Kidney Failure and Dialysis
By: Gale MacDonald and Marie Helene Bond

Presentation Overview

Kidney disease in Canada

Dialysis- hemodialysis and
peritoneal dialysis: nursing
management and equipment

Functions of the kidney

Anatomy and physiology

Transplant- nursing management

Kidney failure- Acute: categories;
phases; causes; clinical
manifestations; prevention; and
nsg interventions and Chronicstages; S/S; risk factors;
prevention; nsg interventins

Conservative care

Case study

Quiz

Questions

Screening procedures; labs test

Treatment for renal failure
Kidney Disease in Canada

An estimated 2.6 million
Canadians have kidney disease,
or are at risk.
The number of Canadians being
treated for kidney failure has tripled
over the past 20 years.

Each day, an average of 16
people are told that their
kidneys have failed.
53% of new renal failure patients
are 65 years of age or older.

The two leading causes of
kidney failure in new patients:
1. Diabetes – 35%
2. Renal Vascular Disease
(including high blood pressure)
– 18 %.
Among the 39,352 people being
treated for kidney failure in Canada
in 2010:
59% (23,188) were on dialysis 41%
(16,164) had a functioning
transplant.
Function of Kidneys
•
Influences blood
pressure and blood
volume
Facilitates electrolyte
balance
•
Renal clearance
•
Facilitates acid-base
balance
•
Secretion of
prostaglandins
•
Manages water balance
and maintain blood
osmolality
•
Conversion of vitamin D
to it’s active form
•
Assists with red blood
cell production
(erythropoietin)
•
Production of urine and
elimination of waste
•
(Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 1405;
Tortora & Derrickson, 2009, p. 1020 )
Anatomy of Kidney
The Nephron
Urine
 The formation of urine involves three major
processes:
1)Glomerular filtration in the renal corpuscles
2)Tubular reabsorption
3)Tubular secretion
Glomerular filtration in the Renal
Corpuscles

“Filtration is a process by which blood pressure forces plasma
and dissolved materials out of capillaries” (Williams & Hopper,
2007, p. 752)

“The blood pressure in the glomeruli is relatively high about
55mmHg. The pressure in Bowmen’s capsule in low and its
inner layer is permeable, so approx 20% to 25 %of blood that
enters the glomeruli becomes renal filtrate in bowmen’s
capsule” (Williams & Hopper, 2007, p. 752)

“Renal filtrate is similar to blood plasma except that there is
far less protein and no blood cells present” (Williams &
Hopper, 2007 , p. 752).

“The glomerular filtration rate (GFR) is the amount of renal
filtrate formed by the kidneys in one minute; It averages 100
to 125mL/min” (Williams & Hopper, 2007, p. 752).
Tubular reabsorption
 “Tubular reabsorption is the recovery of useful
materials from the renal filtrate and their return to
the blood in the peritubular capillaries” (Williams &
Hopper, 2007, p. 753).
 Takes place in proximal convoluted tubules, distal
convoluted tubules and collecting tubules (Williams
& Hopper, 2007, p. 753).
 “Mechanisms of reabsorption are active transport,
osmosis, diffusion, facilitated diffusion and
pinocytosis” (Williams & Hopper, 2007, p. 753).
Tubular Secretion
 “In tubular secretion, substances are actively
secreted from the blood in the peritubular
capillaries into the filtrate in the renal tubules”
(Williams & Hopper, 2007, p. 753).

