Renal Failure

and
Treatment
Vicky Jefferson, RN, CNN
Satellite Dialysis
(modified by Kelle Howard, RN, MSN)

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, Ph.D.
2

REVIEW

What are nephrons?

What are the functions of the kidneys?

Normal creatinine & BUN?

Diagnostic tools

Functions of the Kidneys

Regulates ______ & _________ of

extracellular fluid

Regulates fluid & electrolyte balance thru

processes of: glomerular__________,
tubular _________, and tubular
_____________.

Name some of the F & Es regulated by

kidneys __________________
02/23/15

Functions of the Kidneys

(cont)

Regulates acid-base balance through

HCO3 and H+
*Hormonal functions: (BP control),
multisystem effect.

Renin Release

RAAS=

02/23/15

Functions of the Kidneys

(cont)

Erythropoietin Release
If a patient has chronic renal
failure, what condition will occur?
WHY???

02/23/15

Functions of the Kidneys

(cont)

Activate Vitamin D

Necessary to absorb Calcium in the

GI
tract.

If a patient has renal failure, what

will happen to the patients serum
calcium level? __________________

02/23/15

Functions of the Kidneys

_______________
_______________
_______________

______________
______________
______________
______________

Diagnostic Tools for

Assessing Renal Failure

Blood Tests
BUN
Creatinine
K+
PO4
Ca
Urinalysis
Specific gravity
Protein
Creatinine clearance
9

BUN

Normal 10-30 mg/dl

Nitrogenous waste product of
protein metabolism
Unreliable in measurement of renal
function

10

Creatinine

A waste product of muscle

metabolism
Normal value 0.5 - 1.5 mg/dl
2 times normal = 50% damage
8 times normal = 75% damage
10 times normal = 90% damage
Exception -_______________________
11

Diagnostic Tools

Biopsy
Ultrasound
X-Rays

12

Chronic Renal Failure

Slow progressive renal disorder

related to nephron loss, occurring
over months to years

Culminates in End Stage Renal

Disease

13

Characteristics of
Chronic Renal Failure

Cause & onset often unknown

Loss of function precedes lab
abnormalities
Lab abnormalities precede
symptoms
Symptoms (usually) evolve in orderly
sequence
Renal size is usually decreased
14

Causes of Chronic Renal

Failure

Diabetes
Hypertension
Glomerulonephritis
Cystic disorders
Developmental - Congenital
Infectious Disease

15

Causes of Chronic Renal

Failure

Neoplasms
Obstructive disorders
Autoimmune diseases
Hepatorenal failure
Scleroderma
Amyloidosis
Drug toxicity
16

Glomerular Filtration Rate

GFR

24 hour urine for creatinine clearance

Most accurate indicator of Renal Function

Reflects GFR
Formula:
urine creatinine X urine volume
serum creatinine

Can estimate creatinine clearance by:

Men: {140 age} x IBW (kg)
72 x serum creatinine
Women: {140 age} x IBW (kg)
85 x serum creatinine

What is a normal GFR?

17

Stages of Chronic Renal

Failure
Old System

Reduced Renal Reserve

Renal Insufficiency

End Stage Renal Disease (ESRD)

18

Stages of Chronic Renal

Failure
NKF Classification System

Stage 1:
GFR >/= 90 ml/min despite
kidney damage

19

Stages of Chronic Renal

Failure
NKF Classification System

Stage 2: Mild reduction

(GFR 60 89 ml/min)
1. GFR of 60 may represent
50%
loss in function.
2. Parathyroid hormones
starts to
increase.

20

During Stage 1 - 2

No symptoms

Serum creatinine doubles

Up to 50% nephron loss

21

Stages of Chronic Renal

Failure
NKF Classification System

Stage 3: Moderate reduction

(GFR 30 59 ml/min)
1.
2.
3.
4.

Calcium absorption decreases

Malnutrition onset
Anemia
Left ventricular hypertrophy

22

Stages of Chronic Renal

Failure
NKF Classification System

Stage 4: Severe reduction

(GFR 15 29 ml/min)
1. Serum triglycerides
increase
2. Hyperphosphatemia
3. Metabolic acidosis
4. Hyperkalemia
23

During Stage 3 - 4

Signs and symptoms worsen if

kidneys are stressed
Decreased ability to maintain
homeostasis

24

During stages 3 - 4

75% nephron loss

Decreased: glomerular filtration
rate, solute clearance, ability to
concentrate urine and hormone
secretion
Symptoms: elevated BUN &
Creatinine, mild azotemia, anemia

25

Stages of Chronic Renal

Failure
NKF Classification System

Stage 5: Kidney failure (GFR < 15

ml/min)
1. Azotemia

26

During Stage 5
End Stage Renal Disease

Residual function < 15% of normal

Excretory, regulatory and hormonal
functions severely impaired.
Metabolic acidosis
Marked increase in: BUN,
Creatinine, Phosphorous
Marked decrease in: Hemoglobin,
Hematocrit, Calcium
Fluid overload
27

During Stage 5

Uremic syndrome develops affecting

all body systems

can be diminished with early diagnosis

& treatment

Last stage of progressive CRF

Fatal if no treatment

28

Manifestations of
Chronic Uremia

Fig. 47-5
29

What happens when the

kidneys dont function
correctly?

