1. Renal Failure and Treatment Vicky Jefferson, RN, CNN

2. 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

3. 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.

4. 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.

5. Normal Kidney Function Fluid balance Electrolyte regulation Control acid base balance Waste removal Hormonal function –Erythropoietin –Renin –Active Vitamin D 3 –Prostaglandins

6. Acute Renal Failure (ARF) Sudden onset - hours to days Often reversible Severe - 50% mortality rate overall; generally related to infection.

7. Chronic Renal Failure (CRF) Slow onset - years Not reversible

8. Causes of Chronic Renal Failure Diabetes Hypertension Glomerulonephritis Cystic disorders Developmental - Congenital Infectious Disease

9. Causes of Chronic Renal Failure cont’d Neoplasms Obstructive disorders Autoimmune diseases –Lupus Hepatorenal failure Scleroderma Amyloidosis Drug toxicity

10. Stages of Chronic Renal Failure Reduced Renal Reserve Renal Insufficiency End Stage Renal Disease (ESRD)

11. Stage 1: Reduced Renal Reserve Residual function 40 - 75% of normal BUN and Creatinine normal (early) No symptoms

12. 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

13. Stage II: Renal Insufficiency cont’d Signs and symptoms worsen if kidneys are stressed Decreased ability to maintain homeostasis

14. Stage III: End Stage Renal Disease (ESRD) Residual function < 15% of normal Excretory, regulatory and hormonal functions severely impaired. metabolic acidosis

15. Stage III: End Stage Renal Disease (ESRD) cont’d Marked increase in: BUN, Creatinine, Phosphorous Marked decrease in: Hemoglobin, Hematocrit, Calcium Fluid overload

16. 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

17. Diagnostic Tools for Assessing Renal Failure Blood Tests –BUN elevated (norm 10-20) –Creatinine elevated (norm 0.7-1.3) –K elevated –PO 4 elevated –Ca decreased Urinalysis –Specific gravity –Protein –Creatinine clearance

18. Diagnostic Tools cont’d Biopsy Ultrasound X-Rays

19. Manifestations of Chronic Renal Failure

20. Nervous System Mood swings Impaired judgment Inability to concentrate and perform simple math functions Tremors, twitching, convulsions Peripheral Neuropathy –restless legs –foot drop

21. Integumentary Pale, grayish-bronze color Dry scaly Severe itching Bruise easily Uremic frost

22. Eyes Visual blurring Occasional blindness

23. Fluid - Electrolyte - PH Volume expansion and fluid overload Metabolic Acidosis Electrolyte Imbalances –Hyperkalemia

24. GI Tract Uremic fetor Anorexia, nausea, vomiting GI bleeding

25. Hematologic Anemia Platelet dysfunction

26. Musculoskeletal Muscle cramps Soft tissue calcifications Weakness Related to calcium phosphorous imbalances

27. Heart Lungs Hypertension Congestive heart failure Pericarditis Pulmonary edema Pleural effusions

28. Endocrine/Metabolic Erythropoietin production decreased Hypothyroidism Insulin resistance Growth hormone decreased Gonadal dysfunctions Parathyroid hormone and Vitamin D 3 Hyperlipidemia

29. Treatment Options Hemodialysis Peritoneal Dialysis Transplant

30. Hemodialysis Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane.

31. Hemodialysis Process Blood removed from patient into the extracorporeal circuit. Diffusion and ultrafiltration take place in the dialyzer. Cleaned blood returned to patient.

