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Chronic Renal Failure. Progressive, irreversible damage to the nephrons and glomeruli Causes : recurrent kidney infections, vascular changes (Diabetes/Hypertension) etc. May be diffuse or limited to one kidney

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chronic renal failure2
Progressive, irreversible damage to the nephrons and glomeruli

Causes: recurrent kidney infections, vascular changes (Diabetes/Hypertension) etc. May be diffuse or limited to one kidney

Regardless of the cause: Decreased: GFR, tubular function & tubular reabsorption capabilities. Dysfunction fluids & electrolytes, acid base disturbances, & systemic problems develops

Chronic Renal Failure
chronic renal failure end stage renal disease esrd
Protein and waste metabolism accumulates in the blood (azotemia)

90% of kidney function is lost (kidney cannot adequately function)

Hypothesis: Nephrons remains intact, others progressively destroyed.

Adaptive response maintains function until ¾ are destroyed

Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately

Chronic Renal FailureEnd Stage Renal Disease (ESRD)
slide4
Polyuria is perhaps early sign of ESRD

As the disease progress – unable to rid the body of excess waste products via kidneys –uremia results – eventually other systems affected

When the creatinine clearance falls below 10 ml/min (average), GFR < 5ml/min (average) = dialysis

Other symptoms Nocturia, oliguria/anuria, increased K+, Mg++, PO4 and decrease Ca++, Neurological changes, CV changes, etc.

ESRD
stages of chronic renal failure
Diminished Renal Reserve Normal BUN, and serum creatinine absence of symptoms

Renal Insufficiency GFR is about 25% of normal, BUN Creatinine levels increased

Renal Failure GFR <25% of normal increasing symptoms

ESRD or Uremia GFR < 5-10% normal, creatinine clearance <5-10 ml/min

resulting in a cumulative effect

Stages of Chronic Renal Failure
treatment modalities
Decrease fluid 1000ml/day

Decrease protein (.5-1kg body weight)

Decrease sodium (1-4gm variable)

Decrease potassium

Decrease phosphorous (<1000mg/day)

Dialysis (periotoneal, hemodialysis)

RBC, Vitamin D (calcitrol replacement) etc.

Treatment Modalities
dialysis hemodialyis hemo peritoneal pd
General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another

Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)

Peritoneal – Peritoneal membrane is the semi permeable membrane

Dialysis Hemodialyis(Hemo)Peritoneal (PD)
osmosis diffusion ultrafiltration
Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through

Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment

Osmosis-Diffusion-Ultrafiltration

Osmosis - movement fluidfrom an area of< to >

concentration of solutes(particles)

peritoneal dialysis
Catheter placement – anterior abdominal wall

Tenckoff (25cm length with cuff anchor and migration)

Dialysis solution (1-2 liters sometimes smaller)

Three phases of PD

Inflow (fill) approximately 10 minutes, could be in cycles)

Dwell (equilibration) (approximately 20-30 min or 8 hours+)

Drain (approximately 15 minutes)

These 3 phases are called Exchanges

Peritoneal Dialysis
hemodialysis
Vascular access for high blood flow

Shunts, (telfon, external)

Arteriovenous fistulas and grafts (AV)

Anastomosis between an artery and vein

Fistulas are native vessels (4-6 wks maturity)

Grafts are artificial/synthetic material

Hemodialysis
hemodialysis12
Hemodialysis

AV Fistula Communication

AV Graph Access

hemodialysis13
Hemodialysis

Hemodialysis Circuit

Hemodialysis Machine

pd advantages and disadvantages
Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Bacterial/chemical periotonitis

Protein loss

Exit site of catheter

Self image

Hyperglycemia

Surgical placement of catheter

Multiple abdominal surgery

PD Advantages and Disadvantages

Advantages

Disadvantages

hemo advantages disadvantages
Rapid fluid removal

Rapid removal of urea & creatinine

Effective K+ removal

Less protein loss

Lower triglycerides

Home dialysis possible

Temporary access at the bedside

Vascular access problems

Dietary & fluid restrictions

Heparinization

Extensive equipment

Hypotension

Added blood lost

Trained specialist

Hemo Advantages & Disadvantages

Advantages

Disadvantages

disequalibrium syndrome
Fluid removal and decrease in BUN during hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures

Treatment: Hypertonic saline, Normal saline

Disequalibrium Syndrome
nursing care pre post dialysis
Weigh before & after

Assess site before & after (bruit, thrill, infection, bleeding etc.)

Medications (precautions before & after)

Vital signs before and after etc.

Nursing Care Pre, Post Dialysis
renal transplant
Living and Cadaveric donors

Predialysis: obtain a dry weight free of excess fluids and toxins

More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement

Delay may increase ATN

Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)

Renal Transplant
immunological compatibility of donor and recipient
Done to minimize the destruction (rejection) of the transplanted kidney

HUMAN LEUKOCYTE ANTIGEN (HLA)

This gives you your genetic identity (twins share identical HLA)

HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.

Immunological Compatibility of Donor and Recipient
immunological analysis
WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney

A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation

Immunological Analysis
immulogical analysis
MIXED LYMPHOCYTE CULTURE

The donor and recipient lymphocytes are

mixed. Result = HIGH SENTIVITY, this is contraindicated for renal transplantation.

ABO BLOOD GROUPING

ABO blood group must be compatible

Immulogical Analysis
surgery
LLQ of the abdomen outside of the peritoneal cavity

Renal artery and vein anastomosed to the corresponding iliac vessels

Donor ureters are tunneled into the recipients’ bladder.

Surgery
complications post transplant
Rejection is a major problem

Hyperacute rejection: occurs within minutes to hours after transplantation

Renal vessels thrombosis occurs and the kidney dies

There is no treatment and the transplanted kidney is removed

Complications Post Transplant
complications post transplant24
Acute Rejection: occurs 4 days to 4 months after transplantation

It is not uncommon to have at least one rejection episode

Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)

Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys

Complications Post Transplant
complications post transplant25
Chronic Rejection: occurs over months or years and is irreversible.

The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury

Gradual occlusion renal blood vessels

Signs: proteinuria, HTN, increase serum creatinine levels

Supportive treatment, difficult to manage

Replace on transplant list

Complications Post Transplant
complications post transplant26
Infection

Hypertension

Malignancies (lip, skin, lymphomas, cervical)

Recurrence of renal disease

Retroperiotneal bleed

Arterial stenosis

Urine leakage

Complications Post Transplant