Presentation on theme: "Kidney Failure and Dialysis"— Presentation transcript:
1 Kidney Failure and Dialysis By: Gale MacDonald and Marie Helene Bond
2 Presentation Overview Kidney disease in CanadaFunctions of the kidneyAnatomy and physiologyKidney failure- Acute: categories; phases; causes; clinical manifestations; prevention; and nsg interventions and Chronic- stages; S/S; risk factors; prevention; nsg interventinsScreening procedures; labs testTreatment for renal failureDialysis- hemodialysis and peritoneal dialysis: nursing management and equipmentTransplant- nursing managementConservative careCase studyQuizQuestionsToday we are going to talk about Renal FailureWe will begin by talking about some renal stats in Canada,explain the functions of the kidneys,Anatomy and physiology,describe Acute Renal failure and Chronic Renal Failure,Screening Procedures for renal failure,Different types of treatments,Including Hemodialysis and Peritoneal dialysis,Kidney transplants,And we will discribe conservative care for end-stage renal disease.Then we have a little case study and a quizAnd at the end or anytime feel free to ask 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.mThe kidney foundation of Canada (2012). Retrieved from:
4 Function of Kidneys Influences blood pressure and blood volume Renal clearanceSecretion of prostaglandinsConversion of vitamin D to it’s active formAssists with red blood cell production (erythropoietin)Production of urine and elimination of wasteFacilitates electrolyte balanceFacilitates acid-base balanceManages water balance and maintain blood osmolalityMarieProduction of urine and elimination of waste :“By forming urine, the kidneys help excrete substances that have no function or useful purpose in the body. Some waste excreted in urine results from metabolic reactions in the body. These include ammonia and urea from the deamination of amino acids; bilirubin from the catabolism of hemoglobin; creatinine from the breakdown of creatine phosphate in muscle fibers; and uric acid from the catabolism of nucleic acid. Other wastes excreted in urine are forging substances from diet, such as drug and environmental toxins” (Tortora & Derrickson, 2009, p. 1020).Facilitates electrolyte balance:The kidneys help regulate the blood levels of several ions, most importantly Na+, K+, calcium, chloride, and phosphate. (Tortora & Derrickson, 2009).Facilitates acid-base balance: the kidneys excrete variable amount of hydrogen ions into the urine and conserve bicarbonate, which are an important buffer of hydrogen in the blood. Both of these activities help regulate blood pH (Tortora & Derrickson, 2009).Manages water balance and maintain blood osmolality: By separately regulating loss of water and loss of solutes in the urine, the kidneys maintain a relatively constant blood osmolality- close to 300 milliosmoles per liter (Tortora & Derrickson, 2009).Blood pressure: the kidneys help to regulate blood pressure by secreting the enzyme Renin, which activates the renin-angeotensin- aldosterone pathway-vasoconstriction. The increase in renin causes BP to increase (Tortora & Derrickson, 2009).Blood volume- the kidneys adjust blood volumes by conserving or eliminating water in the urine. An increase in blood volume will blood pressure; a decrease in blood volume will decrease bp (Tortora & Derrickson, 2009).Renal clearance refers to the ability of the kidneys to clear solute from plasma. A 24hr urine collection is the primary test for renal clearence. This test is used to evaluate how the kidneys are functioning as an excretory organ (Day et al., 2010, p. 1410).The kidneys also produce prostaglandin E and prostacyclin , which have a vasodilatory effect and are important in maintaining renal blood flow Day et al., 2010, p. 1411).The kidneys also produce calcitrol, the active form of vit D, which helps regulate calcium homeostasis (Tortora & Derrickson, 2009).AndWhen the kidneys sense a decrease in the oxygen tension in renal blood flow, they release erythropoietin. Erythropoietin stimulated the bone marrow to produce RBC, thereby increasing the amount of hemoglobin available to carry O2 (Day et al., 2010, pp, )(Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 1405;Tortora & Derrickson, 2009, p )
5 Anatomy of Kidney MArie The renal medulla- the inner portion of the of the kidneysRenal pyramids- “the triangular division of the medulla of the kidney. Extension of the cortical tissue that dip down into the medulla between the renal pyramids are called renal columns” (Thibodeau & Patton, 2004, p.438).Renal papilla- “narrow innermost end of the pyramid” (Thibodeau & Patton, 2004).Renal pelvis- “an expanstion of the upper end of the ureter” (Thibodeau & Patton, 2004, p.438).Calyx- “ a division of the renal pelvis (the papilla of a pyramid opens into each calyx)” (Thibodeau & Patton, 2004, p.438).and the nephron, which I will discuss on the next slide
6 The Nephron MArie The nephron the functional unit of the kidneys. According to Thibodeau & Patton “more then a million mirooscopic units called nephrons make up each kidney’s interior” (p. 438). The nephrons is composed of two major components; the renal corpuscle and the renal tubule. The renal corpuscle can be subdivided into two parts and the renal tubular into four regions1) renal corpusclea. Bowman’s capsule- “the cup-shaped top of a nephron (the sac like Bowman’s capsule surrounds the glomerulus) (Thibodeau & Patton, 2004, p.438).b. Glomerulus- “ a network of blood capillaries tucked into Bowman’s capsuleBlood plasma is filtered in the glomerulus capsule, and then the filtered fluids passes into the renal tubules in the order of:Proximal convoluted tubule-Loop of henleDistal convoluted tubuleCollecting tubuleGo back to previous slide and talk about the movement of fluid through the kidneys
