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Renal Failure and Treatment Vicky Jefferson, RN, CNN Satellite Dialysis (modified by Kelle Howard, RN, MSN) 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 What are nephrons? What are the functions of the kidneys? Normal creatinine & BUN? Diagnostic Tools Functions of the Kidneys _______________ _______________ _______________ ______________ ______________ ______________ ______________ II. Functions of the Kidneys Regulates ______ & _________ of extracellular fluid Regulates fluid & electrolyte balance thru processes of: glomerular__________, tubular _________, and tubular _____________. Name some of the F & Es regulated by kidneys __________________ 5/25/2017 5 Functions of the Kidneys (cont) Regulates acid-base balance through HCO3 and H+ *Hormonal functions: (BP control), multisystem effect. Renin Release RAAS= 5/25/2017 6 Functions of the Kidneys (cont) Erythropoietin Release If a patient has chronic renal failure, what condition will occur? WHY??? 5/25/2017 7 BUN Normal 10-30 mg/dl Nitrogenous waste product of protein metabolism Unreliable in measurement of renal function 8 Creatinine A waste product of muscle metabolism Normal value 0.5 - 1.5 mg/dl 2 times normal = 50% damage 8 times normal = 75% damage 10 times normal = 90% damage Exception -_______________________ 9 Diagnostic Tools for Assessing Renal Failure Blood Tests BUN elevated (norm 10-30) Creatinine elevated (norm 0.5 - 1.5) K elevated PO4 elevated Ca decreased Urinalysis Specific gravity Protein Creatinine clearance 10 Diagnostic Tools Biopsy Ultrasound X-Rays 11 Chronic Renal Failure Slow progressive renal disorder related to nephron loss, occurring over months to years Culminates in End Stage Renal Disease 12 Characteristics of Chronic Renal Failure 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 13 Causes of Chronic Renal Failure Diabetes Hypertension Glomerulonephritis Cystic disorders Developmental - Congenital Infectious Disease 14 Causes of Chronic Renal Failure Neoplasms Obstructive disorders Autoimmune diseases Hepatorenal failure Scleroderma Amyloidosis Drug toxicity 15 Glomerular Filtration Rate GFR 24 hour urine for creatinine clearance Most accurate indicator of Renal Function Reflects GFR Formula: urine creatinine X urine volume serum creatinine Can estimate creatinine clearance by: Men: {140 – age} x IBW (kg) 72 x serum creatinine Women: {140 – age} x IBW (kg) 85 x serum creatinine What is a normal GFR? 16 Stages of Chronic Renal Failure Old System Reduced Renal Reserve Renal Insufficiency End Stage Renal Disease (ESRD) 17 Stages of Chronic Renal Failure NKF Classification System Stage 1: GFR >/= 90 ml/min despite kidney damage 18 Stages of Chronic Renal Failure NKF Classification System Stage 2: Mild reduction (GFR 60 – 89 ml/min) 1. GFR of 60 may represent 50% loss in function. 2. Parathyroid hormones starts to increase. 19 During Stage 1 - 2 No symptoms Serum creatinine doubles Up to 50% nephron loss 20 Stages of Chronic Renal Failure NKF Classification System Stage 3: Moderate reduction (GFR 30 – 59 ml/min) 1. 2. 3. 4. Calcium absorption decreases Malnutrition onset Anemia Left ventricular hypertrophy 21 Stages of Chronic Renal Failure NKF Classification System Stage 4: Severe reduction (GFR 15 – 29 ml/min) 1. Serum triglycerides increase 2. Hyperphosphatemia 3. Metabolic acidosis 4. Hyperkalemia 22 During Stage 3 - 4 Signs and symptoms worsen if kidneys are stressed Decreased ability to maintain homeostasis 23 During stages 3 - 4 75% nephron loss Decreased: glomerular filtration rate, solute clearance, ability to concentrate urine and hormone secretion Symptoms: elevated BUN & Creatinine, mild azotemia, anemia 24 Stages of Chronic Renal Failure NKF Classification System Stage 5: Kidney failure (GFR < 15 ml/min) 1. Azotemia 25 During Stage 5 End Stage Renal Disease Residual function < 15% of normal Excretory, regulatory and hormonal functions severely impaired. Metabolic acidosis Marked increase in: BUN, Creatinine, Phosphorous Marked decrease in: Hemoglobin, Hematocrit, Calcium Fluid overload 26 During Stage 5 Uremic syndrome develops affecting all body systems can be diminished with early diagnosis & treatment Last stage of progressive CRF Fatal if no treatment 27 Manifestations of Chronic Uremia Fig. 47-5 28 What happens when the kidneys don’t function correctly? 29 Manifestations of CRF Nervous System Mood swings Impaired judgment Inability to concentrate and perform simple math functions Tremors, twitching, convulsions Peripheral Neuropathy 30 Manifestations of CRF Skin Pale, grayish-bronze color Dry scaly Severe itching Bruise easily Uremic frost 31 Manifestations of CRF Eyes Visual blurring Blindness 32 Manifestations of CRF Fluid - Electrolyte - pH Volume expansion and fluid overload Metabolic Acidosis Electrolyte Imbalances Potassium Magnesium Sodium 33 Manifestations of CRF GI Tract Uremic fetor Anorexia, nausea, vomiting GI bleeding 34 Manifestations of CRF Hematologic Anemia Platelet dysfunction 35 Manifestations of CRF Musculoskeletal Muscle cramps Soft tissue calcifications Weakness Related to calcium phosphorous imbalances RENAL OSTEODYSTROPHY 36 Calcium-Phosphorous Balance 37 Manifestations of CRF Heart - Lungs Hypertension Congestive heart failure Pericarditis Pulmonary edema Pleural effusions Atherosclerotic vascular disease* Cardiac dysrhythmias 38 Manifestations of CRF Endocrine - Metabolic Erythropoietin production decreased Hypothyroidism Insulin resistance Growth hormone decreased Gonadal dysfunction Parathyroid hormone and Vitamin D3 Hyperlipidemia 39 Treatment Options Conservative Therapy Hemodialysis Peritoneal Dialysis Transplant Nothing 40 Conservative Treatment Goals GOALS: Detect & treat potentially reversible causes of renal failure Preserve existing renal function Treat manifestations Prevent complications Provide for comfort 41 Conservative Treatment Control Hyperkalemia Hypertension Hyperphosphatemia Hyperparthryoidism Hyperglycemia Anemia Dyslipidemia Hypothyroidism Nutrition 42 Hemodialysis Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane. 43 History 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. 