Kidney Failure and DialysisBy: Gale MacDonald and Marie Helene Bond

Presentation Overview Kidney disease in Canada

Functions of the kidney

Anatomy and physiology

Kidney failure- Acute: categories; phases; causes; clinical manifestations; prevention; and nsg interventions and Chronic-stages; S/S; risk factors; prevention; nsg interventins

Screening procedures; labs test

Treatment for renal failure

Dialysis- hemodialysis and peritoneal dialysis: nursing management and equipment

Transplant- nursing management

Conservative care

Case study

Quiz

Questions

Kidney Disease in Canada An estimated 2.6 million

Canadians have kidney disease, or are at risk.

Each day, an average of 16 people are told that their kidneys have failed.

The two leading causes of kidney failure in new patients: 1. Diabetes – 35%2. Renal Vascular Disease (including high blood pressure) – 18 %.

The number of Canadians being treated for kidney failure has tripled over the past 20 years. 53% of new renal failure patients are 65 years of age or older. Among the 39,352 people being treated for kidney failure in Canada in 2010: 59% (23,188) were on dialysis 41% (16,164) had a functioning transplant.

Function of Kidneys• Production of urine

and elimination of waste

• Facilitates electrolyte balance

• Facilitates acid-base balance

• Manages water balance and maintain blood osmolality

• Influences blood pressure and blood volume

• Renal clearance• Secretion of

prostaglandins • Conversion of vitamin

D to it’s active form• Assists with red blood

cell production (erythropoietin)

(Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 1405; Tortora & Derrickson, 2009, p. 1020 )

Anatomy of Kidney

The Nephron

Urine The formation of urine involves three major

processes:

1)Glomerular filtration in the renal corpuscles

2)Tubular reabsorption

3)Tubular secretion

Glomerular filtration in the Renal Corpuscles

“Filtration is a process by which blood pressure forces plasma and dissolved materials out of capillaries” (Williams & Hopper, 2007, p. 752)

“The blood pressure in the glomeruli is relatively high about 55mmHg. The pressure in Bowmen’s capsule in low and its inner layer is permeable, so approx 20% to 25 %of blood that enters the glomeruli becomes renal filtrate in bowmen’s capsule” (Williams & Hopper, 2007, p. 752)

“Renal filtrate is similar to blood plasma except that there is far less protein and no blood cells present” (Williams & Hopper, 2007 , p. 752).

“The glomerular filtration rate (GFR) is the amount of renal filtrate formed by the kidneys in one minute; It averages 100 to 125mL/min” (Williams & Hopper, 2007, p. 752).

Tubular reabsorption

“Tubular reabsorption is the recovery of useful materials from the renal filtrate and their return to the blood in the peritubular capillaries” (Williams & Hopper, 2007, p. 753).

Takes place in proximal convoluted tubules, distal convoluted tubules and collecting tubules (Williams & Hopper, 2007, p. 753).

“Mechanisms of reabsorption are active transport, osmosis, diffusion, facilitated diffusion and pinocytosis” (Williams & Hopper, 2007, p. 753).

Tubular Secretion

“In tubular secretion, substances are actively secreted from the blood in the peritubular capillaries into the filtrate in the renal tubules” (Williams & Hopper, 2007, p. 753).

Ammonia, creatinine, excess water soluble vitamins, the metabolic products of medications and Hydrogen ions may be secreted into urine (Williams & Hopper, 2007).

What Happens in the Nephron

Definition: The kidneys failure to expel

wastes, maintain electrolyte balance, concentrate urine, and maintain chemicals in the bloodstream that are regulated by the kidneys (ex. Renin) (Mosby’s Dictionary of Medicine, Nursing & Health Professionals, 2006).

Can be acute or chronic

Renal Failure

Acute Renal Chronic Renal

Failure Failure

Renal Failure

Acute Renal Failure

“Acute renal failure (ARF) is a sudden and almost complete loss of kidney function over a period of hours to days” (Day et al., 2010, p. 1435).