7 Urine The formation of urine involves three major processes: Glomerular filtration in the renal corpusclesTubular reabsorptionTubular secretionmarieThe formation of urine involves three major processes:Glomerular filtration in the renal corpusclesTubular reabsorption, andTubular 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).marieFiltration is a process by which blood pressure forces plasma and dissolved materials out of capillariesIn Glomerular filtration, blood pressure forces plasma, dissolved substances, and small proteins out of the glomeruli into the Bowman’s capsule.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.The larger proteins and and blood cells are too large to be forced out of the glomeruli: they remain in the blood.Waste products such as urea and ammonia are dissolves in plasma, so they pass to the renal filtrate.Renal filtrate is similar to blood plasma except that there is far less protein and no blood cells present.The glomerular filtration rate (GFR) is the amount of renal filtrate formed by the kidneys in one minute; It averages 100 to 125mL/min. The GFR may change if the rate of blood flow through the kidney changes. If blood flow increase, the GFR will increase, more filtrate is formed and urinary output increases. If blood flow decreases, the GFR, less filtrate is formed, and urinary output decreases (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).marie“Tubular reabsorption is the recovery of useful materials from the renal filtrate and their return to the blood in the peritubular capillaries. Approx 99% of the renal filtrate is reabsorbed and normal urinary output is 1000 to 2000 mL per 24 hoursMost reabsorption takes place in the proximal convoluted tubules, whose cells have microvilli that greatly increase their surface area.The distal convoluted tubules and collecting tubules are also important sites for reabsorption of waterThe mechanisms of reabsorption are active transport, osmosis, diffusion, facilitated diffusion and pinocytosis” (Williams & Hopper, 2007, pp ).
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).marie“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).waste products such as ammonia, and creatinine, excess water soluble vitamins and the metabolic products of medications may be secreted into urine. Hydrogen ions may be secreted by the tubules cells to help maintain the normal ph of the blood. (Williams & Hopper, 2007, p. 753)In summary, the tubular reabsorption conserves useful material, tubular secretion adds unwanted substances to the filtrate, and most wate products simply remain in filtrate and are excreted in urine (Williams & Hopper, 2007, p. 753)
11 What Happens in the Nephron marieReally nice diagram that sums it all up ..
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).GRenal Failure can be either acute or chronic, and it is defined as 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 (8th Ed.). (2006). p St.Louis, Missouri; Mosby Elsevier.Renal FailureCan be acute or chronic
13 Renal Failure Acute Renal Chronic Renal Failure Failure Gale Renal Failure, can be acute or chronic.
14 “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 creatinineReversible if treated promptlyMarie“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).Acute Renal Failure
15 Categories of ARF Prerenal: Hypoperfusion of the kidneys. Intrarenal: Acute damage to kidney tissuePostrenal: obstruction to urine flow
16 Phases of ARFInitiation 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”Initiation phase: “begins with the initial insult and ends with oliguria develops” Day et al., 2010, p, 1437)Oliguria phase: manifested by a rise in the concentration of substances usually excreted by the kidney (urea, creatinine, uric acid, potassium and magnisium) the body need to produce at least 400ml/ 24 hr to rid the body of these substances.(Day et al., 2010, p, 1437)
17 Causes of ARF Prerenal failure causes Intrarenal failure Postrenal failureVolume 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.(Day et al., 2010, p. 1435)
18 Clinical Manifestations Pt will appear critically ill and lethargic, and confusedSkin and mucus membranes will be dry from dehydrationdrowsiness, headache, muscle twitching, and seizures.dyspnea, crackles, tachypnea,(Day et al., 2010, p. 1436)Subjective symptomsNauseaLoss of appetiteHeadacheLethargyObjective symptomsOliguric phase –vomitingdisorientation,edema,^K+decrease Na^ BUN and creatinineAcidosisuremic breath CHF and pulmonary edemahypertension caused by hypovolemia, anorexiasudden drop in UOPconvulsions, comachanges in bowelsDiuretic phaseIncreased UOPGradual decline in BUN and creatinineHypokalemiaHyponaturmiaTachycardiaImproved LOC(Day et al., 2010, p. 1436)
19 Comparing the categories of ARF CharacteristicsPrerenalIntrarenalPostrenaletiologyhypoperfusionTissue damageobstructionBUNcreatinineUrine outputVaries but oftenVaries-may be decreased, or sudden anuriaUrine sodium To <20mEq/L To >40 mEq/LVaries- often to 20 mEq/LUrine specific gravatyLow normalVaries(Day et al., 2010, p. 1436)
