Renal Replacement Renal Replacement TherapyTherapy

(RRT)(RRT)Types of therapy available to Types of therapy available to

patients who have failing patients who have failing kidneyskidneys

Debbie Jones RN CNeph(C)Debbie Jones RN CNeph(C)

ObjectivesObjectives

At the end of this presentation you will be familiar At the end of this presentation you will be familiar with:with:

• The stages of progressive renal failure or The stages of progressive renal failure or (Chronic Kidney Disease or CKD)(Chronic Kidney Disease or CKD)

• Causes : Acute vs Chronic Kidney DiseaseCauses : Acute vs Chronic Kidney Disease

• The renal replacement therapies available to The renal replacement therapies available to patients in North Bay and surrounding district who patients in North Bay and surrounding district who have either acute or chronic kidney failurehave either acute or chronic kidney failure

• The types of accesses required for peritoneal and The types of accesses required for peritoneal and

hemodialysishemodialysis

Primary Functions of the Primary Functions of the KidneyKidney

• Removal of metabolic wastes, drugs and Removal of metabolic wastes, drugs and other toxinsother toxins

• Fluid BalanceFluid Balance• Electrolyte BalanceElectrolyte Balance• Acid-Base RegulationAcid-Base Regulation• Blood Pressure Control Blood Pressure Control • Hormone Production ~ Erythropoietin, Hormone Production ~ Erythropoietin,

Vitamin D (Calcitriol), ReninVitamin D (Calcitriol), Renin

““Master Chemists of the Body”Master Chemists of the Body”

Acute Kidney Failure:Acute Kidney Failure:

• Pre-renal factors

• Intra-renal & Nephrotoxic factors

• Post-renal factors

Chronic Kidney Disease ~ Caused by:Chronic Kidney Disease ~ Caused by:• DiabetesDiabetes• HypertensionHypertension• Renal vascular disease Renal vascular disease (also generalized vascular disease)(also generalized vascular disease)

• NephritisNephritis• Pyelonephritis & chronic UT IPyelonephritis & chronic UT I• Polycystic kidney diseasePolycystic kidney disease• Renal NeoplasmsRenal Neoplasms• Analgesic nephropathyAnalgesic nephropathy• Immunological disorders such as Immunological disorders such as Lupus, Scleroderma, Lupus, Scleroderma,

Goodpasture syndromeGoodpasture syndrome• Metabolic disorders: goutMetabolic disorders: gout• Nephrotic Syndrome Nephrotic Syndrome primary or secondaryprimary or secondary

NEPHRON and GLOMERULUSNEPHRON and GLOMERULUS

Stages Of Chronic Kidney Stages Of Chronic Kidney DiseaseDisease

GFR ~ Glomerular Filtration Rate: Volume of plasma filtered from the glomerular capillaries into the Bowman’s GFR ~ Glomerular Filtration Rate: Volume of plasma filtered from the glomerular capillaries into the Bowman’s capsule each minute, expressed in mL/min. Average GFR for a young adult is 100 to 125 mL/mincapsule each minute, expressed in mL/min. Average GFR for a young adult is 100 to 125 mL/min ..

STAGE

DESCRIPTION

GFR

At Increased Risk

Risk factors for kidney disease

( e.g., diabetes, hypertension, family history, older age, ethnic group.

More than 90 mL/min

1

Kidney damage (protein in the urine) and normal GFR

More than 90 mL/min

2

Kidney damage and mild decrease

in GFR

60 to 89 mL/min

3

Moderate decrease in GFR

30 to 59 mL / min

4

Severe decrease in GFR

15 to 29 mL / min

5

Kidney Failure (dialysis or kidney

transplant needed)

Less than

15 mL/ml/min

UREMI C SYNDROMENEUROLOGI CAL

FatigueSleep Disturbances

HeadacheMuscular I rritability

LethargySeizures, Coma

PSYCHOLOGICALDepression

AnxietyDenial

PsychosisOCULAR

Red Eye SyndromeBand Keratopathy

HypertensiveRetinopathy

CARDIOVASCULARHypertension

CHFASHD

PericarditisMyocardiopathy

Uremic Lung

DERMATOLOGI CALPallor

PigmentationPruritis

EcchymosisExcoriations

Calcium DepositionUremic Frost

METABOLI CCarbohydrate I ntolerance

HyperlipidemiaNutrition

Gout

ENDOCRI NEHyperparathyroidismThyroid Abnormalities

AmenorrheaInfertility

Sexual Dysfunction

PERIPHERAL NEUROPATHYRestless Leg Syndrome

ParaesthesiasMotor Weakness

Paralysis

HEMATOLOGI CALAnemiaBleeding

GASTROINTESTINALAnorexiaNauseaVomiting

Uremic Fetor on BreathGastroenteritis

GI BleedingPeptic Ulcer

Does everyone understand Does everyone understand how important we are?how important we are?

