Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Dialysis and Kidney Transplant (Relates to Chapter 47, “Nursing Management: Acute Renal Failure and Chronic Kidney Disease,” in the textbook)

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure Treat drug overdoses

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis (Cont’d) Two methods of dialysis available  Peritoneal dialysis (PD)  Hemodialysis (HD)

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis (Cont’d) Begun when patient’s uremia can no longer be adequately managed conservatively Initiated when GFR (or creatinine clearance) <15 ml/min

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis (Cont’d) Certain uremic complications also indicate a need  Encephalopathy, pericarditis

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. General Principles of Dialysis Diffusion  Movement of solutes from an area of greater concentration to an area of lesser concentration

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. General Principles of Dialysis (Cont’d) Osmosis  Movement of fluid from an area of lesser concentration to an area of greater concentration of solutes

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. General Principles of Dialysis (Cont’d) Ultrafiltration  Water and fluid removal  Results when there is an osmotic gradient across the membrane

Osmosis and Diffusion Across Semipermeable Membrane Fig Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Peritoneal access is obtained by inserting a catheter through the anterior wall Technique for catheter placement varies Usually done via surgery

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis (Cont’d) After catheter inserted, skin is cleaned with antiseptic solution and sterile dressing applied Connected to sterile tubing system Secured to abdomen with tape Catheter irrigated immediately

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis (Cont’d) Waiting period of 7 to 14 days preferable 2 to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness Once site is healed, patient may shower and pat dry

Tenckhoff Catheter Fig Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Fig A-C and Fig Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Dialysis Solutions and Cycles Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25% Electrolyte composition similar to plasma Solution warmed to body temperature

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Three phases of PD cycle  Called an exchange Inflow (fill) Dwell (equilibration) Drain

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Inflow  Prescribed amount of solution infused through established catheter over about 10 minutes  After solution infused, inflow clamp closed to prevent air from entering tubing

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Dwell  Diffusion and osmosis occur between patient’s blood and peritoneal cavity  Duration of time varies depending on method

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Drain  15 to 30 minutes  May be facilitated by gently massaging abdomen or changing position

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Systems Automated peritoneal dialysis (APD)  Cycler delivers the dialysate  Times and controls fill, dwell, and drain Continuous ambulatory peritoneal dialysis (CAPD)  Manual exchange

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Complications Exit site infection Peritonitis Abdominal pain Outflow problems Hernias

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Complications (Cont’d) Lower back problems Bleeding Pulmonary complications Protein loss

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Complications (Cont’d) Carbohydrate and lipid abnormalities Encapsulating sclerosing peritonitis Loss of ultrafiltration

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Effectiveness and Adaptation Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Vascular Access Sites Obtaining vascular access is one of most difficult problems  Types of access include Shunts Internal arteriovenous fistulas and grafts Temporary vascular access

Vascular Access for Hemodialysis Fig Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Dialyzers Long plastic cartridge that contains thousands of parallel hollow tubes or fibers Fibers are the semipermeable membrane

Hemodialysis System Fig Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Procedure Two needles placed in fistula or graft Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer Blood returned from dialyzer to patient through second needle or blue catheter

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Procedure (Cont’d) Dialyzer/blood lines primed with saline solution to eliminate air Heparin added to blood as it flows to dialyzer Terminated by flushing dialyzer with saline to remove all blood Needles removed and firm pressure applied

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Procedure (Cont’d) Before treatment, nurse should  Complete assessment of fluid status, condition of access, temperature, skin condition During treatment, nurse should  Be alert to changes in condition  Perform vital signs every 30 to 60 minutes

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Complications Hypotension Muscle cramps Loss of blood Hepatitis Sepsis Disequilibrium syndrome

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Effectiveness and Adaptation Cannot fully replace metabolic and hormonal functions of kidneys Can ease many of the symptoms Can prevent certain complications

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) Alternative or adjunctive method for treating ARF Means by which uremic toxins and fluids are removed Acid-base status/electrolytes adjusted slowly and continuously

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Can be used in conjunction with HD Contraindication  Presence of manifestations of uremia requiring rapid resolution Continued for 30 to 40 days

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow Specimens may be obtained for evaluation

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Two types of CRRT  Continuous arteriovenous therapies (CAVTs)  Continuous venovenous therapies (CVVTs) Most commonly used  Continuous venovenous hemofiltration (CVVH)  Continuous venovenous hemodialysis (CVVHD)

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Continuous venovenous hemofiltration (CVVH)  Large volume of fluid removed hourly, then replaced  Fluid replacement dependent on stability/individualized needs of patient

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Continuous venovenous hemodialysis (CVVHD)  Uses dialysate  Dialysate bags attached to distal end of hemofilter

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Continuous venovenous hemodialysis (CVVHD) (cont’d)  Fluid pumped countercurrent to blood flow  Ideal treatment for patient who needs fluid/solute control but cannot tolerate rapid fluid shifts with HD

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Highly permeable, hollow fiber hemofilter Uses double-lumen catheter placed in femoral, jugular, or subclavian vein Removes plasma water and nonprotein solutes

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) CRRT versus HD  Continuous rather than intermittent  Solute removal by convection (no dialysate required) in addition to osmosis and diffusion  Less hemodynamic instability

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) CRRT versus HD (cont’d)  Does not require constant monitoring by HD nurse  Does not require complicated HD equipment

