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CKD/ESRD & Management Note-when viewing lab values in PPT-note that values are given as both as “common values” as also the specific values given in textbook (remember, sources vary slightly-think ranges.)2010 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, Ph.D. 2 REVIEW Recall functions of the kidneys? Recall normal creatinine & BUN; other lab tests? Review Diagnostic Tools CKD- Elderly Risk (Review) •Older Adult-normal aging (plus co-morbidities) > risk kidney dysfunction/renal failure •Must: •Identify/prevent damage •Monitor/risk multiple RX/OTC meds (altered renal blood flow/dec. renal clearance etc) •Monitor/risk associated with dehydration (ie diuretics) •Monitor/risk with dec ability to respond to changes to fluid/electrolyte status (manifestation may be atypical Functions of the Kidneys Regulates volume and composition of extracellular fluid Excretion of nitrogenous waste products BP control via reninangiotensin-aldosterone system- Recall RAAS Vitamin D activation Acid-base balance (HCO3 & H) regulation through process of _____, ____ and ______. filtration, secretion, reabsorpton Prostaglandin synthesis Erythropoietin production Functions of the Kidneys (cont) Erythropoietin Release If a patient has chronic renal failure, what condition will occur? WHY??? EPO- glycoprotein hormone that controls erythropoiesis, or red blood cell production 5/25/2017 6 Diagnostic Tools for Assessing Renal Failure Blood Tests BUN elevated (norm 10-20 mg/dl) (text 10-30mg/dl) Creatinine elevated (norm 0.6 - 1.2 mg/dl) (text 0.51.5mg/dl) K elevated (text norm 3.5-5.0 mEq/L) PO4 elevated (text norm 2.8-4.5mg/dl) Ca decreased (text norm 9-11mg/dl) Urinalysis Specific gravity (text norm 1.003-1.030 Protein (text norm 0-trace) Creatinine clearance (text norm 85-135ml/min) 7 BUN Normal 8 - 20 mg/dl (text 10-30mg/dl) Nitrogenous waste product of protein metabolism Unreliable in measurement of renal function Relevance assessed in conjunction with serum creatinine 8 Creatinine A waste product of muscle metabolism Normal value 0.6 - 1.2 mg/dl (text 0.51.5mg/dl) 2 times normal = 50% damage 8 times normal = 75% damage 10 times normal = 90% damage Exception - severe muscular disease can greatly serum creatinine levels 9 Diagnostic Tools Ultrasound X-Rays Biopsy *most definitive 10 Chronic Renal Failure/ Chronic Kidney Disease (CKD) Slow progressive renal disorder related to nephron loss, occurring over months to years Culminates in End Stage Renal Disease (ESRD) 11 Characteristics of CKD > ESRD Cause & onset often unknown Loss of function precedes lab abnormalities Lab abnormalities precede symptoms Symptoms (usually) evolve in orderly sequence Renal size is usually decreased 12 Causes of CKD *Diabetes *Hypertension Glomerulonephritis Cystic disorders Developmental Congenital Infectious Disease •Neoplasms •Obstructive disorders •Autoimmune diseases (lupus) •Hepatorenal failure •Scleroderma •Amyloidosis •Drug toxicity-(overuse some common drugs, as aspirin, NSAID as ibuprofen, cocaine and acetaminophen) NSAIDs-…cause prerenal ARF by blocking prostaglandin production > also alters local glomerular arteriolar perfusion… (reduces renal blood flow) 13 Glomerular Filtration Rate (GFR)-determine stage CKD (most accurate evaluation) 24 hour urine for creatinine clearance Formula- urine creatinine X urine volume serum creatinine Can estimate creatinine clearance by: 140 – {age x weight (kg)} 72 x serum creatinine What is normal GFR? 90 - 120 mL/min 14 Stages of CKD (“old” terminology) Reduced Renal Reserve Renal Insufficiency End Stage Renal Disease (ESRD) 15 Stages of CKD NKF Classification System Stage 1: Stage 2: GFR > 90 ml/min despite kidney damage Mild reduction (GFR 60 – 89 ml/min) 1. GFR of 60 may represent 50% loss in function. 2. Parathyroid hormones starts to increase. (why?) *kidneys unable to reabsorb calcium, blood calcium levels fall, stimulating continual secretion of parathyroid hormone to maintain normal calcium levels in blood. 