disease/ 1

chronic
kidney
failure
kidney
disorders/
hemodialysis
 introduction
2

The kidneys function as excretory,

biosynthetic, and metabolic organs, vital for
maintaining normal physiology. Although
dialysis can replace some kidney functions, it
cannot replicate the biosynthetic and metabolic
activities of the normal kidney. Chronic kidney
disease (CKD) and its terminal complication,
end-stage renal disease (ESRD), may progress
undetected until immediately before
symptomatic kidney failure develops. At this
point in the disease process, few opportunities
 objectives 3

• To have a better • To understand

understanding of how dialysis
the Chronic works
Kidney Disease • The different
• Able to access and its
differentiate the management
stages of CKD • What is
• know the nephrotic and
different nephritic
treatment and syndrome and its
management for management
 4

CHRONI
C
KIDNEY
DISEASE
CHRONIC
RENAL
FAILURE
etiology 6

• Several disease process have been found to cause CKD

These include:
• Hypertension
• diabetes mellitus
• chronic glomerulopathy
• chronic pyelonephritis
• interstitial nephritis
• polycystic disease
• gouty nephropathy
• tubulointerstitial disease
• obstructive uropathy.
Predisposing factors: 7

• DM
• Age 60 or older
• Congenital
• Family history ( SLE)
• BPH, prostatitis
• Race
• Sedentary lifestyle
• Diet
pathophysiology 8

• >50% of total renal mass is loss, compensatory hypertrophy

becomes inadequate to restore normal BUN, Creatinine level
to rise, renal insufficiency, uremic syndrome
Diagnostic studies 9

• ABG- to determine the Acid-Base balance

• Elevated serum creatinine, BUN, potassium, phosphorus
• CBC- anemia
• Decrease serum level of bicarbonate, calcium and proteins

• GFR- is the preferred test to determine kidney function. The

client’s GFR levels are used to determine the stage of CKD
(1-5). Clients in or near stage 5 will require renal
replacement therapy (hemodialysis)
sta descrip gfr action 10

ge tion
At increase >60 Screening, ckd risk
risk with ckd risk reduction
factor
1 Kidney >90 Diagnosis and treatment,
damage with treatment of comorbid
normal or conditions, slowing
gfr progression, ckd risk
reduction
2 Kidney 60-89 Estimating progression
damage with
mild gfr
3 Moderate 30-59 Evaluating and treating
treatment 11

Stage 1: Stage 1:
• Diagnose and treat co-morbid • Monitor GFR yearly
conditions, reduce CV risks, • Anti-proteinuria therapy with
estimate progression rate, slow ACE inhibitors and/or
CKD progression, r/o angiotensin II block receptor
concomitant ARF. blockers
• Clinical testing for electrolytes, • Control BP
BUN, serum creatinine,
urinalysis, lipid profile, EKG
treatment 12

Stage 2:
• Diagnose and treat co-morbid
conditions, estimate
progression
• Slow CKD progression
• CBC, reticulocyte CT (if
anemic)
• Urine Pro:tein to creatinine
every 4-6 months
Stage 2:
• Anti-proteinuria therapy with
ACE inhibitors and/or
angiotensin II receptor
blockers
• Control BP
treatment 13

Stage 3:
• Diagnose and treat co-morbid
condition
• Electrolyte, BUN serum crea,
CBC, Ca
• Iron studies: serum iron, TIBC,
ferritin every 3-6 months
• Urine Pro:tein to creatinine
every 4-6 months
• Renal UTZ
Stage 3:
• Referral to Nephro, renal
dietitian
• Vit. D3, P-lowering therapy
• Correct iron deficiency prior
to epoetin therapy
treatment 14

Stage 4: Stage 4:
• Prep are for EDRD care • CKD educational classes
• Electrolytes, BUN, serum crea, • Preparation for vascular
Ca, P every 3-6months access
• CBC and iron studies • Vit. D
• Correct iron deficiency prior
to epoetin therapy
The progressive deteriation of the kidneys in CKD causes imbalances in electrolytes
levels such as potassium (hypokalemia), calcium (hypocalcemia) and phosphate
(hypophosphatemia). Due to the lack of erythropoietin, erythopietin is a glycoprotein
cytokine secreted by the kidney that stimulates RBC production (erythropoiesis) in the
bone marrow, produces by the healthy kidneys, clients with CKD are chronically
treatment 15

