1. Chronic Renal Failure

2. 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

3. 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.

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. 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

10. Peritoneal Dialysis

11. 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

12. Hemodialysis
AV Fistula Communication
AV Graph Access

13. Hemodialysis
Hemodialysis Circuit
Hemodialysis Machine

14. 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

15. 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

16. 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

17. 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.

18. 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)

19. 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.

20. 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

21. 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

22. 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.

23. 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

24. 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

25. 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

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