Renal Failure

and
Treatment
Vicky Jefferson, RN, CNN
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, PhD
History
Early animal experiments began 1913
1st human dialysis 1940 by Dutch physician
Willem Kolff (2 of 17 patients survived)
Considered experimental through 1950s,
No intermittent blood access; for acute renal
failure only.
History contd
1960 Dr. Scribner developed Scribner Shunt
1960s Machines expensive, scarce, no
funding.
Death Panels panels within community
decided who got to dialyze.
Normal Kidney Function
Fluid balance
Electrolyte regulation
Control acid base balance
Waste removal
Hormonal function
Erythropoietin
Renin
Active Vitamin D3
Prostaglandins
Acute Renal Failure (ARF)
Sudden onset - hours to days
Often reversible
Severe - 50% mortality rate overall;
generally related to infection.
Chronic Renal Failure (CRF)
Slow onset - years
Not reversible
Causes of Chronic Renal Failure
Diabetes
Hypertension
Glomerulonephritis
Cystic disorders
Developmental - Congenital
Infectious Disease
Causes of Chronic Renal Failure
contd
Neoplasms
Obstructive disorders
Autoimmune diseases
Lupus
Hepatorenal failure
Scleroderma
Amyloidosis
Drug toxicity
Stages of Chronic Renal Failure
Reduced Renal Reserve
Renal Insufficiency
End Stage Renal Disease (ESRD)
Stage 1: Reduced Renal Reserve
Residual function 40 - 75% of normal
BUN and Creatinine normal (early)
No symptoms
Stage II: Renal Insufficiency
Residual function 20 - 40 % normal
Decreased: glomerular filtration rate, solute
clearance, ability to concentrate urine and
hormone secretion
Symptoms: elevated BUN & Creatinine,
mild azotemia, anemia
Stage II: Renal Insufficiency
contd
Signs and symptoms worsen if kidneys are
stressed
Decreased ability to maintain homeostasis
Stage III: End Stage Renal
Disease (ESRD)
Residual function < 15% of normal
Excretory, regulatory and hormonal
functions severely impaired.
metabolic acidosis
Stage III: End Stage Renal
Disease (ESRD) contd
Marked increase in: BUN, Creatinine,
Phosphorous
Marked decrease in: Hemoglobin,
Hematocrit, Calcium
Fluid overload
Stage III: End Stage Renal
Disease (ESRD) contd
Uremic syndrome develops affecting all
body systems
Last stage of progressive CRF
Fatal if no treatment
Diagnostic Tools for Assessing
Renal Failure
Blood Tests
BUN elevated (norm 10-20)
Creatinine elevated (norm 0.7-1.3)
K elevated
PO4 elevated
Ca decreased
Urinalysis
Specific gravity
Protein
Creatinine clearance
Diagnostic Tools contd
Biopsy
Ultrasound
X-Rays
Manifestations of Chronic Renal
Failure
Nervous System
Mood swings
Impaired judgment
Inability to concentrate and perform simple
math functions
Tremors, twitching, convulsions
Peripheral Neuropathy
restless legs
foot drop
Integumentary
Pale, grayish-bronze color
Dry scaly
Severe itching
Bruise easily
Uremic frost
Eyes
Visual blurring
Occasional blindness
Fluid - Electrolyte - PH
Volume expansion and fluid overload
Metabolic Acidosis
Electrolyte Imbalances
Hyperkalemia
GI Tract
Uremic fetor
Anorexia, nausea, vomiting
GI bleeding
Hematologic
Anemia
Platelet dysfunction
Musculoskeletal
Muscle cramps
Soft tissue calcifications
Weakness
Related to calcium phosphorous imbalances
Heart Lungs
Hypertension
Congestive heart failure
Pericarditis
Pulmonary edema
Pleural effusions
Endocrine/Metabolic
Erythropoietin production decreased
Hypothyroidism
Insulin resistance
Growth hormone decreased
Gonadal dysfunctions
Parathyroid hormone and Vitamin D3
Hyperlipidemia
Treatment Options
Hemodialysis
Peritoneal Dialysis
Transplant
Hemodialysis
Removal of soluble substances and
water from the blood by diffusion
through a semi-permeable membrane.
Hemodialysis Process
Blood removed from patient into the
extracorporeal circuit.
Diffusion and ultrafiltration take place in
the dialyzer.
Cleaned blood returned to patient.
