Jules Brinley, RN, MSN/Ed, CNE. Which statement does not accurately characterize the kidneys: ◦ A. Each kidney contains millions of nephrons, which

Renal FailureJules Brinley, RN, MSN/Ed, CNE

Which statement does not accurately characterize the kidneys:◦ A. Each kidney contains millions of nephrons,

which produce urine.◦ B. The loop of Henle is the main filtration system

within the nephrons.◦ C. The kidneys receive more than 1 liter of blood

from the heart every minute.◦ D. The afferent arterioles carry unfiltered blood

from the renal arteries to the glomerular capillaries.

Question

Acute Kidney Injury (AKI)

Causes◦ Prerenal failure: decreased blood flow to

glomeruli ◦ Intrarenal failure: nephrotoxic agents, kidney

infections, occlusion of intrarenal arteries, hypertension, diabetes mellitus, or direct trauma to the kidney

◦ Postrenal failure: obstructions beyond the kidneys that cause urine to back up

Question The risk of developing prerenal failure is

greatest in a patient with:◦ A. Systemic lupus erythematosus.◦ B. Acute glomerulonephritis.◦ C. Heart failure.◦ D. Acute pyelonephritis.

Acute Kidney Injury (AKI): Stages Onset stage

◦ Short (1-3 days); increasing BUN and serum creatinine with normal to decreased urine output

Oliguric stage◦ The urine output decreases to 400 mL/day or

less ◦ Serum values for BUN, creatinine, potassium,

and phosphorus increase ◦ Serum calcium and bicarbonate decrease ◦ Follows onset stage and continues for up to 14

days

Question Which laboratory test result reflects the

oliguric phase of acute renal failure? A. BUN = 34 mg/dl B. Creatinine = 1 mg/dl C. Sodium = 159 mEq/liter D. Potassium = 3.4 mEq/liter

Acute Kidney Injury (AKI): Stages Diuretic stage

◦ Urine output exceeds 400 mL/day; may rise above

4 L/day ◦ Kidneys excrete BUN, creatinine, potassium,

and phosphorus and retain calcium and bicarbonate

Recovery stage◦ As renal tissue recovers, serum electrolytes,

BUN, and creatinine return to normal ◦ This stage lasts 1 to 12 months


Medical treatment ◦ Fluid and dietary restrictions, restoration of

electrolyte balance, and dialysis◦ Drug therapy◦ Diet ◦ Fluids ◦ Hemodialysis and peritoneal dialysis ◦ Continuous renal replacement therapy

Question In acute kidney injury (AKI), what

contributes to metabolic acidosis?◦ A. The renal tubules’ inability to form bicarbonate◦ B. Excess sodium conservation by the renal

tubules◦ C. Too few hydrogen ions, which increases the

blood pH◦ D. Potassium movement from extracellular to

intracellular fluid.


Assessment◦ Monitoring fluid status is critical◦ Signs and symptoms of electrolyte imbalances◦ Signs and symptoms related to immobility:

pressure sores, impaired circulation, constipation, and atelectasis

◦ Fears, anxiety, coping strategies, sources of support


Interventions◦ Excess Fluid Volume ◦ Decreased Cardiac Output ◦ Anxiety ◦ Disuse Syndrome ◦ Deficient Knowledge

Question The nurse is developing a plan of care for a

client diagnosed with AKI. Which statement is an appropriate outcome for the patient?◦ A. Monitor intake and output every shift.◦ B. Decrease of pain by 3 levels on a 1-10 scale.◦ C. Electrolytes are within normal limits◦ D. Administer enemas to decrease hyperaklemia.

Involves progressive, irreversible loss of kidney function

Chronic Kidney Disease (CKD)

Defined as presence of ◦ Kidney damage

Pathologic abnormalities Markers of damage

Blood, urine, imaging tests

◦ Glomerular filtration rate (GFR) <60 mL/min for 3 months or longer

Chronic Kidney Disease

Disease staging based on decrease in GFR ◦ Normal GFR 125 mL/min, which is reflected by

urine creatinine clearance◦ Last stage of kidney failure

End-stage renal disease (ESRD) occurs when GFR <15 mL/min


In Chronic renal failure, the GFR usually is affected when how many nephrons are damaged?◦ A. LESS THAN 25%◦ B. FROM 40%-50%◦ C. FROM 60% - 70%◦ D. MORE THAN 75%

Question

Up to 80% of GFR may be lost with few changes in functioning of body.

Remaining nephrons hypertrophy to compensate.

End result is a systemic disease involving every organ.