Ammonia, creatinine, excess water soluble
vitamins, the metabolic products of medications
and Hydrogen ions may be secreted into urine
(Williams & Hopper, 2007).
What
Happens
in the
Nephron
Definition:
Renal Failure
Can be acute or
chronic
The kidneys failure to expel
wastes, maintain electrolyte
balance, concentrate urine,
and maintain chemicals in
the bloodstream that are
regulated by the kidneys
(ex. Renin) (Mosby’s
Dictionary of Medicine,
Nursing & Health
Professionals, 2006).
Acute Renal
Chronic Renal
Failure
Failure
 “Acute renal failure (ARF) is a sudden
and almost complete loss of kidney
function over a period of hours to days”
(Day et al., 2010, p. 1435).
 Oliguria: urine output of less then
400mL /day. is the most common
clinical manifestation (p.1435).
 Anuria (less than 50 ml of urine a day)
Acute Renal
Failure
 Elevated BUN and creatinine
 Reversible if treated promptly
Categories of ARF
1. Prerenal: Hypoperfusion of the kidneys.
2. Intrarenal: Acute damage to kidney tissue
3. Postrenal: obstruction to urine flow
Phases of ARF
 Initiation phase: “begins
with the initial insult and
ends with oliguria”
 Oliguria phase:” manifested
by a rise in the
concentration of substances
usually excreted by the
kidney (urea, creatinine, uric
acid, potassium and
magnisium)”.
 Diuresis:” gradual increase in
urine output, which
indicates GFR has started to
recover.”
 Recovery: “improvement of
renal function may take 3 to
12 months. Lab values may
return to normal. A
permanent damage of 1% to
3% in GFR function is
common, but not clinically
significant”
(Day et al., 2010, p, 1437)
Causes of ARF
Prerenal failure causes
Intrarenal failure
Postrenal failure
• Volume depletion
• Prolong renal ischemia
• Urinary tract obstruction,
resulting from:
resulting from: trauma,
including: calculi
hemorrhage, diuretics,
crush injury, burns,
(stones), tumours, BPH,
vomiting diarrhea
transfusion reactions,
strictures, and blood
nasogastric suction.
hemolytic anemia.
clots.
• Impaired cardiac
• Nephrotoxic agents such
efficiency resulting from:
as: gentamicin, heavy
MI, dysthymias,
metals- lead and
cardiogenic shock.
mercury, NSAID’s, ACE
• Vasodilation resulting
inhibitors, radiopaque
from: sepsis, anaphylaxis,
dyes.
antihypertensive
• Infectious processes such
medications or other
as: acute pyelonephritis,
meds that cause
Acute
vasodilatation.
glomerulonephritis.
Clinical Manifestations
 Pt will appear critically ill
and lethargic, and confused
 Skin and mucus membranes
will be dry from dehydration
 drowsiness, headache,
muscle twitching, and
seizures.
 dyspnea, crackles,
tachypnea,
(Day et al., 2010, p. 1436)
Comparing the categories of ARF
Characteristics
Prerenal
Intrarenal
Postrenal
etiology
hypoperfusion
Tissue damage
obstruction
BUN



creatinine



Urine output

Varies but often

Varies-may be
decreased, or
sudden anuria
Urine sodium
 To <20mEq/L
 To >40 mEq/L
Varies- often 
to 20 mEq/L
Urine specific
gravaty

Low normal
Varies
Prevention of ARF

Provide adequate hydration to clients at risk of dehydration. ( surgical client)

Prevent and treat shock- with blood and fluids

Treat hypotension promptly

Continually assess renal function (output, Labs)

Avoid transfusion reactions (always check two RN, and Five rights and three
checks

Prevent and treat infection promptly (good catheter care) and pay special
attention to wounds, burns, and other precursors to sepsis

Toxic drug effects- monitor blood levels, and ensure safe does

Day et al., 2010, p. 1437
Nursing interventions





Monitor intake and output,
including all body fluids
May need to stimulate
production of urine with IV
fluids, diuretics.
Daily weights
Monitor lab results, CBC,
BUN, creatinine, urea, e’lyles
Watch hyperkalemia
symptoms: malaise,
anorexia, parenthesia, or
muscle weakness, EKG
changes