20 Prevention of ARFProvide adequate hydration to clients at risk of dehydration. ( surgical client)Prevent and treat shock- with blood and fluidsTreat hypotension promptlyContinually assess renal function (output, Labs)Avoid transfusion reactions (always check two RN, and Five rights and three checksPrevent and treat infection promptly (good catheter care) and pay special attention to wounds, burns, and other precursors to sepsisToxic drug effects- monitor blood levels, and ensure safe doesDay et al., 2010, p. 1437“Management of ARF is expensive and complex, and even when optimal, the mortality rate remains. Therefore, prevention is essential” (Day et al., 2010, p. 1437)
21 Nursing interventions Monitor intake and output, including all body fluidsMay need to stimulate production of urine with IV fluids, diuretics.Daily weightsMonitor lab results, CBC, BUN, creatinine, urea, e’lylesWatch hyperkalemia symptoms: malaise, anorexia, parenthesia, or muscle weakness, EKG changesMaintain nutritionMouth care – dry mucus membranesAssess for signs of cardiac involvement- dysthymiasSkin integrity problems. Edema, itching –from toxinsSigns and symptoms of infectionMay need dialysis, or continuous renal replacement therapy.Day et al., 2010, ppAzotemia: concentration of urea and other nitrogenous wastes in the bloodIf caused by meds, must stop medsIf caused by obstruction, must remove obstructionIf caused by blockage of artery, must open arteryDietary restrictions may include : low K+, adequate carbs, also may give TPNFluids : calculate closley I/OHyperkalemia is life threateningLower K+ with Kayexalate, glucose, insulin, NaBicarb, caalcium carbonate“Each patient’s caloric needs are based on their height, weight,age, sex and activity. The prescribed diet should ensure an intakeof 35 to 45 calories per kilogram of body weight.”The vitamin and mineral intake of patients on a restricted protein, potassium and sodium diet often does not meet the recommended daily allowances for certain vitamins and minerals. This is especially true for the water-soluble vitamins such as Vitamin C and the B vitamins, which are abundant in high potassium foods such as fruits, vegetables, meat and milk. Also, there is a loss of water-soluble vitamins during dialysis treatments. When the protein restriction is less than 50 grams per day, the diet tends to be low in folic acid, niacin, riboflavin, thiamineand vitamin B6.“Patients on long-term low-protein, low-sodium, low-potassium diets should receive a multivitamin capsule and folic acid daily to ensure adequate intake and to make up for losses thatoccur during the course of dialysis” (Somers, 2008)
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).m
23 Stages of CRFThe 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).GAs Marie had mentioned,“Glomerular filtration rate (GFR) is the volume of plasma filtered at the glomerulus into the kidney tubules each minute” (Day et al., 2010, pp 1405).The normal glomerular filtration rate (GFR) is 125ml/min/1.73m2The different stages of renal failure is determined by the GFRStages of CRF (Day et al., 2010, p. 1440)
24 Stages of CRFStage 1: GFR>90ml/min/1.73m2 kidney damage with normal or elevated GFRStage 2 : GFR = ml/min/1.73m2 mild decrease in GFRStage 3: GFR = ml/min/1.73m2 moderate decrease in GFRStage 4: GFR = ML/MIN/1.73M2 Severe decrease in GFRStage 5: GFR<15ml/min/1.73m2 Kidney Failure (aka end stage renal failure)Gale(Day, 2010, pp 1440)
25 Retrieved from: http://www.kidney.ca/page.aspx?pid=320 The kidney foundation of canadaNice table that sums it up
26 Signs & Symptoms of CRF Ammonia-like taste in mouth or urinous breath Edema of feet, hands, arms, face and around eyesHypertensionExtended neck veinsAnemiaFatigueNeurologic disturbancesNausea, vomiting, and anorexiaHeadaches and blurred visionGaleAssessing for signs and symptoms of CRF is important.Lab values and urine screening may indicate CRF, but additional signs and symptoms may be present, such as:Ammonia – like taste or breath because of uremia in the blood(“Uremia – excess amounts of urea and other nitrogenous waste products in the blood, as occurs in renal failure”)(Mosby’s Dictionary of Medicine, Nursing & Health Professionals (8th Ed.). (2006). p St.Louis, Missouri; Mosby Elsevier.)Edema of the feet, hands, arms, face and around eyes, caused by fluid overloadHTN develops from elevated serum sodium levels, extracellular fluid volume expansion, and renin hypersecretionExtended veins in the neck from fluid overloadAnemia from decreased RBC production and shortened RBC lifespan because or uremic toxinsFatigue related to anemia and toxins in the bloodNeurologic disturbances including lethargy, impaired mental status, and sleep pattern due to the uremic toxinsRetention of urea and metabolic waste products can cause nausea, vomiting, and anorexiaHeadaches and blurred vision may be caused by uremic toxins and extracellular volume expansion(Cannon, 2004)