16 During Stage 1 - 2 No symptoms Serum creatinine doubles* (Up to 50% nephron loss FYI-older adult- may impaired renal function even in presence of normal serum creatinine 17 Stages of CKD NKF Classification System Stage 3: Moderate reduction (GFR 30 – 59 ml/min) 1. Calcium absorption decreases (from the GI tract) 2. Malnutrition onset 3. Anemia 4. Left ventricular hypertrophy 18 Stages of CKD NKF Classification System Stage 4: Oopstrouble! Severe reduction (GFR 15 – 29 ml/min) 1. Serum triglycerides 2. Hyperphosphatemia 3. Metabolic acidosis 4. Hyperkalemia K Effect & EKG 19 During Stage 3 - 4 Signs and symptoms worsen if kidneys stressed ability to maintain homeostasis 75% nephron loss glomerular filtration rate, solute clearance, ability to concentrate urine and secrete hormone Symptoms: BUN & Creatinine, mild azotemia, anemia 20 Stages of CKD-NKF Classification System Stage 5: Kidney failure (GFR < 15 ml/min) ESRD!!! Azotemia Residual function < 15% of normal Excretory, regulatory, hormonal functions severely impaired Metabolic acidosis (Kussmaul breathing) Marked : BUN, Creatinine, Phosphorous Marked : Hemoglobin, Hematocrit, Calcium Fluid overload 21 During Stage 5 Uremic syndrome develops- affecting all body systems can be diminished with early diagnosis & treatment Last stage of progressive CKD Fatal if no treatment 22 Manifestations of Chronic Uremia Syndromecombination of common symptoms *greater build-up waste products = greater symptoms Fig. 47-5 23 What happens when kidneys don’t function correctly? 24 Manifestations of CKD Nervous System Mood swings Impaired judgment Inability to concentrate and perform simple math functions Tremors, twitching, convulsions Peripheral Neuropathy restless legs foot drop Manifestations due to inc nitrogenous waste products, electrolyte imbalances, metabolic acidosis and axonal atrophy and demyelination of nerve fibers & dec erythropoietin* 25 Manifestations of CRF Skin Pale, grayish-bronze color Dry scaly Severe itching Bruise easily, petechiae, ecchymosis *Uremic frost *Manifestations due to…calcium-phosphate deposition in skin, sensory neuropathy, platelet abnormalities; urea crystallizes (uremic frost) >if BUN extremely high 26 Medical Mystery? What do lab studies, etc indicate ? What causes uremic frost? *57-year-old with HTN and CKD (Stage 5), refused dialysis found in respiratory distress after week of upper respiratory symptoms due to viral infection Before admission to hospital >developed asystolic cardiac arrest, was resuscitated by EMT, admitted to ICU, required vasopressor support. PE- diffuse deposits tiny white crystalline material on skin > lab studies- BUN 208 mg/dl; creatinine 15 mg/dl; bicarbonate level 5 mmol per liter; anion gap-26; arterial pH of 6.74, and arterial partial pressure of carbon dioxide of 50 mm Hg. Blood cultures- revealed-Staphylococcus aureus pneumonia, likely due to prior Walsh S and Parada N. N Engl J Med 2005;352:e13 influenza infection. *Aggressive care measures withdrawn after consultation with patient's family >patient died. *Uremic frost- uncommon skin manifestation due to profound azotemia; occurs when urea and other nitrogenous waste products accumulate in sweat and crystallize after evaporation. Manifestations of CKD Eyes Visual blurring Occasional blindness “Red eye” Due to calcium-phosphate deposits in eyes 28 Manifestations of CKD Fluid - Electrolyte - pH Volume expansion and fluid overload Due to impaired kidneys unable to excrete acid load (mostly Metabolic Acidosis from NH3); defective reabsorption/regeneration of HCO3. Electrolyte Imbalances Potassium Magnesium Sodium Due to dec excretion by kidneys, breakdown of cellular protein, bleeding, metabolic acidosis, food, drugs, etc Kidneys unable to excrete (too much magnesium causes hyporeflexia and can lead to cardiac arrest) Kidneys retain > water retention> fluid overload 29 Manifestations of CKD GI Tract/Bleeding Risk Uremic fetor Anorexia, nausea, vomiting GI bleeding Due to GI irritation, platelet defect; diarrhea from hyperkalemia Anemia Platelet dysfunction Anemia-due to insufficient production of erythropoietin, protein naturally produced in functioning kidneys…circulates through bloodstream to bone marrow, stimulating production of RBCs. Platelet dysfunction-subnormal platelet aggregation -due to fibrinogen fragments, usually absent in normal human blood but present in uremic plasma may lead to platelet dysfunction in uremia. 