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