Download DIALYSIS - Austin Community College District

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 1950’s,
No intermittent blood access; for acute renal
failure only.
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.
Normal Kidney Function
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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
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Diabetes
Hypertension
Glomerulonephritis
Cystic disorders
Developmental - Congenital
Infectious Disease
Causes of Chronic Renal Failure
cont’d
• Neoplasms
• Obstructive disorders
• Autoimmune diseases
– Lupus
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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
cont’d
• 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) cont’d
• Marked increase in: BUN, Creatinine,
Phosphorous
• Marked decrease in: Hemoglobin,
Hematocrit, Calcium
• Fluid overload
Stage III: End Stage Renal
Disease (ESRD) cont’d
• 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 cont’d
• 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
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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
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Muscle cramps
Soft tissue calcifications
Weakness
Related to calcium phosphorous imbalances
Heart Lungs
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Hypertension
Congestive heart failure
Pericarditis
Pulmonary edema
Pleural effusions
Endocrine/Metabolic
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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
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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 veinsubclavian, 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
cont’d
• Between treatments
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Hypertension/Hypotension
Edema
Pulmonary edema
Hyperkalemia
Bleeding
Clotting of access
Complications of Hemodialysis
cont’d
• Long term
– Metabolic
• hyperparathyroidism
• diabetic complications
– Cardiovascular
• CHF
• AV access failure
– Respiratory
• pulmonary edema
– Neuromuscular
• neuropathy
Complications of Hemodialysis
cont’d
• Long term cont’d
– Hematologic
• anemia
– GI
• bleeding
– dermatologic
• calcium phosphorous deposits
– Rheumatologic
• amyloid deposits
Complications of Hemodialysis
cont’d
• Long term cont’d
– Genitourinary
• infection
• sexual dysfunction
– Psychiatric
• depression
– Infection
• bloodborne pathogens
Calcium-Phosphorous Balance
Dietary Restrictions on
Hemodialysis
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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 semipermeable 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
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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 cont’d
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Obesity
Hypokalemia
Hernia
Cuff erosion
Advantages of CAPD
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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 - don’t give with
phosphate binder or calcium
• Antihypertensives - hold prior to dialysis
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
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
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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
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Life long medications
Multiple side effects from medication
Increased risk of tumor
Increased risk of infection
Major surgery
Care of the Recipient
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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
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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 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
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
Immunosuppressant Drugs
• Prednisone
– Prevents infiltration of T lymphocytes
• Side effects
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cushnoid changes
Avascular Necrosis
GI disturbances
Diabetes
infection
risk of tumor
Immunosuppressant Drugs cont’d
• Azathioprine (Imuran)
– Prevents rapid growing lymphocytes
• Side Effects
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bone marrow toxicity
hepatotoxicity
hair loss
infection
risk of tumor
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
Immunosuppressant Drugs cont’d
• Cytoxan - in place of Imuran less toxic
• FK506 - 100 x more potent than
Cyclosporin
• Prograf
• Cellcept
• other in trials
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
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
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