Renal Failure and Treatment

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Renal Failure andTreatment

• Vicky Jefferson, RN, CNN
• Capital Dialysis of Texas

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• 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, Ph.D.

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Functions of the Kidneys

• Renin secretion and the regulation of volume and
  composition of extracellular fluid.
• Excretion
• Blood pressure control

• Vitamin D activation
• Acid-base balance regulation.
• Erythropoietin production
• Urine formation

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Renin

• Renin is important in the regulation of blood
  pressure.
• It is released from the granular cells of the
  efferent arteriole in response to decreased
  arteriole blood pressure, renal ischemia,
  extracellular fluid depletion, increased
  norepinephrine, and increased urinary Na
  concentration.

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Blood Pressure Regulation

• 4 mechanisms are involved
• Volume control
• Aldosterone effect
• Renin-angiotensin-aldosterone
• Renal prostaglandin

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Prostaglandin

• Prostoglandins (PGs)- synthesized by most body
  tissues. In the kidney, PGs are synthesized in
  the medulla and have a vasodilating action and
  promote Na excretion. PGs counteract the
  vasoconstrictor effect of angiotensin and
  norepinephrine. Renal PGs systemically lower
  blood pressure by decreasing systemic vascular
  resistance.

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Vitamin D

• Acquired by the body through diet or through
  synthesis by ultraviolet radiation on the
  cholesterol in the skin.
• The liver and the kidney make the vitamin active
  in the body.

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Erythropoietin

• Erythropoietin is produced and released by the
  kidneys in response to decreased oxygen tension
  in the renal blood supply that is created by the
  loss of red blood cells.
• Erythropoietin stimulates the production of RBCs
  in the bone marrow.
• Erythropoietin deficiency leads to anemia in
  renal failure.

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RBC Synthesis Maturation

• Kidney secrete Erythropoietin, it stimulates
  the bone marrow to produce RBCs
• ? in oxygen delivery simulates release
• in response the RBC count rises in 3 - 5 days
• speeds the maturation of RBCs

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Acid Base Balance

• Kidneys regulate acid-base balance by
  stabilizing body fluid volume flow rate to
  enhance the reabsorption or excretion of
  bicarbonate hydrogen ions

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Electrolyte Regulation

• Sodium
• Potassium
• Calcium Need to Know
• Phosphate Normal Values
• Magnesium Functions
• Chloride Factors affect

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Excretion of Metabolic Waste

• Over 200 waste products excreted
• Only 2 are used for clinical assessment
• BUN
• Creatinine

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Excretion of Metabolic Waste

• Over 200 waste products excreted
• Only 2 are used for clinical assessment
• BUN
• Creatinine

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BUN

• Normal 8 - 20 mg/dl
• Nitrogenous waste product of protein metabolism
• Unreliable in measurement of renal function
• Relevance is assessed in conjunction with
  Creatinine

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Factors Affecting BUN

• Urine flow
• low renal perfusion
• Volume depletion
• Metabolic rate
• Protein metabolism
• Drugs

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Creatinine

• A waste product of muscle metabolism
• Normal value0.6 - 1.5 mg/dl
• 2 times normal 50 damage
• 8 times normal 75 damage
• 10 times normal 90 damage
• Exception - severe muscular disease can greatly ?
  Creatinine levels

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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

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Diagnostic Tools

• Biopsy
• Ultrasound
• X-Rays

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Acute Renal Failure (ARF)

• Sudden onset - hours to days
• Often reversible
• Severe - 50 mortality rate overall generally
  related to infection.

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Characteristics of ARF

• Homeostatic functions affected most
• Electrolyte imbalances
• Volume regulation
• Blood pressure control
• Endocrine functions affected lease
• Require time to evolve
• Renal size is preserved
• Evidence of acute illness or insult exists

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Chronic Renal Failure

• Slow progressive renal disorder related to
  nephron loss, occurring over months to years
• Culminates in End Stage Renal Disease

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Characteristics of Chronic Renal Failure

• Cause onset often unknown
• Loss of function precedes lab abnormalities
• Lab abnormalities precede symptoms
• Symptoms (usually) evolve in orderly sequence
• Renal size is usually decreased

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Causes of Chronic Renal Failure

• Diabetes
• Hypertension
• Glomerulonephritis
• Cystic disorders
• Developmental - Congenital
• Infectious Disease

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Causes of Chronic Renal Failure

• Neoplasms
• Obstructive disorders
• Autoimmune diseases
• Lupus
• Hepatorenal failure
• Scleroderma
• Amyloidosis
• Drug toxicity

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Stages of Chronic Renal FailureOld System

• Reduced Renal Reserve
• Renal Insufficiency
• End Stage Renal Disease (ESRD)

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Stages of Chronic Renal FailureNKF
Classification System

• Stage 1 GFR gt 90 ml/min despite kidney
  damage

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Stages of Chronic Renal FailureNKF
Classification System

• Stage 2 Mild reduction (GFR 60 89 ml/min)
• 1. GFR of 60 may represent 50
  loss in function.
• 2. Parathyroid hormones starts to
  increase.

