Renal Failure
and
Treatment
Vicky Jefferson, RN, CNN
Bones can break, muscles can atrophy,
glands can loaf, even the brain can go to
sleep without immediate danger to survival.
But -- should kidneys fail.... neither bone,
muscle, nor brain could carry on.
Homer Smith, PhD
History
• Early animal experiments began 1913
• 1st human dialysis 1940 by Dutch physician
Willem Kolff (2 of 17 patients survived)
• Considered experimental through 1950’s,
No intermittent blood access; for acute renal
failure only.
History cont’d
• 1960 Dr. Scribner developed Scribner Shunt
• 1960’s Machines expensive, scarce, no
funding.
• “Death Panels” panels within community
decided who got to dialyze.
Normal Kidney Function
•
•
•
•
•
Fluid balance
Electrolyte regulation
Control acid base balance
Waste removal
Hormonal function
– Erythropoietin
– Renin
– Active Vitamin D3
– Prostaglandins
Acute Renal Failure (ARF)
• Sudden onset - hours to days
• Often reversible
• Severe - 50% mortality rate overall;
generally related to infection.
Chronic Renal Failure (CRF)
• Slow onset - years
• Not reversible
Causes of Chronic Renal Failure
•
•
•
•
•
•
Diabetes
Hypertension
Glomerulonephritis
Cystic disorders
Developmental - Congenital
Infectious Disease
Causes of Chronic Renal Failure
cont’d
• Neoplasms
• Obstructive disorders
• Autoimmune diseases
– Lupus
•
•
•
•
Hepatorenal failure
Scleroderma
Amyloidosis
Drug toxicity
Stages of Chronic Renal Failure
• Reduced Renal Reserve
• Renal Insufficiency
• End Stage Renal Disease (ESRD)
Stage 1: Reduced Renal Reserve
• Residual function 40 - 75% of normal
• BUN and Creatinine normal (early)
• No symptoms
Stage II: Renal Insufficiency
• Residual function 20 - 40 % normal
• Decreased: glomerular filtration rate, solute
clearance, ability to concentrate urine and
hormone secretion
• Symptoms: elevated BUN & Creatinine,
mild azotemia, anemia
Stage II: Renal Insufficiency
cont’d
• Signs and symptoms worsen if kidneys are
stressed
• Decreased ability to maintain homeostasis
Stage III: End Stage Renal
Disease (ESRD)
• Residual function < 15% of normal
• Excretory, regulatory and hormonal
functions severely impaired.
• metabolic acidosis
Stage III: End Stage Renal
Disease (ESRD) cont’d
• Marked increase in: BUN, Creatinine,
Phosphorous
• Marked decrease in: Hemoglobin,
Hematocrit, Calcium
• Fluid overload
Stage III: End Stage Renal
Disease (ESRD) cont’d
• Uremic syndrome develops affecting all
body systems
• Last stage of progressive CRF
• Fatal if no treatment
Diagnostic Tools for Assessing
Renal Failure
• Blood Tests
– BUN elevated (norm 10-20)
– Creatinine elevated (norm 0.7-1.3)
– K elevated
– PO4 elevated
– Ca decreased
• Urinalysis
– Specific gravity
– Protein
– Creatinine clearance
Diagnostic Tools cont’d
• Biopsy
• Ultrasound
• X-Rays
Manifestations of Chronic Renal
Failure
Nervous System
• Mood swings
• Impaired judgment
• Inability to concentrate and perform simple
math functions
• Tremors, twitching, convulsions
• Peripheral Neuropathy
– restless legs
– foot drop
Integumentary
•
•
•
•
•
Pale, grayish-bronze color
Dry scaly
Severe itching
Bruise easily
Uremic frost
Eyes
• Visual blurring
• Occasional blindness
Fluid - Electrolyte - PH
• Volume expansion and fluid overload
• Metabolic Acidosis
• Electrolyte Imbalances
– Hyperkalemia
GI Tract
• Uremic fetor
• Anorexia, nausea, vomiting
• GI bleeding
Hematologic
• Anemia
• Platelet dysfunction
Musculoskeletal
•
•
•
•
Muscle cramps
Soft tissue calcifications
Weakness
Related to calcium phosphorous imbalances
Heart Lungs
•
•
•
•
•
Hypertension
Congestive heart failure
Pericarditis
Pulmonary edema
Pleural effusions
Endocrine/Metabolic
•
•
•
•
•
•
•
Erythropoietin production decreased
Hypothyroidism
Insulin resistance
Growth hormone decreased
Gonadal dysfunctions
Parathyroid hormone and Vitamin D3
Hyperlipidemia
Treatment Options
• Hemodialysis
• Peritoneal Dialysis
• Transplant
Hemodialysis
•
Removal of soluble substances and
water from the blood by diffusion
through a semi-permeable membrane.
Hemodialysis Process
• Blood removed from patient into the
extracorporeal circuit.
