1. Focus on Dialysis and Kidney Transplant
(Chapter 47, “Nursing Management: Dialysis and Kidney Transplant,” Lewis—Modified by L. Copenhaver)

2. 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

3. Dialysis Two methods of dialysis available Peritoneal dialysis (PD)
Hemodialysis (HD)

4. Dialysis
Begun when patient’s uremia can no longer be adequately managed conservatively
Initiated when GFR (or creatinine clearance) <15 ml/min

5. General Principles of Dialysis
Diffusion
Movement of solutes from an area of greater concentration to an area of lesser

6. General Principles of Dialysis
Osmosis
Movement of fluid from an area of lesser to area of greater concentration of solutes
Ultrafiltration
Water and fluid removal
Results when there is an osmotic gradient across the membrane

7. Osmosis and Diffusion Across Semipermeable Membrane
Fig. 47-7

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

9. Peritoneal Dialysis
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

10. Peritoneal Dialysis 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 healed patient may shower and pat dry

11. Tenckhoff Catheter
Fig. 47-8

12. Fig and Fig

13. 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

14. Peritoneal Dialysis Dialysis Solutions and Cycles
Three phases of PD cycle
Called an exchange
Inflow (fill)
Dwell (equilibration)
Drain

15. Peritoneal Dialysis Dialysis Solutions and Cycles
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

16. Peritoneal Dialysis Dialysis Solutions and Cycles
Dwell
Diffusion and osmosis occur between patient’s blood and peritoneal cavity
Duration of time varies depending on method

17. Fig

18. Peritoneal Dialysis Dialysis Solutions and Cycles
Drain
15 to 30 minutes
May be facilitated by gently massaging abdomen or changing position

19. 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

20. Peritoneal Dialysis Complications
Exit site infection
Peritonitis
Abdominal pain
Outflow problems
Hernias

21. Peritoneal Dialysis Complications
Lower back problems
Bleeding
Pulmonary complications
Protein loss

22. Peritoneal Dialysis Complications
Carbohydrate and lipid abnormalities
Encapsulating sclerosing peritonitis
Loss of ultrafiltration

23. Peritoneal Dialysis Effectiveness and Adaptation
Short training program
Independence
Ease of traveling
Fewer dietary restrictions
Greater mobility than with HD

24. 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

25. Vascular Access for Hemodialysis
Fig

26. Fig D

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

28. Hemodialysis System
Fig

29. 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

30. Hemodialysis Procedure
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

31. Hemodialysis Procedure
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

32. Fig

33. Hemodialysis Complications
Hypotension
Muscle cramps
Loss of blood
Hepatitis
Sepsis
Disequilibrium syndrome

34. Hemodialysis Effectiveness and Adaptation
Cannot fully replace metabolic and hormonal functions of kidneys
Can ease many of the symptoms
Can prevent certain complications

35. 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

36. Continual Renal Replacement Therapy (CRRT)
Can be used in conjunction with HD
Contraindication
Presence of manifestations of uremia requiring rapid resolution
Continued for 30 to 40 days
Hemofilter change every 24 to 48 hours
Ultrafiltrate should be clear yellow
Specimens may be obtained for evaluation

37. Continual Renal Replacement Therapy (CRRT)
Two types of CRRT
Continuous arteriovenous therapies (CAVTs)
Continuous venovenous therapies (CVVTs)
Most commonly used
Continuous venovenous hemofiltration (CVVH)
Continuous venovenous hemodialysis (CVVHD)

38. Continual Renal Replacement Therapy (CRRT)
Continuous venovenous hemofiltration (CVVH)
Large volumes fluid removed hourly, then replaced
Fluid replacement dependent on stability/individualized needs of patient

39. Continual Renal Replacement Therapy (CRRT)
Continuous venovenous hemodialysis (CVVHD)
Uses dialysate
Dialysate bags attached to distal end of hemofilter
Fluid pumped countercurrent to blood flow
Ideal treatment for patient who needs fluid/solute control but cannot tolerate rapid fluid shifts with HD

40. Continual Renal Replacement Therapy (CRRT)
Highly permeable, hollow fiber hemofilter
Uses double-lumen catheter placed in femoral, jugular, or subclavian vein
Removes plasma water and nonprotein solutes

41. Continual Renal Replacement Therapy (CRRT)
CRRT versus HD
Continuous rather than intermittent
Solute removal by convection (no dialysate required) in addition to osmosis and diffusion
Less hemodynamic instability
Does not require constant monitoring by HD nurse
Does not require complicated HD equipment

42. 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

43. Kidney Transplantation
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

44. Kidney Transplantation Recipient Selection
Contraindications to transplantation
Disseminated malignancies
Cardiac disease
Chronic respiratory failure
Extensive vascular disease
Chronic infection
Unresolved psychosocial disorders

45. Kidney Transplantation Histocompatibility Studies
Purpose of testing is to identify the HLA antigens for both donors and potential recipients

46. Kidney Transplantation Donor Sources
Compatible blood type deceased donors
Blood relatives
Emotionally related living donors
Altruistic living donors

47. 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

48. Kidney Transplantation Surgical Procedure
Live donor
Laparoscopic donor nephrectomy
Alternative to conventional nephrectomy
Primary method of live kidney procurement

49. Kidney Transplantation Surgical Procedure
Kidney transplant recipient
Usually placed extraperitoneally in the iliac fossa
Right iliac fossa is preferred

50. Fig

51. Kidney Transplantation Surgical Procedure
Kidney transplant recipient
Rapid revascularization critical
Donor artery anastomosed to recipient internal/external iliac artery
Donor vein anastomosed to recipient external iliac vein

52. Kidney Transplantation Surgical Procedure
Kidney transplant recipient
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

53. Kidney Transplantation Nursing Management
Preoperative care
Emotional and physical preparation
Immunosuppressive drugs
ECG
Chest x-ray
Laboratory studies

54. Kidney Transplantation Nursing Management
Postoperative care
Live donor
Care is similar to laparoscopic nephrectomy
Close monitoring of renal function
Close monitoring of hematocrit

55. Kidney Transplantation Nursing Management
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

56. Kidney Transplantation Complications
Rejection
Hyperacute (antibody-mediated, humoral) rejection
Occurs minutes to hours after transplantation

57. Kidney Transplantation Complications
Rejection (cont’d)
Acute rejection
Occurs days to months after transplantation

58. Kidney Transplantation Complications
Rejection (cont’d)
Chronic rejection
Process that occurs over months or years and is irreversible

59. Kidney Transplantation Complications
Infection
Most common infections observed in the first month
Pneumonia
Wound infections
IV line and drain infections

60. Kidney Transplantation Complications
Infection (cont’d)
Fungal infections
Candida
Cryptococcus
Aspergillus
Pneumocystis jiroveci

61. Kidney Transplantation Complications
Infection (cont’d)
Viral infections
CMV
One of the most common
Epstein-Barr virus
Herpes simplex virus

62. Kidney Transplantation Complications
Cardiovascular disease
Transplant recipients have increased incidence of atherosclerotic vascular disease
Immunosuppressant can worsen hypertension and hyperlipidemia
Adhere to antihypertensive regimen

63. Kidney Transplantation Complications
Malignancies
Primary cause is immunosuppressive therapy
Regular screening important preventive care

64. Kidney Transplantation Complications
Corticosteroid-related complications
Aseptic necrosis of the hips, knees, and other joints
Peptic ulcer disease
Glucose intolerance and diabetes

65. 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