27 Signs & Symptoms of CRF Pruritus Shortness of breath Bone and joint problemsWeakness, numbness, tremors, bone pain, and paresthesiaUrine that is cloudy, tea-coloured, or bloodyDecreased urine output or trouble urinatingFoaming of urineProteinuriaMore S+S of CRF include:Increased levels of phosphorus, calcium, and aluminum in the body can cause pruritus (itchy)Shortness of breath is caused by the fluid overload and can lead to pulmonary edema if left untreated“Bone and Joint problems from bone resorption associated with vitamin D deficiency, demineralization, and calcium and phosphate imbalances” (Cannon, 2004, pp 52)Uremic toxins can also cause weakness, numbness, tremors, bone pain, and paresthesiaUrine that is cloudy, tea-coloured, or bloody may indicate CRFAnd Decreased urine output or trouble urinatingFoaming of urine and Proteinuria is not normal and may also be a sign of CRFIn addition to watching for these signs and symptoms of renal failure, you should also be mind-full of risk factors that increase a persons likely-hood of developing renal problems (ex. History of diabetes), as well as monitoring lab values (creatinine and urine protein levels are early indicators of renal disease) (Cannon, 2004)(Cannon, 2004; Kidney Foundation of Canada, 2012)
28 CRF Risk FactorsPeople at increased risk of developing kidney disease include people who have:DiabetesHigh blood pressure or blood vessel diseasesGlomerulonephritis and other systemic diseasesFamily history of hereditary kidney diseaseCertain ethnic groups such as Aboriginal, Asian, South Asian, Pacific Island, African/Caribbean and Hispanic originPeople at increased risk of developing kidney disease include people who have:Diabetes, Because Diabetes damages the glomeruliHigh blood pressure damages renal vessels over timeGlomerulonephritis is inflammation of the glomeruli (scar tissue over time)Systemic diseases such as Lupus erythematosus and sickle-cell disease increase your risk of developing renal failureA Hx of disease such as, polycystic kidney disease, which is a hereditary disorder, that causes cysts to form in the kidneys increase your riskAnd Certain ethnic groups are considered to be at increased risk of developing kidney disease because of the greater incidence of high blood pressure and diabetes.Although these are some risk factors that increase you likely-hood of developing CRF, it is important to note that there are people who do develop kidney disease and do not have any of the associated risk factors for kidney disease.(Kidney Foundation of Canada, 2012; Cannon, 2004)
29 Nursing interventions CRF Assessing fluid statusNutrition/DietPatient teachingAssess emotional status and coping strategiesAssessing for complicationsAdministering MedicationsNursing Interventions are basically the same as ARFAssessing fluid status by monitoring intake and output, daily weight, respiratory rate and effort, edema, and distension of neck veins (Day et al., 2010, pp 1445 )Nutrition status should be assessed by monitoring for changes in weight, nutritional dietary patterns, and factors that may contribute to altered nutrition (eg. Depression, stomatitis, anorexia, nausea, and vomiting)Pt teaching is important!!! Teaching is required about treatment options, and things like the vascular access device and monitoring it for patency and using precautions, such as, not having the blood pressure taken in the same arm as the device (fistula).-The client with CRF also needs teaching about when to contact a doctor about increased signs and symptoms of renal failure (nausea, vomiting, changes in urine output, ammonia odour on breath),-Client’s need teaching about how to assess for access problems such as clotted fistula, or infection, and client needs to know to watch for signs of hyperkalemia (muscle weakness, diarrhea, abdominal cramps), (Day et al., 2010, pp 1443 – 1444)Assessing clients emotional status and coping strategies is important for those who are diagnosed with CRF or End Stage Renal Disease, This may involve providing support for patients and families, as well as, accessing additional resources for supports (eg. Kidney support groups, social work, etc.)It is also important for the nurse to be assessing for complications related to dialysis, medications, dietary restrictions, lifestyle, and so on. (Day et al., p. 1444)
30 Sum it up: major complications (Mayo clinic, 2012).Sum it up: major complicationsfailure 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-threateningHeart and blood vessel disease (cardiovascular disease)Weak bones and an increased risk of bone fracturesAnemiaDecreased sex drive or impotenceDamage to your central nervous system, which can cause difficulty concentrating, personality changes or seizuresDecreased immune response, which makes you more vulnerable to infectionPericarditis, an inflammation of the sac- like membrane that envelops your heart (pericardium)Pregnancy complications that carry risks for the mother and the developing fetusIrreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survivalMaireMayo clinic. (2012). Chronic renal failure: complications. Retrieved from:
32 Diagnostic Procedures Renal ultrasoundCTMRIIVPNephrotomogramRenal angiogram:Renal scan:Renal biopsy:(Williams & Hopper, 2007).Renal ultrasoundKUB- Kidneys, ureters and bladder x-ray : also known as a flat plate of the abdomen- help to identify if there is a blockage ie stoneCT scan- note any abnormalities size shape. Can be used to identify non-functioning kidney , renal stones, obstruction, infections nursing mamagement for CT include NPO for 4 hr before the procedure, contrasting dye may be given, if given with compromised renal function assess signs and symptoms of acute failure, also assess for allergies,MRI: claustrophobia, remove all metal objects, may be given contrasting dyeIVP intravenous Pyelogram: this is an invasive procedure- dye is injected into a large vein, the dye is cleared from the blood by the kidneys. Because the x-ray cannot