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 Kidney Failure and Dialysis By: Gale MacDonald and Marie Helene Bond.

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1  Kidney Failure and Dialysis By: Gale MacDonald and Marie Helene Bond

2 Presentation Overview  Kidney disease in Canada  Functions of the kidney  Anatomy and physiology  Kidney failure- Acute: categories; phases; causes; clinical manifestations; prevention; and nsg interventions and Chronic- stages; S/S; risk factors; prevention; nsg interventins  Screening procedures; labs test  Treatment for renal failure  Dialysis- hemodialysis and peritoneal dialysis: nursing management and equipment  Transplant- nursing management  Conservative care  Case study  Quiz  Questions

3 Kidney Disease in Canada  An estimated 2.6 million Canadians have kidney disease, or are at risk.  Each day, an average of 16 people are told that their kidneys have failed.  The two leading causes of kidney failure in new patients: 1. Diabetes – 35% 2. Renal Vascular Disease (including high blood pressure) – 18 %. The number of Canadians being treated for kidney failure has tripled over the past 20 years. 53% of new renal failure patients are 65 years of age or older. Among the 39,352 people being treated for kidney failure in Canada in 2010: 59% (23,188) were on dialysis 41% (16,164) had a functioning transplant.

4 Function of Kidneys Production of urine and elimination of waste Facilitates electrolyte balance Facilitates acid-base balance Manages water balance and maintain blood osmolality Influences blood pressure and blood volume Renal clearance Secretion of prostaglandins Conversion of vitamin D to it’s active form Assists with red blood cell production (erythropoietin) (Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 1405; Tortora & Derrickson, 2009, p )

5 Anatomy of Kidney

6 The Nephron

7 Urine  The formation of urine involves three major processes: 1) Glomerular filtration in the renal corpuscles 2) Tubular reabsorption 3) Tubular secretion

8 Glomerular filtration in the Renal Corpuscles  “Filtration is a process by which blood pressure forces plasma and dissolved materials out of capillaries” (Williams & Hopper, 2007, p. 752)  “The blood pressure in the glomeruli is relatively high about 55mmHg. The pressure in Bowmen’s capsule in low and its inner layer is permeable, so approx 20% to 25 %of blood that enters the glomeruli becomes renal filtrate in bowmen’s capsule” (Williams & Hopper, 2007, p. 752)  “Renal filtrate is similar to blood plasma except that there is far less protein and no blood cells present” (Williams & Hopper, 2007, p. 752).  “The glomerular filtration rate (GFR) is the amount of renal filtrate formed by the kidneys in one minute; It averages 100 to 125mL/min” (Williams & Hopper, 2007, p. 752).

9 Tubular reabsorption  “Tubular reabsorption is the recovery of useful materials from the renal filtrate and their return to the blood in the peritubular capillaries” (Williams & Hopper, 2007, p. 753).  Takes place in proximal convoluted tubules, distal convoluted tubules and collecting tubules (Williams & Hopper, 2007, p. 753).  “Mechanisms of reabsorption are active transport, osmosis, diffusion, facilitated diffusion and pinocytosis” (Williams & Hopper, 2007, p. 753).

10 Tubular Secretion  “In tubular secretion, substances are actively secreted from the blood in the peritubular capillaries into the filtrate in the renal tubules” (Williams & Hopper, 2007, p. 753).  Ammonia, creatinine, excess water soluble vitamins, the metabolic products of medications and Hydrogen ions may be secreted into urine (Williams & Hopper, 2007).

11 What Happens in the Nephron

12 Definition: The kidneys failure to expel wastes, maintain electrolyte balance, concentrate urine, and maintain chemicals in the bloodstream that are regulated by the kidneys (ex. Renin) (Mosby’s Dictionary of Medicine, Nursing & Health Professionals, 2006). Can be acute or chronic Renal Failure

13 Acute Renal Chronic Renal Failure Failure

14 Acute Renal Failure  “Acute renal failure (ARF) is a sudden and almost complete loss of kidney function over a period of hours to days” (Day et al., 2010, p. 1435).  Oliguria: urine output of less then 400mL /day. is the most common clinical manifestation (p.1435).  Anuria (less than 50 ml of urine a day)  Elevated BUN and creatinine  Reversible if treated promptly

15 Categories of ARF 1. Prerenal: Hypoperfusion of the kidneys. 2. Intrarenal: Acute damage to kidney tissue 3. Postrenal: obstruction to urine flow

