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.
Functions of the Kidney Primary function ◦ _________________________ Other functions ◦ ______________________
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?
Biopsy Ultrasound X-Rays Labs Anything else?
Diagnostic studies Blood Tests ◦ BUN ◦ Creatinine ◦ K+ ◦ PO4 ◦ Ca Urinalysis ◦ Specific gravity ◦ Protein ◦ Creatinine clearance
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 -_______________________
Glomerular Filtration Rate GFR- Cannot be directly measured Uses ◦ Serum creatinine ◦ Gender ◦ Ethnicity ◦ Age ◦ Weight ◦ Why would you need to estimate GFR?
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?
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
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
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?
Renal Diet Fluids ? Avoid high protein diet Restrict: ◦ sodium ◦ potassium ◦ phosphorous Consume enough calories, to maintain weight ◦ esp. if losing weight
Dialysis Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane. Peritoneal Dialysis Hemodyalisis
Dialysis Osmosis Diffusion Ultrafiltration What GFR value indicates need for hemodialysis?
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
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
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
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
PD Teaching Asepsis Empty bladder first Monitor urine output Monitor s/s of infection Monitor s/s of FVO
Complications of Peritoneal Dialysis Exit site infection Peritonitis Hernias Low Back problems Bleeding Pulmonary Complications Protein Loss
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
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.
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
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
Hemodialysis Process Blood removed from patient into the extracorporeal circuit. Diffusion and ultrafiltration take place in the dialyzer. Cleaned blood returned to patient
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
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
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
Vascular Access Complications AV fistula with aneursym Steal syndrome
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
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
) 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.
Potential Complications of HD During dialysis – Fluid and electrolyte related Hypotension – Cardiovascular Arrythmias – Associated with the extracorporeal circuit exsanguination
Potential Complications of HD During dialysis – Neurologic Disequilibrium Syndrome & seizures – Musculoskeletal Cramping – Other fever & sepsis blood born diseases
Potential Complications of HD Between treatments Hypertension/Hypotension Edema Pulmonary edema Hyperkalemia Bleeding Clotting of access
Potential Complications of HD Long term Metabolic Hyperparathyroidism Diabetic complications Cardiovascular CHF AV access failure Cardiovascular disease Respiratory Pulmonary edema
Potential Complications of HD Long term Neuromuscular ◦ neuropathy Hematologic ◦ Anemia GI ◦ Bleeding Dermatologic ◦ calcium phosphorous deposits
Potential Complications of HD Long term Rheumatologic amyloid deposits Genitourinary infection sexual dysfunction ◦ Psychiatric depression ◦ *Infection blood borne pathogens
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
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
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
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?
Medications Erythropoietin Calcium Supplements ◦ Between meals, not with ______ Activated Vitamin D 3 Antibiotics ◦ hold dose prior to dialysis ◦ Why?
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
Patient Education Alleviate fear Dialysis process Fistula/catheter care Diet and fluid restrictions Medication Diabetic teaching Ethics-time runs outtime runs out
Transplantation Treatment not cure
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
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
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)
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
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
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
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
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 _____________
Prevention of Infection Major complication of transplantation due to immunosuppression What do you teach?
Rejection Hyperacute preformed antibodies to donor antigen ◦ function ceases within 24 hours ◦ Rx = removal Accelerated same as hyperacute but slower, 1st week to month ◦ Rx = removal
Rejection 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
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
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
Immunosuppressant Drugs 2 categories: Induction agents ◦ Powerful antirejection medications used at the time of transplant Maintenance agents ◦ Antirejection medications used for the long term.
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
Immunosuppressant Drugs Cyclosporine Azathioprine (Imuran) Prednisone OKT 3 Atgam Cytoxan - in place of Imuran less toxic FK x more potent than Cyclosporine Prograf CellCept
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
Patient Education Signs of infection Prevention of infection Signs of rejection ◦ ____________ Medications ◦ _____________
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
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.
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.
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.