Oliguria: urine output of less then 400mL /day. is the most common clinical manifestation (p.1435).

Anuria (less than 50 ml of urine a day)

Elevated BUN and creatinine

Reversible if treated promptly

Categories of ARF

1. Prerenal: Hypoperfusion of the kidneys.

2. Intrarenal: Acute damage to kidney tissue

3. Postrenal: obstruction to urine flow

Phases of ARF Initiation phase: “begins

with the initial insult and ends with oliguria”

Oliguria phase:” manifested by a rise in the concentration of substances usually excreted by the kidney (urea, creatinine, uric acid, potassium and magnisium)”.

Diuresis:” gradual increase in urine output, which indicates GFR has started to recover.”

Recovery: “improvement of renal function may take 3 to 12 months. Lab values may return to normal. A permanent damage of 1% to 3% in GFR function is common, but not clinically significant”

(Day et al., 2010, p, 1437)

Causes of ARFPrerenal failure causes Intrarenal failure Postrenal failure

• Volume depletion resulting from: hemorrhage, diuretics, vomiting diarrhea nasogastric suction.

• Impaired cardiac efficiency resulting from: MI, dysthymias, cardiogenic shock.

• Vasodilation resulting from: sepsis, anaphylaxis, antihypertensive medications or other meds that cause vasodilatation.

• Prolong renal ischemia resulting from: trauma, crush injury, burns, transfusion reactions, hemolytic anemia.

• Nephrotoxic agents such as: gentamicin, heavy metals- lead and mercury, NSAID’s, ACE inhibitors, radiopaque dyes.

• Infectious processes such as: acute pyelonephritis, Acute glomerulonephritis.

• Urinary tract obstruction, including: calculi (stones), tumours, BPH, strictures, and blood clots.

Clinical Manifestations Pt will appear critically ill

and lethargic, and confused

Skin and mucus membranes will be dry from dehydration

drowsiness, headache, muscle twitching, and seizures.

dyspnea, crackles, tachypnea,

(Day et al., 2010, p. 1436)

Comparing the categories of ARF

Characteristics Prerenal Intrarenal Postrenal

etiology hypoperfusion Tissue damage obstruction

BUN

creatinine

Urine output Varies but often

Varies-may be decreased, or sudden anuria

Urine sodium To <20mEq/L To >40 mEq/L Varies- often to 20 mEq/L

Urine specific gravaty

Low normal Varies

Prevention of ARF Provide adequate hydration to clients at risk of dehydration.

( surgical client) Prevent and treat shock- with blood and fluids Treat hypotension promptly Continually assess renal function (output, Labs) Avoid transfusion reactions (always check two RN, and Five rights

and three checks Prevent and treat infection promptly (good catheter care) and pay

special attention to wounds, burns, and other precursors to sepsis Toxic drug effects- monitor blood levels, and ensure safe does

Day et al., 2010, p. 1437

Nursing interventions

Monitor intake and output, including all body fluids

May need to stimulate production of urine with IV fluids, diuretics.

Daily weights Monitor lab results, CBC,

BUN, creatinine, urea, e’lyles Watch hyperkalemia

symptoms: malaise, anorexia, parenthesia, or muscle weakness, EKG changes

Maintain nutrition Mouth care – dry mucus

membranes Assess for signs of cardiac

involvement- dysthymias Skin integrity problems.

Edema, itching –from toxins Signs and symptoms of

infection May need dialysis, or

continuous renal replacement therapy.

Chronic Renal failure (CRF) Definition: “ Chronic Renal failure is a progressive,

irreversible deterioration of renal function in which the body ability to maintain metabolic, fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous waste in blood) (Day et al., 2010, p. 1440).

Stages of CRF

The normal glomerular filtration rate (GFR) is 125ml/min/1.73m2 (Day et al., 2010, p. 1440)

The stages of renal failure is determined by the GFR (Day et al., 2010, p. 1440).

