Kidneys and Kidney Failure

Aboriginal Health

Begbie Hall - Royal Jubilee Hospital 2101 Richmond Ave Victoria, BC V8R 4R7

What are the Kidneys?

The kidneys are two reddish-brown organs located on either side of the spine, under the lower ribs and behind the stomach.

Each kidney is approximately the size of a clenched fist.

: filter waste products from the blood

:produce hormones which stimulate red

blood cell production in the bone marrow, regulate blood pressure, and

balance the absorption of calcium in the intestine

:regulate water in the body

What do the kidneys do?

A) Regulate water—excrete excess water as urine, and retain water as needed

B) Filter waste—excrete excess minerals such as

sodium (Na) and potassium (K) which are found in foods; and excrete creatinine and urea and other

toxins before they hit dangerous levels

C) Produce hormones— encourage red blood cell production in bone marrow; balance calcium and

phosphate absorption for bone formation ; regulate blood pressure to a healthy average of ~130/80

Why are the kidneys so important?

Progressive Renal Insufficiency I

End stage Renal Disease ___________I___________ I I Renal Replacement Death

I Dialysis Hemodialysis Peritoneal Dialysis Transplantation Living Donor Cadaveric

What happens when Kidneys go wrong?

1. Diabetes (lack of, or inability to properly use, insulin)

: high blood sugars—damage small blood vessels in eyes, kidneys, extremities : thickening vessel walls — restriction of blood flow — hypertension :changes in nerve function —- incomplete emptying of bladder —- urinary tract infection — damage to kidneys 2 Hypertension (high blood pressure) : damage small vessels of kidneys — reduces blood flow — damage to kidneys — increased production of hormone controlling blood pressure — pressure rises —damages small vessels of kidneys

What causes Kidneys to fail?

High pressure damages small vessels of kidneys Pressure rises Flow reduces

Increased production Further damage of hormone to kidneys and controlling blood filters pressure

Hypertensive Cycle

3. Drug-induced Chronic Renal Insufficiency :use of illegal drugs (eg. Cocaine, heroine) : long-term use of over-the-counter painkillers or anti-arthritis medications 4. Smoking : thickening of arterial walls due to fatty build up — reduced blood flow — hypertension : reduced oxygen levels 5. Diet (high cholesterol) : thickening of blood vessel walls due to fatty build up — hypertension 6. Glomerulonephritis (immune system attacks kidneys) : antigen-antibody clumps damage the filters in the kidneys 7. Urinary Tract Obstructions (eg. Enlarged prostate, kidney stones, tumors) : blockage of urinary outflow tract may cause urine to backup into kidneys, causing damage

8. Birth Defects (eg. Narrowing of upper or lower urether) : can lead to chronic renal insufficiency in children 9. Reflux Nephropathy : scarring of kidneys due to abnormal flow of urine from bladder to kidney : usually affects children born with an abnormal junction between the ureter and the bladder if not diagnosed early enough, scarring can lead to end-stage renal failure 10. Inherited Diseases a. Autosomal Dominant Polycystid Kidney Disease : kidneys are made up of fluid-filled cysts : pressure from expanding cysts damages kidney tissues and may ultimately lead to end-stage renal failure b. Fabry Disease (deficiency of enzyme Alfa-GAL) : appears more often in males : lack of enzyme — certain fatty substances are not removed from body — accumulation in vessel walls —– increasing damage to body —– early onset renal disease, cardiac disease, stroke : wide variety of symptoms can make diagnosis difficult

Signs: puffiness, swelling in eyes, hand, feet, legs (edema) Bloody, cloudy or dark urine Excessive foaming of urine Frequent nighttime urination Passing less urine, or difficulty in passing urine Weight loss Changes in skin color Vomiting Fatigue Abnormal blood tests Brittle hair and nails Shortness of breath Diarrhea Personality and behavior changes, withdrawal, depression

How do I know if something is wrong?

Symptoms: Apathy Cold intolerance Weakness Nausea Cramps, restless legs Loss of appetite Difficulty sleeping

Itchiness Decreased sexual desire Chest pain Metallic taste in mouth

Reduced insulin needs (in diabetics) Hypertension Anemia Decrease in, difficulty with concentration

The doctor has told me my kidneys

are failing? What happens next?