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During Stage 1 - 2

• No symptoms
• Serum creatinine doubles
• Up to 50 nephron loss

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Stages of Chronic Renal FailureNKF
Classification System

• Stage 3 Moderate reduction (GFR 30 59
  ml/min)
• 1. Calcium absorption decreases
• 2. Malnutrition onset
• 3. Anemia secondary to Erythropoietin
  deficiency
• 4. Left ventricular hypertrophy

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Stages of Chronic Renal FailureNKF
Classification System

• Stage 4 Sever reduction (GFR 15 29 ml/min)
• 1. Serum triglycerides increase
• 2. Hyperphosphatemia
• 3. Metabolic acidosis
• 4. Hyperkalemia

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During Stage 3 - 4

• Signs and symptoms worsen if kidneys are stressed
• Decreased ability to maintain homeostasis

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During stages 3 - 4

• 75 nephron loss
• Decreased glomerular filtration rate, solute
  clearance, ability to concentrate urine and
  hormone secretion
• Symptoms elevated BUN Creatinine, mild
  azotemia, anemia

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Stages of Chronic Renal FailureNKF
Classification System

• Stage 5 Kidney failure (GFR lt 15 ml/min)
• 1. Azotemia

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During Stage 5

• Residual function lt 15 of normal
• Excretory, regulatory and hormonal functions
  severely impaired.
• metabolic acidosis
• Marked increase in BUN, Creatinine, Phosphorous
• Marked decrease in Hemoglobin, Hematocrit,
  Calcium
• Fluid overload

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During Stage 5

• Uremic syndrome develops affecting all body
  systems
• can be diminished with early diagnosis
  treatment
• Last stage of progressive CRF
• Fatal if no treatment

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What happens when the kidneys dont function
correctly?
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Manifestations of CRF -Nervous System

• Mood swings
• Impaired judgment
• Inability to concentrate and perform simple math
  functions
• Tremors, twitching, convulsions
• Peripheral Neuropathy
• restless legs
• foot drop

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Manifestations of CRFSkin

• Pale, grayish-bronze color
• Dry scaly
• Severe itching
• Bruise easily
• Uremic frost

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Manifestations of CRFEyes

• Visual blurring
• Occasional blindness

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Manifestations of CRF Fluid - Electrolyte - pH

• Volume expansion and fluid overload
• Metabolic Acidosis
• Electrolyte Imbalances
• Hyperkalemia

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Manifestations of CRFGI Tract

• Uremic fetor
• Anorexia, nausea, vomiting
• GI bleeding

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Manifestations of CRF Hematologic

• Anemia
• Platelet dysfunction

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Manifestations of CRF Musculoskeletal

• Muscle cramps
• Soft tissue calcifications
• Weakness
• Related to calcium phosphorous imbalances

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Calcium-Phosphorous Balance
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Manifestations of CRFHeart - Lungs

• Hypertension
• Congestive heart failure
• Pericarditis
• Pulmonary edema
• Pleural effusions

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Manifestations of CRF Endocrine - Metabolic

• Erythropoietin production decreased
• Hypothyroidism
• Insulin resistance
• Growth hormone decreased
• Gonadal dysfunction
• Parathyroid hormone and Vitamin D3
• Hyperlipidemia

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Treatment Options

• Hemodialysis
• Peritoneal Dialysis
• Transplant
• Nothing

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Hemodialysis

• Removal of soluble substances and water from
  the blood by diffusion through a semi-permeable
  membrane.

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History

• Early animal experiments began 1913
• 1st human dialysis 1940 by Dutch physician Willem
  Kolff (2 of 17 patients survived)
• Considered experimental through 1950s, No
  intermittent blood access for acute renal
  failure only.

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History contd

• 1960 Dr. Scribner developed Scribner Shunt
• 1960s Machines expensive, scarce, no funding.
• Death Panels panels within community decided
  who got to dialyze.

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Hemodialysis Process

• Blood removed from patient into the
  extracorporeal circuit.
• Diffusion and ultrafiltration take place in the
  dialyzer.
• Cleaned blood returned to patient.