Which of the following is NOT a likely cause of chronic renal failure?◦ A. Diabetes◦ B. Hypertension◦ C. Aplastic anemia◦ D. Glomerulonephritis

Question

Each year, 70,000 people die from causes related to renal failure.

More than 26 million Americans have CKD. Mortality rates are 19% to 24% for those

with stage 5 CKD on dialysis.


Leading causes of ESRD◦ Diabetes◦ Hypertension


Result of retained substances◦ Urea◦ Creatinine◦ Phenols◦ Hormones◦ Electrolytes◦ Water◦ Other substances

Clinical Manifestations

Uremia◦ Syndrome that incorporates all signs and

symptoms seen in various systems throughout the body



Fig. 47-2. Clinical manifestations of chronic kidney disease.

Polyuria◦ Results from inability of kidneys to concentrate

urine ◦ Occurs most often at night◦ Specific gravity fixed around 1.010

Clinical ManifestationsUrinary System

Oliguria ◦ Occurs as CKD worsens

Anuria ◦ Urine output <40 mL per 24 hours

Clinical Manifestations Urinary System

Waste product accumulation◦ As GFR ↓, BUN ↑ and serum creatinine levels ↑

BUN ↑ Not only by kidney failure but by protein intake, fever,

corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and

headache may occur.

Clinical ManifestationsMetabolic Disturbances

Altered carbohydrate metabolism◦ Caused by impaired glucose use

From cellular insensitivity to the normal action of insulin

Clinical Manifestations Metabolic Disturbances

Defective carbohydrate metabolism◦ Patients with diabetes who become uremic may

require less insulin than before onset of CKD.◦ Insulin dependent on kidneys for excretion


Elevated triglycerides◦ Hyperinsulinemia stimulates hepatic production of

triglycerides.◦ Altered lipid metabolism

↓ levels of enzyme lipoprotein lipase Important in breakdown of lipoproteins


Potassium◦ Hyperkalemia

Most serious electrolyte disorder in kidney disease Fatal dysrhythmias

Clinical ManifestationsElectrolyte/Acid-Base Imbalances

Sodium◦ May be normal or low◦ Because of impaired excretion, sodium is

retained. Water is retained.

Edema Hypertension CHF

Clinical Manifestations Electrolyte/Acid-Base Imbalances

Calcium and phosphate alterations Magnesium alterations


When reviewing the laboratory test results for a patient with chronic renal failure, you should NOT expect to find:◦ A. Decreased sodium and calcium levels.◦ B. Increased blood pH and bicarbonate levels◦ C. Urine with red blood cells and a low specific

gravity.◦ D. Decreased red blood cell count, hemoglobin

level, and hematocrit.

Question

Metabolic acidosis◦ Results from

Inability of kidneys to excrete acid load (primary ammonia)

Defective reabsorption/regeneration of bicarbonate


Hematologic System Anemia

◦ Due to ↓ production of erythropoietin From ↓ in functioning renal tubular cells

Bleeding tendencies◦ Defect in platelet function


Hematologic System Infection

◦ Changes in leukocyte function◦ Altered immune response and function◦ Diminished inflammatory response


Cardiovascular System Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis


Respiratory System Kussmaul respiration Dyspnea Pulmonary edema Uremic pleuritis


Respiratory System Pleural effusion Predisposition to respiratory infection


Gastrointestinal System Every part of GI is affected.

◦ Due to excessive urea Mucosal ulcerations Stomatitis Uremic fetor (urinous odor of breath) GI bleeding Anorexia, nausea, vomiting


Neurologic System Expected as renal failure progresses

◦ Attributed to ↑ nitrogenous waste products Electrolyte imbalance Metabolic acidosis Axonal atrophy Demyelination of nerve fibers


Neurologic System Restless leg syndrome Muscle twitching Irritability Decreased ability to concentrate Peripheral neuropathy


Neurologic System Altered mental ability Seizures Coma Dialysis encephalopathy


Musculoskeletal System CKD mineral and bone disorder

◦ Systemic disorder of mineral and bone metabolism

◦ Results in skeletal complications (osteomalacia, ostetis fibrosa) and extraskeletal (vascular) calcifications


Mechanisms of CKD-MBD

Fig. 47-3. Mechanisms of chronic kidney disease–mineral and bone disorder (CKD-MBD). GFR, Glomerularfiltration rate.