Stage 5: Stage 5:
• Dialysis or a kidney transplant • Hemodialysis
• Monthly: CBC, BUN, serum • Transplant 3
crea
 16

HEMODIALY
SIS
HEMODIALYSIS 17

• Hemodialysis is a treatment to filter wastes and water from

your blood, as your kidneys did when they were healthy.
Hemodialysis helps control blood pressure and balance
important minerals, such as potassium, sodium, and calcium,
in your blood.

• Hemodialysis can help you feel better and live longer, but
it’s not a cure for kidney failure.
WHAT HAPPENS DURING 18

HEMODIALYSIS
• During hemodialysis, your blood goes through a filter,
called a dialyzer, outside your body. A dialyzer is sometimes
called an “artificial kidney.”

• At the start of a hemodialysis treatment, a dialysis nurse or

technician places two needles into your arm. You may prefer
to put in your own needles after you’re trained by your
health care team. A numbing cream or spray can be used if
placing the needles bothers you. Each needle is attached to a
soft tube connected to the dialysis machine.
19
WHAT HAPPENS DURING 20

HEMODIALYSIS
• The dialysis machine pumps blood through the filter and
returns the blood to your body. During the process, the
dialysis machine checks your blood pressure and controls
how quickly

• blood flows through the filter

• fluid is removed from your body
WHAT HAPPENS DURING 21

HEMODIALYSIS
• Blood enters at one end of the filter and is forced into many,
very thin, hollow fibers. As your blood passes through the
hollow fibers, dialysis solution passes in the opposite
direction on the outside of the fibers. Waste products from
your blood move into the dialysis solution. Filtered blood
remains in the hollow fibers and returns to your body.
WHAT HAPPENS DURING 22

HEMODIALYSIS
• Your nephrologist—a doctor who specializes in kidney
problems—will prescribe a dialysis solution to meet your
needs. The dialysis solution contains water and chemicals
that are added to safely remove wastes, extra salt, and fluid
from your blood. Your doctor can adjust the balance of
chemicals in the solution if

• your blood tests show your blood has too much or too
little of certain minerals, such as potassium or calcium
• you have problems such as low blood pressure or
muscle cramps during dialysis
Dialysis access 23

• VACULAR ACCESS SURGERY

• One important step before starting hemodialysis
treatment is having minor surgery to create a vascular
access. Your vascular access will be your lifeline
through which you’ll connect to the dialyzer. Dialysis
moves blood through the filter at a high rate. Blood flow
is very strong. The machine withdraws and returns
almost a pint of blood to your body every minute. The
access will be the place on your body where you insert
needles to allow your blood to flow from and return to
your body at a high rate during dialysis.
ACCESS: 24

• an arteriovenous (AV) fistula

• an AV graft
• a catheter
AV FISTULA 25

• The best type of long-term access is an AV

fistula.
• A surgeon connects an artery to a vein,
usually in your arm, to create an AV fistula.
• An artery is a blood vessel that carries blood
away from your heart. A vein is a blood
vessel that carries blood back toward your
heart.
• When the artery to a vein connects, the vein
grows wider and thicker, making it easier to
place the needles for dialysis.
AV FISTULA 26

• Refrain from taking blood pressure or any

extractions on that arm
• Check patency before proceeding to dialysis:
• Palpate for thrill (vibration)
• Auscultate to detect bruit ( swishing)
AV GRAFT
• If problems with your veins prevent
27

you from having an AV fistula, you

may need an AV graft instead.
• To create an AV graft, your surgeon
uses a man-made tube to connect an
artery to a vein. You can use an AV
graft for dialysis soon after surgery.
However, you’re more likely to
have problems with infection and
blood clots. Repeated blood clots
can block the flow of blood through
the graft and make it hard or
ACCESS 28

• If your kidney disease has progressed quickly, or you have

not had a vascular access placed before you need dialysis,
you may need a venous catheter—a small, soft tube inserted
into a vein in your neck (Internal Jugular vein), chest, or leg
near the groin (Femoral vein)
• as a temporary access.
• You’ll receive local anesthesia and medicine to keep you
calm and relaxed during the procedure.
After care of access: 29

