Adult Medical-Surgical Nursing Renal Module: Chronic Renal Failure

Adult Medical-Surgical Adult Medical-Surgical NursingNursing

Renal Module: Renal Module:

Chronic Renal FailureChronic Renal Failure

Chronic Renal Failure:Chronic Renal Failure:CharacteristicsCharacteristics

ProgressiveProgressive deterioration of renal deterioration of renal functionfunction

IrreversibleIrreversible The kidneys are unable to maintain The kidneys are unable to maintain

fluid and electrolyte balance →fluid and electrolyte balance → Uraemia (azotaemia): increased urea Uraemia (azotaemia): increased urea

and nitrogenous waste products in and nitrogenous waste products in the blood, which adversely affects the blood, which adversely affects every system of the bodyevery system of the body

Chronic Renal Failure:Chronic Renal Failure:Aetiology/ Underlying CausesAetiology/ Underlying Causes

Diabetes Mellitus (Diabetic Diabetes Mellitus (Diabetic nephropathy): most common causenephropathy): most common cause

HypertensionHypertension Chronic glomerulonephritis or chronic Chronic glomerulonephritis or chronic

pyelonephritispyelonephritis Renal calculiRenal calculi Obstructions/ deformities of renal tractObstructions/ deformities of renal tract Long-term exposure to toxic agents Long-term exposure to toxic agents

(lead, mercury)(lead, mercury)

Chronic Renal Failure:Chronic Renal Failure:Clinical StagesClinical Stages

Reduced renal reserve (up to 75% Reduced renal reserve (up to 75% loss of nephron function): others loss of nephron function): others compensate therefore no symptomscompensate therefore no symptoms

Renal insufficiency (75-90% nephron Renal insufficiency (75-90% nephron loss): inability to concentrate urine, loss): inability to concentrate urine, ↑serum creatinine and urea, ↑serum creatinine and urea, anaemiaanaemia

End Stage Renal Disease (severely End Stage Renal Disease (severely impaired requiring dialysis): uraemia impaired requiring dialysis): uraemia and fluid/ electrolyte imbalanceand fluid/ electrolyte imbalance

Chronic Renal Failure:Chronic Renal Failure:PathophysiologyPathophysiology

Nephrons unable to produce urine or Nephrons unable to produce urine or concentrate urine (→ retention of fluid and concentrate urine (→ retention of fluid and toxic metabolic waste)toxic metabolic waste)

Altered basement membrane allows Altered basement membrane allows leakage of proteinleakage of protein

Normal renal buffering system fails → Normal renal buffering system fails → metabolic acidosismetabolic acidosis

Retention of phosphates → calcium loss Retention of phosphates → calcium loss (normally balance each other)(normally balance each other)

↓ ↓ production of erythropoietin (anaemia) production of erythropoietin (anaemia)

Chronic Renal Failure:Chronic Renal Failure:Clinical ManifestationsClinical Manifestations

Hypertension (fluid retention) Hypertension (fluid retention) Weight gain, oedema (↓urine output) Weight gain, oedema (↓urine output) Signs of congestive heart failure or Signs of congestive heart failure or

pulmonary oedema, ↑ JVPpulmonary oedema, ↑ JVP Dysrhythmias, pericarditis, pruritisDysrhythmias, pericarditis, pruritis Nausea, vomiting, diarrhoea, hiccoughsNausea, vomiting, diarrhoea, hiccoughs Drowsiness, muscle twitches, Drowsiness, muscle twitches,

restlessnessrestlessness Fatigue, pallor, breathlessness Fatigue, pallor, breathlessness

Chronic Renal Failure:Chronic Renal Failure:Signs of HyperkalaemiaSigns of Hyperkalaemia

Abdominal crampsAbdominal cramps

DiarrhoeaDiarrhoea

Muscle weaknessMuscle weakness

Cardiac dysrhythmiasCardiac dysrhythmias

Chronic Renal Failure:Chronic Renal Failure:Renal OsteodystrophyRenal Osteodystrophy

Kidneys unable to excrete phosphorus→Kidneys unable to excrete phosphorus→ ↑ ↑ serum phosphate and ↓ serum calciumserum phosphate and ↓ serum calcium Kidneys: ↓ vit D to aid calcium absorption Kidneys: ↓ vit D to aid calcium absorption Parathyroids triggered to raise blood Parathyroids triggered to raise blood

calcium through resorption from bonecalcium through resorption from bone ↑ ↑ phosphates form calcification in tissues: phosphates form calcification in tissues:

heart, blood vessels, joints, lungs, musclesheart, blood vessels, joints, lungs, muscles Osteomalacia: ↓ calcium for bone tissueOsteomalacia: ↓ calcium for bone tissue Osteitis fibrosis: bone calcium replaced by Osteitis fibrosis: bone calcium replaced by

fibrosis fibrosis

Chronic Renal Failure:Chronic Renal Failure:DiagnosisDiagnosis

History and clinical pictureHistory and clinical picture ↓ ↓ urine output and specific gravityurine output and specific gravity ↑ ↑ blood urea, creatinineblood urea, creatinine (Creatinine clearance test is valuable for (Creatinine clearance test is valuable for

diagnosis and monitoring disease diagnosis and monitoring disease progression)progression)

