ckd/esrd & transplant note-when viewing lab values in ppt-note that values are given as both as...

CKD/ESRDCKD/ESRD&&

TransplantTransplantNote-when viewing lab values in PPT-note that values are given as both as “common values” as also the specific values given in textbook (remember, sources vary slightly-think ranges.)2010

Bones can break, muscles can atrophy, Bones can break, muscles can atrophy, glands can loaf, even the brain can go to glands can loaf, even the brain can go to sleep without immediate danger to sleep without immediate danger to survival. But -- should kidneys fail.... survival. But -- should kidneys fail.... neither bone, muscle, nor brain could neither bone, muscle, nor brain could carry on. carry on.

Homer Smith, Homer Smith, Ph.D.Ph.D.

2

REVIEWREVIEW

Recall functions of the kidneys?Recall functions of the kidneys?

Recall normal creatinine & BUN; Recall normal creatinine & BUN; other lab tests?other lab tests?

Review Diagnostic ToolsReview Diagnostic Tools

CKD- Elderly Risk (Review)

•Older Adult-normal aging (plus co-morbidities) > risk kidney dysfunction/renal failure•Must:

•Identify/prevent damage•Monitor/risk multiple RX/OTC meds (altered renal blood flow/dec. renal clearance etc)•Monitor/risk associated with dehydration (ie diuretics)•Monitor/risk with dec ability to respond to changes to fluid/electrolyte status (manifestation may be atypical

Functions of the KidneysFunctions of the Kidneys

Regulates Regulates volumevolume and and compositioncomposition of of extracellular fluidextracellular fluid

Excretion of Excretion of nitrogenous waste nitrogenous waste productsproducts

BP control via BP control via renin-renin-angiotensin-angiotensin-aldosterone system- aldosterone system- Recall RAASRecall RAAS

Vitamin D activationVitamin D activation Acid-base balance Acid-base balance

(HCO3 & H) (HCO3 & H) regulation through regulation through process of _____, ____ process of _____, ____ and ______. and ______.

Prostaglandin Prostaglandin synthesissynthesis

Erythropoietin Erythropoietin productionproduction

filtration, secretion, reabsorpton

04/19/23 6

Functions of the Kidneys Functions of the Kidneys (cont)(cont)

Erythropoietin ReleaseErythropoietin Release If a patient has chronic renal failure, what If a patient has chronic renal failure, what

condition will occur?condition will occur? WHY???WHY???

EPO- glycoprotein hormone that controls erythropoiesis, or red blood cell production

http://en.wikipedia.org/wiki/Glycoprotein

http://en.wikipedia.org/wiki/Hormone

http://en.wikipedia.org/wiki/Erythropoiesis

http://images.google.com/imgres?imgurl=http://www.cellsalive.com/pics/cover4.gif&imgrefurl=http://www.cellsalive.com/&h=169&w=220&sz=12&tbnid=ONhq7XTHZ5wJ:&tbnh=78&tbnw=101&prev=/images%3Fq%3Dred%2Bblood%2Bcell%26hl%3Den%26lr%3D&oi=imagesr&start=2

Diagnostic Tools for Diagnostic Tools for Assessing Renal FailureAssessing Renal Failure

Blood TestsBlood Tests BUN elevated (norm 10-20 mg/dl) (text 10-BUN elevated (norm 10-20 mg/dl) (text 10-

30mg/dl)30mg/dl) Creatinine elevated (norm 0.6 - 1.2 mg/dl) (text Creatinine elevated (norm 0.6 - 1.2 mg/dl) (text

0.5-1.5mg/dl)0.5-1.5mg/dl) K elevated (text norm 3.5-5.0 mEq/L)K elevated (text norm 3.5-5.0 mEq/L) POPO4 4 elevated (text norm 2.8-4.5mg/dl)elevated (text norm 2.8-4.5mg/dl) Ca decreased (text norm 9-11mg/dl)Ca decreased (text norm 9-11mg/dl)

UrinalysisUrinalysis Specific gravity (text norm 1.003-1.030Specific gravity (text norm 1.003-1.030 Protein (text norm 0-trace)Protein (text norm 0-trace) Creatinine clearance (text norm 85-135ml/min)Creatinine clearance (text norm 85-135ml/min)

7

BUNBUN

Normal 8 - 20 mg/dl (text 10-Normal 8 - 20 mg/dl (text 10-30mg/dl)30mg/dl)

Nitrogenous waste product of Nitrogenous waste product of protein metabolismprotein metabolism

Unreliable in measurement of renal Unreliable in measurement of renal functionfunction Relevance assessed in conjunction with Relevance assessed in conjunction with

serum creatinineserum creatinine

8

CreatinineCreatinine

A waste product of muscle A waste product of muscle metabolismmetabolism

Normal value 0.6 - 1.2 mg/dl (text Normal value 0.6 - 1.2 mg/dl (text 0.5-1.5mg/dl)0.5-1.5mg/dl)

2 times normal = 50% damage 2 times normal = 50% damage 8 times normal = 75% damage8 times normal = 75% damage 10 times normal = 90% damage10 times normal = 90% damage Exception -Exception -

9

severe muscular disease can severe muscular disease can greatly greatly serum creatinine levels serum creatinine levels

Diagnostic ToolsDiagnostic Tools

UltrasoundUltrasound X-RaysX-Rays Biopsy *most definitive*most definitive

10

Chronic Renal Failure/ Chronic Renal Failure/ Chronic Kidney Disease (CKD)Chronic Kidney Disease (CKD)

Slow progressive renal disorder Slow progressive renal disorder related to nephron loss, occurring related to nephron loss, occurring over months to yearsover months to years

Culminates in End Stage Renal Culminates in End Stage Renal Disease (ESRD)Disease (ESRD)

