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Chronic Kidney Disease CKD Dialysis Renal Transplant.

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Presentation on theme: "Chronic Kidney Disease CKD Dialysis Renal Transplant."— Presentation transcript:

1 Chronic Kidney Disease CKD Dialysis Renal Transplant

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, Ph.D.

3 Functions of the Kidney Primary function ◦ _________________________ Other functions ◦ ______________________

4 Review What are nephrons? Why would a person with kidney disease have anemia? What happens to the serum calcium? Why? How does the kidney control blood pressure?

5 Biopsy Ultrasound X-Rays Labs Anything else?

6 Diagnostic studies Blood Tests ◦ BUN ◦ Creatinine ◦ K+ ◦ PO4 ◦ Ca Urinalysis ◦ Specific gravity ◦ Protein ◦ Creatinine clearance

7 BUN and Creatinine BUN- Normal 6-20 mg/dl ◦ Nitrogenous waste product of protein metabolism ◦ By itself: Unreliable in measurement of renal function Creatinine- Normal mg/dl ◦ A waste product of muscle metabolism ◦ 2 times normal = 50% damage ◦ 8 times normal = 75% damage ◦ 10 times normal = 90% damage Exception -_______________________

8 Glomerular Filtration Rate GFR- Cannot be directly measured Uses ◦ Serum creatinine ◦ Gender ◦ Ethnicity ◦ Age ◦ Weight ◦ Why would you need to estimate GFR?

9 Glomerular Filtration Rate Creatinine Clearance 24 hour urine for creatinine clearance ◦ Most accurate indicator of Renal Function ◦ Reflects GFR ◦ Formula:  urine creatinine X urine volume serum creatinine What is a normal GFR?

10 Chronic Kidney Disease (CKD) Slow and progressive, irreversible loss of kidney function occurring over months to years National Kidney Foundation- ◦ Presence of kidney damage or decreased GFR < 60 mL/min for longer than 3 months ◦ End Stage Renal Disease -GFR<15 mL/min  Renal transplant/dialysis

11 Chronic Kidney Disease (CKD) Cause & onset often unknown Loss of function _________ lab abnormalities Lab abnormalities ________ symptoms Symptoms (usually) evolve in orderly sequence Renal size is usually decreased

12 Chronic Kidney Disease Causes _________________ Cystic disorders Developmental /Congenital Infectious Disease

13 Chronic Kidney Disease Causes Neoplasms Obstructive disorders Autoimmune diseases Hepatorenal failure Scleroderma Amyloidosis Drug toxicity

14 Stages of CKD Stage 1: GFR >/= 90 ml/min despite kidney damage Stage 2: Mild reduction -GFR 60 – 89 ml/min 1. GFR of 60 may represent 50% loss in function 2. Parathyroid hormones starts to increase

15 CKD During Stage 1& 2 No symptoms Serum creatinine doubles Up to 50% nephron loss Why does PTH increase? (2 reasons)

16 Stages of CKD Stage 3: Moderate reduction -GFR ml/min 1. Calcium absorption decreases 2. Malnutrition onset 3. Anemia 4. Left ventricular hypertrophy Why?

17 Stages of CKD Stage 4: Severe reduction -GFR ml/min 1. Serum triglycerides increase 2. Hyperphosphatemia 3. Metabolic acidosis 4. Hyperkalemia Why?

18 Stages of CKD During Stage 3-4 Signs and symptoms worsen if kidneys are stressed Decreased ability to maintain homeostasis 75% nephron loss

19 Stages of CKD During Stage 3 &4 Decreased: ◦ __________ Symptoms: ◦ elevated BUN & Creatinine ◦ mild azotemia ◦ anemia

20 Stages of CKD Stage 5: Kidney failure -GFR < 15 ml/min Azotemia Residual function < 15% of normal Excretory, regulatory and hormonal functions severely impaired. Metabolic acidosis

21 Marked increase in: ___________ Marked decrease in: ___________ Fluid overload

22 CKD Stage 5 Uremic syndrome develops affecting all body systems ◦ can be diminished with early diagnosis & treatment Last stage of progressive CKD Fatal if no treatment


24 CKD Manifestations Urinary Early ◦ may be no change in urine output ◦ May see polyuria (not related to kidney disease) why? Later- ◦ Fluid retention, edema ◦ Dialysis- may develop anuria

25 CKD Manifestations Metabolic ◦ Waste Products Accumulate ◦ Altered carbohydrate Metabolism  Insulin resistance ◦ Elevated triglycerides

26 CKD Manifestations Electrolyte and acid Base ◦ Potassium ◦ Sodium ◦ Calcium and Phosphorus ◦ Magnesium ◦ Metabolic Acidosis ◦ Volume expansion and fluid overload ◦ Change in urine specific gravity