Integumentary System Pruritus Uremic frost


Reproductive System Infertility

◦ Experienced by both sexes Decreased libido Low sperm counts Sexual dysfunction


Psychologic Changes Personality and behavioral changes Emotional ability Withdrawal Depression


History and physical examination Dipstick evaluation Albumin-creatinine ratio (first morning void) GFR

Diagnostic Studies

50

Renal ultrasound Renal scan CT scan Renal biopsy

Diagnostic Studies

Conservative Therapy Correction of extracellular fluid volume

overload or deficit Nutritional therapy Erythropoietin therapy Calcium supplementation, phosphate

binders

Collaborative Care

Conservative Therapy Antihypertensive therapy Measures to lower potassium Adjustment of drug dosages to degree of

renal function

Collaborative Care

Drug Therapy Hyperkalemia

◦ IV insulin IV glucose to manage hypoglycemia

◦ IV 10% calcium gluconate

Collaborative Care

Drug Therapy Hyperkalemia (cont’d)

◦ Sodium polystyrene sulfonate (Kayexalate) Cation-exchange resin Resin in bowel exchanges potassium for sodium.

Collaborative Care

Drug Therapy Hypertension

◦ Weight loss◦ Lifestyle changes◦ Diet recommendations◦ Sodium and fluid restriction

Collaborative Care

Drug Therapy Hypertension (cont’d)

◦ Antihypertensive drugs Diuretics Calcium channel blockers ACE inhibitors ARB agents

Collaborative Care

Drug Therapy CKD-MBD

◦ Phosphate intake restricted to <1000 mg/day

Collaborative Care


◦ Phosphate binders Calcium carbonate (Caltrate)

Binds phosphate in bowel and excretes Sevelamer hydrochloride (Renagel)

Lowers cholesterol and LDLs

Collaborative Care


◦ Phosphate binders (cont’d) Should be administered with each meal Side effect: Constipation

Collaborative Care


◦ Supplementing vitamin D Calcitriol (Rocaltrol) Serum phosphate level must be lowered before

calcium or vitamin D is administered.

Collaborative Care


◦ Controlling secondary hyperparathyroidism Calcimimetic agents

Cinacalcet (Sensipar) ↑ sensitivity of calcium receptors in parathyroid glands

Subtotal parathyroidectomy

Collaborative Care

Drug Therapy Anemia

◦ Erythropoietin Epoetin alfa (Epogen, Procrit) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3

weeks Side effect: Hypertension

Collaborative Care

Drug Therapy Anemia (cont’d)

◦ Iron supplements If plasma ferritin <100 ng/mL Side effects: Gastric irritation,

constipation May make stool dark in color

Collaborative Care

Drug Therapy Anemia (cont’d)

◦ Folic acid supplements Needed for RBC formation Removed by dialysis

◦ Avoid blood transfusions.

Collaborative Care

Drug Therapy Dyslipidemia

◦ Goal Lowering LDL below 100 mg/dL Triglyceride level below 200 mg/dL

◦ Statins HMG-CoA reductase inhibitors

Most effective for lowering LDL

Collaborative Care

Drug Therapy Complications

◦ Drug toxicity Digitalis Antibiotics Pain medication (Demerol, NSAIDs)

Collaborative Care

Nutritional Therapy Protein restriction

◦ Benefits are being studied. Water restriction

◦ Intake depends on daily urine output.

Collaborative Care

Nutritional Therapy Sodium restriction

◦Diets vary from 2 to 4 g, depending on degree of edema and hypertension.

◦Sodium and salt should not be equated. ◦Salt substitutes should not be used

because they contain potassium chloride.

Collaborative Care

Nutritional Therapy Potassium restriction

◦ 2 to 3 g◦ High-potassium foods should be avoided.

Collaborative Care

Nutritional Therapy Phosphate restriction

◦ 1000 mg/day◦ Foods high in phosphate

Dairy products ◦ Most foods high in phosphate are also high in

protein.

Collaborative Care

Complete history of any existing renal disease, family history

Long-term health problems Dietary habits

Nursing ManagementNursing Assessment

Excess fluid volume Risk for injury Imbalanced nutrition: Less than body

requirements Grieving Risk for infection

Nursing ManagementNursing Diagnoses

Overall goals◦ Demonstrate knowledge and ability to comply

with therapeutic regimen.◦ Participate in decision making. ◦ Demonstrate effective coping strategies.

Nursing ManagementPlanning

Overall goals (cont’d)◦ Continue with activities of daily living within

psychologic limitations.

Nursing ManagementPlanning

Health promotion◦ Identify individuals at risk for CKD.

History of renal disease Hypertension Diabetes mellitus Repeated urinary tract infection

◦ Regular checkups and changes in urinary appearance, frequency, and volume should be reported.