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation More than 66,000 patients currently awaiting deceased (cadaveric) kidney transplants 19,549 kidneys were transplanted in 2004 More than 6990 living donor transplants in 2004

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation (Cont’d) Extremely successful 1-year graft survival rate  90% for cadaver transplants  95% for live donor transplants

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation (Cont’d) Advantages of kidney transplant compared with dialysis  Reverses many of the pathophysiologic changes associated with renal failure  Eliminates the dependence on dialysis  Less expensive than dialysis after the first year

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Recipient Selection Candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Recipient Selection (Cont’d) Contraindications to transplantation  Disseminated malignancies  Cardiac disease  Chronic respiratory failure  Extensive vascular disease  Chronic infection  Unresolved psychosocial disorders

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Histocompatibility Studies Purpose of testing is to identify the HLA antigens for both donors and potential recipients

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Donor Sources Compatible–blood-type deceased donors Blood relatives Emotionally related living donors Altruistic living donors

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Surgical Procedure Live donor  Nephrectomy performed by a urologist or transplant surgeon  Begins an hour or two before the recipient’s surgery is started  Rib may need to be removed for adequate view  Takes about 3 hours

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Surgical Procedure (Cont’d) Live donor (cont’d)  Laparoscopic donor nephrectomy Alternative to conventional nephrectomy Primary method of live kidney procurement

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Surgical Procedure (Cont’d) Kidney transplant recipient  Usually placed extraperitoneally in the iliac fossa  Right iliac fossa is preferred

Fig Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Surgical Procedure (Cont’d) Kidney transplant recipient (cont’d)  Before incision Urinary catheter placed into bladder Antibiotic solution instilled  Distends the bladder  Decreases risk of infection Crescent-shaped incision

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Surgical Procedure (Cont’d) Kidney transplant recipient (cont’d)  Rapid revascularization critical  Donor artery anastomosed to recipient internal/external iliac artery  Donor vein anastomosed to recipient external iliac vein

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Surgical Procedure (Cont’d) Kidney transplant recipient (cont’d)  When anastomoses complete, clamps released and blood flow reestablished  Urine may begin to flow or diuretic may be given  Surgery takes 3 to 4 hours

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Nursing Management Preoperative care  Emotional and physical preparation  Immunosuppressive drugs  ECG  Chest x-ray  Laboratory studies

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Nursing Management (Cont’d) Postoperative care  Live donor Care is similar to laparoscopic nephrectomy Close monitoring of renal function Close monitoring of hematocrit

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Nursing Management (Cont’d) Postoperative care (cont’d)  Recipient Maintenance of fluid and electrolyte balance is first priority Large volumes of urine soon after transplanted kidney placed due to  New kidney’s ability to filter BUN  Abundance of fluids during operation  Initial renal tubular dysfunction

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Nursing Management (Cont’d) Postoperative care (cont’d)  Recipient (cont’d) Urine output replaced with fluids milliliter by milliliter hourly  Urine output closely measured Acute tubular necrosis can occur  May need dialysis Maintain catheter patency

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Immunosuppressive Therapy Goals  Adequately suppress the immune response  Maintain sufficient immunity to prevent overwhelming infection

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications Rejection  Hyperacute (antibody-mediated, humoral) rejection Occurs minutes to hours after transplantation

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Rejection (cont’d)  Acute rejection Occurs days to months after transplantation

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Rejection (cont’d)  Chronic rejection Process that occurs over months or years and is irreversible

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Infection  Most common infections observed in the first month Pneumonia Wound infections IV line and drain infections

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Infection (cont’d)  Fungal infections Candida Cryptococcus Aspergillus Pneumocystis jiroveci

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Infection (cont’d)  Viral infections CMV  One of the most common Epstein-Barr virus Herpes simplex virus

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Cardiovascular disease  Transplant recipients have increased incidence of atherosclerotic vascular disease  Immunosuppressant can worsen hypertension and hyperlipidemia  Adhere to antihypertensive regimen

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Malignancies  Primary cause is immunosuppressive therapy  Regular screening important part of preventive care

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Recurrence of original renal disease  Glomerulonephritis  IgA nephropathy  Diabetes mellitus  Focal segmental sclerosis

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Corticosteroid-related complications  Aseptic necrosis of the hips, knees, and other joints  Peptic ulcer disease  Glucose intolerance and diabetes

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidney Transplantation Complications (Cont’d) Corticosteroid-related complications (cont’d)  Hyperlipidemia  Cataracts  Increased incidence of infections and malignancies  Close monitoring of side effects

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Gerontologic Considerations About 35% of ESRD patients are 65 years of age or older Most common diseases leading to renal failure in the older adult  Hypertension  Diabetes

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Evaluation Maintenance of ideal body weight Acceptance of chronic disease No infections No edema Hematocrit, hemoglobin, and serum albumin levels in acceptable range

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study 65-year-old female with history of progressive renal failure for 5 years Diagnosed with type 1 diabetes mellitus when 15 years of age

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) She has diabetic retinopathy with macular degeneration Gives herself insulin using an insulin pen

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Lab values  BUN 72 mg/dl  Serum creatinine 7.5 mg/dl  GFR 12 ml/min

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions 1.What are her options for renal replacement therapy? 2.Which one would be the best choice for her?