Stages of CRF Stage 1:

GFR>90ml/min/1.73m2 kidney damage with normal or elevated GFR

Stage 2 : GFR = 60-89ml/min/1.73m2 mild decrease in GFR

Stage 3: GFR = 30-59ml/min/1.73m2 moderate decrease in GFR

Stage 4: GFR = 15-29ML/MIN/1.73M2 Severe decrease in GFR

Stage 5: GFR<15ml/min/1.73m2 Kidney Failure (aka end stage renal failure)

Signs & Symptoms of CRF

Ammonia-like taste in mouth or urinous breath Edema of feet, hands, arms, face and around eyes Hypertension Extended neck veins Anemia Fatigue Neurologic disturbances Nausea, vomiting, and anorexia Headaches and blurred vision

Signs & Symptoms of CRF

Pruritus Shortness of breath Bone and joint problems Weakness, numbness, tremors, bone pain, and paresthesia Urine that is cloudy, tea-coloured, or bloody Decreased urine output or trouble urinating Foaming of urine Proteinuria

CRF Risk Factors

People at increased risk of developing kidney disease include people who have:

Diabetes

High blood pressure or blood vessel diseases

Glomerulonephritis and other systemic diseases

Family history of hereditary kidney disease

Certain ethnic groups such as Aboriginal, Asian, South Asian, Pacific Island, African/Caribbean and Hispanic origin

Nursing interventions CRF Assessing fluid status

Nutrition/Diet

Patient teaching

Assess emotional status and coping strategies

Assessing for complications

Administering Medications

Sum it up: major complications failure can affect almost every part of

your body. Potential complications may include:

Fluid retention, which could lead to swelling in your arms and legs, high blood pressure, or fluid in your lungs (pulmonary edema)

A sudden rise in potassium levels in your blood (hyperkalemia), which could impair your heart's ability to function and may be life-threatening

Heart and blood vessel disease (cardiovascular disease)

Weak bones and an increased risk of bone fractures

Anemia

Decreased sex drive or impotence Damage to your central nervous

system, which can cause difficulty concentrating, personality changes or seizures

Decreased immune response, which makes you more vulnerable to infection

Pericarditis, an inflammation of the sac-like membrane that envelops your heart (pericardium)

Pregnancy complications that carry risks for the mother and the developing fetus

Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survival

(Mayo clinic, 2012).

Screening for Renal Failure

Diagnostic Procedures Renal ultrasound CT MRI IVP Nephrotomogram Renal angiogram: Renal scan: Renal biopsy:

(Williams & Hopper, 2007)

Screening: Normal blood values to assess Kidney function

Urea 1.8 – 8.2mmol/L

Potassium 3.5 – 5.0mmol/L

Phosphate 0.8 – 1.4mmol/L

Calcium 2.0 – 2.6mmol/L

Creatinine 60 – 110umol/L (female)

70 – 120umol/L (Male)

Hemoglobin 120 – 140g/L (female)

140 – 160g/L (male)

GFR 90 – 120ml/min

(1.5 – 2.0ml/sec)

Assessing renal functionBlood testsCreatinine

Blood urea nitrogenHemoglobinHematocritSodiumPotassiumChlorideCalciumPhosphorusMagnesium

Urine testsUric acidUrine protein

Urine creatinine clearance

Normal value0.6-1.3 mg/dl

10-20 mg/dl12-18 grams/dl40%-50%136-145 mEq/liter3.5-5.1 mEq/liter98-107 mEq/liter8.2-10.2 mg/dl2.7-4.5 mg/dl1.3-2.1 mEq/liter

Normal value2.5-8.0 mg/dlNone

GFR= 120–125 ml/min

Change with chronic renal failureIncreased. Over 1.2 mg/dl in women and 1.4 mg/dl in menmerits further renal assessment.IncreasedDecreasedDecreasedVaries with free waterIncreasedVariesDecreasedIncreasedIncreased or normal

