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Renal Failure and Treatment

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  1. Renal Failure andTreatment Vicky Jefferson, RN, CNN

  2. Bones can break, muscles can atrophy, glands can loaf, even the brain can go to sleep without immediate danger to survival. But -- should kidneys fail.... neither bone, muscle, nor brain could carry on. Homer Smith, PhD

  3. History • Early animal experiments began 1913 • 1st human dialysis 1940 by Dutch physician Willem Kolff (2 of 17 patients survived) • Considered experimental through 1950’s, No intermittent blood access; for acute renal failure only.

  4. History cont’d • 1960 Dr. Scribner developed Scribner Shunt • 1960’s Machines expensive, scarce, no funding. • “Death Panels” panels within community decided who got to dialyze.

  5. Normal Kidney Function • Fluid balance • Electrolyte regulation • Control acid base balance • Waste removal • Hormonal function • Erythropoietin • Renin • Active Vitamin D3 • Prostaglandins


  6. Acute Renal Failure (ARF) • Sudden onset - hours to days • Often reversible • Severe - 50% mortality rate overall; generally related to infection.

  7. Chronic Renal Failure (CRF) • Slow onset - years • Not reversible

  8. Causes of Chronic Renal Failure • Diabetes • Hypertension • Glomerulonephritis • Cystic disorders • Developmental - Congenital • Infectious Disease

  9. Causes of Chronic Renal Failure cont’d • Neoplasms • Obstructive disorders • Autoimmune diseases • Lupus • Hepatorenal failure • Scleroderma • Amyloidosis • Drug toxicity

  10. Stages of Chronic Renal Failure • Reduced Renal Reserve • Renal Insufficiency • End Stage Renal Disease (ESRD)

  11. Stage 1: Reduced Renal Reserve • Residual function 40 - 75% of normal • BUN and Creatinine normal (early) • No symptoms

  12. Stage II: Renal Insufficiency • Residual function 20 - 40 % normal • Decreased: glomerular filtration rate, solute clearance, ability to concentrate urine and hormone secretion • Symptoms: elevated BUN & Creatinine, mild azotemia, anemia

  13. Stage II: Renal Insufficiency cont’d • Signs and symptoms worsen if kidneys are stressed • Decreased ability to maintain homeostasis

  14. Stage III: End Stage Renal Disease (ESRD) • Residual function < 15% of normal • Excretory, regulatory and hormonal functions severely impaired. • metabolic acidosis

  15. Stage III: End Stage Renal Disease (ESRD) cont’d • Marked increase in: BUN, Creatinine, Phosphorous • Marked decrease in: Hemoglobin, Hematocrit, Calcium • Fluid overload

  16. Stage III: End Stage Renal Disease (ESRD) cont’d • Uremic syndrome develops affecting all body systems • Last stage of progressive CRF • Fatal if no treatment

  17. Diagnostic Tools for Assessing Renal Failure • Blood Tests • BUN elevated (norm 10-20) • Creatinine elevated (norm 0.7-1.3) • K elevated • PO4 elevated • Ca decreased • Urinalysis • Specific gravity • Protein • Creatinine clearance

  18. Diagnostic Tools cont’d • Biopsy • Ultrasound • X-Rays

  19. Manifestations of Chronic Renal Failure

  20. Nervous System • Mood swings • Impaired judgment • Inability to concentrate and perform simple math functions • Tremors, twitching, convulsions • Peripheral Neuropathy • restless legs • foot drop

  21. Integumentary • Pale, grayish-bronze color • Dry scaly • Severe itching • Bruise easily • Uremic frost

  22. Eyes • Visual blurring • Occasional blindness

  23. Fluid - Electrolyte - PH • Volume expansion and fluid overload • Metabolic Acidosis • Electrolyte Imbalances • Hyperkalemia

  24. GI Tract • Uremic fetor • Anorexia, nausea, vomiting • GI bleeding

  25. Hematologic • Anemia • Platelet dysfunction

  26. Musculoskeletal • Muscle cramps • Soft tissue calcifications • Weakness • Related to calcium phosphorous imbalances

  27. Heart Lungs • Hypertension • Congestive heart failure • Pericarditis • Pulmonary edema • Pleural effusions

  28. Endocrine/Metabolic • Erythropoietin production decreased • Hypothyroidism • Insulin resistance • Growth hormone decreased • Gonadal dysfunctions • Parathyroid hormone and Vitamin D3 • Hyperlipidemia

  29. Treatment Options • Hemodialysis • Peritoneal Dialysis • Transplant

  30. Hemodialysis • Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane.

  31. Hemodialysis Process • Blood removed from patient into the extracorporeal circuit. • Diffusion and ultrafiltration take place in the dialyzer. • Cleaned blood returned to patient.

  32. Hemodialysis Process

  33. HemodialysisCircuit

  34. ExtracorporealCircuit

  35. Vascular Access • Arterio-venous shunt (Scribner External Shunt) • Arterio-venous (AV) Fistula • PTFE Graft • Temporary catheters • “Permanent” catheters

  36. Scribner Shunt • External- one end into artery, one into vein. • Advantages • place at bedside • use immediately • Disadvantages • infection • skin erosion • accidental separation • limits use of extremity

  37. External (Scribner) Shunt

  38. Arterio-venous (AV) FistulaPrimary Fistula • Patients own artery and vein surgically anastomosed. • Advantages • patients own vein • longevity • low infection and thrombosis rates • Disadvantages • long time to mature, 1- 6 months • “steal” syndrome • requires needle sticks

  39. AV Fistula

  40. PTFE (Polytetraflourethylene) Graft • Synthetic “vessel” anastomosed into an artery and vein. • Advantages • for people with inadequate vessels • can be used in 7-14 days • prominent vessels • Disadvantages • clots easily • “steal” syndrome more frequent • requires needle sticks • infection may necessitate removal of graft

  41. PTFE Graft

  42. Temporary Catheters • Dual lumen catheter placed into a central vein-subclavian, jugular or femoral. • Advantages • immediate use • no needle sticks • Disadvantages • high incidence of infection • subclavian vein stenosis • poor flow-inadequate dialysis • clotting

  43. Cuffed Tunneled Catheters • Dual lumen catheter with Dacron cuff surgically tunneled into subclavian, jugular or femoral vein. • Advantages • immediate use • can be used for patients that can have no other permanent access • no needle sticks • Disadvantages • high incidence of infection • poor flows result in inadequate dialysis • clotting

  44. Cuffed TunneledCatheter

  45. Complications of Hemodialysis • During dialysis • Fluid and electrolyte related • hypotension • Cardiovascular • arrythmias • Associated with the extracorporeal circuit • exsanguination • Neurologic • seizures • other • fever

  46. Complications of Hemodialysis cont’d • Between treatments • Hypertension/Hypotension • Edema • Pulmonary edema • Hyperkalemia • Bleeding • Clotting of access

  47. Complications of Hemodialysis cont’d • Long term • Metabolic • hyperparathyroidism • diabetic complications • Cardiovascular • CHF • AV access failure • Respiratory • pulmonary edema • Neuromuscular • neuropathy

  48. Complications of Hemodialysiscont’d • Long term cont’d • Hematologic • anemia • GI • bleeding • dermatologic • calcium phosphorous deposits • Rheumatologic • amyloid deposits

  49. Complications of Hemodialysis cont’d • Long term cont’d • Genitourinary • infection • sexual dysfunction • Psychiatric • depression • Infection • bloodborne pathogens