44 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. 45 Hemodialysis Process Blood removed from patient into the extracorporeal circuit. Diffusion and ultrafiltration take place in the dialyzer. Cleaned blood returned to patient. 46 Extracorporeal Circuit 47 How Hemodialysis Works 48 Vascular Access Arterio-venous shunt (Scribner External Shunt) Arterio-venous (AV) Fistula PTFE Graft Temporary catheters “Permanent” catheters 49 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 50 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 devita.com 51 PTFE (Polytetrafluoroethylene) 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 52 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 restricts movement 53 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 54 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. 55 Potential Complications of Hemodialysis During dialysis Fluid and electrolyte related hypotension Cardiovascular arrythmias Associated with the extracorporeal circuit exsanguination Neurologic Disequilibrium Syndrome & seizures Musculoskeletal cramping Other fever & sepsis blood born diseases 56 Potential Complications of Hemodialysis Between treatments Hypertension/Hypotension Edema Pulmonary edema Hyperkalemia Bleeding Clotting of access 57 Complications of Hemodialysis cont’d Long term Metabolic hyperparathyroidism diabetic complications *Cardiovascular CHF AV access failure cardiovascular disease Respiratory pulmonary edema Neuromuscular neuropathy 58 Complications of Hemodialysis cont’d Long term cont’d Hematologic GI bleeding Dermatologic anemia calcium phosphorous deposits Rheumatologic amyloid deposits 59 Complications of Hemodialysis cont’d Long term cont’d Genitourinary infection sexual dysfunction Psychiatric depression *Infection blood borne pathogens 60 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 61 Peritoneal Dialysis Removal of soluble substances and water from the blood by diffusion through a semipermeable membrane that is intracorporeal (inside the body). 62 Types of Peritoneal Dialysis CAPD: Continuous ambulatory peritoneal dialysis CCPD: Continuous cycling peritoneal dialysis Aka. APD – Automated Peritoneal Dialysis IPD: Intermittent peritoneal dialysis 63 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 64 65 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 66 Complications of Peritoneal Dialysis Infection peritonitis tunnel infections catheter exit site Hypervolemia hypertension pulmonary edema Hypovolemia hypotension Hyperglycemia Malnutrition 67 Complications of Peritoneal Dialysis cont’d Obesity Hypokalemia Hernia Cuff erosion Low back pain Hyperlipidemia 68 Advantages of CAPD 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 69 Peritoneal Catheter Exit Site 70 71 Medications Common to Dialysis Patients Vitamins - water soluble Phosphate binder ---- GIVE WITH MEALS Phoslo (calcium acetate) Renagel (sevelamere hydrochloride) Caltrate (calcium cabonate) Amphojel (aluminum hydroxide) Iron Supplements – don’t give with phosphate binder or calcium Antihypertensives - hold prior to dialysis 72 Medications Common to Dialysis Patients cont’d Erythropoietin Calcium Supplements Activated Vitamin D3 Between meals, not with iron aids in calcium absorption Antibiotics hold dose prior to dialysis if it dialyzes out 73 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 74 Patient Education Alleviate fear Dialysis process Fistula/catheter care Diet and fluid restrictions Medication Diabetic teaching 75 Transplantation Treatment not cure 76 Kidney Awaiting Transplant 77 78 Transplanted Kidney 79 Advantages Restoration of “normal” renal function Freedom from dialysis Return to “normal” life Reverses pathophysiological changes related to Renal Failure Less expensive than dialysis after 1st year 80 Disadvantages Life long medications Multiple side effects from medication Increased risk of tumor Increased risk of infection Major surgery 81 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 82 Function ATN? (acute tubular necrosis) 50% experience Urine output >100 <500 cc/hr BUN, creatinine, creatinine clearance Fluid Balance Ultrasound Renal scans Renal biopsy 83 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 Postassium (K+)___________ Sodium (Na) _____________ Blood sugrar _____________ 84 Prevention of Infection Major complication of transplantation due to immunosuppression HANDWASHING Crowds, Kids Patient Education 85 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 86 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 87 Rejection cont’d Chronic - gradual process of graft dysfunction Repeated rejection episodes that have not been completely resolved with treatment 4 months to years after transplant Rx = return to dialysis or re-transplantation 88 Immunosuppressant Drugs Prednisone prevents infiltration of T lymphocytes Side effects cushingnoid changes avascular necrosis GI disturbances diabetes infection risk of tumor 89 Immunosuppressant Drugs cont’d Azathioprine (Imuran) Prevents rapid growing lymphocytes Side Effects bone marrow toxicity hepatotoxicity hair loss infection risk of tumor 90 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 91 Immunosuppressant Drugs cont’d Cytoxan - in place of Imuran less toxic FK506 - 100 x more potent than Cyclosporin Prograf Cellcept 92 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 93 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 94 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 95 Exclusion for Transplant 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. 96 Exclusion for Transplant 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. 97 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 98 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 100