Maintain nutrition

Mouth care – dry mucus
membranes

Assess for signs of cardiac
involvement- dysthymias

Skin integrity problems.
Edema, itching –from toxins

Signs and symptoms of
infection

May need dialysis, or
continuous renal
replacement therapy.
Chronic Renal failure (CRF)
 Definition: “ Chronic Renal failure is a progressive,
irreversible deterioration of renal function in which
the body ability to maintain metabolic, fluid and
electrolyte balance fails, resulting in uremia or
azotemia (retention of urea and other nitrogenous
waste in blood) (Day et al., 2010, p. 1440).
Stages of CRF
 The normal glomerular filtration rate
(GFR) is 125ml/min/1.73m2 (Day et al., 2010,
p. 1440)
 The stages of renal failure is determined
by the GFR (Day et al.,
2010, p. 1440).
Stages of CRF
 Stage 1:
GFR>90ml/min/1.73m2
kidney damage with
normal or elevated GFR
 Stage 2 : GFR = 60-
89ml/min/1.73m2 mild
decrease in GFR
 Stage 3: GFR = 30-
59ml/min/1.73m2
moderate decrease in GFR
 Stage 4: GFR = 15-
29ML/MIN/1.73M2 Severe
decrease in GFR
 Stage 5:
GFR<15ml/min/1.73m2
Kidney Failure (aka end
stage renal failure)
Signs & Symptoms of CRF
 Ammonia-like taste in mouth or urinous breath
 Edema of feet, hands, arms, face and around eyes
 Hypertension
 Extended neck veins
 Anemia
 Fatigue
 Neurologic disturbances
 Nausea, vomiting, and anorexia
 Headaches and blurred vision
Signs & Symptoms of CRF
 Pruritus
 Shortness of breath
 Bone and joint problems
 Weakness, numbness, tremors, bone pain, and
paresthesia
 Urine that is cloudy, tea-coloured, or bloody
 Decreased urine output or trouble urinating
 Foaming of urine
 Proteinuria
CRF Risk Factors
 People at increased risk of developing kidney disease include
people who have:
 Diabetes
 High blood pressure or blood vessel diseases
 Glomerulonephritis and other systemic diseases
 Family history of hereditary kidney disease
 Certain ethnic groups such as Aboriginal, Asian, South Asian, Pacific
Island, African/Caribbean and Hispanic origin
Nursing interventions CRF
 Assessing fluid status
 Nutrition/Diet
 Patient teaching
 Assess emotional status and coping strategies
 Assessing for complications
 Administering Medications
(Mayo clinic, 2012).
Sum it up: major complications


Decreased sex drive or impotence

Damage to your central nervous
system, which can cause difficulty
concentrating, personality changes or
seizures

A sudden rise in potassium levels in
your blood (hyperkalemia), which could
impair your heart's ability to function
and may be life-threatening
Decreased immune response, which
makes you more vulnerable to infection

Pericarditis, an inflammation of the saclike membrane that envelops your
heart (pericardium)

Heart and blood vessel disease
(cardiovascular disease)


Weak bones and an increased risk of
bone fractures
Pregnancy complications that carry
risks for the mother and the developing
fetus

Irreversible damage to your kidneys
(end-stage kidney disease), eventually
requiring either dialysis or a kidney
transplant for survival



failure can affect almost every part of
your body. Potential complications may
include:
Fluid retention, which could lead to
swelling in your arms and legs, high
blood pressure, or fluid in your lungs
(pulmonary edema)
Anemia

Diagnostic Procedures








Renal ultrasound
CT
MRI
IVP
Nephrotomogram
Renal angiogram:
Renal scan:
Renal biopsy:
(Williams & Hopper, 2007)
Screening: Normal blood values to assess
Kidney function

Urea
1.8 – 8.2mmol/L

Potassium
3.5 – 5.0mmol/L

Phosphate
0.8 – 1.4mmol/L

Calcium
2.0 – 2.6mmol/L

Creatinine
60 – 110umol/L (female)
70 – 120umol/L (Male)

Hemoglobin
120 – 140g/L (female)
140 – 160g/L (male)

