1. Renal Failure and Treatment
Vicky Jefferson, RN, CNN
Satellite Dialysis
(modified by Kelle Howard, RN, MSN)

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. REVIEW What are nephrons? What are the functions of the kidneys?
Normal creatinine & BUN?
Diagnostic tools
Nephrons basic functional component of the kindey
millions of nephrons in each kidney
Can service with 90% loss of nephons without dialysis. 3

4. Functions of the Kidneys
Regulates ______ & _________ of extracellular fluid
Regulates fluid & electrolyte balance thru
processes of: glomerular__________, tubular _________, and tubular _____________.
Name some of the F & Es regulated by kidneys __________________
Volume & composition
filtration, reabsorption, secretion
Na, K, HCO3, H,
4/19/2017 4 4

5. Functions of the Kidneys (cont)
Regulates acid-base balance through
HCO3 and H+
*Hormonal functions: (BP control), multisystem effect.
Renin Release
RAAS=
4/19/2017 5 5

6. Functions of the Kidneys (cont)
Erythropoietin Release
If a patient has chronic renal failure, what condition will occur?
WHY???
4/19/2017 6 6

7. Functions of the Kidneys (cont)
Activate Vitamin D
Necessary to absorb Calcium in the GI
tract.
If a patient has renal failure, what will happen to the patient’s serum calcium level? __________________
4/19/2017

8. Functions of the Kidneys
_______________
______________

9. Diagnostic Tools for Assessing Renal Failure
Blood Tests
BUN
Creatinine K+
PO4 Ca
Urinalysis
Specific gravity
Protein
Creatinine clearance

10. BUN Normal 10-30 mg/dl Nitrogenous waste product of protein metabolism
Unreliable in measurement of renal function

11. Creatinine A waste product of muscle metabolism
Normal value mg/dl
2 times normal = 50% damage
8 times normal = 75% damage
10 times normal = 90% damage
Exception -_______________________
Muscle trauma

12. Diagnostic Tools
Biopsy
Ultrasound
X-Rays

13. Chronic Renal Failure
Slow progressive renal disorder related to nephron loss, occurring over months to years
Culminates in End Stage Renal Disease

14. Characteristics of Chronic Renal Failure
Cause & onset often unknown
Loss of function precedes lab abnormalities
Lab abnormalities precede symptoms
Symptoms (usually) evolve in orderly sequence
Renal size is usually decreased

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

16. Causes of Chronic Renal Failure
Neoplasms
Obstructive disorders
Autoimmune diseases
Hepatorenal failure
Scleroderma
Amyloidosis
Drug toxicity

17. Glomerular Filtration Rate GFR
24 hour urine for creatinine clearance
Most accurate indicator of Renal Function
Reflects GFR
Formula:
urine creatinine X urine volume
serum creatinine
Can estimate creatinine clearance by:
Men: {140 – age} x IBW (kg)
72 x serum creatinine
Women: {140 – age} x IBW (kg)
85 x serum creatinine
What is a normal GFR?

18. Stages of Chronic Renal Failure Old System
Reduced Renal Reserve
Renal Insufficiency
End Stage Renal Disease (ESRD)

19. Stages of Chronic Renal Failure NKF Classification System
GFR >/= 90 ml/min despite kidney damage

20. Stages of Chronic Renal Failure NKF Classification System
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.

21. During Stage 1 - 2 No symptoms Serum creatinine doubles
Up to 50% nephron loss

22. Stages of Chronic Renal Failure NKF Classification System
Stage 3: Moderate reduction
(GFR 30 – 59 ml/min)
1. Calcium absorption decreases
2. Malnutrition onset
3. Anemia
4. Left ventricular hypertrophy

23. Stages of Chronic Renal Failure NKF Classification System
Stage 4: Severe reduction
(GFR 15 – 29 ml/min)
1. Serum triglycerides increase
2. Hyperphosphatemia
3. Metabolic acidosis
4. Hyperkalemia

24. During Stage 3 - 4 Signs and symptoms worsen if kidneys are stressed
Decreased ability to maintain homeostasis

25. During stages 3 - 4 75% nephron loss
Decreased: glomerular filtration rate, solute clearance, ability to concentrate urine and hormone secretion
Symptoms: elevated BUN & Creatinine, mild azotemia, anemia