30

Manifestations of CRF
Nervous System

Mood swings
Impaired judgment
Inability to concentrate and perform
simple math functions
Tremors, twitching, convulsions
Peripheral Neuropathy

31

Manifestations of CRF
Skin

Pale, grayish-bronze color

Dry scaly
Severe itching
Bruise easily
Uremic frost

32

Manifestations of CRF
Eyes

Visual blurring
Blindness

33

Manifestations of CRF
Fluid - Electrolyte - pH

Volume expansion and fluid overload

Metabolic Acidosis
Change in urine specific gravity
Electrolyte Imbalances
Potassium
Magnesium
Sodium

34

Manifestations of CRF
GI Tract

Uremic fetor
Anorexia, nausea, vomiting
GI bleeding

35

Manifestations of CRF
Hematologic

Anemia
Platelet dysfunction

36

Manifestations of CRF
Musculoskeletal

Muscle cramps
Soft tissue calcifications
Weakness
Related to calcium phosphorous
imbalances
RENAL OSTEODYSTROPHY

37

Calcium-Phosphorous
Balance

38

Manifestations of CRF
Heart - Lungs

Hypertension
Congestive heart failure
Pericarditis
Pulmonary edema
Pleural effusions
Atherosclerotic vascular disease*
Cardiac dysrhythmias
39

Manifestations of CRF
Endocrine - Metabolic

Erythropoietin production decreased

Hypothyroidism
Insulin resistance
Growth hormone decreased
Gonadal dysfunction
Parathyroid hormone and Vitamin D3

Hyperlipidemia

40

Treatment Options

Conservative Therapy
Hemodialysis
Peritoneal Dialysis
Transplant
Nothing

41

Conservative Treatment
Goals
GOALS:
Detect & treat potentially reversible
causes of renal failure
Preserve existing renal function
Treat manifestations
Prevent complications
Provide for comfort
42

Conservative Treatment

Control
Hyperkalemia
Hypertension
Hyperphosphatemia
Hyperparthryoidism
Hyperglycemia
Anemia
Dyslipidemia
Hypothyroidism
Nutrition

43

Hemodialysis

Removal of soluble substances

and
water from the blood by
diffusion
through a semipermeable membrane.

44

History

Early animal experiments began

1913
1st human dialysis 1940s by Dutch
physician Willem Kolff (2 of 17
patients survived)
Considered experimental through
1950s, No intermittent blood
access; for acute renal failure only.
45

History contd

1960 Dr. Scribner developed

Scribner Shunt
1960s Machines expensive, scarce,
no funding.
Death Panels panels within
community decided who got to
dialyze.

46

Hemodialysis Process

Blood removed from patient into the

extracorporeal circuit.
Diffusion and ultrafiltration take
place in the dialyzer.
Cleaned blood returned to patient.

47

Extracorporeal Circuit

48

How Hemodialysis
Works

49

Vascular Access

Arterio-venous shunt (Scribner

External Shunt)
Arterio-venous (AV) Fistula
PTFE Graft
Temporary catheters
Permanent catheters

50

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
51

Arterio-venous (AV)
Fistula
Primary
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
devita.com

52

PTFE
(Polytetrafluoroethylene)
Graft
Synthetic vessel anastomosed into an artery and

vein.
Advantages
for people with inadequate vessels
can be used in 1-4 weeks
prominent vessels
Disadvantages
clots easily
steal syndrome more frequent
requires needle sticks
infection may necessitate removal of graft

53

Temporary Catheters

Dual lumen catheter placed into a central veinsubclavian, jugular or femoral.

Advantages
immediate use
no needle sticks
Disadvantages
high incidence of infection
subclavian vein stenosis
poor flow-inadequate dialysis
clotting
restricts movement
54

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

55

Care of Vascular Access

NO BPs, needle sticks to arm with

vascular access. This includes finger
sticks.
Place ID bands on other arm
whenever possible.
Palpate thrill and listen for bruit.
Teach patient nothing constrictive.