GFR
90 – 120ml/min
(1.5 – 2.0ml/sec)
Assessing renal function
Blood tests
Creatinine
Normal value
0.6-1.3 mg/dl
Blood urea nitrogen
Hemoglobin
Hematocrit
Sodium
Potassium
Chloride
Calcium
Phosphorus
Magnesium
10-20 mg/dl
12-18 grams/dl
40%-50%
136-145 mEq/liter
3.5-5.1 mEq/liter
98-107 mEq/liter
8.2-10.2 mg/dl
2.7-4.5 mg/dl
1.3-2.1 mEq/liter
Urine tests
Uric acid
Urine protein
Normal value
2.5-8.0 mg/dl
None
Urine creatinine clearance
GFR
= 120–125 ml/min
Change with chronic renal failure
Increased. Over 1.2 mg/dl in
women and 1.4 mg/dl in men
merits further renal assessment.
Increased
Decreased
Decreased
Varies with free water
Increased
Varies
Decreased
Increased
Increased or normal
Change with chronic renal failure
Increased
Positive test result dictates
follow- up urinalysis. >3,500 mg
indicates glomerular disease.
Decreased
Screening: Urine Testing
 Creatinine clearance formula:
(Volume of urine [ml/min] X Urine creatinine [MMOL/L])
Serum Creatinine (mmol/L)
 As renal function decreases, creatinine clearance decreases

Day et al., 2010, pp1410
Treatment of Renal Failure
Medication
Proper Diet
Dialysis (2 types: peritoneal & hemodialysis)
Transplantation
Conservation Care

Treatment of Renal Failure
 Medication: Medication may be used to help
maintain or improve kidney function, as well as,
treat complications of renal failure (eg.
Antihypertensives, kayexalate, etc.) (Day et al.,
2010, pp 1442).
Diet for CRF
 Low protein
 Low sodium
 Low potassium
 Fluid restrictions
 Vitamin supplements
 High calorie
Dialysis
 When the kidneys are not removing fluid and uremic waste
from the body, dialysis can be used to do so
 Dialysis can be acute or chronic
 Acute dialysis is used for people with high levels of serum
potassium, fluid overload, or impending pulmonary edema,
increasing acidosis, pericarditis, and severe confusion
 Acute dialysis may also be used to remove certain
medications or other toxins from the blood
Dialysis
 Chronic dialysis is used for chronic renal failure
 Dialysis can be used for years to help maintain people with
no renal function
 Indications may include: uremic signs and symptoms
affecting all body systems, hyperkalemia, fluid overload,
pericardial friction rub, and lack of well being
Types of
Dialysis
Peritoneal
Dialysis
Hemodialysis
Peritoneal Dialysis
 Removes metabolic wastes and toxin’s so the body’s normal
fluid and electrolyte balance is re-established
 The peritoneum that lines the abdominal cavity and covers
the abdominal organs acts as a semipermeable membrane
that allows metabolic end products to be removed from the
blood by means of diffusion and osmosis
Peritoneal Dialysis
 An abdominal catheter allows sterile dialysate fluid to enter
the peritoneal cavity
 The metabolic waste products in the blood move from an
area of high concentration (blood), across the peritoneal
membrane, to an area of low concentration (peritoneal
cavity with dialysate fluid)
Peritoneal Dialysis
 The body’s excess fluid is removed by an osmotic gradient,
because the dialysate fluid in the peritoneal cavity has a
higher glucose concentration
 the fluid is then removed from the peritoneal cavity and
discarded
 This process is repeated 4-6 times ever 24hrs
 The most common complication from peritoneal dialysis is
peritonitis
Peritoneal Dialysis
 Equipment:
Peritoneal Dialysis Nursing management
 Client and family education
 Sterile technique (face mask, gloves, sterile field)
 Signs and symptoms of peritonitis
 Inspect site and dialysate solution for signs and
symptoms of infection
Hemodialysis
 The most common type of dialysis
 Purpose remains to remove toxins from the blood and excess
water from the body
 Usually patients receive Hemodialysis 3 times per week
 Treatment takes about 3-8 hours per treatment
Hemodialysis
 The blood is delivered from the patient and to the dialysis
machine, where a dialyzer (artificial kidney) uses diffusion,
osmosis, and ultrafiltration to remove toxins from the blood,
which is then returned to the patient