16 Phases of ARF  Initiation phase: “begins with the initial insult and ends with oliguria”  Oliguria phase:” manifested by a rise in the concentration of substances usually excreted by the kidney (urea, creatinine, uric acid, potassium and magnisium)”.  Diuresis:” gradual increase in urine output, which indicates GFR has started to recover.”  Recovery: “improvement of renal function may take 3 to 12 months. Lab values may return to normal. A permanent damage of 1% to 3% in GFR function is common, but not clinically significant” (Day et al., 2010, p, 1437)

17 Causes of ARF Prerenal failure causesIntrarenal failurePostrenal failure Volume depletion resulting from: hemorrhage, diuretics, vomiting diarrhea nasogastric suction. Impaired cardiac efficiency resulting from: MI, dysthymias, cardiogenic shock. Vasodilation resulting from: sepsis, anaphylaxis, antihypertensive medications or other meds that cause vasodilatation. Prolong renal ischemia resulting from: trauma, crush injury, burns, transfusion reactions, hemolytic anemia. Nephrotoxic agents such as: gentamicin, heavy metals- lead and mercury, NSAID’s, ACE inhibitors, radiopaque dyes. Infectious processes such as: acute pyelonephritis, Acute glomerulonephritis. Urinary tract obstruction, including: calculi (stones), tumours, BPH, strictures, and blood clots.

18 Clinical Manifestations  Pt will appear critically ill and lethargic, and confused  Skin and mucus membranes will be dry from dehydration  drowsiness, headache, muscle twitching, and seizures.  dyspnea, crackles, tachypnea, (Day et al., 2010, p. 1436)

19 Comparing the categories of ARF CharacteristicsPrerenalIntrarenalPostrenal etiologyhypoperfusionTissue damageobstruction BUN  creatinine  Urine output  Varies but often  Varies-may be decreased, or sudden anuria Urine sodium  To <20mEq/L  To >40 mEq/L Varies- often  to 20 mEq/L Urine specific gravaty  Low normalVaries

20 Prevention of ARF  Provide adequate hydration to clients at risk of dehydration. ( surgical client)  Prevent and treat shock- with blood and fluids  Treat hypotension promptly  Continually assess renal function (output, Labs)  Avoid transfusion reactions (always check two RN, and Five rights and three checks  Prevent and treat infection promptly (good catheter care) and pay special attention to wounds, burns, and other precursors to sepsis  Toxic drug effects- monitor blood levels, and ensure safe does  Day et al., 2010, p. 1437

21 Nursing interventions  Monitor intake and output, including all body fluids  May need to stimulate production of urine with IV fluids, diuretics.  Daily weights  Monitor lab results, CBC, BUN, creatinine, urea, e’lyles  Watch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness, EKG changes  Maintain nutrition  Mouth care – dry mucus membranes  Assess for signs of cardiac involvement- dysthymias  Skin integrity problems. Edema, itching –from toxins  Signs and symptoms of infection  May need dialysis, or continuous renal replacement therapy.

22 Chronic Renal failure (CRF)  Definition: “ Chronic Renal failure is a progressive, irreversible deterioration of renal function in which the body ability to maintain metabolic, fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous waste in blood) (Day et al., 2010, p. 1440).

23 Stages of CRF  The normal glomerular filtration rate (GFR) is 125ml/min/1.73m2 (Day et al., 2010, p. 1440)  The stages of renal failure is determined by the GFR (Day et al., 2010, p. 1440).

24 Stages of CRF  Stage 1: GFR>90ml/min/1.73m2 kidney damage with normal or elevated GFR  Stage 2 : GFR = ml/min/1.73m2 mild decrease in GFR  Stage 3: GFR = ml/min/1.73m2 moderate decrease in GFR  Stage 4: GFR = ML/MIN/1.73M2 Severe decrease in GFR  Stage 5: GFR<15ml/min/1.73m2 Kidney Failure (aka end stage renal failure)


26 Signs & Symptoms of CRF  Ammonia-like taste in mouth or urinous breath  Edema of feet, hands, arms, face and around eyes  Hypertension  Extended neck veins  Anemia  Fatigue  Neurologic disturbances  Nausea, vomiting, and anorexia  Headaches and blurred vision

27 Signs & Symptoms of CRF  Pruritus  Shortness of breath  Bone and joint problems  Weakness, numbness, tremors, bone pain, and paresthesia  Urine that is cloudy, tea-coloured, or bloody  Decreased urine output or trouble urinating  Foaming of urine  Proteinuria

