1. Conservative therapy for chronic renal failure involves dietary modifications like restricting protein intake to manage symptoms and prevent further deterioration.
2. Renal replacement therapy includes hemodialysis, which involves pumping blood through a dialyzer to remove waste, and peritoneal dialysis, which uses the peritoneal membrane for diffusion.
3. The document discusses in detail the various treatment options for managing chronic renal failure from conservative management to renal replacement therapies like hemodialysis and peritoneal dialysis.
Chronic kidney disease (CKD) consists of a spectrum of different pathophysiologic processes associated with abnormal kidney function, and a progressive decline in glomerular filtration rate (GFR).
Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body. Health care providers call this lining the peritoneum. A more convenient method of dialysis in home itself.
Chronic glomerulonephritis is a kidney disorder caused by slow, cumulative damage and scarring of the tiny blood filters in the kidneys. These filters, known as glomeruli, remove waste products from the blood.
Chronic kidney disease (CKD) consists of a spectrum of different pathophysiologic processes associated with abnormal kidney function, and a progressive decline in glomerular filtration rate (GFR).
Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body. Health care providers call this lining the peritoneum. A more convenient method of dialysis in home itself.
Chronic glomerulonephritis is a kidney disorder caused by slow, cumulative damage and scarring of the tiny blood filters in the kidneys. These filters, known as glomeruli, remove waste products from the blood.
Chronic kidney disease, also called chronic kidney failure, describes the gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then excreted in your urine.
Peritoneal dialysis is a way to remove waste products from your blood when your kidneys can no longer do the job adequately.
A cleansing fluid flows through a tube (catheter) into part of your abdomen and filters waste products from your blood. After a prescribed period of time, the fluid with filtered waste products flows out of your abdomen and is discarded.
Peritoneal dialysis differs from hemodialysis, a more commonly used blood-filtering procedure. With peritoneal dialysis, you can give yourself treatments at home, at work or while traveling.
MEANING
Sudden and often temporary loss of kidney function.
DEFINITION
Acute renal failure (ARF) is an abrupt and sudden reduction in renal function resulting in the inability to excrete metabolic wastes and maintain proper fluid & electrolyte balance.
• It usually associated with oliguria (less than 500ml/day), no oliguria (greater than 800ml/day) or anuria (less than 50ml/day).
• BUN &creatinine values are elevated.
Etiology
ARF can be further divided into pre-renal, intra renal and post renal etiologies.
1) Pre- Renal causes
Are those that decrease effective blood flow to the kidney and cause a decrease in the glomerular filtration rate (GFR). Both kidneys need to be affected as one kidney is still more than adequate for normal kidney function.
Volume depletion resulting from:
• Hemorrhage
• Renal losses (diuretics, osmotic diuresis)
• Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)
Impaired cardiac efficiency resulting from:
• Myocardia infraction
• Heart failure
• Dysrhythmias
• Cardiogenic shock
Vasodilation resulting from:
• Sepsis
• Anaphylaxis
• Antihypertensive medications or other medications that cause vasodilation.
2) Intrarenal causes
Refers to disease processes which directly damage the kidney itself. It can be due to one or more of the kidney’s structures including the glomeruli, kidney tubules or the interstitium.
Prolonged renal ischemia resulting from:
• Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)
• Myoglobinuria (trauma, crush injuries, burns)
• Hemoglobinreuria (transfusion reaction, hemolytic anemia)
Nephrotoxic agents such as:
• Aminoglycoside antibiotics (gentamycin, tobramycin)
• Radiopaque contrast agents
• Heavy metals (lead, mercury)
• Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
• NSAIDS
• ACE inhibitors
Infections processes such as:
• Acute pyelonephritis
• Acute glomerulonephritis
3) Post renal causes
Refers to mechanical obstruction of urinary outflow, between the kidney and the urethral meatus, which includes urethral and bladder neck obstruction due to:
Calculi formation
Benign prostatic hyperplasia
Tumors
Strictures
Trauma (to back, pelvis or perineum)
Blood clots
Pathophysiology
The kidneys receive approximately one fourth of cardiac output; therefore, they are very sensitive to alteration in perfusion. Most cases of ARF are caused by ischemia episode. The pathophysiology of ARF is not completely understood.
PrerenalARF, is the result of impaired blood flow that leads to hypo perfusion of the kidney which causes decreased oxygen delivery that leads to hypoxemia and ischemia due to damage the kidney and glomerular filtration rate (GFR) decreases that leads to electrolyte imbalance and increased tubular reabsorption of sodium and water.
