Download Chronic Kidney Disease

Dialysis
• Begun when the patient’s uremia can no
longer be adequately managed
conservatively
• Initiated when the GFR <5 – 10% 0f
normal
Dialysis
• The movement of fluid and molecules
across a semipermeable membrane from
one compartment to another
Dialysis
• Two methods of dialysis available
Peritoneal dialysis (PD)
Hemodialysis (HD)
General Principles of Dialysis
• Diffusion
• Osmosis
• Ultrafiltration
Osmosis and Diffusion Across Semipermeable
Membrane
Fig. 45-5
DIALYSATE
• Is an electrolyte solution that is
similar to that of normal plasma,
except contains no potassium
• Different concentrations
Peritoneal Dialysis
Dialysis Solutions and Cycles
• Available commercially in 1- or 2-L
plastic bags with glucose
concentrations of 1.5%, 2.5%, and
4.25%
Peritoneal Dialysis
Catheter Placement
• Peritoneal access is obtained by inserting
a catheter (Tenckhoff) through the
anterior wall
• Technique for catheter placement varies
• Usually done via surgery
Tenckhoff Catheter
Fig. 45-6
Peritoneal Dialysis
Dialysis Solutions and Cycles
• Three phases of the PD cycle
Inflow (fill)
Dwell (equilibration)
Drain
Peritoneal Dialysis
Complications
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Exit site infection
Peritonitis/Infection: cloudy dialysate
Hypotension
Abdominal pain (may be bowel perforation): brownish dialysate
Bladder perforation: amber dialysate
Outflow problems
Hernias
Lower back problems
Bleeding
Pulmonary complications
Protein loss
CHO and lipid abnormalities
Peritoneal Dialysis
Types
• Automated peritoneal dialysis (APD)
• Continuous ambulatory peritoneal
dialysis (CAPD)
Peritoneal Dialysis
Advantages
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Short training program
Independence
Ease of traveling
Fewer dietary restrictions
Greater mobility than with HD
Hemodialysis
Vascular Access Sites
• Shunts
• Internal arteriovenous fistulas and grafts
• Temporary vascular access
Vascular Access for Hemodialysis
Fig. 45-11
Hemodialysis
Dialyzers
• Long plastic cartridge that contains
thousands of parallel hollow tubes or
fibers
Hemodialysis System
Fig. 45-14
Hemodialysis
Complications
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Hypotension
Muscle cramps
Loss of blood
Hepatitis
Sepsis
Disequilibrium syndrome
Hemodialysis
Effectiveness and Adaptation
• Cannot fully replace the metabolic and
hormonal functions of the kidneys
• Can ease many of the symptoms
• Can prevent certain complications
Kidney Transplantation
• Over 54,000 patients currently awaiting cadaveric
kidney transplants
• Over 5200 living donor transplants done in 2002
• Extremely successful
• 1-year graft survival rate
 90% for cadaver transplants
 95% for live donor transplants
Kidney Transplantation
Advantages of kidney transplant compared with
dialysis:
Reverses many of the pathophysiologic
changes associated with renal failure
Eliminates the dependence on dialysis
Less expensive than dialysis after the 1st year
Kidney Transplantation
Recipient Selection
• Candidacy determined by a variety of medical and
psychosocial factors that vary among transplant
centers
Contraindications to transplantation:
 Disseminated malignancies
 Cardiac disease
 Chronic respiratory failure
 Extensive vascular disease
 Chronic infection
 Unresolved psychological disorders
Kidney Transplantation
Histocompatability Studies
• Purpose of testing is to identify the HLA
antigens for both donors and potential
recipients
Kidney Transplantation
Donor Sources
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Compatible blood type cadaver donors
Blood relatives
Emotionally related living donors
Altruistic living donors
Kidney Transplantation
Surgical Procedure
• Donor nephrectomy performed by a
urologist or transplant surgeon
• Begins an hour or two before the
recipient’s surgery is started
Kidney Transplantation
Kidney Transplant Recipient
Transplanted kidney
 Usually placed extraperitoneally in the iliac fossa
 Right iliac fossa is preferred
Before incision:
 Urinary catheter placed into bladder
 Antibiotic solution instilled
• Distends the bladder
• Decreases risk of infection
Kidney Transplantation
Nursing Management
Preoperative Care
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Emotional and physical preparation
Immunosuppressive drugs
ECG
Chest x-ray
Laboratory studies
Kidney Transplantation
Nursing Management
Postoperative Care
Live donor
Care is similar to laparoscopic nephrectomy
Close monitoring of renal function
Recipient
Maintenance of fluid and electrolyte balance
is 1st priority
Kidney Transplantation
Immunosuppressive Therapy
Goals:
 Adequately suppress the immune response
 Maintain sufficient immunity to prevent
overwhelming infection
Medications:
 Cyclosporin
 Predisone
 Prografin FK 506 (Tacrolimus)
 Mycophenolate Mofetil (CellCept)
Kidney Transplantation
Complications
Rejection
Hyperacute (antibody-mediated,
humoral) rejection
• Occurs minutes to hours after
transplantation
Kidney Transplantation
Complications
Rejection
Acute rejection
• Occurs days to months after
transplantation
Acute Rejection
Fig. 45-19
Kidney Transplantation
Complications
Rejection
Chronic rejection
• Process that occurs over months or
years and is irreversible
Kidney Transplantation
Complications
Infection
 Most common infections observed in the 1st month:
• Pneumonia
• Wound infections
• IV line and drain infections
 Fungal infections
 Viral infections
• CMV
• Epstein-Barr virus
• Herpes simplex virus
Kidney Transplantation
Complications
Cardiovascular disease
Transplant recipients have  incidence of
atherosclerotic vascular disease
Malignancies
Primary cause is immunosuppressive
therapy
Kidney Transplantation
Complications
Recurrence of original renal disease
Glomerulonephritis
IgA nephropathy
Diabetes mellitus
Focal segmental sclerosis
Kidney Transplantation
Complications
Corticosteroid-related complications
 Aseptic necrosis of the hips, knees, and other joints
 Peptic ulcer disease
 Glucose intolerance and diabetes
 Hyperlipidemia
 Cataracts
 Increased incidence of infections and malignancies