Change with chronic renal failureIncreasedPositive test result dictates follow- up urinalysis. >3,500 mg indicates glomerular disease.Decreased

Screening: Urine Testing Creatinine clearance formula:

(Volume of urine [ml/min] X Urine creatinine [MMOL/L])

Serum Creatinine (mmol/L)

As renal function decreases, creatinine clearance decreases

Day et al., 2010, pp1410

Treatment of Renal Failure

MedicationProper DietDialysis (2 types: peritoneal & hemodialysis)TransplantationConservation Care

Treatment of Renal Failure Medication: Medication may be used to help

maintain or improve kidney function, as well as, treat complications of renal failure (eg. Antihypertensives, kayexalate, etc.) (Day et al., 2010, pp 1442).

Diet for CRF Low protein

Low sodium

Low potassium

Fluid restrictions

Vitamin supplements

High calorie

Dialysis

When the kidneys are not removing fluid and uremic waste from the body, dialysis can be used to do so

Dialysis can be acute or chronic

Acute dialysis is used for people with high levels of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusion

Acute dialysis may also be used to remove certain medications or other toxins from the blood

Dialysis

Chronic dialysis is used for chronic renal failure

Dialysis can be used for years to help maintain people with no renal function

Indications may include: uremic signs and symptoms affecting all body systems, hyperkalemia, fluid overload, pericardial friction rub, and lack of well being

Types of Dialysis

Peritoneal Dialysis

Hemodialysis

Peritoneal Dialysis

Removes metabolic wastes and toxin’s so the body’s normal fluid and electrolyte balance is re-established

The peritoneum that lines the abdominal cavity and covers the abdominal organs acts as a semipermeable membrane that allows metabolic end products to be removed from the blood by means of diffusion and osmosis

Peritoneal Dialysis

An abdominal catheter allows sterile dialysate fluid to enter the peritoneal cavity

The metabolic waste products in the blood move from an area of high concentration (blood), across the peritoneal membrane, to an area of low concentration (peritoneal cavity with dialysate fluid)

Peritoneal Dialysis

The body’s excess fluid is removed by an osmotic gradient, because the dialysate fluid in the peritoneal cavity has a higher glucose concentration

the fluid is then removed from the peritoneal cavity and discarded

This process is repeated 4-6 times ever 24hrs

The most common complication from peritoneal dialysis is peritonitis

Peritoneal Dialysis

Equipment:

Peritoneal Dialysis Nursing management

Client and family education

Sterile technique (face mask, gloves, sterile field)

Signs and symptoms of peritonitis

Inspect site and dialysate solution for signs and symptoms of infection

Hemodialysis The most common type of dialysis

Purpose remains to remove toxins from the blood and excess water from the body

Usually patients receive Hemodialysis 3 times per week

Treatment takes about 3-8 hours per treatment

Hemodialysis

The blood is delivered from the patient and to the dialysis machine, where a dialyzer (artificial kidney) uses diffusion, osmosis, and ultrafiltration to remove toxins from the blood, which is then returned to the patient

The metabolic waste products in the blood move from an area of high concentration (blood), to an area of low concentration (dialysate)

Hemodialysis

Dialysate is a solution composed of electrolytes, which concentration levels can be adjusted to accommodate the desired electrolyte level in the patients blood

Osmosis and ultrafiltration is used to remove the body’s excess water

Arteriovenous fistula- is made by sewing a vein and artery together under the skin. Fistulas may take 2 to 4 months to mature. A temporary access device is usually needed until It matures (Williams & Hopper 2007, p. 803).

Arteriovenous graft: uses a tube of systhetic material to attach an artery and a vein. Needles are inserted into the graft to access the clients blood (Williams & Hopper 2007, p. 803).Hemodialy

sis: Vascular Access Device

Drag picture to placeholder or click icon to add

Two tailed subclavian/ double lumen, cuffed hemodialysis catheter used for acute hemodialysis.

