Renal Failure andTreatment

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

• 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

• Diabetes

• Hypertension

• Glomerulonephritis

• Cystic disorders

• Developmental - Congenital

• Infectious Disease

Causes of Chronic Renal Failure cont’d• Neoplasms

• Obstructive disorders

• Autoimmune diseases– Lupus

• 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

• 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

• Muscle cramps

• Soft tissue calcifications

• Weakness

• Related to calcium phosphorous imbalances

Heart Lungs

• Hypertension

• Congestive heart failure

• Pericarditis

• Pulmonary edema

• Pleural effusions

Endocrine/Metabolic

• 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

HemodialysisCircuit

ExtracorporealCircuit

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– infection– skin erosion– accidental separation – limits use of extremity

External (Scribner) Shunt

Arterio-venous (AV) FistulaPrimary 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 vein-subclavian, 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 TunneledCatheter

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

– 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 Hemodialysiscont’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• 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 semi-permeable membrane that is intracorporeal (inside the body).

PeritonealDialysis

Types of Peritoneal Dialysis

• CAPD: Continuous ambulatory peritoneal dialysis

• CCPD: Continuous cycling peritoneal dialysis

• IPD: Intermittent peritoneal dialysis

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

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• Obesity

• Hypokalemia

• Hernia

• Cuff erosion

Advantages of CAPD

• 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

• 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

• Life long medications

• Multiple side effects from medication

• Increased risk of tumor

• Increased risk of infection

• Major surgery

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

Function

• ATN? (acute tubular necrosis) – 50% experience

• 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– cushnoid changes

– Avascular Necrosis

– GI disturbances

– Diabetes

– infection

– risk of tumor

Immunosuppressant Drugs cont’d

• Azathioprine (Imuran)– Prevents rapid growing lymphocytes

• Side Effects– 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