Title: Chronic Renal Failure
1Chronic Renal Failure
2Chronic Renal Failure
- Progressive, irreversible damage to the nephrons
and glomeruli - Causes recurrent kidney infections, vascular
changes (Diabetes/Hypertension) etc. May
be diffuse or limited to one kidney - Regardless of the cause Decreased GFR, tubular
function tubular reabsorption capabilities.
Dysfunction fluids electrolytes, acid base
disturbances, systemic problems develops
3Chronic Renal FailureEnd Stage Renal Disease
(ESRD)
- Protein and waste metabolism accumulates in the
blood (azotemia) - 90 of kidney function is lost (kidney cannot
adequately function) - Hypothesis Nephrons remains intact, others
progressively destroyed. - Adaptive response maintains function until ¾ are
destroyed - Hypertrophy continues kidneys begin to lose
their ability to concentrate the urine adequately
4ESRD
- Polyuria is perhaps early sign of ESRD
- As the disease progress unable to rid the body
of excess waste products via kidneys uremia
results eventually other systems affected - When the creatinine clearance falls below 10
ml/min (average), GFR lt 5ml/min (average)
dialysis - Other symptoms Nocturia, oliguria/anuria,
increased K, Mg, PO4 and decrease Ca,
Neurological changes, CV changes, etc.
5Stages of Chronic Renal Failure
- Diminished Renal Reserve Normal BUN, and serum
creatinine absence of symptoms - Renal Insufficiency GFR is about 25 of
normal, BUN Creatinine levels increased - Renal Failure GFR lt25 of normal increasing
symptoms - ESRD or Uremia GFR lt 5-10 normal, creatinine
clearance lt5-10 ml/min - resulting in a cumulative effect
6Treatment Modalities
- Decrease fluid 1000ml/day
- Decrease protein (.5-1kg body weight)
- Decrease sodium (1-4gm variable)
- Decrease potassium
- Decrease phosphorous (lt1000mg/day)
- Dialysis (periotoneal, hemodialysis)
- RBC, Vitamin D (calcitrol replacement) etc.
7Dialysis Hemodialyis(Hemo)Peritoneal (PD)
- General Principal Movement of fluid and
molecules across a semi permeable membrane from
one compartment to another - Hemodialysis Move substances from blood through
a semi permeable membrane and into a dialysis
solution (dialysate bath) (synethetic membrane) - Peritoneal Peritoneal membrane is the semi
permeable membrane
8Osmosis-Diffusion-Ultrafiltration
Osmosis - movement fluid from an area of lt to gt
concentration of solutes (particles)
- Diffusion - movement of solutes (particles)
from an area of gt concentration to area of lt
concentration Remove urea, creatinine, uric
acid and electrolytes, from the blood to the
dialystate bath RBC, WBC, Large plasma proteins
do not go through - Ultrafiltration Water and fluid removed when
the pressure gradient across the membrane is
created, by increase pressure in the blood
compartment decrease pressure in the dialysate
compartment
9Peritoneal Dialysis
- Catheter placement anterior abdominal wall
- Tenckoff (25cm length with cuff anchor and
migration) - Dialysis solution (1-2 liters sometimes smaller)
- Three phases of PD
- Inflow (fill) approximately 10 minutes, could
be in cycles) - Dwell (equilibration) (approximately 20-30 min
or 8 hours) - Drain (approximately 15 minutes)
- These 3 phases are called Exchanges
10Peritoneal Dialysis
11Hemodialysis
- Vascular access for high blood flow
- Shunts, (telfon, external)
- Arteriovenous fistulas and grafts (AV)
- Anastomosis between an artery and vein
- Fistulas are native vessels (4-6 wks maturity)
- Grafts are artificial/synthetic material
12Hemodialysis
AV Fistula Communication
AV Graph Access
13Hemodialysis
Hemodialysis Machine
Hemodialysis Circuit
14PD Advantages and Disadvantages
Advantages
Disadvantages
- Bacterial/chemical periotonitis
- Protein loss
- Exit site of catheter
- Self image
- Hyperglycemia
- Surgical placement of catheter
- Multiple abdominal surgery
- Immediate initiation
- Less complicated
- Portable (CAPD)
- Fewer dietary restrictions