1.A referral to a Nephrologist, who will decide on a course of treatment depending on your situation; which could possibly include

2 a referral to the Kidney Care Clinic (pre-dialysis clinic) where you will meet with:

- the Receptionist, who will handle your appointment bookings and answer the telephone when you call - the Nurse, who will meet with you and your family to provide information on living with kidney disease, blood test results, treatment options, and ongoing support - the Social Worker, who can provide emotional support, and education on living with a chronic illness including counselling, problem-solving assistance, resources and referrals, and peer support - the Pharmacist, who will review your medication list and help resolve any drug-related questions or concerns - the Nutritionist, who will review your diet and nutritional needs, and suggest ways your diet could be modified to maintain good health and kidney function, while minimizing waste and fluid build up and the development of bone disease - the Nephrologist, who will review your bloodwork with you and discuss your future care plans, as well as answering any questions you might have about your condition

Creatinine - waste product of exercising muscles - numbers increase, kidney function decreases Normal range 40 – 120 µ mol/L Urea - waste product of breakdown of ingested protein - numbers increase, kidney function decreases Normal range 2.0—9.0 mmol/L Potassium - mineral found in foods, necessary for nerves and muscles - numbers greater than 7.0 mmol/L can be potentially dangerous Normal range 3.5—5.0 mmol/L Calcium - mineral needed for nerves, muscles, and bone production - a lack may result in leaching of calcium f rom bones, weakening them Normal range 2.0—2.6 mmol/L

What DO my blood tests mean?

Albumin - a blood protein maintained through good nutrition - number decreases when ill or when kidneys are leaking protein Normal range 35—50 g/L Phosphorus - mineral found in foods and in the blood - an excess may result in calcium being leached from the bones, and a dietary limitation on high- phosphorus foods (eg. Dairy foods, colas, nuts) Normal range 0.8—1.5 mmol/L Hemoglobin — carries oxygen in the healthy red blood cells - kidneys secrete a hormone which stimulates red blood cell production in bone marrow - number decreases when EPO production drops Normal range 115—160 g/L

• Insulin / pills—to metabolize food and reduce blood sugars

• Calcium-channel blockers (eg. Norvasc) - dialates blood vessels to reduce resistance and reduce blood pressure

• Diuretic (eg. HCTZ, Mannitol) - inhibits the absorption of sodium and chloride resulting in water loss

• Iron supplements (eg. Ferrous sulphate, Niferex) - replace or supplement lack of iron required to produce healthy red blood cells

• Phosphate binders (eg. Tums, Calsan) - binds with phosphates in food and is then excreted in the feces

• EPO (eg. Eprex) - stimulates production of red blood cells in the bone marrow

What are my medications for ?

• Multivitamins (eg. Replavite) - replaces vitamins and minerals which are excreted in the urine or are filtered out during dialysis

• Quinine—to prevent and treat cramping from fluid loss

• Albumin—used to increase blood volume and raise blood pressure

• Anticoagulant (eg. Heparin, Coumadin) - reduce chance of clotting n bloodstream or hemodialysis lines

• ACE Inhibitor (eg. Captopril, Ramipril) - reduces arterial resistance and reduces blood pressure

• β-blocker (eg. Atenolol) - slows the heartbeat, making the heart pump more efficiently

Medication Name

Strength Directions What is it for? Time of Day Taken

What is Kidney Replacement Therapy?

Therapy which takes the place of part or all of your kidney functions.

This can be done through DIALYSIS or TRANSPLANTATION

Dialysis is cleaning the blood of wastes and excess minerals and fluids mechanically rather

than naturally. There are 2 types of dialysis:

HEMODIALYSIS

- cleans the blood by pumping it through an “artificial kidney”

And

PERITONEAL DIALYSIS

- cleans the blood inside the body by exchanging fluid inside the abdominal cavity by means of a catheter

What is Dialysis?

A. Creating an access: 1. Fistula—surgically connecting a vein and an artery - needs to be exercised to mature, to increase size and blood flow - usually ready to use 12-16 weeks after surgery 2. Graft—surgically connecting a vein and an artery with a piece of short tubing - does not need to mature - usually ready to use 2-4 weeks after surgery 3. Venous Catheter—tubing inserted into the jugular vein just above the collarbone - ready to use almost immediately

What’s involved in Hemodialysis?