30 Manifestations of CKD-Musculoskeletal Muscle cramps Soft tissue calcifications Weakness Related to calcium phosphorous imbalances RENAL OSTEODYSTROPHY Fracture risk! 31 Manifestations of CKD- Heart & Lungs Hypertension Heart failure > pulmonary edema Pericarditis due to uremia Pulmonary edema Pleural effusions- “Uremic Lung” Atherosclerotic vascular disease* Cardiac dysrhythmias (from HF, electrolyte imblaances) *Major Problem! 32 Manifestations of CKD- Endocrine Metabolic Erythropoietin Hypothyroidism Insulin resistance Growth hormone Gonadal dysfunction Parathyroid hormone Hyperlipidemia and Vitamin D3 33 Treatment Options Conservative Therapy * (Severe restrictions, dietary, fluids maintain renal function as long as possible- if GFR > 10ml/min) Hemodialysis Peritoneal Dialysis Transplant Nothing > Death 34 Conservative Treatment Goals Detect/treat potentially reversible causes of renal failure Preserve existing renal function Treat manifestations Prevent complications Provide for comfort 35 Conservative Treatment Control Hyperkalemia Hypertension Hyperphosphatemia Hyperparthryoidism Anemia Hyperglycemia Dyslipidemia Hypothyroidism Nutrition : Describe a renal diet? Depends on lab values-usually low NA, K, restricted protein, phosphorous, & fluids (See text) 36 Hemodialysis Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane. Early animal experiments began 1913 1st human dialysis 1940’s by Dutch physician Willem Kolff (2 of 17 patients survived) Considered experimental through 1950’s, No intermittent blood access; for acute renal failure only. 1960 Dr. Scribner developed Scribner Shunt-1960’s machines expensive, scarce, no funding. “Death Panels” panels within community decided who got to dialyze. 37 Hemodialysis Process Blood removed from patient into extracorporeal circuit. Diffusion and ultrafiltration take place in dialyzer. Cleaned blood returned to patient. 38 Extracorporeal Circuit 39 How Hemodialysis Works 40 . How Dialysis Works-Interactive! An Introduction to Dialysis-How Stuff Works! (Step by Step) YouTube- Hemodialysis! Great! Vascular Access (click) Arterio-venous shunt (External Shunt) *used now for Continuous Renal Replacement Therapy (CRRT)-temporary access Arterio-venous (AV) Fistula (AKA-native or primary fistula) PTFE Graft Temporary catheters “Permanent” catheters 42 External Shunt (Schribner 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 *Used now only for CRRT-temporary 43 Arterio-venous (AV) Fistula Primary (native) Fistula Patients own artery and vein surgically anastomosed. Advantages patient’s own vein/artery longevity low infection and thrombosis rates Disadvantages long time to mature, 1- 6 months “steal” syndrome requires needle sticks davita.com 44 PTFE (Polytetraflourethylene) Graft Synthetic “vessel” anastomosed into an artery and vein. Advantages for people with inadequate vessels can be used in 1-4 weeks prominent vessels Disadvantages clots easily “steal” syndrome more frequent requires needle sticks infection may necessitate removal of graft 45 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 Restricts movement 46 Cuffed Tunneled Catheters (Dacron cuff) Dual lumen catheter with Dacron cuff surgically tunneled into subclavian, jugular or femoral vein. Advantages immediate use; *permanent/long term 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 47 Above Native fistula (in place for over 20 years) *Remember- assess circulation-listen for bruit, feel for thrill! Buttonhole technique-individual cannulates own fistula for home dialysis YouTube video “Temporary” vascular access catheters- if tunnelled, with Dacron cuff, can be used long-term as Permacath, below. Care of Vascular Access NO BP’s, needle sticks to arm with vascular access. This includes finger sticks. Place ID bands on other arm whenever possible. Palpate thrill and listen for bruit. Teach patient nothing constrictive, feel for thrill. 