Prepared by D. Chaplin Chronic Renal Failure

Prepared by D. Chaplin Chronic Renal Failure Progressive, irreversible damage to the nephrons and glomeruli Regardless of the cause: Decreased: GFR, tubular function & tubular reabsorption capabilities. Dysfunction fluids & electrolytes, acid base disturbances, & systemic problems develops Progressive, irreversible damage to the nephrons and glomeruli Regardless of the cause: Decreased: GFR, tubular function & tubular reabsorption capabilities. Dysfunction fluids & electrolytes, acid base disturbances, & systemic problems develops

Prepared by D. Chaplin Chronic Renal Failure Cause: - most frequent cause of CKD is diabetic nephropathy, most often secondary to type 2 diabetes mellitus - Hypertensive nephropathy is a common cause of CKD in the elderly Cause: - most frequent cause of CKD is diabetic nephropathy, most often secondary to type 2 diabetes mellitus - Hypertensive nephropathy is a common cause of CKD in the elderly

Prepared by D. Chaplin RISK FACTORS hypertension, diabetes mellitus, autoimmune disease, older age, African ancestry, a family history of renal disease, a previous episode of acute renal failure presence of proteinuria, abnormal urinary sediment, or structural abnormalities of the urinary tract

Prepared by D. Chaplin Chronic Renal Failure End 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 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

Prepared by D. Chaplin ESRD 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 < 5ml/min (average) = dialysis Other symptoms Nocturia, oliguria/anuria, increased K +, Mg ++, PO 4 and decrease Ca ++, Neurological changes, CV changes, etc. 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 < 5ml/min (average) = dialysis Other symptoms Nocturia, oliguria/anuria, increased K +, Mg ++, PO 4 and decrease Ca ++, Neurological changes, CV changes, etc.

Prepared by D. Chaplin Stages 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 <25% of normal increasing symptoms ESRD or Uremia GFR < 5-10% normal, creatinine clearance <5-10 ml/min resulting in a cumulative effect 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 <25% of normal increasing symptoms ESRD or Uremia GFR < 5-10% normal, creatinine clearance <5-10 ml/min resulting in a cumulative effect

Prepared by D. Chaplin

Approach to patient Identify if it is ACUTE RENAL FAILURE or CHRONIC. Findings that suggest chronic kidney disease include anemia, evidence of renal osteodystrophy (radiologic or laboratory), and small scarred kidneys

Prepared by D. Chaplin Treatment Modalities Decrease fluid 1000ml/day Decrease protein (.5-1kg body weight) Decrease sodium (1-4gm variable) Decrease potassium Decrease phosphorous (<1000mg/day) Dialysis (periotoneal, hemodialysis) RBC, Vitamin D (calcitrol replacement) etc. Decrease fluid 1000ml/day Decrease protein (.5-1kg body weight) Decrease sodium (1-4gm variable) Decrease potassium Decrease phosphorous (<1000mg/day) Dialysis (periotoneal, hemodialysis) RBC, Vitamin D (calcitrol replacement) etc.

Prepared by D. Chaplin Dialysis 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 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

Prepared by D. Chaplin Diffusion - movement of solutes (particles) from an area of > concentration to area of < 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 Diffusion - movement of solutes (particles) from an area of > concentration to area of < 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 Osmosis - movement fluid from an area of concentration of solutes (particles) Osmosis - movement fluid from an area of concentration of solutes (particles) Osmosis-Diffusion-Ultrafiltration

Prepared by D. Chaplin Peritoneal 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 min or 8 hours+) Drain (approximately 15 minutes) These 3 phases are called Exchanges 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 min or 8 hours+) Drain (approximately 15 minutes) These 3 phases are called Exchanges

Prepared by D. Chaplin Peritoneal Dialysis

Prepared by D. Chaplin Hemodialysis 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 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

Prepared by D. Chaplin Hemodialysis AV Fistula Communication AV Graph Access

Prepared by D. Chaplin Hemodialysis Hemodialysis Machine Hemodialysis Circuit

Prepared by D. Chaplin PD Advantages and Disadvantages Immediate initiation Less complicated Portable (CAPD) Fewer dietary restrictions Short training time Less cardio stress Choice for diabetics Immediate initiation Less complicated Portable (CAPD) Fewer dietary restrictions Short training time Less cardio stress Choice for diabetics Bacterial/chemical periotonitis Protein loss Exit site of catheter Self image Hyperglycemia Surgical placement of catheter Multiple abdominal surgery Bacterial/chemical periotonitis Protein loss Exit site of catheter Self image Hyperglycemia Surgical placement of catheter Multiple abdominal surgery Advantages Disadvantages

Prepared by D. Chaplin Hemo 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 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 Vascular access problems Dietary & fluid restrictions Heparinization Extensive equipment Hypotension Added blood lost Trained specialist Advantages Disadvantages

Prepared by D. Chaplin Disequalibrium 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 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

Prepared by D. Chaplin Nursing 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. Weigh before & after Assess site before & after (bruit, thrill, infection, bleeding etc.) Medications (precautions before & after) Vital signs before and after etc.

Prepared by D. Chaplin Renal 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) 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)

Prepared by D. Chaplin Immunological 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. 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.

Prepared by D. Chaplin Immunological 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 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

Prepared by D. Chaplin Immulogical 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 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

Prepared by D. Chaplin Surgery 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. 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.

Prepared by D. Chaplin Complications 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 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

Prepared by D. Chaplin Complications 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 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

Prepared by D. Chaplin Complications 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 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

Prepared by D. Chaplin Complications Post Transplant Infection Hypertension Malignancies (lip, skin, lymphomas, cervical) Recurrence of renal disease Retroperiotneal bleed Arterial stenosis Urine leakage Infection Hypertension Malignancies (lip, skin, lymphomas, cervical) Recurrence of renal disease Retroperiotneal bleed Arterial stenosis Urine leakage