1. Care of the Renal Failure Patient
DIALYSIS
Care of the Renal Failure Patient
By Denise Cooney, BSN, RN

2. What is Renal Failure
Renal failure occurs when your kidneys are no longer able to filter your blood. Your kidneys remove excess water, minerals, and waste.

3. Types of Renal Failure
Acute Renal Failure (Acute Kidney Injury)- Abrupt deterioration of function over hours or days.
Acute on Chronic Renal Failure- underlying chronic renal failure with an acute incidence.
Chronic Renal Failure- progressive, irreversible deterioration of kidney function happening over a period of years.
End Stage Renal Disease (ESRD)- Little to no kidney function left.
Chronic kidney disease occurs over time. Fluid, waste, and salt build in the patients body and they get sick (may get high blood pressure, anemia). CDC (2014) estimates that 10% of adults in the U.S. or over 20 million people have chronic kidney disease and early detection can prevent kidney failure.
ESRD = Stage 5 CKD (need dialysis or a transplant)

4. Signs and Symptoms Nausea Vomiting Flu like symptoms Hiccups
Increased BUN and Creatinine
Fatigue
The National Kidney Foundation recommends 2 simple tests to check for kidney disease: Albuminuria-to-creatinine ratio (ACR). Albuminuria occurs when there are high amounts of protein (albumin) in the urine (NKF, 2015)
Glomerular filtration rate (GFR) is an estimate from blood creatinine levels, age and gender of patient.
“Creatinine is a waste product that comes from muscle activity and normal wear and tear on the muscles of the body. Healthy kidneys filter it out of the blood. When kidney function is reduced, creatinine levels in the blood increase. Serum creatinine levels can vary depending on age, race, gender, weight and body size. Levels greater than 1.2 for women and 1.4 for men may be an early sign that the kidneys are not working properly” (NKF, 2015, sec. Heart & Kidney Health).
Hiccups caused by a buildup of urea (metabolin of protein) in the body.

5. Risk Factors and Consequences
Increase the risk of developing CKD:
Diabetes
High Blood Pressure
Cardiovascular Disease
Obesity
High Cholesterol
Lupus
Family history of CKD
Increased risk because of CKD:
Cardiovascular disease
Heart attack
Stroke
Weak/Brittle bones
Anemia
Infection
Hypertension causes chronic renal failure and chronic renal failure causes hypertension.
Other causes include: glomerulonephritis which causes inflammation and damage to the filtering system; inherited diseases such as polycystic kidney disease which causes large cysts to form in the kidneys and damage surrounding tissue, or malformations that occur as the baby develops
Heart: increase fluid, HTN, high potassium
Increased phosphorus: brittle bones
Decrease production of RBCs = anemia
Weakened immune system = infection

6. Diagnosis- Acute Renal Failure
Serum Creatinine level that is increased by 0.5mg/dl above normal range.
Serum Creatinine level that is increased by 50% above patient baseline.
Glomerular filtration rate (GFR) that shows a 50% decrease from the patients baseline.
Acute renal failure is an abrupt decrease in kidney function and occurs in up to 20% of hospitalized patients and over 45% of critical care patients (National Kidney Foundation, 2013). Causes can be burns, trauma, severe diarrhea, IV contrast.

7. Diagnosis-Chronic Renal Failure
GFR, CR, BUN, and Electrolytes.
Ct scan or US of kidneys.
24 hour urine for creatinine clearance. UA for proteinuria and RBC casts.
Kidney Biopsy
The Glomerular Filtration Rate (GFR) is the best estimate of kidney function. Tests that can detect chronic kidney disease include BP and urine albumin and serum creatinine.