With fistulas and grafts, AVOID: • Having blood pressure, blood work

or IV drawn from that arm; • Wearing tight sleeves, cuffs or

accessories on that arm; • Sleeping on that arm, or keeping it

bent for long periods of time B. Hooking up 1. Fistula / Graft—site is cleaned, and if necessary, a local anesthetic is administered - needles are inserted into the vein or graft for arterial and venous flows - blood lines are connected - pump is turned on 2. Catheter—lumens are unwrapped, cleaned, and blood lines are connected - pump is turned on

C. The Run - 3-5 hours long, at least 3x per week in a hospital renal unit or a community dialysis unit The Renal Unit can provide medications as needed during the runs, and may provide food and drink for patients who need them. The Nephrologists will make rounds during the runs. The Community Unit is smaller and has less direct supervision. Nephrologists do not attend, clients must bring their own medications and food, and are encouraged to take a more active part in the treatment of their disease. - Pre-dialysis weight is recorded and the amount of fluid to be removed is calculated based on an estimated Dry Weight (optimal weight without retained fluid)

- Blood pressure, pulse, arterial and venous pressures, and amount of fluid removed are monitored periodically and recorded - At the end of the run, blood lines are disconnected, needles are withdrawn / catheter lumens are flushed and capped, blood pressure is taken, and post-dialysis weight is recorded - Client is free to go

A. Creating an access 1. A catheter is surgically inserted in the abdominal wall just below the navel, and will remain as long as PD is being used 2. It can be inserted under local or general anesthetic depending upon client and type of catheter B. The Exchange 1. The peritoneal cavity is filled with approximately 2L of dialysis fluid 2. Blood vessels in the peritoneum are exposed to the fluid, and excess water and wastes are drawn through the peritoneum into the dialysis fluid 3. The fluid is drained, and the abdominal cavity is refilled with fresh fluid 4x a day 4. Each exchange takes approximately 35-40 minutes.

What’s involved in Peritoneal Dialysis?

An organ transplant may NOT be suitable for everyone, depending upon: • general health • History of heart disease • History of blood circulation

problems • History of cancer • Emotional / psychological factors • Evidence of reluctance to comply

with medical treatment

• Obesity

What’s involved in Transplantation?

There are 2 types of kidney transplantation: A. Living Donor Transplant • Transplant from a donor, usually a

blood relative (better genetic match) • Can be planned for a best time

for both donor and recipient • Tends to last longer than a

cadaveric transplant • Donors must be carefully

tested to determine whether they are healthy enough to donate a kidney, and to determine the likelihood of the transplant working

complete medical history physical examination chest x-ray electrocardiogram (ECG) blood and urine tests kidney ultrasound kidney angiogram psychological interview

B. Non-living (Cadaveric) Transplant • A healthy kidney

from someone who has died suddenly is transplanted with the consent of the donor’s family

• Following a series of tests a potential recipient is put on a waiting list until a compatible kidney is found

• Waiting times will vary depending upon difficulty of match and availability of organs

Before surgery: Tests are done for compatibility a. Blood group b. Tissue typing (testing the donor’s and the recipient’s blood to see if there is enough genetic similarity) c. Cross match (mixing donor and recipient’s blood to see if there are any cytotoxic antibodies which might cause the rejection of the transplanted kidney) Surgery: Usually approximately 2-4 hours The new kidney is placed in the lower abdomen, and the ureter is attached to the bladder It may take a few days for the new new kidney to become fully functional , so dialysis may be required until then Old kidneys will not be removed unless there is not enough room for the new kidney, or they are chronically infected

After surgery: Recovery time varies from person to person Tests are done to check the function of the transplanted kidney and to check for signs of rejection a. Blood tests– to assess kidney function and the effects of medications b. Ultrasound— to look at the size of the kidney, blood flow and any blockages c. Renal Scan—a substance is injected into the bloodstream and scanned to see how well the transplant is doing d. Biopsy—using a local anesthetic and a needle, a small piece of kidney tissue is removed and examined to see what is happening inside the kidney e. Fine Needle Aspiration—a fine needle is inserted into the transplanted kidney and a small amount of fluid is withdrawn, which contains kidney cells to be examined for signs of rejection

The resistance of the body to anything it recognizes as

not being its own. It can occur at any time following the transplant, but is more

common in the earlier months.