penetrate the dye, the dye outlines the renal structure. The test will provide a rough estimate of renal function. nursing considerations include: NPO for 8hr prior to the procedure, enema given the evening before to empty the colon; the client should be warned about a warm flushing sensation when the dye is injected. A strange test may occur as well. After the procedure client should be encouraged to drink lots of fluids to flush the dye from the body. On rare occasion the client may develop acute renal failure because the dye is highly concentrated and can obstruct the kidney tubules. Urine output should be monitored after test.Nephrotomogram: same prep as IVP. This procedure takes various x-rays from different 3D angles. Test is useful in identifying of renal cysts, tumours, areas of non perfusion an renal fractures or laceration post trauma.Renal angiogram:: to visualize renal blood vessels. Catheter is inserted in femoral artery and dye is injected. Same pre procedure nursing management as the IVP. But because catheter Is inserted into the femoral artery the nurse will need to monitor for signs and symptoms of bleeding post the procedure. After the procedure the client may be on bed rest for up to 24 hr to prevent bleeding from injection site, check distal pulse q 30 to 60 min. instructed client not to bend leg and HOB is not raised more tthan 45 degrees. The nurse will need to monitor V/S, the dressing, frequently.Renal scan: this is a nuclear scan. Radioactive isotope injected into blood and can be detected by gamma camera similar to x-ray. These isotopes are picked up by this gamma camera. This test measures: kidney function; measure renal blood flow; GFR, kidney shape; diagnosis of renal HTN. The major advantage of this diagnostic test is that is does not use contrasting dye. Therefor, it is better to use with clients with acute or chronic failure. No special prep is needed for this procedure, but may be asked to drink two glasses of water beforehand. Nurse should assess if client is taking NSAID’s or antihypertensive drugs because the may interfere with test. The level of radiation is very low , but is not recommended for pregnant.Renal biopsy: Renal tissue is obtained for lab analysis. Nursing management: NPO 8hr; do not take anticoagulants; CBC and coagulation labs done prior; pt is prone and biopsy is taken through flank area; keep in prone position; assess fro bleeding-kidney highly vascular; bedrest 24hr; assess urin for blood.(Williams & Hopper, 2007)
33 Screening: Normal blood values to assess Kidney function Urea – 8.2mmol/LPotassium 3.5 – 5.0mmol/LPhosphate 0.8 – 1.4mmol/LCalcium 2.0 – 2.6mmol/LCreatinine 60 – 110umol/L (female)70 – 120umol/L (Male)Hemoglobin 120 – 140g/L (female)140 – 160g/L (male)GFR 90 – 120ml/min(1.5 – 2.0ml/sec)This slide identifies the normal ranges for of various substances in the blood that are related to kidney function.When the kidneys are not functioning properly, these ranges may be outside of the normal limits.Urea and Creatinine are some of the waste products that are removed from the body via the kidneys.When kidneys are not functioning properly, the amount of these waste products in the blood increase and can become toxic.Urea is one of the waste product of protein break down, and Creatinine is a waste product of muscle.In addition to removing waste, the kidneys also produce hormones that help regulate some body functions, such as, blood pressure, red blood cell production, and calcium absorption. (Kidney Foundation of Canada, 2012)Again Note that “Renal functions test results may be within normal limits until the GFR is reduced to less than 50% of normal” (Day et al., 2010, pp1418)Don’t read this again:“Glomerular filtration rate (GFR) is the volume of plasma filtered at the glomerulus into the kidney tubules each minute” (Day et al., 2010, pp 1405)
34 Assessing renal function Blood testsCreatinineBlood urea nitrogenHemoglobinHematocritSodiumPotassiumChlorideCalciumPhosphorusMagnesiumUrine testsUric acidUrine proteinUrine creatinine clearanceNormal valuemg/dl10-20 mg/dl12-18 grams/dl40%-50%mEq/litermEq/litermEq/litermg/dlmg/dlmEq/litermg/dlNoneGFR= 120–125 ml/minChange with chronic renal failureIncreased. Over 1.2 mg/dl in women and 1.4 mg/dl in menmerits further renal assessment.IncreasedDecreasedVaries with free waterVariesIncreased or normalPositive test result dictatesfollow- up urinalysis. >3,500 mgindicates glomerular disease.Assessing renal function……..Table from (Cannon, 2004, pp 53)This is just a nice little table that assesses renal function, it tells you the normal blood and urine values, and weather CRF will cause a increase, or decrease, or if it can vary
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 decreasesDay et al., 2010, pp1410Creatine clearance is a good means of determining the Glomerular filtration rate (GFR), and therefore, determining renal function.Creatinine clearance, can be measured by taking a 24hr urine sample and collecting a serum creatinine level midway through the urine collection process, to determine the glomerular filtration rate (GFR).The formula for Creatinine Clearance is:(Volume of urine [ml/min] X Urine creatinine [MMOL/L])Serum Creatinine (mmol/L)As renal function decreases, creatine clearance decreases(Day et al., 2010, pp1410)Additional urine testing can include specific gravity, which indicates the kidneys ability to concentrate solutes in urine ( Day et al., 2010 pp 1419).