27 CKD Manifestations Endocrine ◦ Hyperparathyroidism ◦ Hypothyroidism ◦ Erythropoietin production decreased ◦ Parathyroid hormone and Vitamin D 3 Reproductive ◦ Amennorrhea ◦ Erectile dysfunction ◦ Gonadal dysfunction

28 CKD Manifestations Hematologic Anemia Bleeding tendencies ◦ Platelet dysfunction Infection

29 CKD Manifestations Cardiovascular ◦ Hypertension ◦ Congestive heart failure ◦ Pericarditis ◦ Atherosclerotic vascular disease ◦ Cardiac dysrhythmias Respiratory ◦ Pulmonary edema ◦ Pleural effusions

30 CKD Manifestations GI tract ◦ Uremic fetor ◦ Anorexia, nausea, vomiting ◦ GI bleeding Musculoskeletal ◦ Muscle cramps ◦ Soft tissue calcifications ◦ Weakness ◦ Renal Osteodystrophy

31 CKD Manifestations Psychologic ◦ Anxiety ◦ Depression Neurologic ◦ Mood swings ◦ Impaired judgment ◦ Inability to concentrate and perform simple math functions ◦ Tremors, twitching, convulsions ◦ Peripheral Neuropathy

32 CKD Manifestations Skin ◦ Pale, grayish-bronze color ◦ Dry scaly ◦ Severe itching ◦ Bruise easily ◦ Uremic frost ◦ Calcium/Phos deposits Eyes ◦ Visual blurring ◦ Blindness


34 Treatment Options Conservative Therapy Hemodialysis Peritoneal Dialysis Transplant Nothing

35 Conservative Treatment GOALS: Detect & treat potentially reversible causes of renal failure Preserve existing renal function Treat manifestations Prevent complications Provide for comfort

36 Conservative Treatment Control ◦ Hyperkalemia ◦ Hypertension ◦ Hyperphosphatemia ◦ Hyperparthryoidism ◦ Anemia ◦ Hyperglycemia ◦ Dyslipidemia ◦ Hypothyroidism ◦ Nutrition : Describe a renal diet

37 Control ◦ Hyperkalemia – limit ex: citrus, meats, fish, avocado, beans, spinach ◦ Hypertension -- weight loss, dec. etoh, smoking, DASH diet, meds, fluids ◦ Hyperphosphatemia – meds, low phos diet – ex: milks & cheese ◦ Hyperparthryoidism -- deal with Calcium/Phos issue ◦ Anemia – procrit/epogen (could take 2-3 weeks to see a change in HH)  Why don’t we transfuse these patients? ◦ Hyperglycemia – oral anti-diabetic meds, insulin, diet ◦ Dyslipidemia -- statins, keep LDL <100 & triglycerides <200 ◦ Hypothyroidism – hormone replacement ◦ Nutrition : NOW, describe a renal diet?

38 Renal Diet Fluids ? Avoid high protein diet Restrict: ◦ sodium ◦ potassium ◦ phosphorous Consume enough calories, to maintain weight ◦ esp. if losing weight

39 Patient Teaching

40 Dialysis Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane. Peritoneal Dialysis Hemodyalisis

41 Dialysis Osmosis Diffusion Ultrafiltration What GFR value indicates need for hemodialysis?

42 Peritoneal Dialysis(PD) 12% dialysis in US is PD Types APD: Automated Peritoneal Dialysis (CCPD: Continuous cycling peritoneal dialysis) CAPD: Continuous ambulatory peritoneal dialysis IPD: Intermittent peritoneal dialysis

43 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

44 PD Warm, sterile dialysate infused into peritoneal cavity through catheter ml High concentration of glucose in dialysate Wastes & lytes diffuse into dialysate until equilibrium achieved Bag lowered, gravity drain Solution should be clear/straw colored

45 CAPD Catheter into peritoneal cavity Exchanges times per day Treatment 24 hours; 7 days a week Solution remains in peritoneal cavity except during drain time Independent treatment

46 PD Teaching Asepsis Empty bladder first Monitor urine output Monitor s/s of infection Monitor s/s of FVO

47 Complications of Peritoneal Dialysis Exit site infection Peritonitis Hernias Low Back problems Bleeding Pulmonary Complications Protein Loss

48 Nursing considerations Fluid & electrolyte balance must be maintained to prevent dehydration and/or fluid overload. Assess: ◦ Daily weights. ◦ Lung sounds. ◦ Presence of edema. ◦ Total I & O (including + and – PD fluid balances). ◦ Blood pressure. ◦ Other S&S of dehydration or fluid overload

49 Nursing considerations Assess for alterations in blood glucose levels in diabetics from the use of dextrose-based dialysate. Check visually for changes in the appearance of the effluent with each exchange. Reinforce exit site dressing for newly inserted PD catheters. Do not remove original dressing unless trained to do so. Be alert to tubing getting kinked or caught under patient, which will prevent infusion or draining of dialysate.