11

Characteristics of CKD > ESRDCharacteristics of CKD > ESRD

Cause & onset often unknownCause & onset often unknown Loss of function precedes lab Loss of function precedes lab

abnormalitiesabnormalities Lab abnormalities precede symptomsLab abnormalities precede symptoms Symptoms (usually) evolve in orderly Symptoms (usually) evolve in orderly

sequencesequence Renal size is usually decreasedRenal size is usually decreased

12

Causes of CKDCauses of CKD *Diabetes*Diabetes *Hypertension*Hypertension GlomerulonephritisGlomerulonephritis Cystic disordersCystic disorders Developmental - Developmental -

CongenitalCongenital Infectious DiseaseInfectious Disease

13

•NeoplasmsNeoplasms•Obstructive Obstructive disordersdisorders•Autoimmune Autoimmune diseases (lupus)diseases (lupus)•Hepatorenal failureHepatorenal failure•SclerodermaScleroderma•AmyloidosisAmyloidosis•Drug toxicity-Drug toxicity-((overuse some common overuse some common drugs, as aspirin, NSAID as drugs, as aspirin, NSAID as ibuprofen, cocaine and ibuprofen, cocaine and acetaminophen)acetaminophen)

NSAIDs-…cause prerenal ARF by blocking prostaglandin production > also alters local glomerular arteriolar perfusion… (reduces renal blood flow)

Glomerular Filtration Rate (GFR)-Glomerular Filtration Rate (GFR)-determine stage CKD determine stage CKD (most accurate (most accurate evaluation)evaluation)

24 hour urine for creatinine clearance24 hour urine for creatinine clearance Formula- Formula- urine creatinine X urine volumeurine creatinine X urine volume serum creatinineserum creatinine Can Can estimateestimate creatinine clearance by: creatinine clearance by:

140 – {age x weight (kg)}140 – {age x weight (kg)}

72 x serum creatinine72 x serum creatinine

What is What is normal GFR?

1490 - 120 mL/min

Stages of CKDStages of CKDNKF Classification SystemNKF Classification System

Stage 1: Stage 1: GFR > 90 ml/min despite GFR > 90 ml/min despite kidney kidney damagedamage

Stage 2:Stage 2: Mild reduction (GFR 60 – 89 Mild reduction (GFR 60 – 89 ml/min)ml/min)

1. GFR of 60 may represent 1. GFR of 60 may represent 50% 50% loss in function. loss in function.

2. Parathyroid hormones 2. Parathyroid hormones starts to starts to increase. increase. (why?)

15

*kidneys unable to reabsorb calcium, blood calcium levels fall, stimulating continual secretion of parathyroid hormone to maintain normal calcium levels in blood.

During Stage 1 - 2During Stage 1 - 2

No symptomsNo symptoms

Serum creatinine doubles* Serum creatinine doubles* ((Up to Up to 50%50% nephron loss nephron loss

16

FYI-older adult- may impaired renal function even in presence of normal serum creatinine


Stage 3:Stage 3: Moderate reduction (GFR 30 – Moderate reduction (GFR 30 – 59 59 ml/min)ml/min)

1. Calcium absorption decreases 1. Calcium absorption decreases

(from the GI tract)(from the GI tract)

2. Malnutrition onset2. Malnutrition onset

3. Anemia3. Anemia

4. Left ventricular hypertrophy4. Left ventricular hypertrophy

17


Stage 4:Stage 4: Severe reduction (GFR 15 – Severe reduction (GFR 15 – 29 29 ml/min)ml/min)

1. Serum triglycerides1. Serum triglycerides

2. 2. HyperHyperphosphatemiaphosphatemia

3. Metabolic 3. Metabolic acidosisacidosis

4. 4. HyperHyperkalemiakalemia

18

Oops-trouble!

K Effect & EKG

During Stage 3 - 4During Stage 3 - 4

Signs and symptoms worsen if kidneys Signs and symptoms worsen if kidneys stressedstressed

ability to maintain homeostasisability to maintain homeostasis 75% nephron loss 75% nephron loss glomerular filtration rate, solute glomerular filtration rate, solute

clearance, ability to concentrate urine and clearance, ability to concentrate urine and secrete hormone secrete hormone

Symptoms: BUN & Creatinine, mild Symptoms: BUN & Creatinine, mild azotemia, anemiaazotemia, anemia

19

Stages of CKD-Stages of CKD-NKF Classification NKF Classification SystemSystem

Stage 5: Kidney failure (GFR < 15 ml/min)Stage 5: Kidney failure (GFR < 15 ml/min) AzotemiaAzotemia Residual function < Residual function < 15% of normal15% of normal Excretory, regulatory, hormonal functions Excretory, regulatory, hormonal functions

severely impairedseverely impaired Metabolic Metabolic acidosis acidosis ((Kussmaul breathing))

Marked : BUN, Creatinine, PhosphorousMarked : BUN, Creatinine, Phosphorous Marked : Hemoglobin, Hematocrit, Marked : Hemoglobin, Hematocrit,

CalciumCalcium Fluid Fluid overloadoverload

20

ESRD!!!

During Stage 5During Stage 5

Uremic syndrome develops- syndrome develops- affecting affecting allall body systems body systems can be diminished with early diagnosis & can be diminished with early diagnosis &

treatmenttreatment

Last stage of progressive Last stage of progressive CKDCKD FatalFatal if no treatment if no treatment

21

Manifestations of Manifestations of Chronic UremiaChronic Uremia

Fig. 47-5

22

Syndrome- combination of common symptoms

*greater build-up waste products = greater symptoms

What happens when What happens when kidneys don’t function kidneys don’t function

correctly?correctly?