Intrarenal ARF is the result of actual parenchymal damage to the glomeruli or kidney
End-stage renal disease is a condition in which the kidneys no longer function normally and required excellent medical and nursing care for the managing this condition.
CHRONIC RENAL FAILURE (CRF) or CHRONIC KIDNEY DISEASE (CKD)
Chronic or irreversible renal failure is a progressive reduction of functioning of renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment.
Acute kidney injury is common among hospitalized patients. It affects some 3–7% of patients admitted to the hospital and approximately 25–30% of patients in the intensive care unit.
Glomerulonephritis is inflammation of the tiny filters in your kidneys (glomeruli). Glomeruli remove excess fluid, electrolytes and waste from your bloodstream and pass them into your urine.
Chronic kidney disease, also called chronic kidney failure, describes the gradual loss of kidney function. Your kidneys filter wastes and excess fluids from your blood, which are then excreted in your urine.
Peritoneal dialysis is a way to remove waste products from your blood when your kidneys can no longer do the job adequately.
A cleansing fluid flows through a tube (catheter) into part of your abdomen and filters waste products from your blood. After a prescribed period of time, the fluid with filtered waste products flows out of your abdomen and is discarded.
Peritoneal dialysis differs from hemodialysis, a more commonly used blood-filtering procedure. With peritoneal dialysis, you can give yourself treatments at home, at work or while traveling.
MEANING
Sudden and often temporary loss of kidney function.
DEFINITION
Acute renal failure (ARF) is an abrupt and sudden reduction in renal function resulting in the inability to excrete metabolic wastes and maintain proper fluid & electrolyte balance.
• It usually associated with oliguria (less than 500ml/day), no oliguria (greater than 800ml/day) or anuria (less than 50ml/day).
• BUN &creatinine values are elevated.
Etiology
ARF can be further divided into pre-renal, intra renal and post renal etiologies.
1) Pre- Renal causes
Are those that decrease effective blood flow to the kidney and cause a decrease in the glomerular filtration rate (GFR). Both kidneys need to be affected as one kidney is still more than adequate for normal kidney function.
Volume depletion resulting from:
• Hemorrhage
• Renal losses (diuretics, osmotic diuresis)
• Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)
Impaired cardiac efficiency resulting from:
• Myocardia infraction
• Heart failure
• Dysrhythmias
• Cardiogenic shock
Vasodilation resulting from:
• Sepsis
• Anaphylaxis
• Antihypertensive medications or other medications that cause vasodilation.
2) Intrarenal causes
Refers to disease processes which directly damage the kidney itself. It can be due to one or more of the kidney’s structures including the glomeruli, kidney tubules or the interstitium.
Prolonged renal ischemia resulting from:
• Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)
• Myoglobinuria (trauma, crush injuries, burns)
• Hemoglobinreuria (transfusion reaction, hemolytic anemia)
Nephrotoxic agents such as:
• Aminoglycoside antibiotics (gentamycin, tobramycin)
• Radiopaque contrast agents
• Heavy metals (lead, mercury)
• Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
• NSAIDS
• ACE inhibitors
Infections processes such as:
• Acute pyelonephritis
• Acute glomerulonephritis
3) Post renal causes
Refers to mechanical obstruction of urinary outflow, between the kidney and the urethral meatus, which includes urethral and bladder neck obstruction due to:
Calculi formation
Benign prostatic hyperplasia
Tumors
Strictures
Trauma (to back, pelvis or perineum)
Blood clots
Pathophysiology
The kidneys receive approximately one fourth of cardiac output; therefore, they are very sensitive to alteration in perfusion. Most cases of ARF are caused by ischemia episode. The pathophysiology of ARF is not completely understood.
PrerenalARF, is the result of impaired blood flow that leads to hypo perfusion of the kidney which causes decreased oxygen delivery that leads to hypoxemia and ischemia due to damage the kidney and glomerular filtration rate (GFR) decreases that leads to electrolyte imbalance and increased tubular reabsorption of sodium and water.
Intrarenal ARF is the result of actual parenchymal damage to the glomeruli or kidney
End-stage renal disease is a condition in which the kidneys no longer function normally and required excellent medical and nursing care for the managing this condition.
CHRONIC RENAL FAILURE (CRF) or CHRONIC KIDNEY DISEASE (CKD)
Chronic or irreversible renal failure is a progressive reduction of functioning of renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment.
Acute kidney injury is common among hospitalized patients. It affects some 3–7% of patients admitted to the hospital and approximately 25–30% of patients in the intensive care unit.
Glomerulonephritis is inflammation of the tiny filters in your kidneys (glomeruli). Glomeruli remove excess fluid, electrolytes and waste from your bloodstream and pass them into your urine.