50 Advantages of CAPD Independence for patient No needle sticks Better blood pressure control Some diabetics add insulin to solution Fewer dietary restrictions ◦ protein loses in dialysate ◦ generally need increased potassium ◦ less fluid restrictions

51 Hemodialysis (HD) Dialysis  Survival Rates (probability of survival) approx:  1 year80%  2 years68%  5 years35.8%  10 years11%  5 year survival rate for transplant: 85.5%

52 History of HD Early animal experiments began st human dialysis 1940’s by Dutch physician Willem Kolff Considered experimental through 1950’s, No intermittent blood access; for acute renal kidney injury only. 1940’s -1960’s ◦ Dr. Scribner developed Scribner Shunt 1960’s ◦ machines expensive, scarce, no funding “Death Panels” panels within community decided now who got to dialyze

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


55 Vascular Access Arterio-Venous shunt Arterio-venous fistula (AVF) Arterio-venous Graft (AVG) Temporary Catheters

56 Arterio-Venous (AV) Fistula Primary Fistula Patients 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

57 PTFE (Polytetrafluoroethylene) Graft Synthetic “vessel” anastomosed into an artery and vein. Advantages ◦ for people with inadequate vessels ◦ can be used in 1-4 weeks ◦ prominent vessels Disadvantages ◦ clots easily ◦ “steal” syndrome more frequent ◦ requires needle sticks ◦ infection may necessitate removal of graft

58 Scribner Shunt External ◦ One end into artery ◦ One end into vein Advantage ◦ Place at bedside ◦ Use immediately Disadvantages ◦ Infection ◦ Skin erosion ◦ Accidental separation ◦ Limits use of extremity

59 Vascular Access Complications AV fistula with aneursym Steal syndrome

60 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 – restricts movement

61 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

62 ) Care of Vascular Access (PTFE Graft or AV Fistula ) NO BP’s, needle sticks to arm with vascular access. This includes finger sticks. Place ID bands on other arm whenever possible. Palpate thrill and listen for bruit. Teach patient nothing constrictive.

63 Potential Complications of HD During dialysis – Fluid and electrolyte related Hypotension – Cardiovascular Arrythmias – Associated with the extracorporeal circuit exsanguination

64 Potential Complications of HD During dialysis – Neurologic Disequilibrium Syndrome & seizures – Musculoskeletal Cramping – Other fever & sepsis blood born diseases

65 Potential Complications of HD Between treatments Hypertension/Hypotension Edema Pulmonary edema Hyperkalemia Bleeding Clotting of access

66 Potential Complications of HD Long term Metabolic Hyperparathyroidism Diabetic complications Cardiovascular CHF AV access failure Cardiovascular disease Respiratory Pulmonary edema

67 Potential Complications of HD Long term Neuromuscular ◦ neuropathy Hematologic ◦ Anemia GI ◦ Bleeding Dermatologic ◦ calcium phosphorous deposits

68 Potential Complications of HD Long term Rheumatologic amyloid deposits Genitourinary  infection  sexual dysfunction ◦ Psychiatric  depression ◦ *Infection  blood borne pathogens

69 Continuous Renal Replacement Therapy (CRRT) Used on hemodynamically unstable patients Slower blood flow rates than HD Uses double lumen catheter CVVHD-Continuous venovenous hemodialysis ◦ Solute loss via convection/diffusion CVVH-Continuous venovenous hemofiltration ◦ Solute loss via convection (more like mammalian filtration) ◦ Replacement fluid via hemodilution

70 CVVH/CVVHD When is it indicated? ◦ AKI ◦ patient usually has low blood pressure or other contraindications to hemodialysis  Not a treatment for acute hyperkalemia ◦ slow continuous process ◦ sessions usually last between 12 to 24hrs ◦ usually performed daily in the ICU

71 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

72 Medications Vitamins - water soluble Phosphate binder ---- Give with_____ ◦ Phoslo (calcium acetate) ◦ Renagel (sevelamere hydrochloride) ◦ Caltrate (calcium carbonate) ◦ Amphojel (aluminum hydroxide) Iron Supplements – ◦ don’t give with phosphate binder or calcium Anti-hypertensives ◦ When do we give these?

73 Medications Erythropoietin Calcium Supplements ◦ Between meals, not with ______ Activated Vitamin D 3 Antibiotics ◦ hold dose prior to dialysis ◦ Why?