23

Manifestations of CKD -Manifestations of CKD -Nervous SystemNervous System

Mood swingsMood swings Impaired judgmentImpaired judgment Inability to concentrate and perform Inability to concentrate and perform

simple math functionssimple math functions Tremors, twitching, convulsionsTremors, twitching, convulsions Peripheral NeuropathyPeripheral Neuropathy

restless legs foot dropfoot drop

24

Manifestations due to inc nitrogenous waste products, electrolyte imbalances, metabolic acidosis and axonal atrophy and

demyelination of nerve fibers & dec erythropoietin*

Manifestations of CRFManifestations of CRFSkinSkin

Pale, grayish-bronze colorPale, grayish-bronze color Dry scalyDry scaly Severe itchingSevere itching Bruise easily, petechiae, ecchymosisBruise easily, petechiae, ecchymosis *Uremic frost*Uremic frost

25

*Manifestations due to…calcium-phosphate deposition in skin, sensory neuropathy, platelet abnormalities; urea crystallizes (uremic frost) >if BUN extremely high

Walsh S and Parada N. N Engl J Med 2005;352:e13

Medical Mystery? What do lab studies, etc indicate ? What causes uremic frost?

*57-year-old with HTN and CKD (Stage 5), refused dialysis found in respiratory distress after week of upper respiratory symptoms due to viral infection

Before admission to hospital >developed asystolic cardiac arrest, was resuscitated by EMT, admitted to ICU, required vasopressor support.

PE- diffuse deposits tiny white crystalline material on skin > lab studies- BUN 208 mg/dl; creatinine 15 mg/dl; bicarbonate level 5 mmol per liter; anion gap-26; arterial pH of 6.74, and arterial partial pressure of carbon dioxide of 50 mm Hg. Blood cultures- revealed-Staphylococcus aureus pneumonia, likely due to prior influenza infection. *Aggressive care measures withdrawn after consultation with patient's family >patient died.

*Uremic frost- uncommon skin manifestation due to profound azotemia; occurs when urea and other nitrogenous waste products accumulate in sweat and crystallize after evaporation.

Manifestations of CKDManifestations of CKDEyesEyes

Visual blurringVisual blurring Occasional blindnessOccasional blindness ““Red eye””

27

Due to calcium-phosphate deposits in eyes

Manifestations of CKD Manifestations of CKD Fluid - Electrolyte - pHFluid - Electrolyte - pH

Volume expansion and fluid overloadVolume expansion and fluid overload Metabolic Metabolic AcidosisAcidosis Electrolyte ImbalancesElectrolyte Imbalances

Potassium Potassium MagnesiumMagnesium

SodiumSodium

28

Due to impaired kidneys unable to excrete acid load (mostly from NH3); defective

reabsorption/regeneration of HCO3.

Due to dec excretion by kidneys, breakdown of cellular protein, bleeding,

metabolic acidosis, food, drugs, etcKidneys unable to excrete (too much magnesium causes hyporeflexia and can

lead to cardiac arrest)

Kidneys retain > water retention> fluid overload

Manifestations of CKDManifestations of CKDGI Tract/Bleeding RiskGI Tract/Bleeding Risk

Uremic fetor Uremic fetor Anorexia, nausea, vomitingAnorexia, nausea, vomiting GI bleeding GI bleeding Anemia Platelet dysfunction

29

Due to GI irritation, platelet defect; diarrhea from hyperkalemia

Anemia-due to insufficient production of erythropoietin, protein naturally produced in functioning kidneys…circulates through bloodstream to bone marrow, stimulating production of RBCs. Platelet dysfunction-subnormal platelet aggregation -due to

fibrinogen fragments, usually absent in normal human blood but present in uremic plasma may lead to platelet dysfunction in uremia.

Manifestations of CKD-Manifestations of CKD-MusculoskeletalMusculoskeletal

Muscle crampsMuscle cramps Soft tissue calcificationsSoft tissue calcifications WeaknessWeakness Related to Related to calcium phosphorous

imbalancesimbalances RENAL OSTEODYSTROPHYRENAL OSTEODYSTROPHY

Fracture risk!Fracture risk!

30

Manifestations of CKD- Heart & Manifestations of CKD- Heart & LungsLungs

HypertensionHypertension Heart failure > pulmonary edema Heart failure > pulmonary edema Pericarditis due to uremia due to uremia Pulmonary edemaPulmonary edema Pleural effusions- Pleural effusions- ““Uremic Lung”Uremic Lung” Atherosclerotic vascular disease*Atherosclerotic vascular disease* Cardiac dysrhythmias Cardiac dysrhythmias (from HF, (from HF,

electrolyte imblaances)electrolyte imblaances)

31

*Major Problem!

Manifestations of CKD- Endocrine Manifestations of CKD- Endocrine - Metabolic- Metabolic

ErythropoietinErythropoietin HypothyroidismHypothyroidism Insulin resistanceInsulin resistance Growth hormone Growth hormone Gonadal dysfunctionGonadal dysfunction Parathyroid hormone and Vitamin Parathyroid hormone and Vitamin

DD33

HyperlipidemiaHyperlipidemia32

Treatment OptionsTreatment Options

Conservative Conservative Therapy * Therapy * (Severe (Severe restrictions, dietary, fluids maintain renal restrictions, dietary, fluids maintain renal function as long as possible- if GFR > 10ml/min)function as long as possible- if GFR > 10ml/min)

HemodialysisHemodialysis Peritoneal DialysisPeritoneal Dialysis TransplantTransplant Nothing > DeathNothing > Death

33

Conservative Treatment GoalsConservative Treatment Goals

Detect/treat potentially reversible Detect/treat potentially reversible causes of renal failurecauses of renal failure

Preserve existing renal functionPreserve existing renal function Treat manifestationsTreat manifestations Prevent complicationsPrevent complications Provide for comfortProvide for comfort

34

Conservative Treatment Control Control

HyperkalemiaHyperkalemia HypertensionHypertension HyperphosphatemiaHyperphosphatemia HyperparthryoidismHyperparthryoidism AnemiaAnemia HyperglycemiaHyperglycemia DyslipidemiaDyslipidemia HypothyroidismHypothyroidism Nutrition : Describe a : Describe a renal dietrenal diet??