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).Medication may be used to help maintain or improve kidney function, as well as, treat some of the 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 supplementsHigh calorieThe diet for CRF consists of:Low protein diet because of the by-products from protein breakdown accumulate in the blood (eg. Urea, uric acid, and organic acids)Low sodium because sodium influences your body’s fluid volumeLow potassium diet because if serum potassium levels increase above normal ranges, due to the kidneys not excreting wastes properly, could result in myocardial arrhythmias that could be fatal.Fluid restriction of usually around 500ml to 600ml more than the previous 24hr output.Vitamin supplements are necessary because of the low protein intakeHigh calorie diet, consisting of carbs and fats to prevent wasting. Calorie intake is based on the clients height, weight, age, sex, and activity level; and should reflect 35 to 45 calories per kg of body weight. (Somers, 2008)(Day et al., 2010, 1443; Kidney foundation of Canaday, 2012; Somers, 2008)
39 DialysisWhen the kidneys are not removing fluid and uremic waste from the body, dialysis can be used to do soDialysis can be acute or chronicAcute dialysis is used for people with high levels of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusionAcute dialysis may also be used to remove certain medications or other toxins from the bloodDay, 2010, pp 1444.
40 Dialysis Chronic dialysis is used for chronic renal failure Dialysis can be used for years to help maintain people with no renal functionIndications may include: uremic signs and symptoms affecting all body systems, hyperkalemia, fluid overload, pericardial friction rub, and lack of well beingDay, 2010, pp 1444.Don’t Read:Uremic signs and symptoms include nausea and vomiting, severe anorexia, increasing lethargy, mental confusionFluid overload that does not respond to diuretics and fluid restriction
41 Types of DialysisPeritoneal DialysisHemodialysis
42 Peritoneal DialysisRemoves metabolic wastes and toxin’s so the body’s normal fluid and electrolyte balance is re-establishedThe 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(Day, 2010, pp 1455; Kidney Foundation of Canada, 2012)Note:With peritoneal dialysis, the blood is cleaned without leaving the body, where as with hemodialysis the blood is cleaned while it runs through a machine and then is returned to the body
43 Peritoneal DialysisAn abdominal catheter allows sterile dialysate fluid to enter the peritoneal cavityThe 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 DialysisThe body’s excess fluid is removed by an osmotic gradient, because the dialysate fluid in the peritoneal cavity has a higher glucose concentrationthe fluid is then removed from the peritoneal cavity and discardedThis process is repeated 4-6 times ever 24hrsThe most common complication from peritoneal dialysis is peritonitis(Day, 2010, pp1456; Kidney Foundation of Canada, 2012)“With peritoneal dialysis you always have dialysis fluid in you peritoneal cavity, so your blood is constantly being cleaned. The fluid is changed at regular intervals throughout the day”, (Kidney Foundation of Canada, 2012).Peritonitis is caused by bacteria and causes inflammation of the peritoneum.Signs and symptoms include “abdominal distension, rigidity and pain, rebound tenderness, decreased or absent bowel sounds, nausia, vomiting, and tachycardia. The patient has chills and fever; breathes rapidly and shallowly; is anxious, dehydrated, and unable to defecate. Leukocytosis, an electrolyte imbalance, and hypovolemia are usually present, and shock and heart failure may ensue.” (Mosby’s Dictionary, 2006, pp 1321)Mosby’s Dictionary of Medicine, Nursing & Health Professionals (8th Ed.). (2006).St.Louis, Missouri; Mosby Elsevier.
45 Peritoneal Dialysis Equipment: the peritoneal catheter is implanted through the abdomen wall. Dacron cuffs and a subQ tunnel provides protection against bacterial infection. The dialysate ( m/L) flows by gravity though the peritoneal cavity. After a prescribed period of time, the fluid is drained by gravity and disregarded. New solution is then infused the peritoneal cavity until the next drainage.Continues peritoneal dialysis continues on a 24hr basis, during which the client is allowed to move around and engage in usual activities (Day et al., 2010, p. 1458) acuteWhat do you need.A bag of peritoneal dialysate hung above high.Marie 8031457 day
46 Peritoneal Dialysis Nursing management Client and family educationSterile technique (face mask, gloves, sterile field)Signs and symptoms of peritonitisInspect site and dialysate solution for signs and symptoms of infectionClient and family education is extremely important for peritoneal dialysis to be successful. The client must be taught and be able to demonstrate that he oe she is able to do a successful exchange. Sterile technique while performing the exchange is imperative and the exchange should be done in a clean environment. As mentioned earlier peritonitis (infection if the peritoneum), witch can be life threatening. The major cause of peritonitis is poor technique when connecting the bag of dialyzing solution to the peritoneal catheter. The first sign of peritonitis is pain. Client should notify physician immediately. (Williams & Hopper, 2007, p. 803)
47 Hemodialysis The most common type of dialysis Purpose remains to remove toxins from the blood and excess water from the bodyUsually patients receive Hemodialysis 3 times per weekTreatment takes about 3-8 hours per treatment(Day, 2010, pp 1449)Patients usually receive dialysis three times per week for about 4 hours per treatment, although some patients may require treatment more frequently or for longer durations
48 HemodialysisThe 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 patientThe metabolic waste products in the blood move from an area of high concentration (blood), to an area of low concentration (dialysate)(Day, 2010, pp 1449)
49 HemodialysisDialysate is a solution composed of electrolytes, which concentration levels can be adjusted to accommodate the desired electrolyte level in the patients bloodOsmosis and ultrafiltration is used to remove the body’s excess water(Day, 2010, pp 1449)Osmosis – “the water move from an area of higher solute concentration (the blood) to an area of lower solute concentration (dialysate bath).”“Ultrafiltration is defined as water moving under high pressure to an area of lower pressure.”
