Renal Failure and Treatment Vicky Jefferson, RN, CNN

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

History Early animal experiments began st 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.

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.

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

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

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

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

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

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

Stage 1: Reduced Renal Reserve Residual function % of normal BUN and Creatinine normal (early) No symptoms

Stage II: Renal Insufficiency Residual function % normal Decreased: glomerular filtration rate, solute clearance, ability to concentrate urine and hormone secretion Symptoms: elevated BUN & Creatinine, mild azotemia, anemia

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

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

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

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

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

Diagnostic Tools cont’d Biopsy Ultrasound X-Rays

Manifestations of Chronic Renal Failure

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

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

Eyes Visual blurring Occasional blindness

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

GI Tract Uremic fetor Anorexia, nausea, vomiting GI bleeding

Hematologic Anemia Platelet dysfunction

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

Heart Lungs Hypertension Congestive heart failure Pericarditis Pulmonary edema Pleural effusions

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

Treatment Options Hemodialysis Peritoneal Dialysis Transplant

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

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

Hemodialysis Process

Hemodialysis Circuit

Extracorporeal Circuit

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

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

External (Scribner) Shunt

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

AV Fistula

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

PTFE Graft

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

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

Cuffed Tunneled Catheter

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

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

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

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

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

Calcium-Phosphorous Balance

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

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

Peritoneal Dialysis

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

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

Peritoneal Catheter Exit Site

Draining of Peritoneal Dialysate

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

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

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

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

Peritoneal Dialysis Multi-bag Prong Manifold

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

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

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

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

Transplantation

Treatment Not a Cure

Kidney Awaiting Transplant

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

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

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

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

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

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

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 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

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

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

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

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

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

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

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

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