26. Stages of Chronic Renal Failure NKF Classification System
Stage 5: Kidney failure (GFR < 15 ml/min)
1. Azotemia

27. During Stage 5 End Stage Renal Disease
Residual function < 15% of normal
Excretory, regulatory and hormonal functions severely impaired.
Metabolic acidosis
Marked increase in: BUN, Creatinine, Phosphorous
Marked decrease in: Hemoglobin, Hematocrit, Calcium
Fluid overload

28. During Stage 5 Uremic syndrome develops affecting all body systems
can be diminished with early diagnosis & treatment
Last stage of progressive CRF
Fatal if no treatment

29. Manifestations of Chronic Uremia
Fig. 47-5

30. What happens when the kidneys don’t function correctly?

31. Manifestations of CRF Nervous System
Mood swings
Impaired judgment
Inability to concentrate and perform simple math functions
Tremors, twitching, convulsions
Peripheral Neuropathy

32. Manifestations of CRF Skin
Pale, grayish-bronze color
Dry scaly
Severe itching
Bruise easily
Uremic frost

33. Manifestations of CRF Eyes
Visual blurring
Blindness

34. Manifestations of CRF Fluid - Electrolyte - pH
Volume expansion and fluid overload
Metabolic Acidosis
Change in urine specific gravity
Electrolyte Imbalances
Potassium
Magnesium
Sodium

35. Manifestations of CRF GI Tract
Uremic fetor
Anorexia, nausea, vomiting
GI bleeding

36. Manifestations of CRF Hematologic
Anemia
Platelet dysfunction

37. Manifestations of CRF Musculoskeletal
Muscle cramps
Soft tissue calcifications
Weakness
Related to calcium phosphorous imbalances
RENAL OSTEODYSTROPHY

38. Calcium-Phosphorous Balance

39. Manifestations of CRF Heart - Lungs
Hypertension
Congestive heart failure
Pericarditis
Pulmonary edema
Pleural effusions
Atherosclerotic vascular disease*
Cardiac dysrhythmias

40. Manifestations of CRF Endocrine - Metabolic
Erythropoietin production decreased
Hypothyroidism
Insulin resistance
Growth hormone decreased
Gonadal dysfunction
Parathyroid hormone and Vitamin D3
Hyperlipidemia

41. Treatment Options Conservative Therapy Hemodialysis
Peritoneal Dialysis
Transplant
Nothing

42. Conservative Treatment Goals
Detect & treat potentially reversible causes of renal failure
Preserve existing renal function
Treat manifestations
Prevent complications
Provide for comfort
Heart failure, dehydration, infection, nephrotoxins, urinary traxt obstructions, glomerulonephritis, renal artery stenosis

43. Conservative Treatment
Control
Hyperkalemia
Hypertension
Hyperphosphatemia
Hyperparthryoidism
Hyperglycemia
Anemia
Dyslipidemia
Hypothyroidism
Nutrition

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

45. History Early animal experiments began 1913
1st human dialysis 1940’s by Dutch physician Willem Kolff (2 of 17 patients survived)
Considered experimental through 1950’s, No intermittent blood access; for acute renal failure only.

46. 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.

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

48. Extracorporeal Circuit

49. How Hemodialysis Works

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

51. 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

52. 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 devita.com

53. 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

54. 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

55. 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

56. Care of Vascular Access
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.

57. Potential Complications of Hemodialysis
During dialysis
Fluid and electrolyte related
hypotension
Cardiovascular
arrythmias
Associated with the extracorporeal circuit
exsanguination
Neurologic
Disequilibrium Syndrome & seizures
Musculoskeletal
cramping
Other
fever & sepsis
blood born diseases

58. Potential Complications of Hemodialysis
Between treatments
Hypertension/Hypotension
Edema
Pulmonary edema
Hyperkalemia
Bleeding
Clotting of access