28 CRF Risk Factors  People at increased risk of developing kidney disease include people who have:  Diabetes  High blood pressure or blood vessel diseases  Glomerulonephritis and other systemic diseases  Family history of hereditary kidney disease  Certain ethnic groups such as Aboriginal, Asian, South Asian, Pacific Island, African/Caribbean and Hispanic origin

29 Nursing interventions CRF  Assessing fluid status  Nutrition/Diet  Patient teaching  Assess emotional status and coping strategies  Assessing for complications  Administering Medications

30 Sum it up: major complications  failure can affect almost every part of your body. Potential complications may include:  Fluid retention, which could lead to swelling in your arms and legs, high blood pressure, or fluid in your lungs (pulmonary edema)  A sudden rise in potassium levels in your blood (hyperkalemia), which could impair your heart's ability to function and may be life-threatening  Heart and blood vessel disease (cardiovascular disease)  Weak bones and an increased risk of bone fractures  Anemia  Decreased sex drive or impotence  Damage to your central nervous system, which can cause difficulty concentrating, personality changes or seizures  Decreased immune response, which makes you more vulnerable to infection  Pericarditis, an inflammation of the sac- like membrane that envelops your heart (pericardium)  Pregnancy complications that carry risks for the mother and the developing fetus  Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survival (Mayo clinic, 2012).


32 Diagnostic Procedures  Renal ultrasound  CT  MRI  IVP  Nephrotomogram  Renal angiogram:  Renal scan:  Renal biopsy: (Williams & Hopper, 2007)

33 Screening: Normal blood values to assess Kidney function  Urea1.8 – 8.2mmol/L  Potassium3.5 – 5.0mmol/L  Phosphate0.8 – 1.4mmol/L  Calcium2.0 – 2.6mmol/L  Creatinine60 – 110umol/L (female) 70 – 120umol/L (Male)  Hemoglobin120 – 140g/L (female) 140 – 160g/L (male)  GFR90 – 120ml/min (1.5 – 2.0ml/sec)

34 Assessing renal function Blood tests Creatinine Blood urea nitrogen Hemoglobin Hematocrit Sodium Potassium Chloride Calcium Phosphorus Magnesium Urine tests Uric acid Urine protein Urine creatinine clearance Normal value mg/dl mg/dl grams/dl 40%-50% mEq/liter mEq/liter mEq/liter mg/dl mg/dl mEq/liter Normal value mg/dl None GFR = 120–125 ml/min Change with chronic renal failure Increased. Over 1.2 mg/dl in women and 1.4 mg/dl in men merits further renal assessment. Increased Decreased Varies with free water Increased Varies Decreased Increased Increased or normal Change with chronic renal failure Increased Positive test result dictates follow- up urinalysis. >3,500 mg indicates glomerular disease. Decreased

35 Screening: Urine Testing  Creatinine clearance formula: (Volume of urine [ml/min] X Urine creatinine [MMOL/L]) Serum Creatinine (mmol/L)  As renal function decreases, creatinine clearance decreases  Day et al., 2010, pp1410

36  Treatment of Renal Failure Medication Proper Diet Dialysis (2 types: peritoneal & hemodialysis) Transplantation Conservation Care

37 Treatment of Renal Failure  Medication: Medication may be used to help maintain or improve kidney function, as well as, treat complications of renal failure (eg. Antihypertensives, kayexalate, etc.) (Day et al., 2010, pp 1442).

38 Diet for CRF  Low protein  Low sodium  Low potassium  Fluid restrictions  Vitamin supplements  High calorie

39 Dialysis  When the kidneys are not removing fluid and uremic waste from the body, dialysis can be used to do so  Dialysis can be acute or chronic  Acute dialysis is used for people with high levels of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusion  Acute dialysis may also be used to remove certain medications or other toxins from the blood

40 Dialysis  Chronic dialysis is used for chronic renal failure  Dialysis can be used for years to help maintain people with no renal function  Indications may include: uremic signs and symptoms affecting all body systems, hyperkalemia, fluid overload, pericardial friction rub, and lack of well being

41 Types of Dialysis Peritoneal Dialysis Hemodialysis

42 Peritoneal Dialysis  Removes metabolic wastes and toxin’s so the body’s normal fluid and electrolyte balance is re-established  The peritoneum that lines the abdominal cavity and covers the abdominal organs acts as a semipermeable membrane that allows metabolic end products to be removed from the blood by means of diffusion and osmosis

43 Peritoneal Dialysis  An abdominal catheter allows sterile dialysate fluid to enter the peritoneal cavity  The metabolic waste products in the blood move from an area of high concentration (blood), across the peritoneal membrane, to an area of low concentration (peritoneal cavity with dialysate fluid)

