RCS 6080
Medical and Psychosocial Aspects of
Rehabilitation Counseling
Renal Failure
Function of Kidneys
Remove toxic waste products
 Remove excess water and salts
 Play a part in controlling blood pressure
 Produce erythropoetin (epo) which
stimulates red cell production
 Helps to keep calcium and phosphate in
balance for healthy bones
 Maintains proper pH for the blood
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Definitions
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Azotemia: Elevated blood urea nitrogen
 (BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL)
Uremia: azotemia with symptoms or signs of renal
failure
End Stage Renal Disease (ESRD): uremia
requiring transplantation or dialysis
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)
Glomerular Filtration Rate (GFR): the total rate of
filtration of blood by the kidney.
Nephrons
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Nephrons are the units in the kidney that transfer
waste products from the blood to urine.
A human kidney has approximately one million
nephrons.
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
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
Renal Failure
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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
Chronic Renal Failure
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Diabetic Nephropathy
 50K cases of DN ESRD annually
 Diabetes most common contributor to ESRD
 >30% of ESRD cases attributed to Diabetes
Hypertension
 CFR with Hypertension causes 23% of ESRD annually
Glomerulonephretis: 10%
Polycystic Kidney Disease: 5%
Rapidly progressive glomerulonephrities (vasculitis): 2%
Renal Vascular Disease (i.e., renal artery stenosis)
Medications
Analgesic Nephropathy (progression after many years)
Pregnancy: high incidence of increased creatitine and HTN
during pregnancy associated with CRF
Chronic Renal Failure
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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
Average annual cost is $25,000 – 35,000 per
patient per year
Stages of Chronic Renal Failure
1.
2.
3.
4.
Silent – GFR up to 50 ml/min.
Renal insufficiency – GFR 25 to 50
ml/min.
Renal failure – GFR 5 to 25 ml/min
End-stage renal failure – GFR less than 5
ml/min.
Diabetic Nephropathy
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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
Treatment for Diabetic Nephropathy
Stage
Assessment
Treatment
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
Metabolic changes
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Na+ excretion initially increased
Edema occurs when GFR continues to diminish.
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).
Accumulations of normally secreted uremic toxins
Uremic Syndrome
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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)
Associated problems with CFR
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Immunosuppression
 Increased risk of infection
 People with CFR should be vaccinated regularly
Anemia
 Due to reduced erythropoietin production by kidney. Usually
doesn’t occur until 6-12 mos prior to dialysis
Hyperuricemia (Gout)
 Increased uric acid in system
 Pain in joints, may contribute to renal dysfunction
Hyperphosphatemia
 Increased parathyroid hormone levels
 Increased phosphate load from bone metabolism
Hypertension
Poor coagulation
Proteinuria
Chronic Renal Failure
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Chronic Renal Failure and Its
Progression
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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
Treatment of Chronic Renal Failure
Hypertension
 Metabolic Acidosis
 Anemia
 Renal Osteodystrophy
 Uremic Neuropathy
 Sexual Dysfunction
Conservative
Treatment
Dialysis
Hemodialysis
Transplant
Peritoneal
Home
Related Donor
Center
Cadaver Donor
Treatment of End Stage Renal
Failure
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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.
Hemodialysis
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Vascular preparation
 Surgical procedures usually
completed weeks before
beginning hemodialysis
Treatment of End Stage Renal
Failure
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Peritoneal
Dialysis
 Uses the
abdominal
cavity as a
filter
Treatment of End Stage Renal
Failure
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Transplantation
Treatment of End Stage Renal
Disease
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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
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Adequacy of Dialysis
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Nutrition
Chronic Renal Failure
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Physical Rehabilitation – benefits of exercise
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 selfesteem 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
Additional Resources and
Information from the Web
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Florida End Stage Renal Disease Network
(http://www.fmqai.com/ESRD/esrd.htm)
University Renal Research and Education Association
(www.urrea.org)
National Institute of Diabetes & Digestive & Kidney Diseases
(www.niddk.nih.gov)
 National Kidney & Urologic Diseases Information
Clearinghouse (NKUDIC) (http://kidney.niddk.nih.gov/)
Life Options Rehabilitation Program (www.lifeoptions.org)
United Network for Organ Sharing (UNOS)
(http://www.unos.org)
American Society of Nephrology (www.asn-online.org)
National Kidney Foundation (www.kidney.org)
JAN’s webpage (www.jan.wvu.edu/soar/other/renal.html)