HyperkalaemiaHyperkalaemia Metabolic acidosisMetabolic acidosis ↓ ↓ serum calcium, ↑ phosphorusserum calcium, ↑ phosphorus AnaemiaAnaemia

Chronic Renal Failure:Chronic Renal Failure:Clinical Signs of DeteriorationClinical Signs of Deterioration

Rise in blood pressureRise in blood pressure

Excretion of proteinExcretion of protein

Chronic Renal Failure:Chronic Renal Failure:Medical ManagementMedical Management

Haemodialysis (2-3 times weekly)Haemodialysis (2-3 times weekly)

Peritoneal dialysis (continuous Peritoneal dialysis (continuous ambulatory or 2-3 times weekly)ambulatory or 2-3 times weekly)

Kidney transplantKidney transplant

Diet and medicationsDiet and medications

Chronic Renal Failure:Chronic Renal Failure:Diet and MedicationsDiet and Medications

Fluid restriction: usually previous 24 hour Fluid restriction: usually previous 24 hour urine output + 500ml (insensible loss)urine output + 500ml (insensible loss)

Sodium restrictionSodium restriction Protein reductionProtein reduction Avoid potassium-containing foodsAvoid potassium-containing foods Medications more potent therefore ↓ doseMedications more potent therefore ↓ dose Erythropoietin, iron, folic acid, vitamin D, Erythropoietin, iron, folic acid, vitamin D,

calcium supplements, calcium carbonate calcium supplements, calcium carbonate

Chronic Renal FailureChronic Renal Failure

DialysisDialysis

Chronic Renal Failure:Chronic Renal Failure:Principles of DialysisPrinciples of Dialysis

DiffusionDiffusion: : toxinstoxins pass from high pass from high concentration to ideal blood levels in the concentration to ideal blood levels in the dialysate by diffusion(until equal)dialysate by diffusion(until equal)

OsmosisOsmosis: : excessexcess waterwater passes to passes to dialysate by osmosis (glucose added to dialysate by osmosis (glucose added to draw water)draw water)

Semi-permeableSemi-permeable membranemembrane: impedes : impedes larger moleculeslarger molecules

Ultra-filtrationUltra-filtration (negative pressure applied) (negative pressure applied)

Chronic Renal Failure:Chronic Renal Failure:HaemodialysisHaemodialysis

Arterio-venous fistula (AV fistula)Arterio-venous fistula (AV fistula)

Arterio-venous graft (synthetic, or Arterio-venous graft (synthetic, or formed from saphenous vein) where formed from saphenous vein) where fistula not possiblefistula not possible

Central line (temporary measure): Central line (temporary measure): subclavian, internal jugular, femoral subclavian, internal jugular, femoral

Chronic Renal Failure:Chronic Renal Failure:Nursing Considerations for DialysisNursing Considerations for Dialysis

In case of a fistula or graft, do not use In case of a fistula or graft, do not use this arm for BP, IVI, taking blood, this arm for BP, IVI, taking blood, carrying weightscarrying weights

Feel for “bruit” to check patencyFeel for “bruit” to check patency Weigh prior to dialysis (calculates Weigh prior to dialysis (calculates

excess fluid based on dry weight)excess fluid based on dry weight) BP initially and throughoutBP initially and throughout Emergency measure for hypotensionEmergency measure for hypotension Medications and food Medications and food post-dialysispost-dialysis

Chronic Renal FailureChronic Renal Failure

Kidney TransplantKidney Transplant

Chronic Renal Failure:Chronic Renal Failure:Kidney TransplantKidney Transplant

Once working, a new kidney reverses Once working, a new kidney reverses some of the pathophysiological some of the pathophysiological changes of renal failure allowing a changes of renal failure allowing a more normal lifestyle and dietmore normal lifestyle and diet

The client following transplant will be The client following transplant will be immunosuppressed for the rest of his immunosuppressed for the rest of his lifelife

Chronic Renal Failure:Chronic Renal Failure:Kidney Transplant: DonorKidney Transplant: Donor

The kidney donor may be a living relative The kidney donor may be a living relative (homogeneic) or a cadaver (allogeneic)(homogeneic) or a cadaver (allogeneic)

A living relative is preferable as optimal A living relative is preferable as optimal timing arranged, and minimal “cold” time timing arranged, and minimal “cold” time prior to surgeryprior to surgery