35

Depends on lab values-usually low NA, K, restricted protein, phosphorous, & fluids (See text)

Hemodialysis

Removal of soluble substances and water from the Removal of soluble substances and water from the blood by blood by diffusiondiffusion through a semi-permeable through a semi-permeable membrane.membrane.

Early animal experiments began 1913Early animal experiments began 1913 1st human dialysis 1940’s by Dutch physician Willem 1st human dialysis 1940’s by Dutch physician Willem

Kolff (2 of 17 patients survived)Kolff (2 of 17 patients survived) Considered experimental through 1950’s, No Considered experimental through 1950’s, No

intermittent blood access; for acute renal failure only. intermittent blood access; for acute renal failure only. 1960 Dr. Scribner developed Scribner Shunt-1960’s 1960 Dr. Scribner developed Scribner Shunt-1960’s

machines expensive, scarce, no funding.machines expensive, scarce, no funding. ““Death Panels” panels within community decided who Death Panels” panels within community decided who

got to dialyze.got to dialyze.

36

Hemodialysis ProcessHemodialysis Process

Blood removed from patient into Blood removed from patient into extracorporeal circuit. extracorporeal circuit.

Diffusion and ultrafiltration take and ultrafiltration take place in dialyzer. place in dialyzer.

Cleaned blood returned to patient. Cleaned blood returned to patient.

37

Extracorporeal CircuitExtracorporeal Circuit

38

How Hemodialysis WorksHow Hemodialysis Works

39

How Dialysis Works-Interactive!

An Introduction to Dialysis-How Stuff Works! (Step by Step)

YouTube- Hemodialysis! Great!

.

Vascular Access (click)

Arterio-venous shunt (External Arterio-venous shunt (External Shunt) *used now for Continuous Shunt) *used now for Continuous Renal Replacement Therapy (CRRT)-Renal Replacement Therapy (CRRT)-temporary accesstemporary access

Arterio-venous (AV) Fistula Arterio-venous (AV) Fistula (AKA-native (AKA-native or primary fistula)or primary fistula)

PTFE GraftPTFE Graft Temporary cathetersTemporary catheters ““Permanent” cathetersPermanent” catheters

41

External Shunt External Shunt (Schribner Shunt)(Schribner Shunt)

External- one end External- one end into artery, one into into artery, one into vein. vein.

AdvantagesAdvantages place at bedsideplace at bedside use immediatelyuse immediately

DisadvantagesDisadvantages infectioninfection skin erosionskin erosion accidental separation accidental separation limits use of limits use of

extremityextremity *Used now only for *Used now only for

CRRT-temporary CRRT-temporary 42

Arterio-venous (AV) Arterio-venous (AV) FistulaFistula

Primary (native) FistulaPrimary (native) Fistula Patients own artery and vein surgically Patients own artery and vein surgically

anastomosed.anastomosed. AdvantagesAdvantages

patient’s own vein/arterypatient’s own vein/artery longevitylongevity low infection and thrombosis rateslow infection and thrombosis rates

DisadvantagesDisadvantages long time to mature, 1- 6 monthslong time to mature, 1- 6 months ““steal” syndrome steal” syndrome requires needle sticks requires needle sticks

davita.com davita.com

43

PTFE PTFE (Polytetraflourethylene) (Polytetraflourethylene)

GraftGraft Synthetic “vessel” anastomosed into an artery and Synthetic “vessel” anastomosed into an artery and

vein.vein. AdvantagesAdvantages

for people with inadequate vesselsfor people with inadequate vessels can be used in 1-4 weekscan be used in 1-4 weeks prominent vesselsprominent vessels

DisadvantagesDisadvantages clots easilyclots easily ““steal” syndrome more frequentsteal” syndrome more frequent requires needle sticksrequires needle sticks infection may necessitate removal of graftinfection may necessitate removal of graft

44

Temporary CathetersTemporary Catheters Dual lumen catheter placed into a central vein-

subclavian, jugular or femoral. Advantages

immediate use no needle sticks

Disadvantages high incidence of infection subclavian vein stenosis poor flow-inadequate dialysis clotting Restricts movement

45

Cuffed Tunneled Catheters Cuffed Tunneled Catheters ((Dacron cuffDacron cuff))

Dual lumen catheter with Dual lumen catheter with Dacron cuff surgically tunneled Dacron cuff surgically tunneled into subclavian, jugular or into subclavian, jugular or femoral vein.femoral vein.

AdvantagesAdvantages immediate use; immediate use;

*permanent/long term use*permanent/long term use can be used for patients that can be used for patients that

can have No other permanent can have No other permanent accessaccess

no needle sticksno needle sticks DisadvantagesDisadvantages

high incidence of infectionhigh incidence of infection poor flows result in poor flows result in

inadequate dialysisinadequate dialysis clottingclotting 46

Above Native fistula (in place for

over 20 years)

*Remember- assess circulation-listen for bruit, feel for thrill!

Buttonhole technique-individual cannulates own fistula for home dialysis YouTube video

“Temporary” vascular access catheters- if tunnelled, with Dacron cuff, can be used long-term as Permacath, below.

Care of Vascular AccessCare of Vascular Access

NO BP’s, needle sticksNO BP’s, needle sticks to arm with to arm with vascular access. This includes finger vascular access. This includes finger sticks.sticks.

Place ID bands on other arm Place ID bands on other arm whenever possible.whenever possible.

