1. RCS 6080 Medical and Psychosocial Aspects of Rehabilitation Counseling Renal Failure

2. Function of Kidneys Remove toxic waste products Remove toxic waste products Remove excess water and salts Remove excess water and salts Play a part in controlling blood pressure Play a part in controlling blood pressure Produce erythropoetin (epo) which stimulates red cell production Produce erythropoetin (epo) which stimulates red cell production Helps to keep calcium and phosphate in balance for healthy bones Helps to keep calcium and phosphate in balance for healthy bones Maintains proper pH for the blood Maintains proper pH for the blood

3. Definitions Azotemia: Elevated blood urea nitrogen Azotemia: Elevated blood urea nitrogen  (BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL) Uremia: azotemia with symptoms or signs of renal failure Uremia: azotemia with symptoms or signs of renal failure End Stage Renal Disease (ESRD): uremia requiring transplantation or dialysis End Stage Renal Disease (ESRD): uremia requiring transplantation or dialysis Chronic Renal Failure (CRF): irreversible kidney dysfunction with azotemia >3 mos. Chronic Renal Failure (CRF): irreversible kidney dysfunction with azotemia >3 mos. Creatinine Clearance (CCr): rate of filtration of creatinine by the kidney (marker for GFR) Creatinine Clearance (CCr): rate of filtration of creatinine by the kidney (marker for GFR) Glomerular Filtration Rate (GFR): the total rate of filtration of blood by the kidney. Glomerular Filtration Rate (GFR): the total rate of filtration of blood by the kidney.

4. Nephrons Nephrons are the units in the kidney that transfer waste products from the blood to urine. Nephrons are the units in the kidney that transfer waste products from the blood to urine. A human kidney has approximately one million nephrons. A human kidney has approximately one million nephrons. Glomeruli are the filtration units of the nephron. Glomeruli are the filtration units of the nephron.   The Glomerulus (first structure of the nephron) is a tuft of capillaries. Blood enters the glomerulus by the afferent arteriole and exits by the efferent arteriole Bowman’s capsule is a tough layer of epithelial cells that surrounds the glomerulus ;there is a small holding area for the initial filtrate in between the capillary walls of the glomerulus and the inner layer of Bowman’s capsule; this area is called Bowman’s space. Fluid and solutes filtered by the glomerulus collect in this space. The space connects to the proximal convoluted tubule, which is the first section of the nephron’s tube system Bowman’s capsule is a tough layer of epithelial cells that surrounds the glomerulus ;there is a small holding area for the initial filtrate in between the capillary walls of the glomerulus and the inner layer of Bowman’s capsule; this area is called Bowman’s space. Fluid and solutes filtered by the glomerulus collect in this space. The space connects to the proximal convoluted tubule, which is the first section of the nephron’s tube system  a network of tubules extends from Bowman’s capsule:  proximal convoluted tubule (PCT)  Loop of Henle—has a descending and ascending limb  distal convoluted tubule  Collecting duct

5. Renal Failure Acute Renal Failure Acute Renal Failure  Prerenal azotemia  An abnormally high level of nitrogen-type wastes in the bloodstream. It is caused by conditions that reduce blood flow to the kidneys.  Postrenal azotemia  An obstruction of some kind (i.e., bladder cancer, uric acid crystals, urethral stricture etc)  Intrinsic Renal Disease  Usually glomerular disease  Usually leads to End Stage Renal Disease

6. Chronic Renal Failure Diabetic Nephropathy Diabetic Nephropathy  50K cases of DN ESRD annually  Diabetes most common contributor to ESRD  >30% of ESRD cases attributed to Diabetes Hypertension Hypertension  CFR with Hypertension causes 23% of ESRD annually Glomerulonephretis: 10% Glomerulonephretis: 10% Polycystic Kidney Disease: 5% Polycystic Kidney Disease: 5% Rapidly progressive glomerulonephrities (vasculitis): 2% Rapidly progressive glomerulonephrities (vasculitis): 2% Renal Vascular Disease (i.e., renal artery stenosis) Renal Vascular Disease (i.e., renal artery stenosis) Medications Medications Analgesic Nephropathy (progression after many years) Analgesic Nephropathy (progression after many years) Pregnancy: high incidence of increased creatitine and HTN during pregnancy associated with CRF Pregnancy: high incidence of increased creatitine and HTN during pregnancy associated with CRF

7. Chronic Renal Failure CRF is defined as a permanent reduction in glomerular filtration rate (GFR) sufficient to produce detectable alterations in well-being and organ function. This usually occurs at GFR below 25 ml/min. About 100 to 150 per million persons in the U.S. develop CRF annually About 100 to 150 per million persons in the U.S. develop CRF annually Average annual cost is $25,000 – 35,000 per patient per year Average annual cost is $25,000 – 35,000 per patient per year

8. Stages of Chronic Renal Failure 1. Silent – GFR up to 50 ml/min. 2. Renal insufficiency – GFR 25 to 50 ml/min. 3. Renal failure – GFR 5 to 25 ml/min 4. End-stage renal failure – GFR less than 5 ml/min.

