Chronic Kidney Disease &

TreatmentVicky Jefferson, RN, CNN

Satellite Dialysis

(modified by Kelle Howard, MSN, RN, CNE)revised Fall 2012

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.

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REVIEW

• What are nephrons?

• What are the functions of the kidneys?

• Normal creatinine & BUN?

• Diagnostic tools

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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 __________________

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Functions of the Kidneys (cont) • Regulates acid-base balance through– HCO3 and H+

• *Hormonal functions: (BP control), multisystem effect.

– Renin Release

RAAS=

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Functions of the Kidneys (cont)

• Erythropoietin Release– If a patient has chronic renal failure, what

condition will occur?– WHY???

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 patient’s serum calcium level? __________________

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Functions of the Kidneys

• _______________• _______________• _______________

• ______________• ______________• ______________• ______________

Diagnostic Tools for Assessing Kidney Failure

• Blood Tests– BUN – Creatinine – K+ – PO4

– Ca • Urinalysis– Specific gravity– Protein– Creatinine clearance

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BUN

• Normal 6-20 mg/dl• Nitrogenous waste product of protein

metabolism• By itself: Unreliable in measurement of renal

function

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Creatinine

• A waste product of muscle metabolism• Normal value 0.6 – 1.3 mg/dl• 2 times normal = 50% damage • 8 times normal = 75% damage• 10 times normal = 90% damage• Exception -_______________________

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Diagnostic Tools

• Biopsy• Ultrasound• X-Rays• Labs• Anything else?

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Chronic Kidney Disease

• Slow progressive renal disorder related to nephron loss– occurring over months to years

• Culminates in End Stage Renal Disease

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Chronic Kidney Disease:Characteristics

• Cause & onset often unknown• Loss of function _________ lab abnormalities• Lab abnormalities ________ symptoms• Symptoms (usually) evolve in orderly

sequence• Renal size is usually decreased

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Chronic Kidney DiseaseCauses

• ___________• ___________• ___________• Cystic disorders• Developmental/Congenital• Infectious Disease

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Chronic Kidney DiseaseCauses (cont)

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

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Glomerular Filtration RateGFR

• 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 creatinineWomen: {140 – age} x IBW (kg)

85 x serum creatinineWhat is a normal GFR?

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Stages of Chronic Kidney DiseaseOld System

• Reduced Renal Reserve

• Renal Insufficiency

• End Stage Renal Disease (ESRD)

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Stages of Chronic Kidney DiseaseNKF Classification System

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

damage

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Stages of Chronic Kidney DiseaseNKF 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.

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During Stage 1 - 2

• No symptoms

• Serum creatinine doubles

• Up to 50% nephron loss

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Stages of Chronic Kidney DiseaseNKF Classification System

Stage 3: Moderate reduction (GFR 30 – 59 ml/min)

1. Calcium absorption decreases 2. Malnutrition onset3. Anemia4. Left ventricular hypertrophy

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Stages of Chronic Kidney DiseaseNKF Classification System

Stage 4: Severe reduction (GFR 15 – 29 ml/min)

1. Serum triglycerides increase2. Hyperphosphatemia3. Metabolic acidosis4. Hyperkalemia

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During Stage 3 - 4

• Signs and symptoms worsen if kidneys are stressed

• Decreased ability to maintain homeostasis

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During stages 3 - 4

• 75% nephron loss • Decreased: – __________– __________– __________– __________

• Symptoms: – elevated BUN & Creatinine, mild azotemia, anemia

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Stages of Chronic Kidney DiseaseNKF Classification System

Stage 5: Kidney failure (GFR < 15 ml/min)1. Azotemia

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During Stage 5End Stage Renal Disease

• Residual function < 15% of normal• Excretory, regulatory and hormonal functions severely

impaired. • Metabolic acidosis• Marked increase in: • ___________• ___________• ___________

• Marked decrease in: • ___________• ___________• ___________

• Fluid overload

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During Stage 5

• Uremic syndrome develops affecting all body systems– can be diminished with early diagnosis &

treatment

• Last stage of progressive CKD• Fatal if no treatment

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Manifestations of Chronic Uremia

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Fig. 47-5

What happens when the kidneys don’t function correctly?

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Manifestations of CKD Nervous System

• Mood swings• Impaired judgment• Inability to concentrate and perform simple

math functions• Tremors, twitching, convulsions• Peripheral Neuropathy

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Manifestations of CKDSkin

• Pale, grayish-bronze color• Dry scaly• Severe itching• Bruise easily• Uremic frost• Calcium/Phos deposits

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Manifestations of CKDEyes

• Visual blurring• Blindness

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Manifestations of CKD Fluid - Electrolyte - pH

• Volume expansion and fluid overload• Metabolic Acidosis• Change in urine specific gravity• Electrolyte Imbalances– Potassium– Magnesium– Sodium

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Manifestations of CKDGI Tract

• Uremic fetor• Anorexia, nausea, vomiting• GI bleeding

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Manifestations of CKD Hematologic

• Anemia• Platelet dysfunction

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Manifestations of CKD Musculoskeletal

• Muscle cramps• Soft tissue calcifications• Weakness• RENAL OSTEODYSTROPHY

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Calcium-Phosphorous Balance

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Manifestations of CKDHeart - Lungs

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

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Manifestations of CKD Endocrine - Metabolic

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

• Hyperlipidemia

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Treatment Options

• Conservative Therapy• Hemodialysis• Peritoneal Dialysis• Transplant• Nothing

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Conservative Treatment

GOALS:• Detect & treat potentially reversible causes of

renal failure• Preserve existing renal function• Treat manifestations• Prevent complications• Provide for comfort

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Conservative Treatment• Control – Hyperkalemia– Hypertension– Hyperphosphatemia– Hyperparthryoidism– Hyperglycemia– Anemia– Dyslipidemia– Hypothyroidism– Nutrition

– Describe a renal diet while on conservative treatment?