- Short training time
- Less cardio stress
- Choice for diabetics
15Hemo Advantages Disadvantages
Advantages
Disadvantages
- Rapid fluid removal
- Rapid removal of urea creatinine
- Effective K removal
- Less protein loss
- Lower triglycerides
- Home dialysis possible
- Temporary access at the bedside
- Vascular access problems
- Dietary fluid restrictions
- Heparinization
- Extensive equipment
- Hypotension
- Added blood lost
- Trained specialist
16Disequalibrium Syndrome
- Fluid removal and decrease in BUN during
hemodilaysis which cause changes in blood
osmolarity.These changes trigger a fluid shift
from the vascular compartment into the cells. In
the brain, this can cause cerebral edema,
resulting in increase intracranial pressure and
visible signs of decreasing level of
consciousness. Symptoms Sudden onset of
headache, nausea and vomiting, nervousness,
muscle twitching, palpitation, disorientation and
seizures - Treatment Hypertonic saline, Normal saline
17Nursing Care Pre, Post Dialysis
- Weigh before after
- Assess site before after (bruit, thrill,
infection, bleeding etc.) - Medications (precautions before after)
- Vital signs before and after etc.
18Renal Transplant
- Living and Cadaveric donors
- Predialysis obtain a dry weight free of excess
fluids and toxins - More preparation time from a living donor vs.
cadaveric transplant within 36 hours of
procurement - Delay may increase ATN
- Pre-transplant Immunotherapy (IV
methylprednisolone sodium succinate, (A
methaPred, Solu-Medrol), cyclosporine
(Sandimmune and azathioprine ((Imuran)
19Immunological Compatibility of Donor and
Recipient
- Done to minimize the destruction (rejection) of
the transplanted kidney - HUMAN LEUKOCYTE ANTIGEN (HLA)
- This gives you your genetic identity (twins share
identical HLA) - HLA compatibility minimizes the recognition of
the transplanted kidney as foreign tissues.
20Immunological Analysis
- WHITE CELL CROSS MATCH (the recipient serum is
mixed with donor lymphocytes to test for
performed cytotoxic (anti-HLA) antibodies to the
potential donor kidney - A positive cross match indicates that the
recipient has cytotoxic antibodies to the donor
and is an absolute contraindication to
transplantation
21Immulogical Analysis
- MIXED LYMPHOCYTE CULTURE
- The donor and recipient lymphocytes are
- mixed. Result HIGH SENTIVITY, this is
contraindicated for renal transplantation. - ABO BLOOD GROUPING
- ABO blood group must be compatible
22Surgery
- LLQ of the abdomen outside of the peritoneal
cavity - Renal artery and vein anastomosed to the
corresponding iliac vessels - Donor ureters are tunneled into the recipients
bladder.
23Complications Post Transplant
- Rejection is a major problem
- Hyperacute rejection occurs within minutes to
hours after transplantation - Renal vessels thrombosis occurs and the kidney
dies - There is no treatment and the transplanted kidney
is removed
24Complications Post Transplant
- Acute Rejection occurs 4 days to 4 months after
transplantation - It is not uncommon to have at least one rejection
episode - Episodes are usually reversible with additional
immunosuppressive therapy (Corticosteroids,
muromonab-CD3, ALG, or ATG) - Signs increasing serum creatinine, elevated BUN,
fever, wt. gain, decrease output, increasing BP,
tenderness over the transplanted kidneys
25Complications Post Transplant
- Chronic Rejection occurs over months or years
and is irreversible. - The kidney is infiltrated with large numbers of T
and B cells characteristic of an ongoing , low
grade immunological mediated injury - Gradual occlusion renal blood vessels
- Signs proteinuria, HTN, increase serum
creatinine levels - Supportive treatment, difficult to manage
- Replace on transplant list
26Complications Post Transplant
- Infection
- Hypertension
- Malignancies (lip, skin, lymphomas, cervical)
- Recurrence of renal disease
- Retroperiotneal bleed
- Arterial stenosis
- Urine leakage