32. Hemodialysis Process

33. Hemodialysis Circuit

34. Extracorporeal Circuit

36. Vascular Access Arterio-venous shunt (Scribner External Shunt) Arterio-venous (AV) Fistula PTFE Graft Temporary catheters “Permanent” catheters

37. 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

38. External (Scribner) Shunt

39. Arterio-venous (AV) Fistula Primary 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

40. AV Fistula

41. 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

42. PTFE Graft

43. 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

44. 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

45. Cuffed Tunneled Catheter

46. Complications of Hemodialysis During dialysis –Fluid and electrolyte related hypotension –Cardiovascular arrythmias –Associated with the extracorporeal circuit exsanguination –Neurologic seizures –other fever

47. Complications of Hemodialysis cont’d Between treatments –Hypertension/Hypotension –Edema –Pulmonary edema –Hyperkalemia –Bleeding –Clotting of access

48. Complications of Hemodialysis cont’d Long term –Metabolic hyperparathyroidism diabetic complications –Cardiovascular CHF AV access failure –Respiratory pulmonary edema –Neuromuscular neuropathy

49. Complications of Hemodialysis cont’d Long term cont’d –Hematologic anemia –GI bleeding –dermatologic calcium phosphorous deposits –Rheumatologic amyloid deposits

50. Complications of Hemodialysis cont’d Long term cont’d –Genitourinary infection sexual dysfunction –Psychiatric depression –Infection bloodborne pathogens

51. Calcium-Phosphorous Balance

52. 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

53. Peritoneal Dialysis Removal of soluble substances and water from the blood by diffusion through a semi- permeable membrane that is intracorporeal (inside the body).

54. Peritoneal Dialysis

55. Types of Peritoneal Dialysis CAPD: Continuous ambulatory peritoneal dialysis CCPD : Continuous cycling peritoneal dialysis IPD: Intermittent peritoneal dialysis

56. 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

57. Peritoneal Catheter Exit Site

58. Draining of Peritoneal Dialysate

59. 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

60. Complications of Peritoneal Dialysis Infection –peritonitis –tunnel infections –catheter exit site Hypervolemia –hypertension –pulmonary edema Hypovolemia –hypotension Hyperglycemia Malnutrition

61. Complications of Peritoneal Dialysis cont’d Obesity Hypokalemia Hernia Cuff erosion

62. 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

63. Peritoneal Dialysis Multi-bag Prong Manifold

65. 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

66. Medications Common to Dialysis Patients cont’d Erythropoietin Calcium Supplements - Between meals, not with iron Activated Vitamin D 3 - aids in calcium absorption Antibiotics - hold dose prior to dialysis if it dialyzes out

67. 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

68. Patient Education Alleviate fear Dialysis process Fistula/catheter care Diet and fluid restrictions Medication Diabetic teaching

69. Transplantation

70. Treatment Not a Cure

71. Kidney Awaiting Transplant

73. Advantages Restoration of “normal” renal function Freedom from dialysis Return to “normal” life

74. Disadvantages Life long medications Multiple side effects from medication Increased risk of tumor Increased risk of infection Major surgery

75. 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

76. Function ATN? (acute tubular necrosis) –50% experience Urine output >100 <500 cc/hr BUN, creatinine, creatinine clearance Fluid Balance Ultrasound Renal scans Renal biopsy

77. 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

78. Prevention of Infection Major complication of transplantation due to immunosuppression HANDWASHING Crowds, Kids Patient Education

79. 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

80. 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 (OKT 3 ), or polyclonal (HTG) antibodies

81. 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

82. Immunosuppressant Drugs Prednisone –Prevents infiltration of T lymphocytes Side effects –cushnoid changes –Avascular Necrosis –GI disturbances –Diabetes –infection –risk of tumor

83. Immunosuppressant Drugs cont’d Azathioprine (Imuran) –Prevents rapid growing lymphocytes Side Effects –bone marrow toxicity –hepatotoxicity –hair loss –infection –risk of tumor

84. 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

85. Immunosuppressant Drugs cont’d Cytoxan - in place of Imuran less toxic FK506 - 100 x more potent than Cyclosporin Prograf Cellcept other in trials

86. Immunosuppressant Drugs cont’d OKT 3 - monoclonal antibody used to treat rejection or induce immunosuppression –decreases CD 3 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

87. 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

88. 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