56

Potential
Complications of
Hemodialysis
During dialysis

Fluid and electrolyte related

hypotension
Cardiovascular
arrythmias
Associated with the extracorporeal circuit
exsanguination
Neurologic
Disequilibrium Syndrome & seizures
Musculoskeletal
cramping
Other
fever & sepsis
blood born diseases

57

Potential
Complications of
Hemodialysis
Between
treatments
Hypertension/Hypotension
Edema
Pulmonary edema
Hyperkalemia
Bleeding
Clotting of access

58

Complications of
Hemodialysis contd

Long term

Metabolic
hyperparathyroidism
diabetic complications
*Cardiovascular
CHF
AV access failure
cardiovascular disease
Respiratory
pulmonary edema
Neuromuscular
neuropathy
59

Complications of
Hemodialysis
contd

Long term contd

Hematologic

GI

bleeding

Dermatologic

anemia

calcium phosphorous deposits

Rheumatologic

amyloid deposits
60

Complications of
Hemodialysis contd

Long term contd

Genitourinary
infection
sexual dysfunction

Psychiatric

depression

*Infection

blood borne pathogens

61

Dietary Restrictions on
Hemodialysis

Fluid restrictions
Phosphorous restrictions
Potassium restrictions
Sodium restrictions
Protein to maintain nitrogen balance
too high - waste products
too low - decreased albumin, increased
mortality

Calories to maintain or reach ideal weight

62

Peritoneal Dialysis

Removal of soluble substances and

water from the blood by diffusion
through a semi-permeable
membrane that is intracorporeal
(inside the body).

63

Types of Peritoneal
Dialysis

CAPD: Continuous ambulatory peritoneal

dialysis

CCPD: Continuous cycling peritoneal

dialysis

Aka. APD Automated Peritoneal Dialysis

IPD:

Intermittent peritoneal dialysis

64

CAPD

Catheter into peritoneal cavity

Exchanges 4 - 5 times per day
Treatment 24 hours; 7 days a week
Solution remains in peritoneal cavity
except during drain time
Independent treatment

65

66

Phases of A Peritoneal
Dialysis Exchange

Fill: fluid infused into peritoneal

cavity
Dwell: time fluid remains in
peritoneal cavity
Drain: time fluid drains from
peritoneal cavity

67

Complications of
Peritoneal Dialysis

Infection
peritonitis
tunnel infections
catheter exit site
Hypervolemia
hypertension
pulmonary edema
Hypovolemia
hypotension
Hyperglycemia
Malnutrition
68

Complications of
Peritoneal Dialysis contd

Obesity
Hypokalemia
Hernia
Cuff erosion
Low back pain
Hyperlipidemia

69

Advantages of CAPD

Independence for patient

No needle sticks
Better blood pressure control
Some diabetics add insulin to solution
Fewer dietary restrictions
protein loses in dialysate
generally need increased potassium
less fluid restrictions

70

Peritoneal Catheter Exit

Site

71

72

Medications Common to
Dialysis Patients

Vitamins - water soluble

Phosphate binder ---- GIVE WITH MEALS
Phoslo (calcium acetate)
Renagel (sevelamere hydrochloride)
Caltrate (calcium cabonate)
Amphojel (aluminum hydroxide)

Iron Supplements

dont give with phosphate binder or calcium

Antihypertensives - hold prior to dialysis

73

Medications Common to
Dialysis Patients contd

Erythropoietin
Calcium Supplements

Activated Vitamin D3

Between meals, not with iron

aids in calcium absorption

Antibiotics

hold dose prior to dialysis if it dialyzes

out
74

Medications

Many drugs or their metabolites are

excreted by the kidney
Dosages

many change when used in renal failure

patients

Dialyzability

many removed by dialysis varies

between HD and PD
75

Patient Education

Alleviate fear
Dialysis process
Fistula/catheter care
Diet and fluid restrictions
Medication
Diabetic teaching

76

Transplantation

Treatment not cure

77

Kidney Awaiting
Transplant

78

79

Transplanted Kidney

80

Advantages

Restoration of normal renal

function
Freedom from dialysis
Return to normal life
Reverses pathophysiological
changes related to Renal Failure
Less expensive than dialysis after 1st
year
81

Disadvantages

Life long medications

Multiple side effects from
medication
Increased risk of tumor
Increased risk of infection
Major surgery

82

Care of the Recipient

Major surgery with general

anesthesia
Assessment of renal function
Assessment of fluid and electrolyte
balance
Prevention of infection
Prevention and management of
rejection
83

Function

ATN? (acute tubular necrosis)