9. Diabetic Nephropathy What can be done to reduce the risk of problems?   Blood glucose control   Blood pressure control   Using ACE inhibitors and AT II antagonists   Diet   Controlling blood lipids and cholesterol   Smoking

10. Treatment for Diabetic Nephropathy StageAssessmentTreatment No Proteinuria Monitor BP & Glucose Screen for micoalbumininuria Hypertension drugs if needed (BP should be 130/85 or lower). Dietary advice for sugar and fat, stop smoking Microalbuminuria Close monitoring of BP, Glucose and blood lipids, monitor urinary proteins & CCr Add more Hypertension drugs if needed needed. Monitor cholesterol and add ACE inhibitor if needed Proteinuria Close monitoring of BP, glucose and blood lipids, monitor urinary protein and 24 CCr BP should be lower than 125/75, low protein diet Declining kidney function Prepare for dialysis &/or transplant

11. Metabolic changes Na+ excretion initially increased Na+ excretion initially increased Edema occurs when GFR continues to diminish. Edema occurs when GFR continues to diminish. NH4+ excretion declines adding to metabolic acidosis. NH4+ excretion declines adding to metabolic acidosis. Bone CaCO3 begins to act as a buffer for the acidosis and leading to chronic bone loss and bone lesions develop (renal osteodystrophy). Bone CaCO3 begins to act as a buffer for the acidosis and leading to chronic bone loss and bone lesions develop (renal osteodystrophy). Accumulations of normally secreted uremic toxins Accumulations of normally secreted uremic toxins

12. Uremic Syndrome Uremia occurs in stage 3 & 4 of CRF. It means literally “urine in the blood” Uremia occurs in stage 3 & 4 of CRF. It means literally “urine in the blood”  Symptomatic azotemia  Fever, Malaise  Anorexia, Nausea  Mild neural dysfunction  Uremic pruritus (itching)

13. Associated problems with CFR Immunosuppression Immunosuppression  Increased risk of infection  People with CFR should be vaccinated regularly Anemia Anemia  Due to reduced erythropoietin production by kidney. Usually doesn’t occur until 6-12 mos prior to dialysis Hyperuricemia (Gout) Hyperuricemia (Gout)  Increased uric acid in system  Pain in joints, may contribute to renal dysfunction Hyperphosphatemia Hyperphosphatemia  Increased parathyroid hormone levels  Increased phosphate load from bone metabolism Hypertension Hypertension Poor coagulation Poor coagulation Proteinuria Proteinuria

14. Chronic Renal Failure Chronic Renal Failure and Its Progression Chronic Renal Failure and Its Progression Functional Adaptation to Nephron Loss Functional Adaptation to Nephron Loss  Increased amount of sodium that escapes reabsorption  Excessive amount of potassium in blood  Increased ammonia concentration  Calcium and phosphorus metabolism are markedly altered

15. Treatment of Chronic Renal Failure Hypertension Metabolic Acidosis Metabolic Acidosis Anemia Anemia Renal Osteodystrophy Renal Osteodystrophy Uremic Neuropathy Uremic Neuropathy Sexual Dysfunction Sexual Dysfunction

16. Conservative Treatment Dialysis Hemodialysis Home Peritoneal Center Transplant Related Donor Cadaver Donor

17. Treatment of End Stage Renal Failure Hemodialysis Hemodialysis  Uses a mechanized filter to remove impurities from the blood system  Essentially replaces kidney with a machine  Dialysis usually occurs a couple times per week.

18. Hemodialysis Vascular preparation Vascular preparation  Surgical procedures usually completed weeks before beginning hemodialysis

19. Treatment of End Stage Renal Failure Peritoneal Dialysis Peritoneal Dialysis  Uses the abdominal cavity as a filter

20. Treatment of End Stage Renal Failure Transplantation Transplantation

21. Treatment of End Stage Renal Disease Survival of People with ESRD Survival of People with ESRD  Data show a mean expected remaining life span of just under 8 years for people 40-44 beginning dialysis and just over 4 years for people 60-64 Adequacy of Dialysis Adequacy of Dialysis Nutrition Nutrition

22. Chronic Renal Failure Physical Rehabilitation – benefits of exercise Physical Rehabilitation – benefits of exercise Vocational Rehabilitation Vocational Rehabilitation  The goal should be to help the person with chronic renal failure to resume all the duties, responsibilities and benefits he or she enjoyed prior to the illness  Gainful employment is extremely important for an adult in the earning period of his or her life, to regain self- esteem and to interact with society confidently  Fear of losing financial benefits may deter some people  Some research has shown that multidisciplinary predialysis intervention leads to maintenance of job

23. Additional Resources and Information from the Web Florida End Stage Renal Disease Network (http://www.fmqai.com/ESRD/esrd.htm) Florida End Stage Renal Disease Network (http://www.fmqai.com/ESRD/esrd.htm)http://www.fmqai.com/ESRD/esrd.htm University Renal Research and Education Association (www.urrea.org) University Renal Research and Education Association (www.urrea.org)www.urrea.org National Institute of Diabetes & Digestive & Kidney Diseases (www.niddk.nih.gov) National Institute of Diabetes & Digestive & Kidney Diseases (www.niddk.nih.gov)www.niddk.nih.gov  National Kidney & Urologic Diseases Information Clearinghouse (NKUDIC) (http://kidney.niddk.nih.gov/) http://kidney.niddk.nih.gov/ Life Options Rehabilitation Program (www.lifeoptions.org) Life Options Rehabilitation Program (www.lifeoptions.org)www.lifeoptions.org United Network for Organ Sharing (UNOS) (http://www.unos.org) United Network for Organ Sharing (UNOS) (http://www.unos.org)http://www.unos.org American Society of Nephrology (www.asn-online.org) American Society of Nephrology (www.asn-online.org)www.asn-online.org National Kidney Foundation (www.kidney.org) National Kidney Foundation (www.kidney.org)www.kidney.org JAN’s webpage (www.jan.wvu.edu/soar/other/renal.html) JAN’s webpage (www.jan.wvu.edu/soar/other/renal.html)www.jan.wvu.edu/soar/other/renal.html