Transcript Renal Failure and Treatment

Chronic Kidney Disease
&
Treatment
Vicky Jefferson, RN, CNN
Satellite Dialysis
(modified by Kelle Howard, MSN, RN, CNE)
revised Fall 2012
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.
2
REVIEW
• What are nephrons?
• What are the functions of the kidneys?
• Normal creatinine & BUN?
• Diagnostic tools
Functions of the Kidneys
•
•
Regulates ______ & _________ of extracellular fluid
Regulates fluid & electrolyte balance thru
processes of: glomerular__________, tubular
_________, and tubular _____________.
Name some of the F & Es regulated by kidneys
__________________
3/25/2016
4
Functions of the Kidneys (cont)
• Regulates acid-base balance through
– HCO3 and H+
• *Hormonal functions: (BP control), multisystem effect.
– Renin Release
RAAS=
3/25/2016
5
Functions of the Kidneys
(cont)
• Erythropoietin Release
– If a patient has chronic renal failure, what
condition will occur?
– WHY???
3/25/2016
6
Functions of the Kidneys
(cont)
• Activate Vitamin D
– Necessary to absorb Calcium in the GI
tract.
If a patient has renal failure, what will happen to
the patient’s serum calcium level?
__________________
3/25/2016
7
Functions of the Kidneys
• _______________
• _______________
• _______________
•
•
•
•
______________
______________
______________
______________
Diagnostic Tools for Assessing
Kidney Failure
• Blood Tests
– BUN
– Creatinine
– K+
– PO4
– Ca
• Urinalysis
– Specific gravity
– Protein
– Creatinine clearance
9
BUN
• Normal 6-20 mg/dl
• Nitrogenous waste product of protein
metabolism
• By itself: Unreliable in measurement of renal
function
10
Creatinine
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•
•
•
•
•
A waste product of muscle metabolism
Normal value 0.6 – 1.3 mg/dl
2 times normal = 50% damage
8 times normal = 75% damage
10 times normal = 90% damage
Exception -_______________________
11
Diagnostic Tools
•
•
•
•
•
Biopsy
Ultrasound
X-Rays
Labs
Anything else?
12
Chronic Kidney Disease
• Slow progressive renal disorder related to
nephron loss
– occurring over months to years
• Culminates in End Stage Renal Disease
13
Chronic Kidney Disease:
Characteristics
•
•
•
•
Cause & onset often unknown
Loss of function _________ lab abnormalities
Lab abnormalities ________ symptoms
Symptoms (usually) evolve in orderly
sequence
• Renal size is usually decreased
14
Chronic Kidney Disease
Causes
•
•
•
•
•
•
___________
___________
___________
Cystic disorders
Developmental/Congenital
Infectious Disease
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Chronic Kidney Disease
Causes (cont)
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Neoplasms
Obstructive disorders
Autoimmune diseases
Hepatorenal failure
Scleroderma
Amyloidosis
Drug toxicity
16
Glomerular Filtration Rate
GFR
• 24 hour urine for creatinine clearance
– Most accurate indicator of Renal Function
– Reflects GFR
– Formula:
• urine creatinine X urine volume
serum creatinine
• Can estimate creatinine clearance by:
Men: {140 – age} x IBW (kg)
72 x serum creatinine
Women: {140 – age} x IBW (kg)
85 x serum creatinine
What is a normal GFR?
17
Stages of Chronic Kidney Disease
Old System
• Reduced Renal Reserve
• Renal Insufficiency
• End Stage Renal Disease (ESRD)
18
Stages of Chronic Kidney Disease
NKF Classification System
Stage 1:
GFR >/= 90 ml/min despite kidney damage
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Stages of Chronic Kidney Disease
NKF 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
21
Stages of Chronic Kidney Disease
NKF Classification System
Stage 3:
Moderate reduction
(GFR 30 – 59 ml/min)
1.
2.
3.
4.
Calcium absorption decreases
Malnutrition onset
Anemia
Left ventricular hypertrophy
22
Stages of Chronic Kidney Disease
NKF Classification System
Stage 4:
Severe reduction
(GFR 15 – 29 ml/min)
1.
2.
3.
4.