• Diffusion and ultrafiltration take place in
the dialyzer.
• Cleaned blood returned to patient.
Hemodialysis Process
Hemodialysis
Circuit
Extracorporeal
Circuit
Vascular Access
• Arterio-venous shunt (Scribner External
Shunt)
• Arterio-venous (AV) Fistula
• PTFE Graft
• Temporary catheters
• “Permanent” catheters
Scribner Shunt
• External- one end into artery, one into vein.
• Advantages
– place at bedside
– use immediately
• Disadvantages
–
–
–
–
infection
skin erosion
accidental separation
limits use of extremity
External (Scribner) Shunt
Arterio-venous (AV) Fistula
Primary Fistula
• Patients own artery and vein surgically anastomosed.
• Advantages
– patients own vein
– longevity
– low infection and thrombosis rates
• Disadvantages
– long time to mature, 1- 6 months
– “steal” syndrome
– requires needle sticks
AV Fistula
PTFE (Polytetraflourethylene)
Graft
• Synthetic “vessel” anastomosed into an artery and vein.
• Advantages
– for people with inadequate vessels
– can be used in 7-14 days
– prominent vessels
• Disadvantages
– clots easily
– “steal” syndrome more frequent
– requires needle sticks
– infection may necessitate removal of graft
PTFE Graft
Temporary Catheters
• Dual lumen catheter placed into a central veinsubclavian, jugular or femoral.
• Advantages
– immediate use
– no needle sticks
• Disadvantages
– high incidence of infection
– subclavian vein stenosis
– poor flow-inadequate dialysis
– clotting
Cuffed Tunneled Catheters
• Dual lumen catheter with Dacron cuff surgically tunneled
into subclavian, jugular or femoral vein.
• Advantages
– immediate use
– can be used for patients that can have no other
permanent access
– no needle sticks
• Disadvantages
– high incidence of infection
– poor flows result in inadequate dialysis
– clotting
Cuffed Tunneled
Catheter
Complications of Hemodialysis
• During dialysis
– Fluid and electrolyte related
• hypotension
– Cardiovascular
• arrythmias
– Associated with the extracorporeal circuit
• exsanguination
– Neurologic
• seizures
– other
• fever
Complications of Hemodialysis
cont’d
• Between treatments
–
–
–
–
–
–
Hypertension/Hypotension
Edema
Pulmonary edema
Hyperkalemia
Bleeding
Clotting of access
Complications of Hemodialysis
cont’d
• Long term
– Metabolic
• hyperparathyroidism
• diabetic complications
– Cardiovascular
• CHF
• AV access failure
– Respiratory
• pulmonary edema
– Neuromuscular
• neuropathy
Complications of Hemodialysis
cont’d
• Long term cont’d
– Hematologic
• anemia
– GI
• bleeding
– dermatologic
• calcium phosphorous deposits
– Rheumatologic
• amyloid deposits
Complications of Hemodialysis
cont’d
• Long term cont’d
– Genitourinary
• infection
• sexual dysfunction
– Psychiatric
• depression
– Infection
• bloodborne pathogens
Calcium-Phosphorous Balance
Dietary Restrictions on
Hemodialysis
•
•
•
•
•
Fluid restrictions
Phosphorous restrictions
Potassium restrictions
Sodium restrictions
Protein to maintain nitrogen balance
– too high - waste products
– too low - decreased albumin, increased
mortality
• Calories to maintain or reach ideal weight
Peritoneal Dialysis
• Removal of soluble substances and water
from the blood by diffusion through a semipermeable membrane that is intracorporeal
(inside the body).