Hemodialysis is a treatment to filter wastes and water from your blood; In hemodialysis, the blood is cleaned outside the body using a dialysis machine and then sent back into the body.
Hemodialysis is a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy. Hemodialysis helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in your blood.
Hemodialysis is one way to treat advanced kidney failure and can help you carry on an active life despite failing kidneys.
Mechanism of Hemodialysis:
Hemodialysis is a procedure by which waste products and excess water are removed from a patient’s blood. This is done by directly removing blood from the patient’s circulation, passing it through the dialysis filter, and then returning it directly back into the circulation.
Apparatus needed:
Dialyzer or dialysis filter
Dialysate (dialysis solution)
Tubing for transport of blood and dialysate
Machine that powers and monitors the filtration
Hemodialysis has 5 main steps which are as follows:
1.Two sets of tubing are connected to the patient’s dialysis access:
Connected directly to central venous catheter
Two needles inserted into AVF/AVG and taped down
2. Azotemic blood pumped from patient into dialysis filter
3. Dialysis filter removes toxins primarily through diffusion:
Dialysis filter is a plastic cylinder filled with thousands of tiny individual tubes composed of the filtering material.
Blood flows through the inside of the tiny tubes in one direction.
Dialysis fluid (dialysate) flows on the outside of the tiny tubes (but still within the single plastic cylinder that contains them) in the opposite direction.
The opposing directions of blood and dialysate result in maximal concentration gradients that drive the diffusion of toxins:
Known as “countercurrent” mechanism
Also results in correction of electrolyte/acid–base abnormalities via diffusion.
4. Dialysis filter removes excess water from the blood through ultrafiltration.
Suction force is applied by the dialysis machine across the dialysis filter.
Water is pulled from the blood side into the dialysate side.
5. Clean blood and waste-filled dialysate exit the dialysis filter.
Clean blood is pumped back into the patient’s Circulation.
Waste-filled dialysate is disposed of (including the excess water from the patient’s body that was removed during ultrafiltration).
Chronic dialysis
3–4 hours each session
3 times a week (Monday/Wednesday/Friday or Tuesday/Thursday/Saturday)
Acute dialysis:
Treatment duration and daily schedule are
Variable.
Priscriptions: The nephrologist may control many variables within the dialysis procedure:
Duration of treatment
Ultrafiltration goal
Anticoagulation
Electrolyte composition of the dialysate
Speed of blood flow and dialysate flow
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2. 1.CONSERVATIVE THERAPY
Dietary
Modifications
Elimination of symptoms and prevention of further
1. Aim deterioration
2.Initiated When patient becomes azotemic
Manage diet,fluid,electrolytes and calcium phosphate
3.What we do? balance
3. (A)DIETARY MODIFICATIONS
Includes
1.Dietary regulation of protein 2.Nutritional supplements,if
(20 -40 g/day) needed
(a)Improves acidosis,azotemia and (a)Multivitamin supplements
nausea (b) Patients with early renal
(b)Reduces the excretory load of insufficiency,supplement diet with
the kidney & CaCO3 along with limited intake of
Thereby intraglomerular pressure phosphate containing foods
and secondary injury to nephrons
4. Take Care of “BEANS”
(Practical clinical approach to the management of patients with chronic
renal failure)
1. Blood pressure should be maintained in a target range lower than
130/80 mm Hg
2.Haemoglobin levels should be maintained at 10-12 g/dL
3.Hyperlipidemia should be treated with a “statin” lipid lowering
medication
4.Smoking cessation should also be encouraged
5. (B) DIALYSIS (DIA-THROUGH , LYSIS –LOOSENING)
Serum creatinine> 4.0g/dL
*When the access should be
created??? GFR falls to <20 mL/min
*Close monitoring of nutritional status is
important
6. INDICATIONS:
The decision to initiate dialysis renal failure depends on several
factors. divided into acute or chronic indications.
in the patient with acute kidney injury -vowel acronym of
"AEIOU":
1.Acidemia from metabolic acidosis
2.Electrolyte abnormality, such as severe hyperkalemia,
3.Intoxication, that is, acute poisoning with a dialyzable substance.
4.Overload of fluid
5.Uremia complications, such as pericarditis, encephalopathy,
or gastrointestinal bleeding.
