Transcript Renal Failure and Treatment

Renal Failure
and
Treatment
Vicky Jefferson, RN, CNN
Satellite Dialysis
(modified by Kelle Howard, RN, MSN)
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?
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Diagnostic tools
Functions of the Kidneys
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
Regulates ______ & _________ of extracellular fluid
Regulates fluid & electrolyte balance thru
processes of: glomerular__________, tubular
_________, and tubular _____________.
Name some of the F & Es regulated by kidneys
__________________
3/27/2016
4
Functions of the Kidneys (cont)


Regulates acid-base balance through
 HCO3 and H+
*Hormonal functions: (BP control), multisystem effect.
 Renin Release
RAAS=
3/27/2016
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Functions of the Kidneys
(cont)

Erythropoietin Release
If a patient has chronic renal failure, what
condition will occur?
 WHY???

3/27/2016
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?
__________________
3/27/2016
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Functions of the Kidneys
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_______________
_______________
_______________
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______________
______________
______________
______________
Diagnostic Tools for Assessing
Renal Failure
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Blood Tests
 BUN
 Creatinine
 K+
 PO4
 Ca
Urinalysis
 Specific gravity
 Protein
 Creatinine clearance
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BUN
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
Normal 10-30 mg/dl
Nitrogenous waste product of protein
metabolism
Unreliable in measurement of renal function
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Creatinine
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A waste product of muscle metabolism
Normal value 0.5 - 1.5 mg/dl
2 times normal = 50% damage
8 times normal = 75% damage
10 times normal = 90% damage
Exception -_______________________
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Diagnostic Tools
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Biopsy
Ultrasound
X-Rays
12
Chronic Renal Failure

Slow progressive renal disorder related to
nephron loss, occurring over months to years

Culminates in End Stage Renal Disease
13
Characteristics of
Chronic Renal Failure
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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
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Diabetes
Hypertension
Glomerulonephritis
Cystic disorders
Developmental - Congenital
Infectious Disease
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Causes of Chronic Renal Failure
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Neoplasms
Obstructive disorders
Autoimmune diseases
Hepatorenal failure
Scleroderma
Amyloidosis
Drug toxicity
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Glomerular Filtration Rate
GFR

24 hour urine for creatinine clearance
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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?
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Stages of Chronic Renal Failure
Old System
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Reduced Renal Reserve
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Renal Insufficiency
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End Stage Renal Disease (ESRD)
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Stages of Chronic Renal Failure
NKF Classification System
Stage 1:
GFR >/= 90 ml/min despite kidney damage
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Stages of Chronic Renal Failure
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
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No symptoms
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Serum creatinine doubles
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Up to 50% nephron loss
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Stages of Chronic Renal Failure
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
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Stages of Chronic Renal Failure
NKF Classification System
Stage 4:
Severe 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
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Signs and symptoms worsen if kidneys are
stressed
Decreased ability to maintain homeostasis
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During stages 3 - 4
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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 Failure
NKF Classification System
Stage 5:
Kidney failure (GFR < 15 ml/min)
1. Azotemia
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During Stage 5
End Stage Renal Disease
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Residual function < 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
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can be diminished with early diagnosis & treatment
Last stage of progressive CRF
Fatal if no treatment
28
Manifestations of Chronic Uremia
Fig. 47-5
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What happens when the kidneys
don’t function correctly?
30
Manifestations of CRF
Nervous System
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Mood swings
Impaired judgment
Inability to concentrate and perform simple
math functions
Tremors, twitching, convulsions
Peripheral Neuropathy
31
Manifestations of CRF
Skin
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Pale, grayish-bronze color
Dry scaly
Severe itching
Bruise easily
Uremic frost
32
Manifestations of CRF
Eyes
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Visual blurring
Blindness
33
Manifestations of CRF
Fluid - Electrolyte - pH
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Volume expansion and fluid overload
Metabolic Acidosis
Change in urine specific gravity
Electrolyte Imbalances
Potassium
 Magnesium
 Sodium

34
Manifestations of CRF
GI Tract
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Uremic fetor
Anorexia, nausea, vomiting
GI bleeding
35
Manifestations of CRF
Hematologic
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Anemia
Platelet dysfunction
36
Manifestations of CRF
Musculoskeletal
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Muscle cramps
Soft tissue calcifications
Weakness
Related to calcium phosphorous imbalances
RENAL OSTEODYSTROPHY
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Calcium-Phosphorous Balance
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Manifestations of CRF
Heart - Lungs
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Hypertension
Congestive heart failure
Pericarditis
Pulmonary edema
Pleural effusions
Atherosclerotic vascular disease*
Cardiac dysrhythmias
39
Manifestations of CRF
Endocrine - Metabolic
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Erythropoietin production decreased
Hypothyroidism
Insulin resistance
Growth hormone decreased
Gonadal dysfunction
Parathyroid hormone and Vitamin D3
Hyperlipidemia
40
Treatment Options
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Conservative Therapy
Hemodialysis
Peritoneal Dialysis
Transplant
Nothing
41
Conservative Treatment Goals
GOALS:
 Detect & treat potentially reversible causes of
renal failure
 Preserve existing renal function
 Treat manifestations
 Prevent complications
 Provide for comfort
42
Conservative Treatment