Kidneys UrineKidneys Urine

Types of DialysisTypes of DialysisDialysis is a way to clean blood of wastes, Dialysis is a way to clean blood of wastes, fluids and salts that build up in the body fluids and salts that build up in the body when the kidneys fail. when the kidneys fail.

There are two types of dialysis, the first type There are two types of dialysis, the first type we will talk about is:we will talk about is:

Peritoneal Dialysis:Peritoneal Dialysis:• Uses the peritoneal membrane as the filter. Uses the peritoneal membrane as the filter.

The membrane covers the abdominal organs The membrane covers the abdominal organs and lines the abdominal wall. This treatment and lines the abdominal wall. This treatment takes place takes place insideinside the body and requires the body and requires surgical placement of a catheter in the surgical placement of a catheter in the peritoneal cavity to allow fluid to be instilled peritoneal cavity to allow fluid to be instilled and drain out.and drain out.

Peritoneal DialysisPeritoneal Dialysis

Peritoneal DialysisPeritoneal Dialysis• Uses the Uses the peritoneal membraneperitoneal membrane as the as the filterfilter. The . The

membrane covers the abdominal organs and lines the membrane covers the abdominal organs and lines the abdominal wall. The abdominal wall. The membrane size is 1 – 2 mmembrane size is 1 – 2 m22 and and approximates the body surface area. Uses the following approximates the body surface area. Uses the following principles:principles:

• DiffusionDiffusion: movement of solutes across the peritoneal : movement of solutes across the peritoneal membrane from an area of higher concentration (in the membrane from an area of higher concentration (in the blood) to an area of lower concentration (the fluid within blood) to an area of lower concentration (the fluid within the peritoneal cavity)the peritoneal cavity)

• OsmosisOsmosis:: movement of water across the peritoneal movement of water across the peritoneal membrane from an area of lower solute concentration to membrane from an area of lower solute concentration to an area of higher solute concentration.an area of higher solute concentration.

• Ultrafiltration:Ultrafiltration: water removal related to an osmotic water removal related to an osmotic pressure gradient with the use of various concentrations pressure gradient with the use of various concentrations of dialysate fluid. Glucose is the main ingredient in the of dialysate fluid. Glucose is the main ingredient in the solution that aids in the fluid removal.solution that aids in the fluid removal.

How does PD work?How does PD work?

• Fluid called Fluid called DIALYSATE DIALYSATE is put into the is put into the abdomen through a PD catheter. abdomen through a PD catheter. This fluid is left to dwell in the This fluid is left to dwell in the peritoneum for several hours.peritoneum for several hours.

• While in the abdomen, the fluid While in the abdomen, the fluid collects wastes that have been collects wastes that have been filtered through the peritoneal filtered through the peritoneal membrane. These wastes pass from membrane. These wastes pass from the body when the fluid is drained.the body when the fluid is drained.

Peritoneal DialysisPeritoneal Dialysis

• Performed daily, by the patient at home, Performed daily, by the patient at home, therefore more physiologicaltherefore more physiological

• Allows for independence, patients can Allows for independence, patients can work or travelwork or travel

• Fewer fluid and dietary restrictionsFewer fluid and dietary restrictions• Often fewer medications or lower doses Often fewer medications or lower doses

requiredrequired• Residual renal function preservedResidual renal function preserved• Ministry of Health funded Ministry of Health funded home therapyhome therapy

Peritoneal DialysisPeritoneal DialysisPatient responsibilities:Patient responsibilities:

• must have a clean room to perform must have a clean room to perform exchanges and a large enough area to exchanges and a large enough area to store all supplies no pets allowed in the store all supplies no pets allowed in the roomroom

• must learn to monitor their own weight must learn to monitor their own weight and blood pressuresand blood pressures

• must be able to follow important must be able to follow important instructions to prevent infection in the instructions to prevent infection in the peritoneumperitoneum

• must also be able to determine the must also be able to determine the choice of dialysate fluid and when to use choice of dialysate fluid and when to use itit

Peritoneal Dialysis CatheterPeritoneal Dialysis Catheter

Peritoneal Dialysis Peritoneal Dialysis 2 Types of Delivery2 Types of Delivery

Continuous Ambulatory Peritoneal Dialysis orContinuous Ambulatory Peritoneal Dialysis or CAPDCAPD

• The blood is cleaned constantly by dialysate fluid while The blood is cleaned constantly by dialysate fluid while it is in the abdomen.it is in the abdomen.

• CAPD does not require the use of a machine, the CAPD does not require the use of a machine, the exchanges are completed manually. Usually 4 times exchanges are completed manually. Usually 4 times daily.daily.