Palpate Palpate thrill thrill and listen for and listen for bruit.bruit. Teach patient nothing constrictive, Teach patient nothing constrictive,

feel for thrill.feel for thrill.

48

Potential Potential Complications of HemodialysisComplications of Hemodialysis

During dialysisDuring dialysis Fluid and electrolyte related Fluid and electrolyte related

hypotensionhypotension CardiovascularCardiovascular

arrhythmiasarrhythmias Associated with the extracorporeal circuitAssociated with the extracorporeal circuit

exsanguinationexsanguination NeurologicNeurologic

Disequilibrium Syndrome & seizuresDisequilibrium Syndrome & seizures MusculoskeletalMusculoskeletal

crampingcramping OtherOther

fever & sepsisfever & sepsis blood born diseasesblood born diseases

49

Potential Complications of HemodialysisPotential Complications of Hemodialysis

Between treatmentsBetween treatments Hypertension/HypotensionHypertension/Hypotension EdemaEdema Pulmonary edemaPulmonary edema HyperkalemiaHyperkalemia BleedingBleeding Clotting of accessClotting of access

50

Long term Long term (due to (due to disease process & disease process &

managementmanagement) ) •MetabolicMetabolic•HyperparathyroidiHyperparathyroidismsm•Diabetic Diabetic complicationscomplications•CardiovascularCardiovascular

CHFCHFAV access failureAV access failureCardiovascular Cardiovascular diseasedisease

•RespiratoryRespiratoryPulmonary Pulmonary

edemaedema•NeuromuscularNeuromuscular

NeuropathyNeuropathy

Complications HemodialysisComplications Hemodialysis- - con’t-long con’t-long term, ESRDterm, ESRD

Long term cont’d Hematologic

anemia GI

bleeding dermatologic

calcium phosphorous deposits

Rheumatologic amyloid deposits

51

Long term cont’d•Genitourinary

•infection•Sexual dysfunction

•Psychiatric•depression

•Infection•blood borne pathogens

Dietary Restrictions-HemodialysisDietary Restrictions-Hemodialysis

Fluid restrictionsFluid restrictions Phosphorous restrictionsPhosphorous restrictions Potassium restrictionsPotassium restrictions Sodium restrictionsSodium restrictions Protein to maintain nitrogen balance Protein to maintain nitrogen balance

((complete)complete) too high - waste productstoo high - waste products too low - decreased albumin, increased too low - decreased albumin, increased

mortalitymortality Calories to maintain or reach ideal weightCalories to maintain or reach ideal weight

52

Urine output + 600 ml

Approx 800-1200 mg/day

Approx 1-2 g/day; 40 mg/kg/IBWApprox 1-2 g/day

Peritoneal Dialysis Removal of soluble substances and water from blood by Removal of soluble substances and water from blood by

diffusion diffusion through a semi-permeable membrane through a semi-permeable membrane (peritoneum) that is intracorporeal (inside body).(peritoneum) that is intracorporeal (inside body).

Solution warm to body temperature Solution warm to body temperature prior to prior to instillation into peritoneal cavity via peritoneal instillation into peritoneal cavity via peritoneal cathetercatheter

Metabolic waste products and excessive electrolytes Metabolic waste products and excessive electrolytes diffuse diffuse into dialysate while it remains in abdomeninto dialysate while it remains in abdomen

Fluid removal Fluid removal controlled by glucose (dextrosecontrolled by glucose (dextrose) ) concentration in dialysate (acts as “osmotic” agent)concentration in dialysate (acts as “osmotic” agent)

Excess fluid/solutes removed- gradual/constant-Excess fluid/solutes removed- gradual/constant- Fluid drained by gravity into sterileFluid drained by gravity into sterile bag at set bag at set

intervals- intervals- 1.1. ““Clear”Clear” solution ‘fills” abdomen solution ‘fills” abdomen2.2. ““Yellow”Yellow” urine-like fluid drains out (like urine, clear) urine-like fluid drains out (like urine, clear)3.3. Types of Peritoneal DialysisTypes of Peritoneal Dialysis

1.1. *CAPD*CAPD: Continuous ambulatory peritoneal dialysis: Continuous ambulatory peritoneal dialysis2.2. *APD – Automated Peritoneal Dialysis*APD – Automated Peritoneal Dialysis

53

54

1. Fill (inflow): fluid infused into peritoneal cavity (usually 10-15 min).

2. Dwell time (equilibrium): time solution (dialysate) fluid remains in peritoneal cavity (duration depends on method- as CAPD 4-5 exchanges/day).

3. Drain (equilibrium): time fluid drains from peritoneal cavity by gravity flow (usually 20-30 min); facilitate by gently massaging abdomen, changing position.

CAPD

Phases of Peritoneal Dialysis Exchange

CAPD APDCAPD APD Catheter into peritoneal cavityCatheter into peritoneal cavity Exchanges 4 - 5 times per dayExchanges 4 - 5 times per day Treatment 24 hrs; 7 days a Treatment 24 hrs; 7 days a

weekweek Solution remains in peritoneal Solution remains in peritoneal

cavity except during drain cavity except during drain timetime

Independent treatmentIndependent treatment

Automated Peritoneal Dialysis- fluid exchanges automatically by machine-(also known as continuous cycling peritoneal dialysis (CCPD), requires “cycler machine”- programmable- to automate filling and draining process.