Serum triglycerides increase
Hyperphosphatemia
Metabolic acidosis
Hyperkalemia
23
During Stage 3 - 4
• Signs and symptoms worsen if kidneys are
stressed
• Decreased ability to maintain homeostasis
24
During stages 3 - 4
• 75% nephron loss
• Decreased:
– __________
– __________
– __________
– __________
• Symptoms:
– elevated BUN & Creatinine, mild azotemia, anemia
25
Stages of Chronic Kidney Disease
NKF Classification System
Stage 5:
Kidney failure (GFR < 15 ml/min)
1. Azotemia
26
During Stage 5
End Stage Renal Disease
• Residual function < 15% of normal
• Excretory, regulatory and hormonal functions severely
impaired.
• Metabolic acidosis
• Marked increase in:
• ___________
• ___________
• ___________
• Marked decrease in:
• ___________
• ___________
• ___________
• Fluid overload
27
During Stage 5
• Uremic syndrome develops affecting all body
systems
– can be diminished with early diagnosis &
treatment
• Last stage of progressive CKD
• Fatal if no treatment
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Manifestations of Chronic Uremia
Fig. 47-5
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What happens when the kidneys don’t
function correctly?
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Manifestations of CKD
Nervous System
• Mood swings
• Impaired judgment
• Inability to concentrate and perform simple
math functions
• Tremors, twitching, convulsions
• Peripheral Neuropathy
31
Manifestations of CKD
Skin
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Pale, grayish-bronze color
Dry scaly
Severe itching
Bruise easily
Uremic frost
Calcium/Phos deposits
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Manifestations of CKD
Eyes
• Visual blurring
• Blindness
33
Manifestations of CKD
Fluid - Electrolyte - pH
•
•
•
•
Volume expansion and fluid overload
Metabolic Acidosis
Change in urine specific gravity
Electrolyte Imbalances
– Potassium
– Magnesium
– Sodium
34
Manifestations of CKD
GI Tract
• Uremic fetor
• Anorexia, nausea, vomiting
• GI bleeding
35
Manifestations of CKD
Hematologic
• Anemia
• Platelet dysfunction
36
Manifestations of CKD
Musculoskeletal
•
•
•
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Muscle cramps
Soft tissue calcifications
Weakness
RENAL OSTEODYSTROPHY
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Calcium-Phosphorous Balance
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Manifestations of CKD
Heart - Lungs
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Hypertension
Congestive heart failure
Pericarditis
Pulmonary edema
Pleural effusions
Atherosclerotic vascular disease
Cardiac dysrhythmias
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Manifestations of CKD
Endocrine - Metabolic
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Erythropoietin production decreased
Hypothyroidism
Insulin resistance
Growth hormone decreased
Gonadal dysfunction
Parathyroid hormone and Vitamin D3
Hyperlipidemia
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Treatment Options
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Conservative Therapy
Hemodialysis
Peritoneal Dialysis
Transplant
Nothing
41
Conservative Treatment
GOALS:
• Detect & treat potentially reversible causes of
renal failure
• Preserve existing renal function
• Treat manifestations
• Prevent complications
• Provide for comfort
42
Conservative Treatment
• Control
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Hyperkalemia
Hypertension
Hyperphosphatemia
Hyperparthryoidism
Hyperglycemia
Anemia
Dyslipidemia
Hypothyroidism
Nutrition
– Describe a renal diet while on conservative treatment?
43
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’s by Dutch physician
Willem Kolff
• Considered experimental through 1950’s, No
intermittent blood access; for acute renal
kidney injury only.
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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.
46
Hemodialysis Process
• Blood removed from patient into the
extracorporeal circuit.
• Diffusion and ultrafiltration take place in the
dialyzer.
• Cleaned blood returned to patient.
47
Extracorporeal Circuit
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How Hemodialysis Works
49
Vascular Access
• Arterio-Venous shunt
– (Scribner External Shunt)
• Arterio-Venous
– (AV) Fistula
• PTFE Graft
• Temporary catheters
• “Permanent” catheters
50
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
51
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
devita.com
52
PTFE (Polytetrafluoroethylene) Graft
• Synthetic “vessel” anastomosed into an artery and vein.