Automated Peritoneal Dialysis or Automated Peritoneal Dialysis or APDAPD

• Requires the use of a machine called a CYCLERRequires the use of a machine called a CYCLER• The CYCLER is used during the night and is set to The CYCLER is used during the night and is set to

deliver the fluid in and out of the abdomendeliver the fluid in and out of the abdomen..

Automated Peritoneal Dialysis Automated Peritoneal Dialysis

CyclerCycler

Second Type of Dialysis Second Type of Dialysis

Hemodialysis:Hemodialysis: • Uses a dialyzer or artificial kidney to Uses a dialyzer or artificial kidney to

filter the blood. This takes place filter the blood. This takes place outsideoutside the body and requires some form of the body and requires some form of access to the circulatory system. access to the circulatory system.

• Hemodialysis is accomplished with the Hemodialysis is accomplished with the use of a computerized control unit or use of a computerized control unit or dialysis machine.dialysis machine.

HemodialysisHemodialysis• Blood is circulated through an artificial kidney Blood is circulated through an artificial kidney

which has two compartments: Blood & Dialysate, which has two compartments: Blood & Dialysate, which are separated by a thin semi-permeable which are separated by a thin semi-permeable membranemembrane

• Waste and excess water pass from the blood side Waste and excess water pass from the blood side to the dialysate side and is discarded in the drain. to the dialysate side and is discarded in the drain. The cleaned blood is returned to the patient. The cleaned blood is returned to the patient. During the treatment, about 200 to 300 mL of During the treatment, about 200 to 300 mL of blood is out of the body at any given time.blood is out of the body at any given time.

• Hemodialysis results in Hemodialysis results in mass transfer based on mass transfer based on diffusiondiffusion (changing the levels of BUN, Creat,(changing the levels of BUN, Creat, lytes) & lytes) & fluid removal by the exertion of pressure within fluid removal by the exertion of pressure within the system (ultrafiltration) the system (ultrafiltration) usually done 3x /week usually done 3x /week ~ 3 to 4hrs~ 3 to 4hrs

HemodialysisHemodialysis• Hemodialysis treatments every other day are not Hemodialysis treatments every other day are not

as physiological as peritoneal dialysisas physiological as peritoneal dialysis

• Requires a trip to the hospital up to 3 times Requires a trip to the hospital up to 3 times weeklyweekly

• Patients can travel to other units but this must be Patients can travel to other units but this must be pre-arranged and space is not always availablepre-arranged and space is not always available

• Patients are more restricted in dietary and fluid Patients are more restricted in dietary and fluid intake between treatments intake between treatments

• Medication requirements different than for those Medication requirements different than for those on peritoneal dialysis e.g. require more on peritoneal dialysis e.g. require more antihypertensive meds, higher doses of antihypertensive meds, higher doses of ErythropoietinErythropoietin

Hemodialysis ~ The Hemodialysis ~ The “Integra”“Integra”

HemodialysisHemodialysis

• Requires access to the blood streamRequires access to the blood stream• Arterio – venous Arterio – venous fistulafistula• Arterio – venous Arterio – venous graftgraft

Or central venous access devices:Or central venous access devices:• Temporary catheter Temporary catheter • Long – term catheterLong – term catheter

Hemodialysis ~ fistulaHemodialysis ~ fistula

Hemodialysis ~ GraftHemodialysis ~ Graft

Temporary Hemodialysis Temporary Hemodialysis CatheterCatheter

Exit site at Exit site at surface of surface of the skinthe skin

Tip located Tip located at junction at junction of SVC and of SVC and right Atriumright Atrium

Tunneled Hemodialysis Tunneled Hemodialysis CatheterCatheter

Exit site Exit site

Catheter tunnelCatheter tunnel

Tip located Tip located at junction at junction of SVC and of SVC and right Atriumright Atrium

Other choices of treatment for Other choices of treatment for kidney failurekidney failure

kidney transplantation:kidney transplantation: • To be placed on a transplant list the patient To be placed on a transplant list the patient

must be on some form of renal replacement must be on some form of renal replacement therapy, whether it is peritoneal dialysis or therapy, whether it is peritoneal dialysis or hemodialysishemodialysis

• Once a patient is accepted for transplant, the Once a patient is accepted for transplant, the date of start of dialysis is the date they are date of start of dialysis is the date they are active on the list active on the list

• If the patient has a living donor who has been If the patient has a living donor who has been accepted as healthy donor, it is possible to accepted as healthy donor, it is possible to have a pre-emptive transplant, bypassing have a pre-emptive transplant, bypassing dialysis.dialysis.

No treatment or palliative careNo treatment or palliative care

TransplantationTransplantation

THAT’S ALL FOLKS!THAT’S ALL FOLKS! QUESTIONS? QUESTIONS?