Peritoneal
Dialysis
Types of Peritoneal Dialysis
• CAPD: Continuous ambulatory peritoneal dialysis
• CCPD: Continuous cycling peritoneal dialysis
• IPD: Intermittent peritoneal dialysis
CAPD
•
•
•
•
Catheter into peritoneal cavity
Exchanges 4 - 5 times per day
Treatment 24 hours; 7 days a week
Solution remains in peritoneal cavity except
during drain time
• Independent treatment
Peritoneal Catheter Exit Site
Draining of Peritoneal Dialysate
Phases of A Peritoneal Dialysis
Exchange
• Fill: fluid infused into peritoneal cavity
• Dwell: time fluid remains in peritoneal
cavity
• Drain: time fluid drains from peritoneal
cavity
Complications of Peritoneal
Dialysis
• Infection
– peritonitis
– tunnel infections
– catheter exit site
• Hypervolemia
– hypertension
– pulmonary edema
• Hypovolemia
– hypotension
• Hyperglycemia
• Malnutrition
Complications of Peritoneal
Dialysis cont’d
•
•
•
•
Obesity
Hypokalemia
Hernia
Cuff erosion
Advantages of CAPD
•
•
•
•
•
Independence for patient
No needle sticks
Better blood pressure control
Diabetics add insulin to solution
Fewer dietary restrictions
– protein loses in dialysate
– generally need increased potassium
– less fluid restrictions
Peritoneal Dialysis Multi-bag
Prong Manifold
Medications Common to Dialysis
Patients
• Vitamins - water soluble
• Phosphate binder - (Phoslo, Calcium,
Aluminum hydroxide) Give with meals
• Iron Supplements - don’t give with
phosphate binder or calcium
• Antihypertensives - hold prior to dialysis
Medications Common to Dialysis
Patients cont’d
• Erythropoietin
• Calcium Supplements - Between meals, not
with iron
• Activated Vitamin D3 - aids in calcium
absorption
• Antibiotics - hold dose prior to dialysis if it
dialyzes out
Medications
• Many drugs or their metabolites are
excreted by the kidney
• Dosages - many change when used in renal
failure patients
• Dialyzability - many removed by dialysis
varies between HD and PD
Patient Education
•
•
•
•
•
•
Alleviate fear
Dialysis process
Fistula/catheter care
Diet and fluid restrictions
Medication
Diabetic teaching
Transplantation
Treatment Not a Cure
Kidney Awaiting Transplant
Advantages
• Restoration of “normal” renal function
• Freedom from dialysis
• Return to “normal” life
Disadvantages
•
•
•
•
•
Life long medications
Multiple side effects from medication
Increased risk of tumor
Increased risk of infection
Major surgery
Care of the Recipient
•
•
•
•
•
Major surgery with general anesthesia
Assessment of renal function
Assessment of fluid and electrolyte balance
Prevention of infection
Prevention and management of rejection
Function
• ATN? (acute tubular necrosis)
– 50% experience
•
•
•
•
•
•
Urine output >100 <500 cc/hr
BUN, creatinine, creatinine clearance
Fluid Balance
Ultrasound
Renal scans
Renal biopsy
Fluid & Electrolyte Balance
• Accurate I & O
– CRITICAL TO AVOID DEHYDRATION
– Output normal - >100 <500 cc/hr, could be 1-2
L/hr
– Potential for volume overload/deficit
• Daily weights
• Hyper/Hypokalemia potential
• Hyponatremia
• Hyperglycemia
Prevention of Infection
• Major complication of transplantation due
to immunosuppression
• HANDWASHING
• Crowds, Kids
• Patient Education
Rejection
• Hyperacute - preformed antibodies to donor
antigen
– function ceases within 24 hours
– Rx = removal
• Accelerated - same as hyperacute but
slower, 1st week to month
– Rx = removal
Rejection cont’d
• Acute - generally after 1st 10 days to end of
2nd month
– 50% experience
– must differentiate between rejection and
cyclosporine toxicity
– Rx = steroids, monoclonal (OKT3), or
polyclonal (HTG) antibodies
Rejection cont’d
• Chronic - gradual process of graft
dysfunction
– Repeated rejection episodes that have not been
completely resolved with treatment
– Rx = return to dialysis or re-transplantation
Immunosuppressant Drugs
• Prednisone
– Prevents infiltration of T lymphocytes
• Side effects
–
–
–
–
–
–
cushnoid changes
Avascular Necrosis
GI disturbances
Diabetes
infection
risk of tumor
Immunosuppressant Drugs cont’d
• Azathioprine (Imuran)
– Prevents rapid growing lymphocytes
• Side Effects
–
–
–
–
–
bone marrow toxicity
hepatotoxicity
hair loss
infection
risk of tumor
Immunosuppressant Drugs cont’d
• Cyclosporin
– Interferes with production of interleukin 2
which is necessary for growth and activation of
T lymphocytes.
• Side Effects
– Nephrotoxicity
– HTN
– Hepatotoxicity
– Gingival hyperplasia
– Infection
Immunosuppressant Drugs cont’d
• Cytoxan - in place of Imuran less toxic
• FK506 - 100 x more potent than
Cyclosporin
• Prograf
• Cellcept
• other in trials
Immunosuppressant Drugs cont’d
• OKT3 - monoclonal antibody used to treat rejection or
induce immunosuppression
– decreases CD3 cells within 1 hour
• Side effects
– anaphylaxis
– fever/chills
– pulmonary edema
– risk of infection
– tumors
• 1st dose reaction expected & wanted, pre-treat with
Benadryl, Tylenol, Solumedrol
Immunosuppressant Drugs cont’d
• Atgam - polyclonal antibody used to treat rejection or
induce immunosuppression
– decreased number of T lymphocytes
• Side effects
– anaphylaxis
– fever chills
– leukopenia
– thrombocytopenia
– risk of infection
– tumor
Patient Education
• Signs of infection
• Prevention of infection
• Signs of rejection
– decreased urine output
– increased weight gain
– tenderness over kidney
– fever > 100 degrees F
• Medications
• time, dose, side effects