The metabolic waste products in the blood move from an
area of high concentration (blood), to an area of low
concentration (dialysate)
Hemodialysis
 Dialysate is a solution composed of electrolytes, which
concentration levels can be adjusted to accommodate the
desired electrolyte level in the patients blood
 Osmosis and ultrafiltration is used to remove the body’s
excess water
 Arteriovenous fistula- is made by
sewing a vein and artery together under
the skin. Fistulas may take 2 to 4
months to mature. A temporary access
device is usually needed until It matures
(Williams & Hopper 2007, p. 803).
 Arteriovenous graft: uses a tube of
systhetic material to attach an artery
and a vein. Needles are inserted into
the graft to access the clients blood
(Williams & Hopper 2007, p. 803).
Hemodialysis:
Vascular
Access Device
 Two tailed subclavian/ double lumen,
cuffed hemodialysis catheter used for
acute hemodialysis.
 Red port: blood line
 Blue port: return dialyzed blood to
client.
Hemodialysis Equipment
Nursing Management for Hemodialysis

Consult with physician about
medications to hold prior to
dialysis

Apply emla patch to numb
fistula or graft area

When the client returns assess
for signs and symptoms of
bleeding

Obtain weigh before dialysis
and after dialysis note changes.

Coordinate blood draws with
the dialysis nurse to avoid
unnecessary needle pokes

Assess vital signs and admin
medications that were held in
the AM unless contraindicated

Get morning care done early
and give breakfast before
dialysis

Allow for rest. Clients often
exhausted after dialysis
(Williams & Hopper 2007, p. 803)
Nursing Management for Hemodialysis



Listen for a bruit at the site by placing
stethoscope gently on the site. A bruit is a
swishing sound made as the blood passes
through the access site.
Gently palpate for a thrill, which is a
buzzing or pulsing feeling that indicates
good blood flow
Do not take BP, draw blood, start IV, or use
tourniquet, on affected arm. injections
should also be avoided. (Place sign above
bed).
(Williams & Hopper 2007, p. 803)

Teach client to keep site clean, not to
bump, or cut.

Teach client to not lift heavy objects with
affected arm

Teach client to avoid tight jewellery and
restrictive cloths on affected arm.

Teach client to avoid sleeping or bending
affected arm for long periods of time

Notify physician of signs of bleeding,
reduced circulation, or infection, coldness,
numbness, weakness, redness, fever,
drainage, swelling
Hemodialysis V.S peritoneal
Hemodialysis






Requires vascular access device.
Either temporary (ARF) or permanent
(CRF).
Requires a complex specialized
dialyzer
Peritoneal

Requires a insertion of a catheter
into the peritoneal cavity

Does not require specialized dialyzer

Can be done by client (sterile
technique)

Continuous (4-6 q 24hr)

Principals of osmosis and diffusion

Have few cardio side effects can be
used in unstable clients.
Requires a skilled hemodialysis nurse
Intermittent (q3-4days)
Principals of osmosis and diffusion
Preferred for end-stage renal failure
Kidney Transplantation
 Surgically transplanting a functioning kidney into a
patient with end-stage renal disease
 The donated kidney may be from either a living
donor or a deceased donor
Kidney Transplantation
Nursing Management

Pre and postoperative teaching

Assessing patient coping and anxiety

Assessing for signs and symptoms of transplant rejection

Preventing infection

Monitoring urinary functioning

Psychological concerns

Monitoring and managing potential complications

Promoting home and community based care
Conservative Care
 Some patients may view their quality of life as dramatically
impaired by the renal replacement therapy, and consider it to
be not worth the benefit of continued life.
 Conservative Care offers physical and emotional comfort care
to those patient who decide not to receive or continue with
active treatment for renal failure. Allowing renal failure to
take its natural course.
Conservative Care
 The decision not to receive treatment for renal failure should
only be made after serious consideration and assistance from
the healthcare team.
 The patient is supported by the healthcare team and efforts
are made to manage symptoms until death occurs.
Quiz: true or false