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Extracorporeal Circuit
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How Hemodialysis Works
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Vascular Access

• Arterio-venous shunt (Scribner External Shunt)
• Arterio-venous (AV) Fistula
• PTFE Graft
• Temporary catheters
• Permanent catheters

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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

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Arterio-venous (AV) FistulaPrimary 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

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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

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Temporary Catheters

• Dual lumen catheter placed into a central
  vein-subclavian, jugular or femoral.
• Advantages
• immediate use
• no needle sticks
• Disadvantages
• high incidence of infection
• subclavian vein stenosis
• poor flow-inadequate dialysis
• clotting

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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

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Complications of Hemodialysis

• During dialysis
• Fluid and electrolyte related
• hypotension
• Cardiovascular
• arrythmias
• Associated with the extracorporeal circuit
• exsanguination
• Neurologic
• seizures
• other
• fever

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Complications of Hemodialysis contd

• Between treatments
• Hypertension/Hypotension
• Edema
• Pulmonary edema
• Hyperkalemia
• Bleeding
• Clotting of access

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Complications of Hemodialysis contd

• Long term
• Metabolic
• hyperparathyroidism
• diabetic complications
• Cardiovascular
• CHF
• AV access failure
• Respiratory
• pulmonary edema
• Neuromuscular
• neuropathy

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Complications of Hemodialysiscontd

• Long term contd
• Hematologic
• anemia
• GI
• bleeding
• dermatologic
• calcium phosphorous deposits
• Rheumatologic
• amyloid deposits

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Complications of Hemodialysis contd

• Long term contd
• Genitourinary
• infection
• sexual dysfunction
• Psychiatric
• depression
• Infection
• bloodborne pathogens

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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

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Peritoneal Dialysis

• Removal of soluble substances and water from the
  blood by diffusion through a semi-permeable
  membrane that is intracorporeal (inside the body).

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Types of Peritoneal Dialysis

• CAPD Continuous ambulatory peritoneal dialysis
• CCPD Continuous cycling peritoneal dialysis
• IPD Intermittent peritoneal dialysis

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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

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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

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Complications of Peritoneal Dialysis

• Infection
• peritonitis
• tunnel infections
• catheter exit site
• Hypervolemia
• hypertension
• pulmonary edema
• Hypovolemia
• hypotension
• Hyperglycemia
• Malnutrition

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Complications of Peritoneal Dialysis contd

• Obesity
• Hypokalemia
• Hernia
• Cuff erosion

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Advantages of CAPD

• Independence for patient
• No needle sticks
• Better blood pressure control
• Some diabetics add insulin to solution
• Fewer dietary restrictions
• protein loses in dialysate
• generally need increased potassium
• less fluid restrictions

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Peritoneal Catheter Exit Site
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Medications Common to Dialysis Patients

• Vitamins - water soluble
• Phosphate binder - (Phoslo, Calcium, Aluminum
  hydroxide) Give with meals
• Iron Supplements - dont give with phosphate
  binder or calcium
• Antihypertensives - hold prior to dialysis

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Medications Common to Dialysis Patients contd

• 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

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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

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Patient Education

• Alleviate fear
• Dialysis process
• Fistula/catheter care
• Diet and fluid restrictions
• Medication
• Diabetic teaching

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Transplantation

• Treatment not cure

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Kidney Awaiting Transplant
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Advantages

• Restoration of normal renal function
• Freedom from dialysis
• Return to normal life

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Disadvantages

• Life long medications
• Multiple side effects from medication
• Increased risk of tumor
• Increased risk of infection
• Major surgery

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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

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Function

• ATN? (acute tubular necrosis)
• 50 experience
• Urine output gt100 lt500 cc/hr
• BUN, creatinine, creatinine clearance
• Fluid Balance
• Ultrasound
• Renal scans
• Renal biopsy

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Fluid Electrolyte Balance

• Accurate I O
• CRITICAL TO AVOID DEHYDRATION
• Output normal - gt100 lt500 cc/hr, could be 1-2
  L/hr
• Potential for volume overload/deficit
• Daily weights
• Hyper/Hypokalemia potential
• Hyponatremia
• Hyperglycemia

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Prevention of Infection

• Major complication of transplantation due to
  immunosuppression
• HANDWASHING
• Crowds, Kids
• Patient Education

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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

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Rejection contd

• 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

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Rejection contd

• Chronic - gradual process of graft dysfunction
• Repeated rejection episodes that have not been
  completely resolved with treatment
• Rx return to dialysis or re-transplantation

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Immunosuppressant Drugs

• Prednisone
• Prevents infiltration of T lymphocytes
• Side effects
• cushnoid changes
• Avascular Necrosis
• GI disturbances
• Diabetes
• infection
• risk of tumor

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Immunosuppressant Drugs contd

• Azathioprine (Imuran)
• Prevents rapid growing lymphocytes
• Side Effects
• bone marrow toxicity
• hepatotoxicity
• hair loss
• infection
• risk of tumor

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Immunosuppressant Drugs contd

• 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

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Immunosuppressant Drugs contd

• Cytoxan - in place of Imuran less toxic
• FK506 - 100 x more potent than Cyclosporin
• Prograf
• Cellcept
• other in trials

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Immunosuppressant Drugs contd

• 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

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Immunosuppressant Drugs contd

• 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

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Patient Education

• Signs of infection
• Prevention of infection
• Signs of rejection
• decreased urine output
• increased weight gain
• tenderness over kidney
• fever gt 100 degrees F
• Medications
• time, dose, side effects