What is Rejection?

A variety of medications are used alone or in combination

to block the activity of the immune system to prevent rejection. But it can occur even if medication is taken

faithfully.

Early stages of rejection may not be felt, but rejection

can be detected through routine blood tests, and treated immediately with

special short-term medications, usually

successfully.

Signs and Symptoms of Rejection

Decrease in urine output Increased edema Pain over the transplant area Fever Generally feeling ill Increased creatinine level

Living Donor Transplant: 90-95 % success for the first year (this means that after 1 year, 80-85 of every 100 transplanted kidneys are still working) Cadaveric Transplant: 80 –85 % success for the first year Long-term success is good for people of all ages

What is the success rate of transplants?

How long a transplanted kidney will last varies. If a transplanted kidney does fail, you can go back to dialysis, and may even

qualify for another kidney in the future.

Pros Cons

Pros and Cons

Hemodialysis 1. Quick and effi-cient relief of edema 2. “Quiet time” 3. Able to bathe, swim, play sports, work as usual

1. Medications, limited diet and fluid intake 2. Needles 3. Must plan your week around your dialysis schedule 4. Must plan months ahead for vacations 5. Traveling to and from dialysis units 6. Some people have difficulty with suitable blood vessels for an access

Pros Cons

Peritoneal Dialysis 1. Less stressful on the body (continuous vs. intermittent) 2. More liberal diet 3. Not necessary to be in a hospital or clinic 4. Easier travel 5. Greater flexibility 6. Supplies can be de-livered to your desti-nation when traveling 7. Cost of supplies covered by provincial Renal Agency

1. Permanent catheter in abdomen 2. Possibility of infec-tion in peritoneal cav-ity 3. Daily routine 4. Medications, diet limitations and modi-fications 5. Taking time several times daily to ex-change

6. Limited bathing, no swimming, catheter needs to stay covered and dry

Transplantation 1. Free from dialysis 2. Greater variety on food choices 3. Increased energy and stamina 4. More normal life-style

1. Anti-rejection medi-cation 2. Uncertainty about rejection 3. Increased possibil-ity of infection 4. Increased possibil-ity of certain types of cancer

BC Transplant Society West Tower, 3rd Floor 555 West 12th Ave. Vancouver, BC (604) 877 2240 1 800 663 6189

BC NurseLine Vancouver, BC (604) 215 4700 1 866 215 4700

Your General / Family Practitioner

Aboriginal Liaison Nurse in your area South Island—Cora Jacks 370 8847 West Coast General—Ina Seecher Campbell River—Sandy Millar

Aboriginal Diabetes Team Fiona Devereaux Sue Schaefer Aboriginal Health Vancouver Island Health Author-ity Royal Jubilee Hospital Victoria, BC (250) 370 8258

Diabetes Outreach Worker Monique Taylor Victoria Native Friendship Centre 635 Johnson St. Victoria, BC (250) 384 3211

Diabetes Education Cen-tre Royal Jubilee Hospital Victoria, BC (250 ) 370 8322

Your Endocrinologist

Who can I ask for more information?

Your Nephrologist and/or your Family Doctor

Kidney Care Clinic In Victoria 1-250-370-8224 Toll free 1-800-370-8224

Kidney Foundation of Canada, BC Chapter 320—1600 West 6th Ave. Vancouver, BC (604) 736 9775 1 800 567 8112

Community Dialysis Unit In your community Duncan—715-2000 Nanaimo—741-5564 Cumberland—336-8508/8509 Port Alberni—724-1379 Victoria—356-9796

Canadian Diabetes Association—Native Project Vancouver, BC (604) 732 1331 1 800 665 6526

Canadian Diabetes Association—Diabetes Resource Centre Vancouver, BC (604) 732 4636 1 800 268 4656

Community Health Reps / Public Health Nurses

In the meantime...

Remember...

The Creator gives us nothing we cannot handle.

...to remember those who have gone before...

Live well...

...and to guide those who come after.

Prepared for Aboriginal Health by Faye Gray, a Metis woman who shares her personal story of strength & courage with all!