin D3  Hyperlipidemia
  50. 50. Treatment Options  Hemodialysis  Peritoneal Dialysis  Transplant  Nothing
  51. 51. Hemodialysis  Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane.
  52. 52. 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.
  53. 53. 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.
  54. 54. Hemodialysis Process  Blood removed from patient into the extracorporeal circuit.  Diffusion and ultrafiltration take place in the dialyzer.  Cleaned blood returned to patient.
  55. 55. Extracorporeal Circuit
  56. 56. How Hemodialysis Works
  57. 57. Vascular Access  Arterio-venous shunt (Scribner External Shunt)  Arterio-venous (AV) Fistula  PTFE Graft  Temporary catheters  “Permanent” catheters
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. Care of Vascular Access  NO BP’s, needle sticks to arm with vascular access. This includes finger sticks.  Place ID bands on other arm whenever possible.  Palpate thrill and listen for bruit.  Teach patient nothing constrictive, feel for thrill.
  64. 64. Complications of Hemodialysis  During dialysis  Fluid and electrolyte related  hypotension  Cardiovascular  arrythmias  Associated with the extracorporeal circuit  exsanguination  Neurologic  seizures  other  fever
  65. 65. Complications of Hemodialysis cont’d  Between treatments  Hypertension/Hypotension  Edema  Pulmonary edema  Hyperkalemia  Bleeding  Clotting of access
  66. 66. Complications of Hemodialysis cont’d  Long term  Metabolic  hyperparathyroidism  diabetic complications  Cardiovascular  CHF  AV access failure  Respiratory  pulmonary edema  Neuromuscular  neuropathy
  67. 67. Complications of Hemodialysis cont’d  Long term cont’d  Hematologic  anemia  GI  bleeding  dermatologic  calcium phosphorous deposits  Rheumatologic  amyloid deposits
  68. 68. Complications of Hemodialysis cont’d  Long term cont’d  Genitourinary  infection  sexual dysfunction  Psychiatric  depression  Infection  bloodborne pathogens
  69. 69. 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
  70. 70. Peritoneal Dialysis  Removal of soluble substances and water from the blood by diffusion through a semi- permeable membrane that is intracorporeal (inside the body).
  71. 71. Types of Peritoneal Dialysis  CAPD: Continuous ambulatory peritoneal dialysis  CCPD: Continuous cycling peritoneal dialysis  IPD: Intermittent peritoneal dialysis
  72. 72. 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
  73. 73. 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
  74. 74. Complications of Peritoneal Dialysis  Infection  peritonitis  tunnel infections  catheter exit site  Hypervolemia  hypertension  pulmonary edema  Hypovolemia  hypotension  Hyperglycemia  Malnutrition
  75. 75. Complications of Peritoneal Dialysis cont’d  Obesity  Hypokalemia  Hernia  Cuff erosion
  76. 76. Advantages of CAPD  Independence for patient  No needle sticks  Better blood pressure control  Some diabetics add insulin to solution  Fewer dietary restrictions  protein loses in dialysate  generally need increased potassium  less fluid restrictions
  77. 77. Peritoneal Catheter Exit Site
  78. 78. Medications Common to Dialysis Patients  Vitamins - water soluble  Phosphate binder - (Phoslo, Renagel, Calcium, Aluminum hydroxide) Give with meals  Iron Supplements - don’t give with phosphate binder or calcium  Antihypertensives - hold prior to dialysis
  79. 79. 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
  80. 80. 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
  81. 81. Patient Education  Alleviate fear  Dialysis process  Fistula/catheter care  Diet and fluid restrictions  Medication  Diabetic teaching
  82. 82. Case Study A 48 year old female with a history of uncontrolled diabetes presents to the ER. Her chief complaints are nausea, vomiting and fatigue. Lab: BUN 100; Creatinine 10; H&H 7.0/21.4; K+ 6.0, PO4 5.5; Ca++ 7.5 What do you suspect? How would she possibly be treated?
  83. 83. Transplantation  Treatment not cure
  84. 84. Kidney Awaiting Transplant
  85. 85. Transplanted Kidney
  86. 86. Advantages  Restoration of “normal” renal function  Freedom from dialysis  Return to “normal” life
  87. 87. Disadvantages  Life long medications  Multiple side effects from medication  Increased risk of tumor  Increased risk of infection  Major surgery
  88. 88. 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
  89. 89. Function  ATN? (acute tubular necrosis)  50% experience  Urine output >100 <500 cc/hr  BUN, creatinine, creatinine clearance  Fluid Balance  Ultrasound  Renal scans  Renal biopsy
  90. 90. 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
  91. 91. Prevention of Infection  Major complication of transplantation due to immunosuppression  HANDWASHING  Crowds, Kids  Patient Education
  92. 92. 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
  93. 93. 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
  94. 94. 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
  95. 95. Immunosuppressant Drugs  Prednisone  Prevents infiltration of T lymphocytes  Side effects  cushnoid changes  Avascular Necrosis  GI disturbances  Diabetes  infection  risk of tumor
  96. 96. Immunosuppressant Drugs cont’d  Azathioprine (Imuran)  Prevents rapid growing lymphocytes  Side Effects  bone marrow toxicity  hepatotoxicity  hair loss  infection  risk of tumor
  97. 97. 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
  98. 98. Immunosuppressant Drugs cont’d  Cytoxan - in place of Imuran less toxic  FK506 - 100 x more potent than Cyclosporin  Prograf  Cellcept
  99. 99. 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
  100. 100. 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
  101. 101. 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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