Red port: blood line

Blue port: return dialyzed blood to client.

Hemodialysis Equipment

Nursing Management for Hemodialysis

Consult with physician about medications to hold prior to dialysis

Obtain weigh before dialysis and after dialysis note changes.

Coordinate blood draws with the dialysis nurse to avoid unnecessary needle pokes

Get morning care done early and give breakfast before dialysis

Apply emla patch to numb fistula or graft area

When the client returns assess for signs and symptoms of bleeding

Assess vital signs and admin medications that were held in the AM unless contraindicated

Allow for rest. Clients often exhausted after dialysis

(Williams & Hopper 2007, p. 803)

Nursing Management for Hemodialysis

Listen for a bruit at the site by placing stethoscope gently on the site. A bruit is a swishing sound made as the blood passes through the access site.

Gently palpate for a thrill, which is a buzzing or pulsing feeling that indicates good blood flow

Do not take BP, draw blood, start IV, or use tourniquet, on affected arm. injections should also be avoided. (Place sign above bed).

(Williams & Hopper 2007, p. 803)

Teach client to keep site clean, not to bump, or cut.

Teach client to not lift heavy objects with affected arm

Teach client to avoid tight jewellery and restrictive cloths on affected arm.

Teach client to avoid sleeping or bending affected arm for long periods of time

Notify physician of signs of bleeding, reduced circulation, or infection, coldness, numbness, weakness, redness, fever, drainage, swelling

Hemodialysis V.S peritonealHemodialysis

Requires vascular access device. Either temporary (ARF) or permanent (CRF).

Requires a complex specialized dialyzer

Requires a skilled hemodialysis nurse

Intermittent (q3-4days)

Principals of osmosis and diffusion

Preferred for end-stage renal failure

Peritoneal Requires a insertion of a catheter

into the peritoneal cavity

Does not require specialized dialyzer

Can be done by client (sterile technique)

Continuous (4-6 q 24hr)

Principals of osmosis and diffusion

Have few cardio side effects can be used in unstable clients.

Kidney Transplantation

Surgically transplanting a functioning kidney into a patient with end-stage renal disease

The donated kidney may be from either a living donor or a deceased donor

Kidney TransplantationNursing Management

Pre and postoperative teaching

Assessing patient coping and anxiety

Assessing for signs and symptoms of transplant rejection

Preventing infection

Monitoring urinary functioning

Psychological concerns

Monitoring and managing potential complications

Promoting home and community based care

Conservative Care

Some patients may view their quality of life as dramatically impaired by the renal replacement therapy, and consider it to be not worth the benefit of continued life.

Conservative Care offers physical and emotional comfort care to those patient who decide not to receive or continue with active treatment for renal failure. Allowing renal failure to take its natural course.

Conservative Care

The decision not to receive treatment for renal failure should only be made after serious consideration and assistance from the healthcare team.

The patient is supported by the healthcare team and efforts are made to manage symptoms until death occurs.

Quiz: true or false 1. Many of the body's organs need the kidneys to function properly and you could

die without healthy kidneys.

2. Kidney disease is a one-time acute illness that is strictly inherited.

3. There are no 'at risk' categories for kidney disease.

4. Usually, kidney disease starts slowly and silently, and progresses over a number of years.

5. There are 5 stages in kidney disease and everyone gets to Stage 5 sooner or later.

6. Chronic kidney failure is curable.

7. The gap between the need for kidneys and the number of available organs for transplantation is growing

Case study Mrs. Jacksons is a single, 56 year old women with a 20 Hx of type

two 1 diabetes, HTN, Hyperlipidemia, chronic anemia, and a total knee replacement. She has been diagnosed with chronic renal failure. She was admitted to a medical unit for treatment of SOB and renal failure. She had increasing SOB, pitting edema, urine output of 300 mL per day and is having PVC’s as seen on her cardiac monitor. Her labs are: Na 131; K 6; Cl 97; ca 10; iron 64; WBC 4000; RBC 3.12; Hgb 10.1; Hct 32; creatinine 7; BUN 30. She is having a two tailed subclavian catheter place in for blood access. She is having an eco and chest x-ray. She is withdrawn and quite in her room alone.