• Wash area with sap and water

• Check for any sign of infection (warm and tenderness)
• Check for patency
Problems encountered
during dialysis
30

• Problem with the vascular access

• Infection
• Poor blood flow
• Sudden changes in your body’s water and chemical balance
during treatment
• Muscle cramps
• Hypertension (weakness, dizziness)
• Blood loss
• Leak with the dialyzer
 31

NEPHROT
IC
SYNDRO
ME
NEPHRITIC
SYNDROME
32
33
Nephrotic syndrome
34

• Nephrotic syndrome is a group of symptoms that show your

kidneys are not working as well as they should. These
symptoms include too much protein in your urine, not
enough protein in your blood, too much fat or cholesterol in
your blood, and swelling.
• The most common primary cause of nephrotic syndrome in
adults is a disease called focal segmental glomerulosclerosis
(FSGS). The only way to know for sure whether you have
FSGS is to get a kidney biopsy. Even when treated, most
people with FSGS will eventually develop kidney failure
and will need to start dialysis or have a kidney transplant to
Nephrotic syndrome
35

• In children, the most common primary cause of nephrotic

syndrome is minimal change disease.
• Most of the time, nephrotic syndrome happens because of
secondary causes. The most common secondary cause of
nephrotic syndrome in adults is diabetes.

• The most common secondary cause of nephrotic syndrome

in children is diabetes.
 36

At risk
• More common in men
• Children ages 2-6
• Have a disease that affects the kidneys such as FSGS, lupus,
or diabetes
• Take certain medicines like nonsteroidal anti-inflammatory
drugs (NSAIDS) or antibiotics
• Have an infection such as HIV, hepatitis B and C, or malaria
Signs and symptoms:
37

• Swelling in your legs, feet, ankles, and sometimes face and

hands
• Weight gain
• Feeling very tired
• Foamy or bubbly urine
• Not feeling hungry
 38

Complications:
• Anemia
• Heart disease
• High blood pressure
• Fluid buildup
• Acute kidney injury
• End-stage renal disease (ESRD) or kidney failure
 39

Diagnostic test
• Urine tests – Your urine test results can tell your doctor if
there is protein in your urine. If so, you may have nephrotic
syndrome. Protein in the urine is one of the earliest signs of
kidney disease.
• Blood tests – Your blood test results can tell your doctor if
your kidneys are filtering waste like they should. If not, it
could be a sign of nephrotic syndrome.
• Kidney biopsy – In a kidney biopsy, your doctor will look at
a small piece of your kidneys under a microscope for signs
of damage and disease.
 40

Treatment:
• Control of blood pressure and cholesterol
• Diuretics to remove excess fluids
• Healthier lifestyle
• Diet
41
 42

Nephritic syndrome
• The nephritic syndrome is a clinical syndrome that presents
as hematuria, elevated blood pressure, decreased urine
output, and edema. The major underlying pathology is
inflammation of the glomerulus that results in nephritic
syndrome. It causes a sudden onset of the appearance of red
blood cell (RBC) casts and blood cells, a variable amount of
proteinuria, and white blood cells in the urine. The primary
pathology can be in the kidney, or it can be a consequence of
systemic disorders.
 43

Nephritic syndrome
• Nephritic syndrome is a manifestation of glomerular
inflammation (glomerulonephritis) and occurs at any age.
Causes differ by age and mechanisms differ by cause. The
syndrome can be
• Acute (serum creatinine rises over many weeks or less)
• Chronic (renal insufficiency may progress over years)
• Nephritic syndrome can also be
• Primary (idiopathic)
• Secondary
 44

Signs and symptoms

• Intermittent gross hematuria
• Hematuria → Classification (red or brown urine, i.e., cola-
colored urine)
• Hypertension
• Pitting edema
• In ↓ GFR: oliguria and uremic symptoms
 45

Treatment and management

• Antihypertensive medications
• Diuretics; loop
• Corticosteroids
• Immunomodulators
• Antibiotics
• dialysis
46