Chronic Renal Failure

Chronic 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

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 The kidney has a remarkable renal reserve. Up to 80% of the GFR (reflected in creatinine clearance measurement may be lost with few overt changes in functioning of the body.

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++, PO4 and decrease Ca++, Neurological changes, CV changes, etc.

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

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.

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

Osmosis-Diffusion-Ultrafiltration Osmosis - movement fluid from an area of < to > concentration of solutes (particles) 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

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 20-30 min or 8 hours+) Drain (approximately 15 minutes) These 3 phases are called Exchanges

Peritoneal Dialysis

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

Hemodialysis AV Fistula Communication AV Graph Access

Hemodialysis Hemodialysis Circuit Hemodialysis Machine

PD Advantages and 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

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 Vascular access problems Dietary & fluid restrictions Heparinization Extensive equipment Hypotension Added blood lost Trained specialist

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

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.

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)

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.

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

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

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.

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

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

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

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