1. Many of the body's organs need the kidneys to function properly and you could die
without healthy kidneys.

2. Kidney disease is a one-time acute illness that is strictly inherited.

3. There are no 'at risk' categories for kidney disease.

4. Usually, kidney disease starts slowly and silently, and progresses over a number of years.

5. There are 5 stages in kidney disease and everyone gets to Stage 5 sooner or later.

6. Chronic kidney failure is curable.

7. The gap between the need for kidneys and the number of available organs for
transplantation is growing
Case study
 Mrs. Jacksons is a single, 56 year old women with a 20 Hx of
type two 1 diabetes, HTN, Hyperlipidemia, chronic anemia, and
a total knee replacement. She has been diagnosed with chronic
renal failure. She was admitted to a medical unit for treatment
of SOB and renal failure. She had increasing SOB, pitting edema,
urine output of 300 mL per day and is having PVC’s as seen on
her cardiac monitor. Her labs are: Na 131; K 6; Cl 97; ca 10; iron
64; WBC 4000; RBC 3.12; Hgb 10.1; Hct 32; creatinine 7; BUN
30. She is having a two tailed subclavian catheter place in for
blood access. She is having an eco and chest x-ray. She is
withdrawn and quite in her room alone.
(Williams & Hopper 2007, p. 809)
Potential Nsg Diagnosis
Fluid volume excess R/T edema and failure of renal regulatory mechanism.
Electrolyte abnormalities R/T edema and failure of renal regulatory mechanism.
Imbalanced nutrition: less than body requirements due to hyper catabolic sate
Urinary retention R/T neuropathy
Anxiety R/T illness/death
Infection R/T supressed immune system
Ineffective coping R/T loss of control
Noncompliance R/T apathy or denial
??Questions??
References

References

Day, R. A., Paul, P., Williams, B., Smeltzer, S. C. & Bare, B. (2007). Brunner & Suddarth’s textbook of medical-surgical
nursing (1st Canadian Ed.). PA: Lippincott, Williams & Wilkins.

Cannon, J. (2004). Recognizing chronic renal failure...the sooner the better. Nursing. 34(1), 50-53.

Mayo clinic. (2012). Chronic renal failure: complications. Retrieved from: http://www.mayoclinic.com/health/kidneyfailure/DS00682/DSECTION=complications

Mosby’s Dictionary of Medicine, Nursing & Health Professionals (8th Ed.). (2006). p. 1485 St.Louis, Missouri; Mosby
Elsevier.

Power, A., Chan, K., Singh, S. K., Taube, D., & Duncan, N. (2012). Appraising stroke risk in maintenance hemodialysis
patients: A large single-center cohort study. American Journal of Kidney Diseases, 59(2), 249-257. Retrieved from:
http://www.sciencedirect.com.libproxy.stfx.ca/science/article/pii/S0272638611011917

The kidney Foundation of Canada (2012). Facing the facts. Retrieved from: www.kidney.ca/document.doc?id=1376

Sens, F., Schott-Pethelaz, A. M., Labeeuw, M., Colin, C., Villar, E., & Rein Registry. (2011). Survival advantage of hemodialysis relative to
peritoneal dialysis in patients with end-stage renal disease and congestive heart failure. Kidney International, 80(9), 970-7. Retrieved from:
www.nature.com.libproxy.stfx.ca/ki/journal/v80/n9/full/ki2011233a.html?WT.ec_id=KI-201111
References

Somers, J. (2008). Dietary management of renal disease. CANNT Journal, 18(3), 20-20. Retrieved from:
http://web.ebscohost.com.libproxy.stfx.ca/ehost/pdfviewer/pdfviewer?sid=1bd4242d-09f4-45598b60-b6a89c6dd895%40sessionmgr4&vid=2&hid=21

The Kidney Foundation of Canada. (2012). Retrieved From: www.kidney.caThe Kidney

Thibodeau & Patton, (2004). Structure& function of the body. St. Louis: Mosby.

Tortora, G. J., Derrickson, B. (2009). Principals of anatomy and physiology (12th Ed.). Danvers, MA:
John Wiley & Sons, Inc.

Williams, L.S., Hopper, P.D. (2007). Understanding Medical Surgical Nursing. Philadelphia, PA: F. A.
Davis Company.

Zarifian, A. (2006). Symptom occurrence, symptom distress, and quality of life in renal transplant
recipients. Nephrology Nursing Journal : Journal of the American Nephrology Nurses' Association,
33(6), 609-618. Retrieved from: http://web.ebscohost.com.libproxy.stfx.ca/ehost/detail?sid=e2f8fd8cb951-4e1c-a984c0bbea9ad5fd%40sessionmgr4&vid=1&hid=21&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#d
b=c8h&AN=2009489628