74 Medications Many drugs or their metabolites are excreted by the kidney Dosages ◦ many change when used in kidney failure patients  Why? Dialyzability ◦ many removed by dialysis varies between HD and PD

75 Patient Education Alleviate fear Dialysis process Fistula/catheter care Diet and fluid restrictions Medication Diabetic teaching Ethics-time runs outtime runs out

76 Transplantation Treatment not cure

77 Transplantation Only 4% ESRD get transplant 75,000 on list in 2010 ◦ 17,500 received kidney Most die while on wait list 1 year survival rate ◦ 90% for deceased donor ◦ 95% for live donor

78 Advantages Disadvantages Restoration of “normal” renal function Freedom from dialysis Return to “normal” life Reverses pathophysiological changes related to Renal Failure Less expensive than dialysis after 1 st year Life long medications Multiple side effects from medication Increased risk of tumor Increased risk of infection Major surgery

79 Exclusion for Transplant Morbidly obese or Current smoker CV disease and DM considered high risk Malignancies that have metastasized untreated cardiac disease chronic respiratory failure extensive vascular disease chronic infection unresolved psych disorder (non-compliance with prescribed medications, alcoholism, drug addiction)

80 Criteria for Living Donors Psychiatric evaluation Anesthesia evaluation Medical Evaluation ◦ Free from diseases listed under deceased donor criteria ◦ Kidney function ◦ Cross-matches done at time of evaluation and 1 week prior to procedure ◦ Radiological evaluation ethics and organ transplant

81 Criteria for Deceased Donors Usually irreversible brain injury ◦ MVA, gunshot wounds, hemorrhage, anoxic brain injury from MI Must have effective cardiac function Must be supported by ventilator to preserve organs Age 2-70 No IV drug use, HTN, DM, Malignancies, Sepsis, disease Permission from legal next of kin & pronouncement of death made by MD

82 Nurses Role in Event of Potential Donation Notify TOSA of possible organ donation ◦ Identify possible donors ◦ Make referral in timely manner Do not discuss organ donation with family Offer support to families after referral is made & donation coordinator has met with family

83 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

84 Monitoring Transplant Function ATN? (acute tubular necrosis) Urine output >100 <500 ml/hr (initially) Labs Fluid Balance Ultrasound Renal scans Renal biopsy

85 Fluid & Electrolyte Balance Accurate I & O ◦ CRITICAL TO AVOID DEHYDRATION ◦ Output normal - >100 <500 ml/hr,  could be 1-2 L/hr ◦ Potential for volume overload/deficit Daily weights Postassium (K+)___________ Sodium (Na) _____________ Blood sugar _____________

86 Prevention of Infection Major complication of transplantation due to immunosuppression What do you teach?

87 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

88 Rejection Acute – First 6 months ◦ 50% experience ◦ must differentiate between rejection and cyclosporine toxicity ◦ Rx= Usually reversible with additional immunosuppressants- put at higher risk for infection

89 Rejection Chronic gradual process over months or years Irreversible ◦ Repeated rejection episodes that have not been completely resolved with treatment ◦ Rx = return to dialysis or re-transplantation

90 Immunosuppressant Drugs Need to balance suppression with maintenance of adequate defense Side effects- ◦ Infection ◦ Malignancies ◦ Toxicity Require frequent monitoring Lowest dose to get response will least side effects

91 Immunosuppressant Drugs 2 categories: Induction agents ◦ Powerful antirejection medications used at the time of transplant Maintenance agents ◦ Antirejection medications used for the long term.

92 Immunosuppressant Drugs Maintenance agents -4 classes 1. Calcineurin Inhibitors: Tacrolimus,Cyclosporine 2. Antiproliferative agents:Mycophenolate Mofetil 3. mTOR inhibitor: Sirolimus 4. Steroids: Prednisone Used in combination ◦ Triple therapy ◦ Wean off steroids or avoid use

93 Immunosuppressant Drugs Cyclosporine Azathioprine (Imuran) Prednisone OKT 3 Atgam Cytoxan - in place of Imuran less toxic FK x more potent than Cyclosporine Prograf CellCept

94 Immunosuppressant Drugs many medications and food and supplements can alter blood levels ◦ Grapefruit juice ◦ St. John's Wort ◦ Erythromycin ◦ anti TB medications ◦ antiseizure medications ◦ common blood pressure medications (cardizem or diltiazem, and Verapamil

95 Patient Education Signs of infection Prevention of infection Signs of rejection ◦ ____________ Medications ◦ _____________

96 The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client’s temperature is Which of the following is the most appropriate nursing action? Encourage fluids Notify the physician Monitor the site of the shunt for infection Continue to monitor vital signs

97 A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include which of the following instructions? Follow a high potassium diet Strictly follow the hemodialysis schedule There will be a few changes in your lifestyle. Use alcohol on the skin and clean it due to integumentary changes.

98 A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first? Change the client’s position. Call the physician. Check the catheter for kinks or obstruction. Clamp the catheter and instill more dialysate at the next exchange time.

99 A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first? Administer oxygen Elevate the foot of the bed Restrict the client’s fluids Prepare the client for hemodialysis.

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