Hemodialysis Process
Hemodialysis
Circuit
Extracorporeal
Circuit
Vascular Access
Arterio-venous shunt (Scribner External
Shunt)
Arterio-venous (AV) Fistula
PTFE Graft
Temporary catheters
Permanent catheters
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
External (Scribner) Shunt
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
AV Fistula
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
PTFE Graft
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
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
Cuffed Tunneled
Catheter
Complications of Hemodialysis
During dialysis
Fluid and electrolyte related
hypotension
Cardiovascular
arrythmias
Associated with the extracorporeal circuit
exsanguination
Neurologic
seizures
other
fever
Complications of Hemodialysis
contd
Between treatments
Hypertension/Hypotension
Edema
Pulmonary edema
Hyperkalemia
Bleeding
Clotting of access
Complications of Hemodialysis
contd
Long term
Metabolic
hyperparathyroidism
diabetic complications
Cardiovascular
CHF
AV access failure
Respiratory
pulmonary edema
Neuromuscular
neuropathy
Complications of Hemodialysis
contd
Long term contd
Hematologic
anemia
GI
bleeding
dermatologic
calcium phosphorous deposits
Rheumatologic
amyloid deposits
Complications of Hemodialysis
contd
Long term contd
Genitourinary
infection
sexual dysfunction
Psychiatric
depression
Infection
bloodborne pathogens
Calcium-Phosphorous Balance
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
Peritoneal Dialysis
Removal of soluble substances and water
from the blood by diffusion through a semi-
permeable membrane that is intracorporeal
(inside the body).
Peritoneal
Dialysis
Types of Peritoneal Dialysis
CAPD: Continuous ambulatory peritoneal dialysis
CCPD: Continuous cycling peritoneal dialysis
IPD: Intermittent peritoneal dialysis
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
Peritoneal Catheter Exit Site
Draining of Peritoneal Dialysate
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
Complications of Peritoneal
Dialysis
Infection
peritonitis
tunnel infections
catheter exit site
Hypervolemia
hypertension
pulmonary edema
Hypovolemia
hypotension
Hyperglycemia
Malnutrition
Complications of Peritoneal
Dialysis contd
Obesity
Hypokalemia
Hernia
Cuff erosion
Advantages of CAPD
Independence for patient
No needle sticks
Better blood pressure control
Diabetics add insulin to solution
Fewer dietary restrictions
protein loses in dialysate
generally need increased potassium
less fluid restrictions
Peritoneal Dialysis Multi-bag
Prong Manifold
Medications Common to Dialysis
Patients
Vitamins - water soluble
Phosphate binder - (Phoslo, Calcium,
Aluminum hydroxide) Give with meals
Iron Supplements - dont give with
phosphate binder or calcium
Antihypertensives - hold prior to dialysis
Medications Common to Dialysis
Patients contd
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
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
Patient Education
Alleviate fear
Dialysis process
Fistula/catheter care
Diet and fluid restrictions
Medication
Diabetic teaching
Transplantation
Treatment Not a Cure
Kidney Awaiting Transplant
Advantages
Restoration of normal renal function
Freedom from dialysis
Return to normal life
Disadvantages
Life long medications
Multiple side effects from medication
Increased risk of tumor
Increased risk of infection
Major surgery
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
Function
ATN? (acute tubular necrosis)
50% experience
Urine output >100 <500 cc/hr
BUN, creatinine, creatinine clearance
Fluid Balance
Ultrasound
Renal scans
Renal biopsy
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
Prevention of Infection
Major complication of transplantation due
to immunosuppression
HANDWASHING
Crowds, Kids
Patient Education
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
Rejection contd
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
Rejection contd
Chronic - gradual process of graft
dysfunction
Repeated rejection episodes that have not been
completely resolved with treatment
Rx = return to dialysis or re-transplantation
Immunosuppressant Drugs
Prednisone
Prevents infiltration of T lymphocytes
Side effects
cushnoid changes
Avascular Necrosis
GI disturbances
Diabetes
infection
risk of tumor
Immunosuppressant Drugs contd
Azathioprine (Imuran)
Prevents rapid growing lymphocytes
Side Effects
bone marrow toxicity
hepatotoxicity
hair loss
infection
risk of tumor
Immunosuppressant Drugs contd
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
Immunosuppressant Drugs contd
Cytoxan - in place of Imuran less toxic
FK506 - 100 x more potent than
Cyclosporin
Prograf
Cellcept
other in trials
Immunosuppressant Drugs contd
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
Immunosuppressant Drugs contd
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
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