Chronic indications for dialysis:
1.Symptomatic renal failure
2.Low glomerular filtration rate (GFR) In diabetics, dialysis is
started earlier <15cc/min
3.Difficulty in medically controlling fluid overload, serum
potassium, and/or serum phosphorus when the GFR is very low
7. (a)Haemodialysis
Dialysis
(b)Peritoneal dialysis
(a)Haemodialysis is the removal of
nitrogenous and toxic products of
metabolism from the blood by means of a
haemodialyzer system
#Exchange occurs between the patient’s
plasma and dialysate (electrolyte
composition of which mimics that of
extracellular fluid) across a semi permeable
membrane that allows uremic toxins to
diffuse out of the plasma while retaining
the formed components and protein
composition of blood
NOT provides the same degree of health as renal function provides because
there is no resorptive capability in the dialysis membrane.
8. COMPONENTS of dialysis unit
1.Dialyzer
2.Dialysate production unit
3.Roller blood pump
4.Heparin infusion pump
5.Devices to monitor the
conductivity,temperature,flow rate and
pressure of dialysate
9. The frequency and duration of dialysis treatment are related to
1. Body size
2. residual renal function
3.Protein intake
4.Tolerance to fluid removal
#The typical patient undergoes
haemodialysis 3 times/week with each
treatment lasting approximately 3-4 hours
on standard dialysis units and slightly less
time on high efficiency/high flux dialysis
units
NEWER FORMS :Nocturnal and daily
dialysis with improved control of
1.Biochemical abnormalities
2.Blood pressure and volume status
10.
11. 1. In hemodialysis, the patient's blood is pumped through the blood
compartment of a dialyzer, exposing it to a partially permeable membrane.
2.Blood flows through the fibers, dialysis solution flows around the outside
of the fibers, and water and wastes move between these two solutions.
3.The cleansed blood is then returned via the circuit back to the body.
***. Ultrafiltration occurs by increasing the hydrostatic pressure across the
dialyzer membrane.
This usually is done by applying a negative pressure to the dialysate
compartment of the dialyzer
.
4.This pressure gradient causes water and dissolved solutes to move from
blood to dialysate, and allows the removal of several liters of excess fluid
during a typical 3- to 5-hour treatment
12. Types of vascular access foe maintenance
haemodialysis
**Classic construction is side to side
anastomosis b/w the radial artery and
cephalic vein at the forearm
1.Primary arteriovenous(AV)
fistula/shunt/external cannula system:
Preferred for long term treatment.
2. Synthetic AV graft: Fistulae are created by
means of autografts,PTFE grafts ,Dacron etc.
A fistula is an enlarged vein (usually in your
arm), created by connecting an artery directly
to a vein.
3.Double lumen
4.Cuffed tunneled catheters: indwelling
central venous catheters used
13. (B) Peritoneal dialysis(accounts for10% of dialysis t/t)
1. access is achieved via a catheter through the
abdominal wall into the peritoneum
2. 1-2 liters of dialysate is placed in the peritoneal
cavity and is allowed to remain for varying intervals
of time
3. Substances diffuse across the semipermeable
peritoneal membrane to dialysate
4. #Tenckhoff Silastic catheter has made peritoneal
puncture for each dialysis unnecessary
**little baby who needed dialysis. You can see
his Tenckhoff Catheter coming out of his
tummy. This type of catheter is used for
peritoneal dialysis.
#
15. Various Regimens for peritoneal dialysis:
1.Chronic ambulatory patients..:2 L of
dialysis fluid instilled in the peritoneal cavity,
allowed to remain for 30 mins and drained out
2.Continuous cyclic peritoneal dialysis,in
which 2-3 L of dialysate is exchanged every
hour over a 6-8 hour period overnight,7days
/week
*** as it allows (a)great deal of personal freedom
(b)No risk of air embolism and blood leaks
(c) Hepariniztion unnecessary
SO used as PRIMARY therapy/as a TEMPORARY MEASURE
16. 2.RENAL TRANSPLANTATION
Treatment of choice for patients with
irreversible kidney failure
However the use of transplantation is
limited by organ availability
INDICATIONS:1. ESRD
2. Glomerulonephritis
3.Pyelonephritis
4.Congenital abnormalities
5.Nephrotic syndrome
17. Other Approaches:
1.Hemofilteration
a) based on the principle of convection and physiologic function of glomerulus
b) Standard dialysis technique is modified prediluting the blood with an electrolyte
sol’n and ‘ultrafiltering’ it under high hydraulic pressure
2.Adjunctive techniques used with
maintenance dialysis include the use of
ABSORBENT materials for solute removal
The Recirculating DialYsis System( REDY
2000, REDY Sorbent system)
Differs from regular single- pass dialysis in
that after passing through dialyzer, the REDY
dialysate fluid is regenerated, rather than
discarded, by passing through a sorbent
cartridge.