• Advantages
– for people with inadequate vessels
– can be used in 1-4 weeks
– prominent vessels
• Disadvantages
– clots easily
– “steal” syndrome more frequent
– requires needle sticks
– infection may necessitate removal of graft
53
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
– restricts movement
54
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
55
Care of Vascular Access
• NO BP’s, needle sticks to arm with vascular
access. This includes finger sticks.
• Place ID bands on other arm whenever
possible.
• Palpate thrill and listen for bruit.
• Teach patient nothing constrictive.
56
Potential
Complications of Hemodialysis
• During dialysis
– Fluid and electrolyte related
• hypotension
– Cardiovascular
• arrythmias
– Associated with the extracorporeal circuit
• exsanguination
– Neurologic
• Disequilibrium Syndrome & seizures
– Musculoskeletal
• cramping
– Other
• fever & sepsis
• blood born diseases
57
Potential
Complications of Hemodialysis
• Between treatments
– Hypertension/Hypotension
– Edema
– Pulmonary edema
– Hyperkalemia
– Bleeding
– Clotting of access
58
Complications of Hemodialysis cont’d
• Long term
– Metabolic
• hyperparathyroidism
• diabetic complications
– *Cardiovascular
• CHF
• AV access failure
• cardiovascular disease
– Respiratory
• pulmonary edema
– Neuromuscular
• neuropathy
59
Complications of Hemodialysis
cont’d
• Long term cont’d
– Hematologic
• anemia
– GI
• bleeding
– Dermatologic
• calcium phosphorous deposits
– Rheumatologic
• amyloid deposits
60
Complications of Hemodialysis cont’d
• Long term cont’d
– Genitourinary
• infection
• sexual dysfunction
– Psychiatric
• depression
– *Infection
• blood borne pathogens
61
Dietary Restrictions on
Hemodialysis
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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
62
Peritoneal Dialysis
• Removal of soluble substances and water from
the blood by diffusion through a semipermeable membrane that is intracorporeal
(inside the body).
63
Types of Peritoneal Dialysis
• CAPD: Continuous ambulatory peritoneal dialysis
• CCPD: Continuous cycling peritoneal dialysis
– Aka. APD – Automated Peritoneal Dialysis
• IPD:
Intermittent peritoneal dialysis
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Peritoneal Dialysis
• Warm sterile dialysate  into peritoneal
cavity from previously placed catheter 
wastes & lytes diffuse into dialysate until
equilibrium achieved  diffuse controlled by
dextrose concentration
• Concentrations available: 1.5%, 2.5%, 4.25%
– Usually about 2L -----(can be 1.5L-3L)
What does this do to blood sugar & calorie count?
65
Peritoneal Catheter Exit Site
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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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CAPD
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•
•
•
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
70
Complications of Peritoneal
Dialysis
• Infection
– peritonitis
– tunnel infections
– catheter exit site
• Hypervolemia
– hypertension
– pulmonary edema
• Hypovolemia
– hypotension
• Hyperglycemia
• Malnutrition
71
Complications of Peritoneal
Dialysis cont’d
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Obesity
Hypokalemia
Hernia
Cuff erosion
Low back pain
Hyperlipidemia
72
Advantages of CAPD
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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
73
Let’s Talk About
Medications
74
Medications Common to
Dialysis Patients
• Vitamins - water soluble
• Phosphate binder ---- GIVE WITH _____
– Phoslo (calcium acetate)
– Renagel (sevelamere hydrochloride)
– Caltrate (calcium cabonate)
– Amphojel (aluminum hydroxide)
• Iron Supplements –
– don’t give with phosphate binder or calcium
• Antihypertensives
– When do we give these?
75
Medications Common to Dialysis
Patients cont’d
• Erythropoietin
• Calcium Supplements
– Between meals, not with ______
• Activated Vitamin D3
• Antibiotics
– hold dose prior to dialysis
– Why?
76
Medications
• Many drugs or their metabolites are excreted
by the kidney
• Dosages
– many change when used in kidney failure patients
• Why?