Treatment at home, typically at night (while sleeping-thus no fluid in “the belly” at daytime

Click to play animation

Videos-Dialysis, all types! Click to locate desired video

Complications of Peritoneal of Peritoneal DialysisDialysis

InfectionInfection peritonitisperitonitis tunnel infectionstunnel infections catheter exit site catheter exit site

HypervolemiaHypervolemia hypertensionhypertension pulmonary edemapulmonary edema

HypovolemiaHypovolemia hypotensionhypotension

Hyperglycemia Hyperglycemia MalnutritionMalnutrition

ObesityObesity HypokalemiaHypokalemia HerniaHernia Cuff erosionCuff erosion Low back painLow back pain HyperlipidemiaHyperlipidemia

Peritoneal Catheter Exit SitePeritoneal Catheter Exit Site

57

Advantages of PDAdvantages of PD

Independence for patientIndependence for patient No needle sticksNo needle sticks Better blood pressure controlBetter blood pressure control Some diabetics add insulin to solutionSome diabetics add insulin to solution Fewer dietary restrictionsFewer dietary restrictions

protein loses in dialysateprotein loses in dialysate generally need increased potassiumgenerally need increased potassium less fluid restrictionsless fluid restrictions

58

59

Multi-prong system occasionally used with PD patients in hospital settings

Which dialysis “bags” have already been infused?

The “yellow” ones!- dialysis nurse sets up bags, staff nurse infuses, drains according to schedule.

Medications - Dialysis Patients & CKD Dialysis Patients & CKD (Stages 4-5)(Stages 4-5)

Vitamins - water solubleVitamins - water soluble Phosphate binder - (Phoslo, Renagel, Calcium, - (Phoslo, Renagel, Calcium,

*Aluminum hydroxide-*Aluminum hydroxide-risksrisks) Give with meals) Give with meals Iron - don’t give with phosphate binder or calciumIron - don’t give with phosphate binder or calcium Antihypertensives – Antihypertensives – typicallytypically hold prior to dialysis hold prior to dialysis ErythropoietinErythropoietin Calcium Supplements - Calcium Supplements - BetweenBetween meals, meals, notnot with iron with iron Activated Vitamin DActivated Vitamin D3 3 - aids in calcium absorption- aids in calcium absorption Antibiotics - hold dose prior to dialysis if it dialyzes Antibiotics - hold dose prior to dialysis if it dialyzes

outout

61

MedicationsMedications

Many drugs or their metabolites are excreted by the kidney

Dosages - many change when used in renal failure patients

Dialyzability - many removed by dialysis varies between HD and PD

62

Patient Patient EducationEducation

Alleviate fearAlleviate fear Dialysis processDialysis process Fistula/catheter careFistula/catheter care Diet and fluid restrictionsDiet and fluid restrictions MedicationMedication Diabetic teachingDiabetic teaching

63

Case StudyCase StudyA 48 year old female with a history of A 48 year old female with a history of

uncontrolled diabetes presents to the ER. Her uncontrolled diabetes presents to the ER. Her chief complaints are nausea, vomiting and chief complaints are nausea, vomiting and fatigue.fatigue.

Lab: BUN 100; Creatinine 10; H&H 7.0/21.4; Lab: BUN 100; Creatinine 10; H&H 7.0/21.4;

KK+ + 6.0, PO 6.0, PO4 4 5.5; Ca5.5; Ca++ ++ 7.57.5

What do you suspect? How would she possibly What do you suspect? How would she possibly be treated?be treated?

*Access *Access Evolve Apply Case Study- Chronic Renal Failure Chronic Renal Failure

*Access *Access Renal Case Study64

65

Case StudyCase Study

35-year-old man began to notice 35-year-old man began to notice weakness with activities such as walking weakness with activities such as walking distances or running.distances or running.

Also began experiencing tingling all over Also began experiencing tingling all over his body, particularly in his hands and feethis body, particularly in his hands and feet

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

66

Case Study: HistoryCase Study: History

At age 11, he was admitted to the same At age 11, he was admitted to the same hospital with gross hematuria.hospital with gross hematuria. Albuminuria 4+Albuminuria 4+ BUN 10.5 mg/dLBUN 10.5 mg/dL Hb 15.7 g/dLHb 15.7 g/dL Diagnosed with recurring acute Diagnosed with recurring acute

glomerulonephritisglomerulonephritis


67


He had no follow-up medical care after He had no follow-up medical care after that hospitalization until his current that hospitalization until his current admission to the hospital. admission to the hospital.


68


Current lab valuesCurrent lab values Potassium 6.0 mEq/LPotassium 6.0 mEq/L BUN 110 mg/dLBUN 110 mg/dL Creatinine 12 mg/dLCreatinine 12 mg/dL Hct 20%Hct 20% Hb 6 g/dLHb 6 g/dL


69

Discussion QuestionsDiscussion Questions

1.1. Why would his symptoms seem similar to Why would his symptoms seem similar to diabetes?diabetes?

2.2. Why is he developing chronic renal failure Why is he developing chronic renal failure so many years after his primary so many years after his primary diagnosis?diagnosis?


Kidney TransplantKidney Transplant

TreatmentTreatment not not curecure

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View also Organ Donation video

Kidney TransplantKidney Transplant

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•More than 75,000 patients currently awaiting kidney transplants.

•Less than ¼ ever receive a kidney

Kidney awaiting “owner!”

•Extremely successful1-year graft survival rate

•90% cadaver transplants•95% live donor transplants

Advantages Advantages DisadvantagesDisadvantages

Restoration of Restoration of “normal” renal “normal” renal functionfunction

Freedom from dialysisFreedom from dialysis Return to “normal” lifeReturn to “normal” life Reverses Reverses

pathophysiological pathophysiological changes related to RFchanges related to RF

Less expensive than Less expensive than dialysis after 1dialysis after 1stst year year

Life long Life long medicationsmedications

Multiple side Multiple side effects from effects from medicationmedication

Increased risk of Increased risk of tumortumor

Increased risk Increased risk infectioninfection

Major surgeryMajor surgery

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Kidney TransplantationKidney TransplantationRecipient SelectionRecipient Selection

Candidacy determined by a variety of medical and

psychosocial factors that vary among transplant centers. .