Thorough health check of donorThorough health check of donor Screen for HIV, HBsAg, HCV, CMV Screen for HIV, HBsAg, HCV, CMV Histocompatibility (HLA) on initial serum Histocompatibility (HLA) on initial serum

test test andand by crossmatch: by crossmatch: NONO antibodies as antibodies as would cause immediate rejectionwould cause immediate rejection

Chronic Renal Failure:Chronic Renal Failure:Kidney Transplant: RecipientKidney Transplant: Recipient

Optimal recipient health at time of surgeryOptimal recipient health at time of surgery Old kidney left to reduce rejection riskOld kidney left to reduce rejection risk Cadaver kidney more at risk of acute Cadaver kidney more at risk of acute

tubular necrosis/ malfunction (from delay)tubular necrosis/ malfunction (from delay) Usually huge diuresis from live donor Usually huge diuresis from live donor

kidney : kidney : Monitor and counteract risk of dehydration Monitor and counteract risk of dehydration

and hypovolaemia, electrolyte imbalance, and hypovolaemia, electrolyte imbalance, metabolic acidosismetabolic acidosis

Chronic Renal Failure:Chronic Renal Failure: Kidney Transplant: Rejection Kidney Transplant: Rejection

Rejection of the kidney is common in the Rejection of the kidney is common in the first 3 months:first 3 months:

Hyper-acute rejection (antibodies): occurs Hyper-acute rejection (antibodies): occurs immediatelyimmediately post-op and requires removal post-op and requires removal of the kidneyof the kidney

Acute rejection (killer T cells) occurs days Acute rejection (killer T cells) occurs days to months post-op: is manageable by to months post-op: is manageable by increasing immunosuppressivesincreasing immunosuppressives

Chronic rejection (months to years) is Chronic rejection (months to years) is irreversible and requires another donorirreversible and requires another donor

Kidney Transplant:Kidney Transplant:Signs of RejectionSigns of Rejection

Reduced urine outputReduced urine output Pyrexia (fever)Pyrexia (fever) Raised BPRaised BP Weight gain and oedemaWeight gain and oedema Tenderness and pain over the Tenderness and pain over the

transplant site (usually iliac fossa)transplant site (usually iliac fossa) Raised serum creatinine and ureaRaised serum creatinine and urea

Kidney Transplant: Management Kidney Transplant: Management and Nursing Considerationsand Nursing Considerations

Ensure vascular access (“bruit”) in case Ensure vascular access (“bruit”) in case haemodialysis required once morehaemodialysis required once more

Observe for signs of rejectionObserve for signs of rejection Record diuresis and replace fluid regimenRecord diuresis and replace fluid regimen Monitor fluid/ electrolyte balance, ABGs Monitor fluid/ electrolyte balance, ABGs Monitor vital signs (haemo-dynamics)Monitor vital signs (haemo-dynamics) Immunosuppressive therapy, immediate/ Immunosuppressive therapy, immediate/

long-term: initial isolation/ patient long-term: initial isolation/ patient educationeducation

Kidney Transplant:Kidney Transplant:Immunosuppressive TherapyImmunosuppressive Therapy

CyclosporineCyclosporine PrografPrograf PrednisolonePrednisolone CellceptCellcept

These drugs will be gradually tapered These drugs will be gradually tapered but a combination will be taken for but a combination will be taken for lifelife

Kidney Transplant:Kidney Transplant:Side Effects of ImmunosuppressionSide Effects of Immunosuppression Increased risk of infectionIncreased risk of infection Risk of opportunistic infections eg candidaRisk of opportunistic infections eg candida Increased risk of malignancyIncreased risk of malignancy Risk of atherosclerosis and cardiovascular Risk of atherosclerosis and cardiovascular

diseasedisease Problems associated with steroid therapy: Problems associated with steroid therapy:

hypertension, weight gain, Diabetes hypertension, weight gain, Diabetes Mellitus, muscle wasting, Cushing’s Mellitus, muscle wasting, Cushing’s syndrome, osteoporosis, cholelithiasis, syndrome, osteoporosis, cholelithiasis, renal calculi, cataract, glaucomarenal calculi, cataract, glaucoma

Kidney Transplant:Kidney Transplant:Long-term Health EducationLong-term Health Education

Be aware of signs of rejectionBe aware of signs of rejection Regular BP, weight checksRegular BP, weight checks Report infection Report infection Advise health care providers that Advise health care providers that

taking immunosuppressives (card)taking immunosuppressives (card) NEVER stop steroids suddenlyNEVER stop steroids suddenly Injury, surgery, stress or infection Injury, surgery, stress or infection

may require increased steroid dosemay require increased steroid dose Dietary modifications Dietary modifications