Control
Hyperkalemia
 Hypertension
 Hyperphosphatemia
 Hyperparthryoidism
 Hyperglycemia
 Anemia
 Dyslipidemia
 Hypothyroidism
 Nutrition

43
Hemodialysis

Removal of soluble substances and
water from the blood by diffusion
through a semi-permeable membrane.
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History
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Early animal experiments began 1913
1st human dialysis 1940’s by Dutch physician
Willem Kolff (2 of 17 patients survived)
Considered experimental through 1950’s, No
intermittent blood access; for acute renal failure
only.
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History cont’d
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1960 Dr. Scribner developed Scribner Shunt
1960’s Machines expensive, scarce, no funding.
“Death Panels” panels within community
decided who got to dialyze.
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Hemodialysis Process
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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
48
How Hemodialysis Works
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Vascular Access
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Arterio-venous shunt (Scribner External Shunt)
Arterio-venous (AV) Fistula
PTFE Graft
Temporary catheters
“Permanent” catheters
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Scribner Shunt
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External- one end into
artery, one into vein.
Advantages

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place at bedside
use immediately
Disadvantages
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infection
skin erosion
accidental separation
limits use of extremity
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Arterio-venous (AV) Fistula
Primary Fistula
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
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
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PTFE (Polytetrafluoroethylene)
Graft
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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
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Temporary Catheters
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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
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Cuffed Tunneled Catheters
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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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Care of Vascular Access
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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.
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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
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Potential
Complications of Hemodialysis

Between treatments
Hypertension/Hypotension
 Edema
 Pulmonary edema
 Hyperkalemia
 Bleeding
 Clotting of access

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Complications of Hemodialysis
cont’d

Long term
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Metabolic
 hyperparathyroidism
 diabetic complications
*Cardiovascular
 CHF
 AV access failure
 cardiovascular disease
Respiratory
 pulmonary edema
Neuromuscular
 neuropathy
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Complications of Hemodialysis
cont’d

Long term cont’d
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Hematologic
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GI
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bleeding
Dermatologic
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anemia
calcium phosphorous deposits
Rheumatologic

amyloid deposits
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Complications of Hemodialysis
cont’d

Long term cont’d

Genitourinary
infection
 sexual dysfunction
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Psychiatric
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
depression
*Infection

blood borne pathogens
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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
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
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 semipermeable membrane that is intracorporeal
(inside the body).
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Types of Peritoneal Dialysis
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
CAPD: Continuous ambulatory peritoneal dialysis
CCPD: Continuous cycling peritoneal dialysis
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Aka. APD – Automated Peritoneal Dialysis
IPD:
Intermittent peritoneal dialysis
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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
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Phases of A Peritoneal Dialysis
Exchange
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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
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Infection
 peritonitis
 tunnel infections
 catheter exit site
Hypervolemia
 hypertension
 pulmonary edema
Hypovolemia
 hypotension
Hyperglycemia
Malnutrition
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Complications of Peritoneal
Dialysis cont’d



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
Obesity
Hypokalemia
Hernia
Cuff erosion
Low back pain
Hyperlipidemia
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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

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Peritoneal Catheter Exit Site
71
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Medications Common to Dialysis
Patients


Vitamins - water soluble
Phosphate binder ---- GIVE WITH MEALS
Phoslo (calcium acetate)
 Renagel (sevelamere hydrochloride)
 Caltrate (calcium cabonate)
 Amphojel (aluminum hydroxide)


Iron Supplements –


don’t give with phosphate binder or calcium
Antihypertensives - hold prior to dialysis
73
Medications Common to Dialysis
Patients cont’d

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Erythropoietin
Calcium Supplements


Activated Vitamin D3


Between meals, not with iron
aids in calcium absorption
Antibiotics

hold dose prior to dialysis if it dialyzes out
74
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

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
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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
77
Kidney Awaiting Transplant
78
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Transplanted Kidney
80
Advantages





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
81
Disadvantages





Life long medications
Multiple side effects from medication
Increased risk of tumor
Increased risk of infection
Major surgery
82
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
83
Function

ATN? (acute tubular necrosis)

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50% experience
Urine output >100 <500 cc/hr
BUN, creatinine, creatinine clearance
Fluid Balance
Ultrasound
Renal scans
Renal biopsy
84
Fluid & Electrolyte Balance



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
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
Postassium (K+)___________
Sodium (Na) _____________
Blood sugrar _____________
85
Prevention of Infection




Major complication of transplantation due to
immunosuppression
HANDWASHING
Crowds, Kids
Patient Education
86
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
87
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

88
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

89
Immunosuppressant Drugs

Prednisone


prevents infiltration of T lymphocytes
Side effects
cushingnoid changes
 avascular necrosis
 GI disturbances
 diabetes
 infection
 risk of tumor

90
Immunosuppressant Drugs
cont’d

Azathioprine (Imuran)


Prevents rapid growing lymphocytes
Side Effects
bone marrow toxicity
 hepatotoxicity
 hair loss
 infection
 risk of tumor

91
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
92
Immunosuppressant Drugs
cont’d




Cytoxan - in place of Imuran less toxic
FK506 - 100 x more potent than Cyclosporin
Prograf
Cellcept
93
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
94
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
95
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
96
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.

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
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
99
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
101