59. Complications of Hemodialysis cont’d
Long term
Metabolic
hyperparathyroidism
diabetic complications
*Cardiovascular
CHF
AV access failure
cardiovascular disease
Respiratory
pulmonary edema
Neuromuscular
neuropathy

60. Complications of Hemodialysis cont’d
Long term cont’d
Hematologic
anemia GI
bleeding
Dermatologic
calcium phosphorous deposits
Rheumatologic
amyloid deposits

61. Complications of Hemodialysis cont’d
Long term cont’d
Genitourinary
infection
sexual dysfunction
Psychiatric
depression
*Infection
blood borne pathogens

62. 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

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

64. Types of Peritoneal Dialysis
CAPD: Continuous ambulatory peritoneal dialysis
CCPD: Continuous cycling peritoneal dialysis
Aka. APD – Automated Peritoneal Dialysis
IPD: Intermittent peritoneal dialysis

65. 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

67. 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

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

69. Complications of Peritoneal Dialysis cont’d
Obesity
Hypokalemia
Hernia
Cuff erosion
Low back pain
Hyperlipidemia

70. 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

71. Peritoneal Catheter Exit Site

73. Medications Common to Dialysis Patients
Vitamins - water soluble
Phosphate binder ---- GIVE WITH MEALS
Phoslo (calcium acetate)
Renagel (sevelamere hydrochloride)
Caltrate (calcium cabonate)
Amphojel (aluminum hydroxide)
Iron Supplements –
don’t give with phosphate binder or calcium
Antihypertensives - hold prior to dialysis
Calcium may inhibit absorption of iron

74. Medications Common to Dialysis Patients cont’d
Erythropoietin
Calcium Supplements
Between meals, not with iron
Activated Vitamin D3
aids in calcium absorption
Antibiotics
hold dose prior to dialysis if it dialyzes out

75. 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

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

77. Transplantation
Treatment not cure

78. Kidney Awaiting Transplant

80. Transplanted Kidney

81. Advantages Restoration of “normal” renal function
Freedom from dialysis
Return to “normal” life
Reverses pathophysiological changes related to Renal Failure
Less expensive than dialysis after 1st year

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

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

85. 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
Postassium (K+)___________
Sodium (Na) _____________
Blood sugrar _____________

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

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

88. 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 (OKT3), or polyclonal (HTG) antibodies

89. Rejection cont’d Chronic - gradual process of graft dysfunction
Repeated rejection episodes that have not been completely resolved with treatment
4 months to years after transplant
Rx = return to dialysis or re-transplantation

90. Immunosuppressant Drugs
Prednisone
prevents infiltration of T lymphocytes
Side effects
cushingnoid changes
avascular necrosis
GI disturbances
diabetes
infection
risk of tumor

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

92. 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

93. Immunosuppressant Drugs cont’d
Cytoxan - in place of Imuran less toxic
FK x more potent than Cyclosporin
Prograf
Cellcept

94. Immunosuppressant Drugs cont’d
OKT3 - monoclonal antibody used to treat rejection or induce immunosuppression
decreases CD3 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

95. 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

96. 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

97. Exclusion for Transplant
Exclusion for Transplant not limited too
Active vasculitis; or
Life threatening extrarenal congenital abnormalities; or
Untreated coagulation disorder; or
Ongoing alcohol or drug abuse; or
Age over 70 years with severe co-morbidities; or
Severe neurological or mental impairment, in persons without adequate social support, such that the person is unable to adhere to the regimen necessary to preserve the transplant.

98. Exclusion for Transplant
Exclusion for Transplant not limited too
Active vasculitis; or
Life threatening extrarenal congenital abnormalities; or
Untreated coagulation disorder; or
Ongoing alcohol or drug abuse; or
Age over 70 years with severe co-morbidities; or
Severe neurological or mental impairment, in persons without adequate social support, such that the person is unable to adhere to the regimen necessary to preserve the transplant.

99. Official 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 & pronoucement of death made by MD

100. Official Criteria for Living Donors
Psychiatric evaluation
Anesthesia evaluation
Medical Evaluation
Free from diseases listed under deceased donor criteria
Kidney function evaluated
Crossmatches done at time of evaluation and 1 week prior to procedure
Radiological evaluation

101. 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