44 Peritoneal Dialysis  The body’s excess fluid is removed by an osmotic gradient, because the dialysate fluid in the peritoneal cavity has a higher glucose concentration  the fluid is then removed from the peritoneal cavity and discarded  This process is repeated 4-6 times ever 24hrs  The most common complication from peritoneal dialysis is peritonitis

45 Peritoneal Dialysis  Equipment:

46 Peritoneal Dialysis Nursing management  Client and family education  Sterile technique (face mask, gloves, sterile field)  Signs and symptoms of peritonitis  Inspect site and dialysate solution for signs and symptoms of infection

47 Hemodialysis  The most common type of dialysis  Purpose remains to remove toxins from the blood and excess water from the body  Usually patients receive Hemodialysis 3 times per week  Treatment takes about 3-8 hours per treatment

48 Hemodialysis  The blood is delivered from the patient and to the dialysis machine, where a dialyzer (artificial kidney) uses diffusion, osmosis, and ultrafiltration to remove toxins from the blood, which is then returned to the patient  The metabolic waste products in the blood move from an area of high concentration (blood), to an area of low concentration (dialysate)

49 Hemodialysis  Dialysate is a solution composed of electrolytes, which concentration levels can be adjusted to accommodate the desired electrolyte level in the patients blood  Osmosis and ultrafiltration is used to remove the body’s excess water

50  Arteriovenous fistula- is made by sewing a vein and artery together under the skin. Fistulas may take 2 to 4 months to mature. A temporary access device is usually needed until It matures (Williams & Hopper 2007, p. 803).  Arteriovenous graft: uses a tube of systhetic material to attach an artery and a vein. Needles are inserted into the graft to access the clients blood (Williams & Hopper 2007, p. 803). Hemodialysis: Vascular Access Device

51  Two tailed subclavian/ double lumen, cuffed hemodialysis catheter used for acute hemodialysis.  Red port: blood line  Blue port: return dialyzed blood to client.

52 Hemodialysis Equipment

53 Nursing Management for Hemodialysis  Consult with physician about medications to hold prior to dialysis  Obtain weigh before dialysis and after dialysis note changes.  Coordinate blood draws with the dialysis nurse to avoid unnecessary needle pokes  Get morning care done early and give breakfast before dialysis  Apply emla patch to numb fistula or graft area  When the client returns assess for signs and symptoms of bleeding  Assess vital signs and admin medications that were held in the AM unless contraindicated  Allow for rest. Clients often exhausted after dialysis (Williams & Hopper 2007, p. 803)

54 Nursing Management for Hemodialysis  Listen for a bruit at the site by placing stethoscope gently on the site. A bruit is a swishing sound made as the blood passes through the access site.  Gently palpate for a thrill, which is a buzzing or pulsing feeling that indicates good blood flow  Do not take BP, draw blood, start IV, or use tourniquet, on affected arm. injections should also be avoided. (Place sign above bed). (Williams & Hopper 2007, p. 803)  Teach client to keep site clean, not to bump, or cut.  Teach client to not lift heavy objects with affected arm  Teach client to avoid tight jewellery and restrictive cloths on affected arm.  Teach client to avoid sleeping or bending affected arm for long periods of time  Notify physician of signs of bleeding, reduced circulation, or infection, coldness, numbness, weakness, redness, fever, drainage, swelling

55 Hemodialysis V.S peritoneal Hemodialysis  Requires vascular access device. Either temporary (ARF) or permanent (CRF).  Requires a complex specialized dialyzer  Requires a skilled hemodialysis nurse  Intermittent (q3-4days)  Principals of osmosis and diffusion  Preferred for end-stage renal failure Peritoneal  Requires a insertion of a catheter into the peritoneal cavity  Does not require specialized dialyzer  Can be done by client (sterile technique)  Continuous (4-6 q 24hr)  Principals of osmosis and diffusion  Have few cardio side effects can be used in unstable clients.

56 Kidney Transplantation  Surgically transplanting a functioning kidney into a patient with end-stage renal disease  The donated kidney may be from either a living donor or a deceased donor

57 Kidney Transplantation Nursing Management  Pre and postoperative teaching  Assessing patient coping and anxiety  Assessing for signs and symptoms of transplant rejection  Preventing infection  Monitoring urinary functioning  Psychological concerns  Monitoring and managing potential complications  Promoting home and community based care

58 Conservative Care  Some patients may view their quality of life as dramatically impaired by the renal replacement therapy, and consider it to be not worth the benefit of continued life.  Conservative Care offers physical and emotional comfort care to those patient who decide not to receive or continue with active treatment for renal failure. Allowing renal failure to take its natural course.