(Williams & Hopper 2007, p. 809)

Potential Nsg Diagnosis Fluid volume excess R/T edema and failure of renal regulatory mechanism.

Electrolyte abnormalities R/T edema and failure of renal regulatory mechanism.

Imbalanced nutrition: less than body requirements due to hyper catabolic sate

Urinary retention R/T neuropathy

Anxiety R/T illness/death

Infection R/T supressed immune system

Ineffective coping R/T loss of control

Noncompliance R/T apathy or denial

??Questions??

References References

Day, R. A., Paul, P., Williams, B., Smeltzer, S. C. & Bare, B. (2007). Brunner & Suddarth’s textbook of medical-surgical nursing (1st Canadian Ed.). PA: Lippincott, Williams & Wilkins.

Cannon, J. (2004). Recognizing chronic renal failure...the sooner the better. Nursing. 34(1), 50-53.

Mayo clinic. (2012). Chronic renal failure: complications. Retrieved from: http://www.mayoclinic.com/health/kidney-failure/DS00682/DSECTION=complications

Mosby’s Dictionary of Medicine, Nursing & Health Professionals (8th Ed.). (2006). p. 1485 St.Louis, Missouri; Mosby Elsevier.

Power, A., Chan, K., Singh, S. K., Taube, D., & Duncan, N. (2012). Appraising stroke risk in maintenance hemodialysis patients: A large single-center cohort study. American Journal of Kidney Diseases, 59(2), 249-257. Retrieved from: http://www.sciencedirect.com.libproxy.stfx.ca/science/article/pii/S0272638611011917

The kidney Foundation of Canada (2012). Facing the facts. Retrieved from: www.kidney.ca/document.doc?id=1376

Sens, F., Schott-Pethelaz, A. M., Labeeuw, M., Colin, C., Villar, E., & Rein Registry. (2011). Survival advantage of hemodialysis relative to peritoneal dialysis in patients with end-stage renal disease and congestive heart failure. Kidney International, 80(9), 970-7. Retrieved from: www.nature.com.libproxy.stfx.ca/ki/journal/v80/n9/full/ki2011233a.html?WT.ec_id=KI-201111

References Somers, J. (2008). Dietary management of renal disease. CANNT Journal, 18(3), 20-20. Retrieved

from: http://web.ebscohost.com.libproxy.stfx.ca/ehost/pdfviewer/pdfviewer?sid=1bd4242d-09f4-4559-8b60-b6a89c6dd895%40sessionmgr4&vid=2&hid=21

The Kidney Foundation of Canada. (2012). Retrieved From: www.kidney.caThe Kidney

Thibodeau & Patton, (2004). Structure& function of the body. St. Louis: Mosby.

Tortora, G. J., Derrickson, B. (2009). Principals of anatomy and physiology (12th Ed.). Danvers, MA: John Wiley & Sons, Inc.

Williams, L.S., Hopper, P.D. (2007). Understanding Medical Surgical Nursing. Philadelphia, PA: F. A. Davis Company.

Zarifian, A. (2006). Symptom occurrence, symptom distress, and quality of life in renal transplant recipients. Nephrology Nursing Journal : Journal of the American Nephrology Nurses' Association, 33(6), 609-618. Retrieved from: http://web.ebscohost.com.libproxy.stfx.ca/ehost/detail?sid=e2f8fd8c-b951-4e1c-a984-c0bbea9ad5fd%40sessionmgr4&vid=1&hid=21&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=c8h&AN=2009489628