50 Hemodialysis: Vascular Access Device 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 requires a permanent way to access the blood stream for blood removal and return to the body during dialysis (Williams & Hopper 2007).Hemodialysis: Vascular Access Device
51 Two tailed subclavian/ double lumen, cuffed hemodialysis catheter used for acute hemodialysis. Red port: blood lineBlue port: return dialyzed blood to client.
52 Hemodialysis Equipment Blood leaves the artery and goes through a BP monitor then the Blood from is pumped into the dialyzer where is flows through the cellophane tubes, which acts a semipermeable membrane. The dialysate, which has the same chemical composition as the blood except for urea and waste products, flows in and around the tubules. The waste products in the blood diffuse through the semipermeable membrane onto the dialysate.After the blood leaves the dialyzer it is pumped through an air filter trap and clot trap before it is returned to the client via the vein.Ask Cathy if they always add heparin to blood ? Conflict in the lit
53 Nursing Management for Hemodialysis Consult with physician about medications to hold prior to dialysisObtain weigh before dialysis and after dialysis note changes.Coordinate blood draws with the dialysis nurse to avoid unnecessary needle pokesGet morning care done early and give breakfast before dialysisApply emla patch to numb fistula or graft areaWhen the client returns assess for signs and symptoms of bleedingAssess vital signs and admin medications that were held in the AM unless contraindicatedAllow for rest. Clients often exhausted after dialysis(Williams & Hopper 2007, p. 803)Pt careConsult with physician about medications to hold prior to dialysis. Some medications, such as antihypertensive, can be harmful when they become effective during dialysi and can reduce BP to dangerously low levels. Other medication that are water soluble will be dialyzed out of blood and should be given after.
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 flowDo 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 armTeach client to avoid tight jewellery and restrictive cloths on affected arm.Teach client to avoid sleeping or bending affected arm for long periods of timeNotify physician of signs of bleeding, reduced circulation, or infection, coldness, numbness, weakness, redness, fever, drainage, swellingCare of blood access graft or fistula (Williams & Hopper 2007, p. 803)
55 Hemodialysis V.S peritoneal Requires vascular access device. Either temporary (ARF) or permanent (CRF).Requires a complex specialized dialyzerRequires a skilled hemodialysis nurseIntermittent (q3-4days)Principals of osmosis and diffusionPreferred for end-stage renal failureRequires a insertion of a catheter into the peritoneal cavityDoes not require specialized dialyzerCan be done by client (sterile technique)Continuous (4-6 q 24hr)Principals of osmosis and diffusionHave few cardio side effects can be used in unstable clients.In a research study done that compared survival advantages of hemodialysis relative to peritoneal dialysis in clients with end stage renal disease and congestive heart failure found that mortality risk was higher with peritoneal dialysis clients. (Sens, Schott-Pethelaz, , Labeeuw, Colin, Villar, & Rein Registry, 2011). In saying that, although hemodialysis is peered to peritoneal dialysis for clients with end stage renal failure, hemodialisis is associated with an increase risk of stroke (Power, Chan, Singh, Taube & Duncan, 2012).