50% experience

Urine output >100 <500 cc/hr

BUN, creatinine, creatinine clearance
Fluid Balance
Ultrasound
Renal scans
Renal biopsy
84

Fluid & Electrolyte

Balance

Accurate I & O
CRITICAL TO AVOID DEHYDRATION
Output normal - >100 <500 cc/hr, could be
1-2 L/hr
Potential for volume overload/deficit
Daily weights
Postassium (K+)___________
Sodium (Na) _____________
Blood sugrar _____________
85

Prevention of Infection

Major complication of
transplantation due to
immunosuppression
HANDWASHING
Crowds, Kids
Patient Education

86

Rejection

Hyperacute - preformed antibodies

to donor antigen
function ceases within 24 hours
Rx = removal

Accelerated - same as hyperacute

but slower, 1st week to month

Rx = removal

87

Rejection contd

Acute - generally after 1st 10 days to

end of 2nd month
50% experience
must differentiate between rejection
and cyclosporine toxicity
Rx = steroids, monoclonal (OKT3), or
polyclonal (HTG) antibodies

88

Rejection contd

Chronic - gradual process of graft

dysfunction
Repeated rejection episodes that have
not been completely resolved with
treatment
4 months to years after transplant
Rx = return to dialysis or retransplantation

89

Immunosuppressant
Drugs

Prednisone

prevents infiltration of T lymphocytes

Side effects
cushingnoid changes
avascular necrosis
GI disturbances
diabetes
infection
risk of tumor

90

Immunosuppressant
Drugs contd

Azathioprine (Imuran)

Prevents rapid growing lymphocytes

Side Effects
bone marrow toxicity
hepatotoxicity
hair loss
infection
risk of tumor

91

Immunosuppressant
Drugs contd

Cyclosporin
Interferes with production of interleukin
2 which is necessary for growth and
activation of T lymphocytes.
Side Effects

Nephrotoxicity
HTN
Hepatotoxicity
Gingival hyperplasia
Infection
92

Immunosuppressant
Drugs contd

Cytoxan - in place of Imuran less

toxic
FK506 - 100 x more potent than
Cyclosporin
Prograf
Cellcept

93

Immunosuppressant
Drugs contd

OKT3 - monoclonal antibody used to treat rejection

or induce immunosuppression
decreases CD3 cells within 1 hour
Side effects
anaphylaxis
fever/chills
pulmonary edema
risk of infection
tumors
1st dose reaction expected & wanted, pre-treat with
Benadryl, Tylenol, Solumedrol
94

Immunosuppressant
Drugs contd

Atgam - polyclonal antibody used to treat

rejection or induce immunosuppression
decreased number of T lymphocytes
Side effects
anaphylaxis
fever chills
leukopenia
thrombocytopenia
risk of infection
tumor
95

Patient Education

Signs of infection
Prevention of infection
Signs of rejection
decreased urine output
increased weight gain
tenderness over kidney
fever > 100 degrees F
Medications
time, dose, side effects
96

Exclusion for Transplant

Exclusion for Transplant not limited too

Active vasculitis; or
Life threatening extrarenal congenital
abnormalities; or
Untreated coagulation disorder; or
Ongoing alcohol or drug abuse; or
Age over 70 years with severe co-morbidities; or
Severe neurological or mental impairment, in
persons without adequate social support, such
that the person is unable to adhere to the
regimen necessary to preserve the transplant.

97

Exclusion for Transplant

Exclusion for Transplant not limited too

Active vasculitis; or
Life threatening extrarenal congenital
abnormalities; or
Untreated coagulation disorder; or
Ongoing alcohol or drug abuse; or
Age over 70 years with severe co-morbidities; or
Severe neurological or mental impairment, in
persons without adequate social support, such
that the person is unable to adhere to the
regimen necessary to preserve the transplant.

98

Official Criteria for

Deceased Donors

Usually irreversible brain injury

MVA, gunshot wounds, hemorrhage, anoxic
brain injury from MI
Must have effective cardiac function
Must be supported by ventilator to preserve
organs
Age 2-70
No IV drug use, HTN, DM, Malignancies, Sepsis,
disease
Permission from legal next of kin & pronoucement
of death made by MD
99

Official Criteria for Living

Donors

Psychiatric evaluation
Anesthesia evaluation
Medical Evaluation
Free from diseases listed under deceased
donor criteria
Kidney function evaluated
Crossmatches done at time of evaluation
and 1 week prior to procedure
Radiological evaluation

Nurses Role in Event of

Potential Donation

Notify TOSA of possible organ

donation
Identify possible donors
Make referral in timely manner

Do not discuss organ donation with

family
Offer support to families after referral
is made & donation coordinator has
met with family
101