•Contraindications to transplantationDisseminated malignanciesUntreated cardiac diseaseChronic respiratory failureExtensive vascular diseaseChronic infectionUnresolved psychosocial disorders

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Kidney TransplantationKidney TransplantationHistocompatibility Studies Donor SourcesHistocompatibility Studies Donor Sources

Purpose of testing is to identify the HLA antigens for both donors and potential recipients. .

•Compatible blood type deceased donors•Blood relatives•Emotionally related living donors•Altruistic living donors•Paired organ donation

Donor SourcesDonor Sources

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Kidney TransplantationKidney TransplantationNursing ManagementNursing Management

Preoperative carePreoperative care Emotional and physical preparationEmotional and physical preparation Immunosuppressive drugsImmunosuppressive drugs ECGECG Chest x-rayChest x-ray Laboratory studies Laboratory studies


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Kidney TransplantationKidney TransplantationSurgical ProcedureSurgical Procedure

Live donor Nephrectomy performed by urologist or transplant

surgeon Begins an hour or two before recipient’s surgery started Rib may need to be removed for adequate view Takes about 3 hours Laparoscopic donor nephrectomy

Alternative to conventional nephrectomy Most common approach of live kidney procurement


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Kidney TransplantationKidney TransplantationSurgical ProcedureSurgical Procedure

Kidney transplant recipient Usually placed extraperitoneally in the iliac fossa Right iliac fossa is preferred.


Care of RecipientCare of Recipient

Major surgery with general anesthesiaMajor surgery with general anesthesia Assessment of renal functionAssessment of renal function Assessment of fluid and electrolyte Assessment of fluid and electrolyte

balancebalance Prevention of infectionPrevention of infection Prevention and management of rejectionPrevention and management of rejection

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Kidney TransplantationKidney Transplantation Surgical ProcedureSurgical Procedure

Kidney transplant recipient Before incision

Urinary catheter placed into bladder Antibiotic solution instilled

Distends bladder Decreases risk of infection

Crescent-shaped incision


•Rapid revascularization critical•Donor artery anastomosed to recipient internal/external iliac artery•Donor vein anastomosed to recipient external iliac vein

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Kidney TransplantationKidney Transplantation Surgical ProcedureSurgical Procedure

Kidney transplant recipient When anastomoses complete,

clamps released -blood flow reestablished Urine may begin to flow, or diuretic may be given. Surgery takes 3 to 4 hours.


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Postoperative care Live donor

Care is similar to laparoscopic nephrectomy. Close monitoring of renal function Close monitoring of hematocrit

Recipient Maintenance of fluid and electrolyte balance-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

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Postoperative care (cont’d) Recipient

Urine output replaced with fluids milliliter by milliliter hourly

Urine output closely measured Acute tubular necrosis can occur.

May need dialysis Maintain catheter patency.


Post-op Care- cont- cont

ATN? (acute tubular necrosis) ATN? (acute tubular necrosis) 50% experience50% experience

Urine output >100 <500 cc/hrUrine output >100 <500 cc/hr BUN, creatinine, creatinine clearanceBUN, creatinine, creatinine clearance Fluid Balance-careful monitorFluid Balance-careful monitor UltrasoundUltrasound Renal scansRenal scans Renal biopsyRenal biopsy

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Kidney TransplantationKidney TransplantationImmunosuppressive TherapyImmunosuppressive Therapy

Goals Adequately suppress immune response. Maintain sufficient immunity to prevent overwhelming

infection.

•Major complicationMajor complication of transplantation due to of transplantation due to immunosuppressionimmunosuppression HANDWASHING keyHANDWASHING key•AvoidAvoid Crowds, Kids Crowds, Kids•Patient EducationPatient Education

Complications-RejectionComplications-Rejection Hyperacute Hyperacute - preformed antibodies to donor antigen- preformed antibodies to donor antigen

function ceases within 24 hoursfunction ceases within 24 hours Rx = removalRx = removal

Acute -Acute - generally after 1st 10 days to end of 2nd month generally after 1st 10 days to end of 2nd month 50% experience50% experience differentiate between rejection and cyclosporine differentiate between rejection and cyclosporine

toxicitytoxicity Rx = steroids, monoclonal (OKTRx = steroids, monoclonal (OKT33), or polyclonal ), or polyclonal

(HTG) antibodies(HTG) antibodies ChronicChronic - gradual process of graft dysfunction- gradual process of graft dysfunction

Repeat rejection episodes- not completely resolved Repeat rejection episodes- not completely resolved with treatmentwith treatment

4 months to years after transplant4 months to years after transplant Rx = return to dialysis or re-transplantationRx = return to dialysis or re-transplantation

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Immunosuppressant DrugsImmunosuppressant Drugs

Corticosteroids-Corticosteroids-PrednisonePrednisone Prevents infiltration Prevents infiltration

of T lymphocytesof T lymphocytes Side effectsSide effects

cushingnoid cushingnoid changeschanges

Avascular NecrosisAvascular Necrosis GI disturbancesGI disturbances DiabetesDiabetes infectioninfection risk of tumorrisk of tumor

Cytoxic AgentsCytoxic Agents--Azathioprine (Imuran); Azathioprine (Imuran); Mycophenolate Mycophenolate (*(*CellceptCellcept), *Cytoxin ), *Cytoxin (less toxic than Imuran)(less toxic than Imuran) PreventsPrevents rapid rapid

growing lymphocytesgrowing lymphocytes Side EffectsSide Effects

bone marrow toxicitybone marrow toxicity hepatotoxicityhepatotoxicity hair losshair loss infectioninfection risk of tumorrisk of tumor

Immunosuppressant DrugsImmunosuppressant Drugs

Calcineuin Inhibitors-Calcineuin Inhibitors-Cyclosporin, Neoral, Cyclosporin, Neoral, **PrograftPrograft, *, *FK506FK506 (more potent than (more potent than cyclosporincyclosporin)) Interferes Interferes with production of with production of

interleukin 2 which is interleukin 2 which is necessary for growth and necessary for growth and activation of T lymphocytesactivation of T lymphocytes..