8. Stages of Chronic Renal Failure
Renal failure is diagnosed and treated in five stages: Stage 1 =normal or high GFR (>90 ml/min)
Stage 2 = Mild CKD (GFR = ml/min)
Stage 3 = Moderate CKD (GFR = ml/min)
Stage 4 = Severe CKD (GFR = ml/min)
Stage 5 = End stage CKD (GFR < 15 ml/min)
ultracare-dialysis.com

9. Treatment plan Acute RF Treat the underlying cause of the RF.
Extreme cases will need dialysis to help the kidney bounce back from the injury.
Chronic RF
Aimed at slowing progression of stages.
Dialysis or Kidney transplant.
Fluid Challenge

10. What is Hemodialysis?

11. Fistula vs AV Graft
Fistula- surgically enlarged blood vessel made from the patient’s own veins. May take 6 months to 1 year to develop.
AV Graft- artificial vein made from a synthetic material for HD. This is not the preferred option.

12. AV Fistula and Graft
Getting ready for hemodialysis, Blood Access

13. Continuous Ambulatory Peritoneal Dialysis
What is CAPD?
Continuous Ambulatory Peritoneal Dialysis

14. How to care for your renal failure patient

15. Assessment Watch for signs of: Fluid overload Over sedation Sepsis
Anemia
Anemia occurs because your kidneys make a hormone called erythropoietin a messenger that tells your body to make red blood cells. With kidney disease you do not make enough of the hormone so you get anemia.
Too much fluid can increase BP and cause CHF; makes it harder to breathe, causes swelling, if too much fluid is gained between treatments, removal can cause painful cramping during dialysis treatment

16. Lab work to monitor CR and BUN
Potassium- 6 or greater is a critical value.
Sodium
Calcium
Phosphorus
* Troponins will be slightly elevated in dialysis patients. A large jump in Troponins and other clinical indicators need to be looked for in suspicious MI.
Increased phosphorus can cause severe itching; long term effects of high phosphorus can lead to weak, brittle bones and hardened blood vessels (Fresenius Medical Care, 2013)
Limit high phosphorus foods and take phosphorus binders with meals and snacks.
BUN (upper limit = 100mg/dl) - normal is <20 Creatinine (upper limit = 6.0mg/dl)
Calcium normal = 8.5 to Phosphorus normal = 2.7 to 4.6

17. Vitals
HTN is common-Dialysis balances out HTN. If a patient is standing sitting up BP will drop. If the patient is lying down BP will be higher.
Daily weights are essential. They must be obtained in the am before the patient goes to dialysis.

18. Diet No orange juice- All high potassium foods need to be avoided.
Protein needs to be consumed in moderation.
Sodium, phosphorus, and calcium should be avoided.
Fluid intake must be monitored.
**Pass around diet /snack sheets

19. Medications Renagel Phosphate binders Midodrine Epogen
BP meds (may need to hold until after dialysis treatment)
The renal patients need the phosphate binders to reduce the absorption of phosphate because renal patients can not get rid of the phosphate in their blood and is taken with meals or snacks. The phosphate binders bind the phosphate in the GI tract so it is not available in the blood. High phosphate levels can lead to heart disease

20. Complications of RF Anemia- Iron is needed with epogen.
Bone disease and calcifications- lead to amputations.
High PTH levels- Vitamin D
Vitamin depletion

21. Hemodialysis Catheter
Permanent or temporary
Keep HD cath clean dry and infection free.
Dressing change done by dialysis nurse unless soiled or coming off.
DO NOT USE HD catheter for anything. This is to only be used by trained dialysis nurses for dialysis

22. HD Catheter

23. Assessment of fistula
No BP, Labs, PICC done in the arm of a RF patient with graft or fistula.
Every shift check for thrill and bruit of fistula/graft. Also check for blistering or open areas on site.

24. Interesting Dialysis facts
Not all dialysis patients urinate.
Dialysis patients are not allowed to eat in dialysis
Life expectancy for a patient at 60 years or older starting dialysis is 4 years.
The average age of a dialysis patient in Jackson County is in their 70’s.
Age years old – avg 5 year survival is 70%
65-74 is 30%
over 75 years is <20%

25. Questions?

26. References
Fresenius Medical Care (2013). Picture it! Healthy labs and a healthier you. Rightstart guides Fresenius Medical Care.
National Kidney Foundation (2013). About chronic kidney disease. Retrieved from
National Kidney Foundation (2015). Kidney Disease. Retrieved from: