Download Renal Replacement Therapy (RRT)

Renal Replacement Therapy
(RRT)
Choices available to patients who
have failing kidneys
Debbie Jones RN CNeph(C)
Objectives
At the end of this presentation the learner will be
familiar with:
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The stages of progressive renal failure
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The renal replacement therapies available to
patients in North Bay and surrounding district who
have either acute or chronic kidney failure
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The types of accesses required for peritoneal and
hemodialysis
Primary Functions of the Kidney
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Removal of metabolic wastes, drugs and
other toxins
Fluid Balance
Electrolyte Balance
Acid-Base Regulation
Blood Pressure Control
Hormone Production ~ Erythropoietin,
Vitamin D (Calcitriol), Renin
“Master Chemists of the Body”
Sidney the Kidney
Stages Of Chronic Kidney Disease
STAGE
DESCRIPTION
GFR
At Increased
Risk
Risk factors for kidney disease
e.g., diabetes, hypertension,
family history,
older age, ethnic group.
More than
90 mL/min
1
Kidney damage (protein in the
urine) and normal GFR
More than
90 mL/min
2
Kidney damage and mild decrease
in GFR
60 to 89 mL/min
3
Moderate decrease in GFR
30 to 59 mL / min
4
Severe decrease in GFR
15 to 29 mL / min
5
Kidney Failure (dialysis or kidney
transplant needed)
Less than
15 mL/ml/min
(
UREMIC SYNDROME
NEUROLOGICAL
Fatigue
Sleep Disturbances
Headache
Muscular Irritability
Lethargy
Seizures, Coma
PSYCHOLOGICAL
Depression
Anxiety
Denial
Psychosis
OCULAR
Red Eye Syndrome
Band Keratopathy
Hypertensive
Retinopathy
GASTROINTESTINAL
Anorexia
Nausea
Vomiting
Uremic Fetor on Breath
Gastroenteritis
GI Bleeding
Peptic Ulcer
CARDIOVASCULAR
Hypertension
CHF
ASHD
Pericarditis
Myocardiopathy
Uremic Lung
HEMATOLOGICAL
Anemia
Bleeding
DERMATOLOGICAL
Pallor
Pigmentation
Pruritus
Ecchymosis
Excoriations
Calcium Deposition
Uremic Frost
PERIPHERAL NEUROPATHY
Restless Leg Syndrome
Paraesthesias
Motor Weakness
Paralysis
ENDOCRINE
Hyperparathyroidism
Thyroid Abnormalities
Amenorrhea
Infertility
Sexual Dysfunction
METABOLIC
Carbohydrate Intolerance
Hyperlipidemia
Nutrition
Gout
Causes of Acute Kidney Failure:
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Pre-renal factors
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Intra-renal & Nephrotoxic factors
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Post-renal factors
Causes of Chronic Kidney Disease:
Diabetes
• Hypertension
• Renal vascular disease (also generalized vascular disease)
• Nephritis
• Pyelonephritis & chronic UT I
• Polycystic kidney disease
• Renal Neoplasms
• Analgesic nephropathy
• Immunological disorders: Lupus, Goodpasture syndrome,
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scleroderma
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Metabolic disorders: gout
Nephrotic Syndrome primary or secondary
Does everyone understand how
important we are?
Kidneys
Urine
Types of Dialysis
Dialysis is a way to clean blood of wastes, fluids and
salts that build up in the body when the kidneys fail.
There are 2 kinds of Dialysis:
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Peritoneal Dialysis:
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Uses the peritoneal membrane as the filter. The membrane
covers the abdominal organs and lines the abdominal wall.
This takes place inside the body and requires placement of
a catheter in the peritoneal cavity to allow fluid to be
instilled and drained out.
Hemodialysis:
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Uses a dialyzer or artificial kidney to filter the blood. This
takes place outside the body and requires some form of
access to the circulatory system. Accomplished with the
use of a sophisticated computerized control unit (dialysis
machine )
Other choices
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kidney transplantation:
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To be placed on a transplant list the patient
must be on some form of renal replacement
therapy, whether it is peritoneal dialysis or
hemodialysis
Once a patient is accepted for transplant, the
date of start of dialysis is the date they are
active on the list
If the patient has a living donor who has been
accepted as healthy donor, it is possible to have
a pre-emptive transplant, bypassing dialysis.
No treatment or palliative care
Peritoneal Dialysis
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Uses the peritoneal membrane as the filter. The membrane
covers the abdominal organs and lines the abdominal wall.
The membrane size is 1 – 2 m2 and approximates the body
surface area. Uses the following principles:
Diffusion: movement of solutes across the peritoneal
membrane from an area of higher concentration to an area
of lower concentration
Osmosis: movement of water across the peritoneal
membrane from an area of lower solute concentration to
an area of higher solute concentration.
Ultrafiltration: water removal related to an osmotic
pressure gradient with the use of various concentrations
of dialysate fluid
How does PD work?
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Fluid called DIALYSATE is put into the
abdomen through a PD catheter. This fluid
is left to dwell in the peritoneum for several
hours.
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While in the abdomen, the fluid collects
wastes that have been filtered through the
peritoneal membrane. These wastes pass
from the body when the fluid is drained.
Peritoneal Dialysis
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Performed daily, by the patient at home,
more physiological
Allows for independence, patients can work
or travel
Fewer fluid and dietary restrictions
Often fewer medications or lower doses
required
Residual renal function preserved
Ministry of Health funded home therapy
Peritoneal Dialysis
Patients
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must have a clean room to perform
exchanges and a large enough area to
store all supplies
no pets allowed in the room
must learn to monitor their own weight
and blood pressures
must be able to follow important
instructions to prevent infection in the
peritoneum
must also be able to determine the choice
of dialysate fluid and when to use it
Peritoneal Dialysis
Peritoneal Dialysis Catheter
Types of Peritoneal Dialysis
CAPD ~ Continuous Ambulatory Peritoneal Dialysis
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The blood is cleaned constantly by dialysate fluid while
it is in the abdomen.
CAPD does not require the use of a machine, the
exchanges are completed manually.
APD ~ Automated Peritoneal Dialysis
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Requires the use of a machine called a CYCLER
The CYCLER is used during the night and is set to
deliver the fluid in and out of the abdomen.
Hemodialysis
• Blood is circulated through an artificial kidney
which has two compartments: Blood & Dialysate,
separated by a thin semi-permeable membrane
• Waste and excess water pass from the blood side
to the dialysate side and is discarded in the drain
The cleaned blood is returned to the patient.
• It is diffusion-based mass transfer (BUN, Creat, lytes)
& Pressure-driven water removal (ultrafiltration)
• usually done 3x /week ~ 4hrs M-W-F or T-Th-Sat
Hemodialysis
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Hemodialysis treatments every other day are not as
physiological as peritoneal dialysis
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Requires a trip to the hospital up to 3 times weekly
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Patients can travel to other units but must be prearranged and space is not always available
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Patients are more restricted in dietary and fluid
intake between treatments
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Medication requirements different than for those
on peritoneal dialysis e.g. require more
antihypertensive meds, higher doses of
Erythropoietin
Hemodialysis ~ The “Integra”
Hemodialysis
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Requires access to the blood stream
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Arterio – venous fistula
Arterio – venous graft
Temporary catheter
Long – term catheter
Hemodialysis ~ fistula
Hemodialysis ~ Graft
Temporary Hemodialysis Catheter
Exit site at
surface of
the skin
Inserted in
the jugular
vein
Tip located
at junction
of SVC and
right Atrium
Tunneled Hemodialysis Catheter
Dacron
cuff
Exit site
Catheter tunnel
Inserted in
the jugular
vein
Tip located
at junction
of SVC and
right Atrium
Transplantation