• Dialyzability
– many removed by dialysis varies between HD and
PD
77
Patient Education
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Alleviate fear
Dialysis process
Fistula/catheter care
Diet and fluid restrictions
Medication
Diabetic teaching
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Transplantation
• Treatment not cure
79
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Transplanted Kidney
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Advantages
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•
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Restoration of “normal” renal function
Freedom from dialysis
Return to “normal” life
Reverses pathophysiological changes related
to Renal Failure
• Less expensive than dialysis after 1st year
82
Disadvantages
•
•
•
•
•
Life long medications
Multiple side effects from medication
Increased risk of tumor
Increased risk of infection
Major surgery
83
Care of the Recipient
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Major surgery with general anesthesia
Assessment of renal function
Assessment of fluid and electrolyte balance
Prevention of infection
Prevention and management of rejection
84
Monitoring Transplant Function
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ATN? (acute tubular necrosis)
Urine output >100 <500 cc/hr (initially)
Labs
Fluid Balance
Ultrasound
Renal scans
Renal biopsy
85
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
• FLUID RESCUITATION = 24HR URINE OUPUT
•
•
•
•
Daily weights
Postassium (K+)___________
Sodium (Na) _____________
Blood sugar _____________
86
Prevention of Infection
• Major complication of transplantation due to
immunosuppression
• What do you teach?
87
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
88
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
89
Rejection cont’d
• Chronic - gradual process of graft dysfunction
– Repeated rejection episodes that have not been
completely resolved with treatment
– 4 months to years after transplant
– Rx = return to dialysis or re-transplantation
90
Immunosuppressant Drugs
• Prednisone
– prevents infiltration of T lymphocytes
• Side effects
– cushingnoid changes
– avascular necrosis
– GI disturbances
– diabetes
– infection
– risk of tumor
91
Immunosuppressant Drugs cont’d
• Azathioprine (Imuran)
– Prevents rapid growing lymphocytes
• Side Effects
– bone marrow toxicity
– hepatotoxicity
– hair loss
– infection
– risk of tumor
92
Immunosuppressant Drugs cont’d
• Cyclosporine
– Interferes with production of interleukin 2 which
is necessary for growth and activation of T
lymphocytes.
– Side Effects
– Nephrotoxicity
– HTN
– Hepatotoxicity
– Gingival hyperplasia
– Infection
93
Immunosuppressant Drugs cont’d
•
•
•
•
Cytoxan - in place of Imuran less toxic
FK506 - 100 x more potent than Cyclosporine
Prograf
CellCept
94
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
95
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
96
Patient Education
• Signs of infection
• Prevention of infection
• Signs of rejection
– ____________
– ____________
– ____________
– ____________
• Medications
– _____________
97
Exclusion for Transplant
• Exclusion for Transplant not limited too
•
•
•
•
•
•
Active vasculitis; or
Life threatening extrarenal congenital abnormalities; or
Untreated coagulation disorder; or
Ongoing alcohol or drug abuse; or
Age over 70 years with severe co-morbidities; or
Severe neurological or mental impairment, in persons
without adequate social support, such that the person
is unable to adhere to the regimen necessary to
preserve the transplant.
98
Exclusion for Transplant
• Exclusion for Transplant not limited too
•
•
•
•
•
•
Active vasculitis; or
Life threatening extrarenal congenital abnormalities; or
Untreated coagulation disorder; or
Ongoing alcohol or drug abuse; or
Age over 70 years with severe co-morbidities; or
Severe neurological or mental impairment, in persons
without adequate social support, such that the person
is unable to adhere to the regimen necessary to
preserve the transplant.
99
Official Criteria for Deceased Donors
• Usually irreversible brain injury
– MVA, gunshot wounds, hemorrhage, anoxic brain injury
from MI
• Must have effective cardiac function
• Must be supported by ventilator to preserve organs
• Age 2-70
• No IV drug use, HTN, DM, Malignancies, Sepsis, disease
• Permission from legal next of kin & pronoucement of death
made by MD
100
Official Criteria for Living Donors
• Psychiatric evaluation
• Anesthesia evaluation
• Medical Evaluation
– Free from diseases listed under deceased donor
criteria
– Kidney function evaluated
– Crossmatches done at time of evaluation and 1
week prior to procedure
– Radiological evaluation
Nurses Role in Event of Potential
Donation
• Notify TOSA of possible organ donation
– Identify possible donors
– Make referral in timely manner
• Do not discuss organ donation with family
• Offer support to families after referral is made
& donation coordinator has met with family
102