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Hemodialysis

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

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History

• Early animal experiments began 1913• 1st human dialysis 1940’s by Dutch physician

Willem Kolff• Considered experimental through 1950’s, No

intermittent blood access; for acute renal kidney injury only.

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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.

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Hemodialysis Process

• Blood removed from patient into the extracorporeal circuit.

• Diffusion and ultrafiltration take place in the dialyzer.

• Cleaned blood returned to patient.

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Extracorporeal Circuit

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How Hemodialysis Works

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Vascular Access

• Arterio-Venous shunt – (Scribner External Shunt)

• Arterio-Venous – (AV) Fistula

• PTFE Graft• Temporary catheters• “Permanent” catheters

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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

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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 devita.com

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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

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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– restricts movement

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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 BP’s, 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.

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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

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Potential Complications of Hemodialysis

• Between treatments– Hypertension/Hypotension– Edema– Pulmonary edema– Hyperkalemia– Bleeding– Clotting of access

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Complications of Hemodialysis cont’d

• Long term– Metabolic

• hyperparathyroidism• diabetic complications

– *Cardiovascular• CHF• AV access failure• cardiovascular disease

– Respiratory• pulmonary edema

– Neuromuscular• neuropathy

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Complications of Hemodialysiscont’d

• Long term cont’d– Hematologic• anemia

– GI• bleeding

– Dermatologic• calcium phosphorous deposits

– Rheumatologic• amyloid deposits

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Complications of Hemodialysis cont’d

• Long term cont’d– Genitourinary• infection• sexual dysfunction

– Psychiatric• depression

– *Infection• blood borne pathogens

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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 weight62

Peritoneal Dialysis

• Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane that is intracorporeal (inside the body).

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Types of Peritoneal Dialysis

• CAPD: Continuous ambulatory peritoneal dialysis

• CCPD: Continuous cycling peritoneal dialysis – Aka. APD – Automated Peritoneal Dialysis

• IPD: Intermittent peritoneal dialysis

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Peritoneal Dialysis

• Warm sterile dialysate into peritoneal cavity from previously placed catheter wastes & lytes diffuse into dialysate until equilibrium achieved diffuse controlled by dextrose concentration

• Concentrations available: 1.5%, 2.5%, 4.25%– Usually about 2L -----(can be 1.5L-3L)

What does this do to blood sugar & calorie count?

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Peritoneal Catheter Exit Site

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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

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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

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Complications of Peritoneal Dialysis

• Infection– peritonitis– tunnel infections– catheter exit site

• Hypervolemia– hypertension– pulmonary edema

• Hypovolemia– hypotension

• Hyperglycemia• Malnutrition

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Complications of Peritoneal Dialysis cont’d

• Obesity• Hypokalemia• Hernia• Cuff erosion• Low back pain• Hyperlipidemia

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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

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Let’s Talk About

Medications

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Medications Common to Dialysis Patients

• Vitamins - water soluble• Phosphate binder ---- GIVE WITH _____– Phoslo (calcium acetate)– Renagel (sevelamere hydrochloride)– Caltrate (calcium cabonate) – Amphojel (aluminum hydroxide)

• Iron Supplements –– don’t give with phosphate binder or calcium

• Antihypertensives – When do we give these?

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Medications Common to Dialysis Patients cont’d

• Erythropoietin• Calcium Supplements– Between meals, not with ______

• Activated Vitamin D3

• Antibiotics – hold dose prior to dialysis – Why?

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Medications

• Many drugs or their metabolites are excreted by the kidney

• Dosages – many change when used in kidney failure patients• Why?

• Dialyzability – many removed by dialysis varies between HD and

PD

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Patient Education

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

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Transplantation

• Treatment not cure

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Transplanted Kidney

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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

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Disadvantages

• Life long medications• Multiple side effects from medication• Increased risk of tumor• Increased risk of infection• Major surgery

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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

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Monitoring Transplant Function

• ATN? (acute tubular necrosis) • Urine output >100 <500 cc/hr (initially)• Labs• Fluid Balance• Ultrasound• Renal scans• Renal biopsy

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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

• FLUID RESCUITATION = 24HR URINE OUPUT

• Daily weights• Postassium (K+)___________• Sodium (Na) _____________ • Blood sugar _____________

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Prevention of Infection

• Major complication of transplantation due to immunosuppression

• What do you teach?

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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

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Rejection cont’d

• 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

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Rejection cont’d

• 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 re-transplantation

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Immunosuppressant Drugs

• Prednisone– prevents infiltration of T lymphocytes

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

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Immunosuppressant Drugs cont’d

• Azathioprine (Imuran)– Prevents rapid growing lymphocytes

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

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Immunosuppressant Drugs cont’d

• Cyclosporine– Interferes with production of interleukin 2 which

is necessary for growth and activation of T lymphocytes.

– Side Effects– Nephrotoxicity– HTN– Hepatotoxicity– Gingival hyperplasia– Infection

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Immunosuppressant Drugs cont’d

• Cytoxan - in place of Imuran less toxic• FK506 - 100 x more potent than Cyclosporine• Prograf• CellCept

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Immunosuppressant Drugs cont’d

• 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

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Immunosuppressant Drugs cont’d

• 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

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Patient Education

• Signs of infection• Prevention of infection• Signs of rejection– ____________– ____________– ____________– ____________

• Medications– _____________

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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.

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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.

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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

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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

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