Side EffectsSide Effects– NephrotoxicityNephrotoxicity– HTNHTN– HepatotoxicityHepatotoxicity– Gingival hyperplasiaGingival hyperplasia– InfectionInfection

Monoclonal Monoclonal antibody-antibody- OKT OKT33 - - used to treat used to treat rejection/induce rejection/induce immunosuppressionimmunosuppression decreases CDdecreases CD3 3 cells cells

within 1 hourwithin 1 hour Side effectsSide effects

anaphylaxisanaphylaxis fever/chillsfever/chills pulmonary edemapulmonary edema risk of infectionrisk of infection tumorstumors

1st dose reaction 1st dose reaction expected & wanted, expected & wanted, pre-treat with Benadryl, pre-treat with Benadryl, Tylenol, SolumedrolTylenol, Solumedrol

Immunosuppressant Drugs Immunosuppressant Drugs cont’dcont’d

Polyclonal antibody-Atgam-Polyclonal antibody-Atgam-treat rejection treat rejection or induce immunosuppressionor induce immunosuppression decreased number of T lymphocytesdecreased number of T lymphocytes

Side effectsSide effects anaphylaxisanaphylaxis fever chillsfever chills leukopenialeukopenia thrombocytopeniathrombocytopenia risk of infectionrisk of infection tumortumor

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Kidney TransplantationKidney TransplantationComplicationsComplications

Infection Most common infections observed in the first monthMost common infections observed in the first month

Pneumonia Pneumonia Wound infectionsWound infections IV line and drain infectionsIV line and drain infections

Fungal infectionsFungal infections CandidaCandida Cryptococcus Cryptococcus AspergillusAspergillus Pneumocystis jiroveci Pneumocystis jiroveci

Viral infectionsViral infections CMVCMV

One of the most commonOne of the most common Epstein-Barr virusEpstein-Barr virus Herpes simplex virusHerpes simplex virus


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Cardiovascular disease Transplant recipients-inc incidence of atherosclerotic

vascular disease. Immunosuppressant >worsen HTN and hyperlipidemia. Adhere to antihypertensive regimen.

Malignancies Primary cause -immunosuppressive therapy. Regular screening-important preventive care.


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Recurrence of original renal disease Glomerulonephritis; IgA nephropathy Diabetes mellitus; Focal segmental sclerosis

Corticosteroid-related complications Aseptic necrosis of the hips, knees, and other joints Peptic ulcer disease Glucose intolerance and diabetes Dyslipidemia; Cataracts Inc incidence of infection and malignancy Close monitoring of side effects


Patient EducationPatient Education

Signs of infection Prevention of infection Signs of rejection

decreased urine output increased weight gain tenderness over kidney fever > 100 degrees F

Medications time, dose, side effects

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TransplantsTransplantsNotes from Organ Donation slides

Exclusion for Transplant not limited too Active vasculitis; or Life threatening extrarenal congenital

abnormalities; or Untreated coagulation disorder; or Ongoing alcohol or drug abuse; or Age over 70 years with severe co-morbidities; or Severe neurological or mental impairment, in

persons without adequate social support, such that the person is unable to adhere to the regimen necessary to preserve the transplant.

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Official Criteria for Deceased Official Criteria for Deceased DonorsDonors

Usually irreversible brain injuryUsually irreversible brain injury MVA, gunshot wounds, hemorrhage, anoxic brain MVA, gunshot wounds, hemorrhage, anoxic brain

injury from MIinjury from MI Must have effective cardiac functionMust have effective cardiac function Must be supported by ventilator to preserve organsMust be supported by ventilator to preserve organs Age 2-70Age 2-70 No IV drug use, HTN, DM, Malignancies, Sepsis, diseaseNo IV drug use, HTN, DM, Malignancies, Sepsis, disease Permission from legal next of kin & pronoucement of Permission from legal next of kin & pronoucement of

death made by MDdeath made by MD *Brain Death is the complete cessation of *Brain Death is the complete cessation of

all brain & brainstem function. It is death. all brain & brainstem function. It is death.

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Official Criteria for Living DonorsOfficial Criteria for Living Donors

Psychiatric evaluation Anesthesia evaluation Medical Evaluation

Free from diseases listed under deceased donor criteria

Kidney function evaluated Crossmatches done at time of

evaluation and 1 week prior to procedure

Radiological evaluation

Nurses Role in Event of Nurses Role in Event of Potential DonationPotential Donation

Notify TOSA of possible organ donation Identify possible donors Make referral in timely manner

Do not discuss organ donation with family Offer support to families after referral is

made & donation coordinator has met with family

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Six days after a kidney transplant from a deceased donor , the patient develops a temperature of 101.2° F (38.5°C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate:

1. Acute rejection, which is not uncommon and is usually reversible.

2. Hyperacute rejection, which will necessitate removal of the transplanted kidney.

3. An infection of the kidney, which can be treated with intravenous antibiotics.

4. The onset of chronic rejection of the kidney with eventual failure of the kidney.

Question

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Case Study Case Study

65-year-old woman with history of progressive renal failure for 5 years

Diagnosed with type 1 diabetes mellitus when 15 years old

After waiting for 9 months, she is notified that a diseased (cadaver) kidney has become available.

The kidney transplant is done.


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Discussion QuestionsDiscussion Questions

1. She does very well postoperatively and is ready for discharge. What are the priority teaching interventions?

ckd/esrd & transplant note-when viewing lab values in ppt-note that values are given as both as...

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