Renal Replacement Therapy (RRT) Choices available to patients who have failing kidneys Debbie Jones RN CNeph(C)

Objectives At the end of this presentation the learner will be familiar with: The stages of progressive renal failure The renal replacement therapies available to patients in North Bay and surrounding district who have either acute or chronic kidney failure The types of accesses required for peritoneal and hemodialysis

Primary Functions of the Kidney Removal of metabolic wastes, drugs and other toxins Fluid Balance Electrolyte Balance Acid-Base Regulation Blood Pressure Control Hormone Production ~ Erythropoietin, Vitamin D (Calcitriol), Renin “Master Chemists of the Body” Metabolic wastes ~ urea, creatinine, uric acid, beta-2microglobulin and many other waste products. Urea is from the breakdown of dietary protein intake. Creatinine>an end product of phosphocreatine, high energy substance used to form ATP to be used as energy by muscles Fluid Balance ~ Regulate body fld. volume and osmolality by regulating urine volume and osmolality Electrolyte Balance ~ regulates sodium, potassium, chloride, calcium, phosphate, magnesium. Regulate acid-base balance of body fluids in conjunction with body buffer systems and respiratory system Regulate BP by controlling vascular volume and by secreting renin, which causes synthesis of angiotensin II and secretion of aldosterone. Regulate bone marrow production of RBCs by secreting erythropoetin. Synthesize vitamin D to its physiologically active form which helps regulate calcium and phosphorus balance and bone formation Excrete drugs and toxins from the body fluids.

Sidney the Kidney

Stages Of Chronic Kidney Disease

Causes of Acute Kidney Failure: Pre-renal factors Intra-renal & Nephrotoxic factors Post-renal factors PRE RENAL FACTORS ~any conditions that result in hypotension & shock, burns Cardiac disorders: MI,CHF, cardiac tamponade, arrhythmias. Altered Peripheral Vascular resistance: sepsis, post-op hypovolemia, antihypertensive meds, drug overdose, anaphylactic reactions, neurogenic shock. Renal Artery Disorders: renal artery occlusion, emboli, thrombi, stenosis, aneruysm, occlusion, trauma. Any condition that results in reduced blood flow to the kidneys INTRA RENAL FACTORS ~ trauma, radiation to the kidney, injury to renal tissue associated with intra-renal ischemia, toxins or both. The condition results in Acute Tubular Necrosis ~ATN NEPHROTOXINS ~ antineoplastics, anaesthetics, antimicrobes(Gentamicin), immunosuppressants, X-Ray contrast, pesticides, organic solvents, heavy metals (lead, mercury, gold). Plant and animal substances ~ mushrooms, snake venom POST RENAL FACTORS ~ Interference with the flow of urine from the kidneys to the exterior of the body. Associated with obstruction or disruption of the urinary tract such as: Calculi, Neoplasms, Strictures (ureters or urethra), Blood Clots, Prostate Hypertrophy, Abdominal or Pelvic Neoplasms, and inadvertent surgical ligation. In the case of Methanol poisoning, the need for acute hemodialysis is related to the need for correction of metabolic acidosis caused by the poisoning as well as to hasten the elimination of the methyl alcohol and the toxic metabolites like formaldehyde, formic acid and lactic acid.

Causes of Chronic Kidney Disease: Diabetes Hypertension Renal vascular disease (also generalized vascular disease) Nephritis Pyelonephritis & chronic UT I Polycystic kidney disease Renal Neoplasms Analgesic nephropathy Immunological disorders: Lupus, Goodpasture syndrome, scleroderma Metabolic disorders: gout Nephrotic Syndrome primary or secondary

