Dialysis

1. Dialysis • Begun when the patient’s uremia can no longer be adequately managed conservatively • Initiated when the GFR <5 – 10% 0f normal

2. Dialysis • The movement of fluid and molecules across a semipermeable membrane from one compartment to another

3. Dialysis • Two methods of dialysis available • Peritoneal dialysis (PD) • Hemodialysis (HD)

4. General Principles of Dialysis • Diffusion • Osmosis • Ultrafiltration

5. Osmosis and Diffusion Across Semipermeable Membrane Fig. 45-5

6. DIALYSATE • Is an electrolyte solution that is similar to that of normal plasma, except contains no potassium • Different concentrations

7. Peritoneal DialysisDialysis Solutions and Cycles • Available commercially in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%

8. Peritoneal DialysisCatheter Placement • Peritoneal access is obtained by inserting a catheter (Tenckhoff) through the anterior wall • Technique for catheter placement varies • Usually done via surgery

9. Tenckhoff Catheter Fig. 45-6

10. Peritoneal DialysisDialysis Solutions and Cycles • Three phases of the PD cycle • Inflow (fill) • Dwell (equilibration) • Drain

11. Peritoneal DialysisComplications • Exit site infection • Peritonitis/Infection: cloudy dialysate • Hypotension • Abdominal pain (may be bowel perforation): brownish dialysate • Bladder perforation: amber dialysate • Outflow problems • Hernias • Lower back problems • Bleeding • Pulmonary complications • Protein loss • CHO and lipid abnormalities

12. Peritoneal DialysisTypes • Automated peritoneal dialysis (APD) • Continuous ambulatory peritoneal dialysis (CAPD)

13. Peritoneal DialysisAdvantages • Short training program • Independence • Ease of traveling • Fewer dietary restrictions • Greater mobility than with HD

14. HemodialysisVascular Access Sites • Shunts • Internal arteriovenous fistulas and grafts • Temporary vascular access

15. Vascular Access for Hemodialysis Fig. 45-11

16. HemodialysisDialyzers • Long plastic cartridge that contains thousands of parallel hollow tubes or fibers

17. Hemodialysis System Fig. 45-14

18. HemodialysisComplications • Hypotension • Muscle cramps • Loss of blood • Hepatitis • Sepsis • Disequilibrium syndrome

19. HemodialysisEffectiveness and Adaptation • Cannot fully replace the metabolic and hormonal functions of the kidneys • Can ease many of the symptoms • Can prevent certain complications

20. Kidney Transplantation • Over 54,000 patients currently awaiting cadaveric kidney transplants • Over 5200 living donor transplants done in 2002 • Extremely successful • 1-year graft survival rate • 90% for cadaver transplants • 95% for live donor transplants

21. Kidney Transplantation Advantages of kidney transplant compared with dialysis: • Reverses many of the pathophysiologic changes associated with renal failure • Eliminates the dependence on dialysis • Less expensive than dialysis after the 1st year

22. Kidney TransplantationRecipient Selection • Candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers Contraindications to transplantation: • Disseminated malignancies • Cardiac disease • Chronic respiratory failure • Extensive vascular disease • Chronic infection • Unresolved psychological disorders

23. Kidney TransplantationHistocompatability Studies • Purpose of testing is to identify the HLA antigens for both donors and potential recipients

24. Kidney TransplantationDonor Sources • Compatible blood type cadaver donors • Blood relatives • Emotionally related living donors • Altruistic living donors

25. Kidney TransplantationSurgical Procedure • Donor nephrectomy performed by a urologist or transplant surgeon • Begins an hour or two before the recipient’s surgery is started

26. Kidney TransplantationKidney Transplant Recipient Transplanted kidney • Usually placed extraperitoneally in the iliac fossa • Right iliac fossa is preferred Before incision: • Urinary catheter placed into bladder • Antibiotic solution instilled • Distends the bladder • Decreases risk of infection

27. Kidney TransplantationNursing ManagementPreoperative Care • Emotional and physical preparation • Immunosuppressive drugs • ECG • Chest x-ray • Laboratory studies

28. Kidney TransplantationNursing ManagementPostoperative Care Live donor • Care is similar to laparoscopic nephrectomy • Close monitoring of renal function Recipient • Maintenance of fluid and electrolyte balance is 1st priority

29. Kidney TransplantationImmunosuppressive Therapy Goals: • Adequately suppress the immune response • Maintain sufficient immunity to prevent overwhelming infection Medications: • Cyclosporin • Predisone • Prografin FK 506 (Tacrolimus) • Mycophenolate Mofetil (CellCept)

30. Kidney TransplantationComplications Rejection • Hyperacute (antibody-mediated, humoral) rejection • Occurs minutes to hours after transplantation

31. Kidney TransplantationComplications Rejection • Acute rejection • Occurs days to months after transplantation

32. Acute Rejection Fig. 45-19

33. Kidney TransplantationComplications Rejection • Chronic rejection • Process that occurs over months or years and is irreversible

34. Kidney TransplantationComplications Infection • Most common infections observed in the 1st month: • Pneumonia • Wound infections • IV line and drain infections • Fungal infections • Viral infections • CMV • Epstein-Barr virus • Herpes simplex virus

35. Kidney TransplantationComplications Cardiovascular disease • Transplant recipients have  incidence of atherosclerotic vascular disease Malignancies • Primary cause is immunosuppressive therapy

36. Kidney TransplantationComplications Recurrence of original renal disease • Glomerulonephritis • IgA nephropathy • Diabetes mellitus • Focal segmental sclerosis

37. Kidney TransplantationComplications Corticosteroid-related complications • Aseptic necrosis of the hips, knees, and other joints • Peptic ulcer disease • Glucose intolerance and diabetes • Hyperlipidemia • Cataracts • Increased incidence of infections and malignancies