56 Kidney Transplantation Surgically transplanting a functioning kidney into a patient with end-stage renal diseaseThe donated kidney may be from either a living donor or a deceased donorKidney Transplantation is when they surgically transplant a functioning kidney into a patient with end-stage renal disease.Also know as renal replacement therapy (RRT) for those with end-stage renal disease.The donated kidney may be from either a living donor or a deceased donor.Prior to transplant surgery, patient will have to have a complete physical examination, for things like tissue typing, blood typing, antibody screen, and etc.;A thorough past medical history is collected (eg. Hx of MI).In addition to , a psychosocial evaluation to assess coping, supports systems, financial resources, and so on.The patient must be free from infection prior to surgery to help prevent complications, and attempts to improve patients current health status may be made as a way of preparing the patient for surgery (Day et al., 2010, pp ).Postoperatively, treatment will be directed toward maintaining homeostasis (monitoring blood levels, some ppl have dialysis until new kidney begins to work, not all transplant pts though) , usual abdominal postoperative interventions (Intake + Output….restrictions, early ambulation, deep breathing/incentive spirometer, wound, etc) and preventing complications (Day et al., 2010, pp ).Transplant pt’s are required to use immunosuppressive agents such as cyclosporine, to block the bodies immune response to the transplanted kidney.These medications are used to try and avoid transplant rejection.Patients must remain on immunosuppressive therapy for as long as they have the transplanted organ (often for the rest of their life) (Day et al., 2010, pp ).Careful assessment of cyclosporine levels are important because of the adverse effects that toxic levels can have.These include tremors, acute confusion, status epilepticus (continuous seizures lasting longer than 30 min), speech abnormalities, and even coma.Because transplant patients are on immunosuppressant's, monitoring of blood work is essential because of immunosuppressive effects such as depressing leukocyte formation and platelets.In addition, patients need to be assessed carefully for signs and symptoms of infection do to these immunosuppressant's (Day et al., 2010, pp ).
57 Kidney Transplantation Nursing Management Pre and postoperative teachingAssessing patient coping and anxietyAssessing for signs and symptoms of transplant rejectionPreventing infectionMonitoring urinary functioningPsychological concernsMonitoring and managing potential complicationsPromoting home and community based carePatient teaching involves teaching the patient about what they can expect before and after surgery.This includes things like pulmonary hygiene, pain management, diet, invasive lines such as IV, and catheters, early ambulation, infection prevention, medication regime, and so on (Day et al., 2010, pp ).It important to acknowledge patient’s worries and fears.Many patients are anxious for a variety of reasons, about things like the surgical procedure and transplant rejection.You may be able to help reduce anxiety by supporting the client, further teaching, or consulting further support systems (Day et al., 2010, pp ).“Signs and symptoms of transplant rejection include oliguria, edema, fever, increasing blood pressure, weight gain, and swelling or tenderness over the transplanted kidney or graft.Patients receiving cyclosporine may not exhibit the usual signs and symptoms of acute rejection” , They may only show signs of an elevation in serum creatinine level (Day et al., 2010, pp 1473).Preventing infection and assessing for infection is important because of the patients increased risk due to immunosuppressant therapy.Some signs and symptoms of infection may include, fever, tachycardia, chills, shaking, tachypnea, and an increase or decrease in WBC’s (Day et al., 2010, pp ).Monitoring urinary functioning involves assessing fluid and electrolyte status (eg. intake and output, IV fluid administration, lab values) (Day et al., 2010, pp ).Psychological concerns of the patient are important because of the immense impact that a kidney transplant can have on patients and their family (fears of transplant rejection, financial concerns, complications, etc.) (Day et al., 2010, pp ).Try to recognize, minimize, and avoid complications by using “strategies that promote surgical recovery (breathing exercises, early ambulation, care of the surgical incision)” and assess for complication associated with corticosteroid use ( GI ulceration, fungal colonization) (Day et al., 2010, pp 1474).Promoting home and community based care by doing ongoing teaching and assessing the patient’s understand, and contacting appropriate resources for patient (eg. Support groups, etc.), and ensuring that patient is aware the follow up care is a life long process (Day et al., 2010, pp ).
58 Conservative CareSome 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.Kidney Foundation of Canada, 2012Patients have the right to refuse treatment and conservative care supports them through this process.
59 Conservative CareThe 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.Kidney Foundation of Canada, 2012Before a decision is made regarding treatment, the patient should talk openly about their thoughts and feelings with their doctor and family.The patient may also speak with a mental health worker, and/or religious consultant.After careful consideration, and if a decision is made to refuse tx, the healthcare team can begin to explain conservative care to the patient and family, and work together to develop a plan of care that is appropriate for both the patient and family.Symptoms management includes both physical and emotional symptoms
60 Quiz: true or false1. 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 growingMarie and GaleQuiz @1.T2.F3.F4. T5.F6. F7. T
61 Case studyMrs. 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.IWhat might be the first thing you do after report ?What do her physical symptoms and the lab values reflect?What should the nurse do about Mrs. Jackson related to her withdrawn behaviour?Possible Nursing diagnosis?(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
64 References References Day, R. A., Paul, P., Williams, B., Smeltzer, S. C. & Bare, B. (2007). Brunner & Suddarth’s textbook of medical-surgical nursing (1st 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=complicationsMosby’s Dictionary of Medicine, Nursing & Health Professionals (8th 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 ReferencesSomers, J. (2008). Dietary management of renal disease. CANNT Journal, 18(3), Retrieved from: 8b60-b6a89c6dd895%40sessionmgr4&vid=2&hid=21The Kidney Foundation of Canada. (2012). Retrieved From: KidneyThibodeau & Patton, (2004). Structure& function of the body. St. Louis: Mosby.Tortora, G. J., Derrickson, B. (2009). Principals of anatomy and physiology (12th 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=
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