59 Conservative Care  The decision not to receive treatment for renal failure should only be made after serious consideration and assistance from the healthcare team.  The patient is supported by the healthcare team and efforts are made to manage symptoms until death occurs.

60 Quiz: true or false  1. Many of the body's organs need the kidneys to function properly and you could die without healthy kidneys.  2. Kidney disease is a one-time acute illness that is strictly inherited.  3. There are no 'at risk' categories for kidney disease.  4. Usually, kidney disease starts slowly and silently, and progresses over a number of years.  5. There are 5 stages in kidney disease and everyone gets to Stage 5 sooner or later.  6. Chronic kidney failure is curable.  7. The gap between the need for kidneys and the number of available organs for transplantation is growing

61 Case study  Mrs. Jacksons is a single, 56 year old women with a 20 Hx of type two 1 diabetes, HTN, Hyperlipidemia, chronic anemia, and a total knee replacement. She has been diagnosed with chronic renal failure. She was admitted to a medical unit for treatment of SOB and renal failure. She had increasing SOB, pitting edema, urine output of 300 mL per day and is having PVC’s as seen on her cardiac monitor. Her labs are: Na 131; K 6; Cl 97; ca 10; iron 64; WBC 4000; RBC 3.12; Hgb 10.1; Hct 32; creatinine 7; BUN 30. She is having a two tailed subclavian catheter place in for blood access. She is having an eco and chest x-ray. She is withdrawn and quite in her room alone. (Williams & Hopper 2007, p. 809)

62 Potential Nsg Diagnosis Fluid volume excess R/T edema and failure of renal regulatory mechanism. Electrolyte abnormalities R/T edema and failure of renal regulatory mechanism. Imbalanced nutrition: less than body requirements due to hyper catabolic sate Urinary retention R/T neuropathy Anxiety R/T illness/death Infection R/T supressed immune system Ineffective coping R/T loss of control Noncompliance R/T apathy or denial

63 ??Questions??

64 References  References  Day, R. A., Paul, P., Williams, B., Smeltzer, S. C. & Bare, B. (2007). Brunner & Suddarth’s textbook of medical-surgical nursing (1 st Canadian Ed.). PA: Lippincott, Williams & Wilkins.  Cannon, J. (2004). Recognizing chronic renal failure...the sooner the better. Nursing. 34(1),  Mayo clinic. (2012). Chronic renal failure: complications. Retrieved from: failure/DS00682/DSECTION=complications failure/DS00682/DSECTION=complications  Mosby’s Dictionary of Medicine, Nursing & Health Professionals (8 th Ed.). (2006). p St.Louis, Missouri; Mosby Elsevier.  Power, A., Chan, K., Singh, S. K., Taube, D., & Duncan, N. (2012). Appraising stroke risk in maintenance hemodialysis patients: A large single-center cohort study. American Journal of Kidney Diseases, 59(2), Retrieved from:  The kidney Foundation of Canada (2012). Facing the facts. Retrieved from:  Sens, F., Schott-Pethelaz, A. M., Labeeuw, M., Colin, C., Villar, E., & Rein Registry. (2011). Survival advantage of hemodialysis relative to peritoneal dialysis in patients with end-stage renal disease and congestive heart failure. Kidney International, 80(9), Retrieved from:

65 References  Somers, J. (2008). Dietary management of renal disease. CANNT Journal, 18(3), Retrieved from: 8b60-b6a89c6dd895%40sessionmgr4&vid=2&hid=21  The Kidney Foundation of Canada. (2012). Retrieved From:  Thibodeau & Patton, (2004). Structure& function of the body. St. Louis: Mosby.  Tortora, G. J., Derrickson, B. (2009). Principals of anatomy and physiology (12 th Ed.). Danvers, MA: John Wiley & Sons, Inc.  Williams, L.S., Hopper, P.D. (2007). Understanding Medical Surgical Nursing. Philadelphia, PA: F. A. Davis Company.  Zarifian, A. (2006). Symptom occurrence, symptom distress, and quality of life in renal transplant recipients. Nephrology Nursing Journal : Journal of the American Nephrology Nurses' Association, 33(6), Retrieved from: b951-4e1c-a984- c0bbea9ad5fd%40sessionmgr4&vid=1&hid=21&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#d b=c8h&AN= b951-4e1c-a984- c0bbea9ad5fd%40sessionmgr4&vid=1&hid=21&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#d b=c8h&AN=

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