Does everyone understand how important we are? Kidneys Urine

Types of Dialysis Peritoneal Dialysis: Hemodialysis: Dialysis is a way to clean blood of wastes, fluids and salts that build up in the body when the kidneys fail. There are 2 kinds of Dialysis: Peritoneal Dialysis: Uses the peritoneal membrane as the filter. The membrane covers the abdominal organs and lines the abdominal wall. This takes place inside the body and requires placement of a catheter in the peritoneal cavity to allow fluid to be instilled and drained out. Hemodialysis: Uses a dialyzer or artificial kidney to filter the blood. This takes place outside the body and requires some form of access to the circulatory system. Accomplished with the use of a sophisticated computerized control unit (dialysis machine )

Other choices kidney transplantation: No treatment or palliative care To be placed on a transplant list the patient must be on some form of renal replacement therapy, whether it is peritoneal dialysis or hemodialysis Once a patient is accepted for transplant, the date of start of dialysis is the date they are active on the list If the patient has a living donor who has been accepted as healthy donor, it is possible to have a pre-emptive transplant, bypassing dialysis. No treatment or palliative care

Peritoneal Dialysis Uses the peritoneal membrane as the filter. The membrane covers the abdominal organs and lines the abdominal wall. The membrane size is 1 – 2 m2 and approximates the body surface area. Uses the following principles: Diffusion: movement of solutes across the peritoneal membrane from an area of higher concentration to an area of lower concentration Osmosis: movement of water across the peritoneal membrane from an area of lower solute concentration to an area of higher solute concentration. Ultrafiltration: water removal related to an osmotic pressure gradient with the use of various concentrations of dialysate fluid

How does PD work? Fluid called DIALYSATE is put into the abdomen through a PD catheter. This fluid is left to dwell in the peritoneum for several hours. While in the abdomen, the fluid collects wastes that have been filtered through the peritoneal membrane. These wastes pass from the body when the fluid is drained.

Peritoneal Dialysis Performed daily, by the patient at home, more physiological Allows for independence, patients can work or travel Fewer fluid and dietary restrictions Often fewer medications or lower doses required Residual renal function preserved Ministry of Health funded home therapy

Peritoneal Dialysis Patients must have a clean room to perform exchanges and a large enough area to store all supplies no pets allowed in the room must learn to monitor their own weight and blood pressures must be able to follow important instructions to prevent infection in the peritoneum must also be able to determine the choice of dialysate fluid and when to use it

Peritoneal Dialysis

Peritoneal Dialysis Catheter

Types of Peritoneal Dialysis CAPD ~ Continuous Ambulatory Peritoneal Dialysis The blood is cleaned constantly by dialysate fluid while it is in the abdomen. CAPD does not require the use of a machine, the exchanges are completed manually. APD ~ Automated Peritoneal Dialysis Requires the use of a machine called a CYCLER The CYCLER is used during the night and is set to deliver the fluid in and out of the abdomen.

Hemodialysis Blood is circulated through an artificial kidney which has two compartments: Blood & Dialysate, separated by a thin semi-permeable membrane Waste and excess water pass from the blood side to the dialysate side and is discarded in the drain The cleaned blood is returned to the patient. It is diffusion-based mass transfer (BUN, Creat, lytes) & Pressure-driven water removal (ultrafiltration) usually done 3x /week ~ 4hrs M-W-F or T-Th-Sat

Hemodialysis Hemodialysis treatments every other day are not as physiological as peritoneal dialysis Requires a trip to the hospital up to 3 times weekly Patients can travel to other units but must be pre-arranged and space is not always available Patients are more restricted in dietary and fluid intake between treatments Medication requirements different than for those on peritoneal dialysis e.g. require more antihypertensive meds, higher doses of Erythropoietin

Hemodialysis ~ The “Integra”

Hemodialysis Requires access to the blood stream Arterio – venous fistula Arterio – venous graft Temporary catheter Long – term catheter

Hemodialysis ~ fistula

Hemodialysis ~ Graft

Temporary Hemodialysis Catheter Exit site at surface of the skin Inserted in the jugular vein Tip located at junction of SVC and right Atrium

Tunneled Hemodialysis Catheter Dacron cuff Catheter tunnel Exit site Inserted in the jugular vein Tip located at junction of SVC and right Atrium

Transplantation