49 Potential Complications of Hemodialysis During dialysis Fluid and electrolyte related Cardiovascular arrhythmias Associated with the extracorporeal circuit Disequilibrium Syndrome & seizures Musculoskeletal exsanguination Neurologic hypotension cramping Other fever & sepsis blood born diseases 50 Potential Complications of Hemodialysis Between treatments Long term (due to disease process & management) •Metabolic Hypertension/Hypotension •Hyperparathyroidism Edema •Diabetic complications Pulmonary edema •Cardiovascular Hyperkalemia CHF Bleeding AV access failure Clotting of access Cardiovascular disease •Respiratory Pulmonary edema •Neuromuscular Neuropathy 51 Complications Hemodialysis- con’t-long term, ESRD Long term cont’d Hematologic GI bleeding dermatologic anemia calcium phosphorous deposits Long term cont’d •Genitourinary •infection •Sexual dysfunction •Psychiatric •depression •Infection •blood borne pathogens Rheumatologic amyloid deposits 52 Dietary Restrictions-Hemodialysis Fluid restrictions Urine output + 500-600 Phosphorous restrictions Approx 800-1200 mg/day Potassium restrictions Approx 1-2 g/day; 40 mg/kg/IBW Approx 1-2 g/day Sodium restrictions Protein to maintain nitrogen balance (complete) too high - waste products too low - decreased albumin, increased mortality Calories to maintain or reach ideal weight 53 Peritoneal Dialysis 1. 2. 3. Removal of soluble substances and water from blood by diffusion through a semi-permeable membrane (peritoneum) that is intracorporeal (inside body). Solution warmed to body temperature prior to instillation into peritoneal cavity via peritoneal catheter Metabolic waste products and excessive electrolytes diffuse into dialysate while it remains in abdomen Fluid removal controlled by glucose (dextrose) concentration in dialysate (acts as “osmotic” agent) Excess fluid/solutes removed- gradual/constant Fluid drained by gravity into sterile bag at set intervals“Clear” solution ‘fills” abdomen “Yellow” urine-like fluid drains out (like urine, clear) Types of Peritoneal Dialysis 1. *CAPD: Continuous ambulatory peritoneal dialysis 2. CCPD: Continuous cycling peritoneal dialysis/Aka. *APD – Automated Peritoneal Dialysis 3. IPD: Intermittent peritoneal dialysis (also) 54 Phases of Peritoneal Dialysis Exchange 1. Fill (inflow): fluid infused into peritoneal cavity (usually 10-15 min). 2. Dwell time (equilibrium): time solution (dialysate) fluid remains in peritoneal cavity (duration depends on method- as CAPD 4-5 exchanges/day). 3. Drain (equilibrium): time fluid drains from peritoneal cavity by gravity flow (usually 20-30 min); facilitate by gently massaging abdomen, changing position. CAPD 55 CAPD APD Catheter into peritoneal cavity Exchanges 4 - 5 times per day Treatment 24 hrs; 7 days a week Solution remains in peritoneal cavity except during drain time Independent treatment Click to play animation Videos-Dialysis, all types! Click to locate desired video Automated Peritoneal Dialysisfluid exchanges automatically by machine-(also known as continuous cycling peritoneal dialysis (CCPD), requires “cycler machine”programmable- to automate filling and draining process. Treatment at home, typically at night (while sleeping-thus no fluid in “the belly” at daytime Complications of Peritoneal Dialysis Infection peritonitis tunnel infections catheter exit site Hypervolemia hypertension pulmonary edema Hypovolemia hypotension Hyperglycemia Malnutrition Obesity Hypokalemia Hernia Cuff erosion Low back pain Hyperlipidemia Peritoneal Catheter Exit Site 58 Advantages of PD Independence for patient No needle sticks Better blood pressure control Some diabetics add insulin to solution Fewer dietary restrictions protein loses in dialysate generally need increased potassium less fluid restrictions 59 Multi-prong system occasionally used with PD patients in hospital settings Which dialysis “bags” have already been infused? The “yellow” ones!- dialysis nurse sets up bags, staff nurse infuses, drains according to schedule. 60 Medications - Dialysis Patients & CKD (Stages 4-5) Vitamins - water soluble Phosphate binder - (Phoslo, Renagel, Calcium, *Aluminum hydroxide-risks) Give with meals Iron - don’t give with phosphate binder or calcium Antihypertensives – typically hold prior to dialysis 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 62 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 63 Patient Education Alleviate fear Dialysis process Fistula/catheter care Diet and fluid restrictions Medication Diabetic teaching 64 Case Study A 48 year old female with a history of uncontrolled diabetes presents to the ER. Her chief complaints are nausea, vomiting and fatigue. Lab: BUN 100; Creatinine 10; H&H 7.0/21.4; K+ 6.0, PO4 5.5; Ca++ 7.5 What do you suspect? How would she possibly be treated? *Access Evolve Apply Case Study- Chronic Renal Failure *Access Renal Case Study 65 Transplantation Treatment not cure View also Organ Donation video 66 Kidney Awaiting Transplant 67 “Old” kidneys typically left in place 68 Advantages Restoration of “normal” renal function Freedom from dialysis Return to “normal” life Reverses pathophysiological changes related to RF Less expensive than dialysis after 1st year Disadvantages Life long medications Multiple side effects from medication Increased risk of tumor Increased risk infection Major surgery Care of Recipient Major surgery with general anesthesia Assessment of renal function Assessment of fluid and electrolyte balance Prevention of infection Prevention and management of rejection 70 Post-op Care ATN? (acute tubular necrosis) 50% experience Urine output >100 <500 cc/hr BUN, creatinine, creatinine clearance Fluid Balance-careful monitor Ultrasound Renal scans Renal biopsy 71 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 72 Prevention of Infection Major complication of transplantation due to immunosuppression HANDWASHING Avoid Crowds, Kids Patient Education 73 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 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 Chronic - gradual process of graft dysfunction Repeat rejection episodes- not completely resolved with treatment 4 months to years after transplant Rx = return to dialysis or re-transplantation 74 Immunosuppressant Drugs CorticosteroidsPrednisone Prevents infiltration of T lymphocytes Side effects cushingnoid changes Avascular Necrosis GI disturbances Diabetes infection risk of tumor Cytoxic Agents-Azathioprine (Imuran); Mycophenolate (*Cellcept), *Cytoxin (less toxic than Imuran) Prevents rapid growing lymphocytes Side Effects bone marrow toxicity hepatotoxicity hair loss infection risk of tumor Immunosuppressant Drugs Calcineuin InhibitorsCyclosporin, Neoral, *Prograft, *FK506 (more potent than 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 Monoclonal antibodyOKT3 - used to treat rejection/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 Polyclonal antibody-Atgam-treat rejection or induce immunosuppression decreased number of T lymphocytes Side effects anaphylaxis fever chills leukopenia thrombocytopenia risk of infection tumor 77 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 78 Transplants Notes from Organ Donation slides Exclusion for Transplant not limited too Active vasculitis; or Life threatening extrarenal congenital abnormalities; or Untreated coagulation disorder; or Ongoing alcohol or drug abuse; or Age over 70 years with severe co-morbidities; or Severe neurological or mental impairment, in persons without adequate social support, such that the person is unable to adhere to the regimen necessary to preserve the transplant. 79 Official Criteria for Deceased Donors Usually irreversible brain injury MVA, gunshot wounds, hemorrhage, anoxic brain injury from MI Must have effective cardiac function Must be supported by ventilator to preserve organs Age 2-70 No IV drug use, HTN, DM, Malignancies, Sepsis, disease Permission from legal next of kin & pronoucement of death made by MD *Brain Death is the complete cessation of all brain & brainstem function. It is death. 80 Official Criteria for Living Donors Psychiatric evaluation Anesthesia evaluation Medical Evaluation Free from diseases listed under deceased donor criteria Kidney function evaluated Crossmatches done at time of evaluation and 1 week prior to procedure Radiological evaluation Nurses Role in Event of Potential Donation Notify TOSA of possible organ donation Identify possible donors Make referral in timely manner Do not discuss organ donation with family Offer support to families after referral is made & donation coordinator has met with family 82