Nursing ManagementNursing Implementation

Acute intervention◦ Daily weight◦ Daily BPs◦ Identify signs and symptoms of fluid overload.◦ Identify signs and symptoms of hyperkalemia.◦ Strict dietary adherence


Acute intervention◦ Medication education◦ Motivate patients in management of their disease.


Ambulatory and home care◦ When conservative therapy is no longer effective,

HD, PD, and transplantation are treatment options.

◦ Patient/family need clear explanation of dialysis and transplantation.


Maintenance of ideal body weight Acceptance of chronic disease No infection No edema Hematocrit, hemoglobin, and serum

albumin levels in acceptable range

Nursing ManagementEvaluation

When teaching a patient with chronic kidney disease about prevention of complications, the nurse instructs the patient to:

1. Monitor for proteinuria daily with a urine dipstick.

2. Weigh daily and report a gain of greater than 4 pounds.

3. Take calcium-based phosphate binders on an empty stomach.

4. Perform self-catheterization every 4 hours to accurately measure I & O.

Question

81

Case Study

82

35-year-old man began to notice weakness with activities such as walking distances or running.

Also began experiencing tingling all over his body, particularly in his hands and feet

Case Study

Symptoms progressed over 4 months, with 10 pounds of weight lost with no decline in appetite.

Increased urinary output with normal frequency

Strong thirst at night

Case Study

Sought out medical help because he was afraid he was getting diabetes

History reveals grandmother and aunt have diabetes with no family history of renal disease.

Case Study

At age 5, he was admitted to the hospital for hematuria.◦ Urinary protein 4+◦ BUN 31 mg/dL◦ Hb 11.6 g/dL◦ Was diagnosed with acute glomerulonephritis

Case Study: History

At age 11, he was admitted to the same hospital with gross hematuria.◦ Albuminuria 4+◦ BUN 10.5 mg/dL◦ Hb 15.7 g/dL◦ Diagnosed with recurring acute

glomerulonephritis

Case Study: History

He had no follow-up medical care after that hospitalization until his current admission to the hospital.

Case Study

Current lab values◦ Potassium 6.0 mEq/L◦ BUN 110 mg/dL◦ Creatinine 12 mg/dL◦ Hct 20%◦ Hb 6 g/dL

Case Study

1. Why would his symptoms seem similar to diabetes?

2. Why is he developing chronic renal failure so many years after his primary diagnosis?

Discussion Questions

3. What is the priority of care for him?

4. What patient teaching should be done with him?


Focus on Dialysis

JSB

Movement of fluid/molecules across a semipermeable membrane from one compartment to another

Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure

Treat drug overdoses

Dialysis

Two methods of dialysis available◦ Peritoneal dialysis (PD)◦ Hemodialysis (HD)

Dialysis

Begun when patient’s uremia can no longer be adequately managed conservatively

Initiated when GFR (or creatinine clearance) <15 mL/min

Dialysis

Diffusion◦ Movement of solutes from an area of greater

concentration to an area of lesser

General Principles of Dialysis

Osmosis and Diffusion Across Semipermeable Membrane

Osmosis◦ Movement of fluid from an area of lesser to an

area of greater concentration of solutes


Ultrafiltration◦ Water and fluid removal◦ Results when an osmotic gradient occurs across

the membrane


Peritoneal access is obtained by inserting a catheter through the anterior wall.

Technique for catheter placement varies. Usually done via surgery

Peritoneal Dialysis

Tenckhoff Catheter

Fig. 47-5. Peritoneal dialysis showing peritoneal catheter inserted into peritoneal cavity.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

After catheter is inserted, skin is cleaned with antiseptic solution and sterile dressing applied.

Connected to sterile tubing system Secured to abdomen with tape Catheter irrigated immediately

Peritoneal Dialysis

Waiting period of 7 to 14 days preferable 2 to 4 weeks after implantation,

exit site should be clean, dry, and free of redness/tenderness.

Once site has healed, patient may shower and pat dry.

Peritoneal Dialysis

Peritoneal Catheter Exit Site

Fig. 47-6. Peritoneal catheter exit site.


Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%

Electrolyte composition similar to plasma Solution warmed to body temperature

Peritoneal DialysisDialysis Solutions and Cycles


Three phases of PD cycle◦ Inflow (fill)◦ Dwell (equilibration)◦ Drain

Called an exchange



Inflow◦ Prescribed amount of solution infused through

established catheter over about 10 minutes◦ After solution infused, inflow clamp closed to

prevent air from entering tubing



Dwell◦ Diffusion and osmosis occur between patient’s

blood and peritoneal cavity.◦ Duration of time varies, depending on the

method.



Drain◦ 15 to 30 minutes◦ May be facilitated by gently

massaging abdomen or changing position



Automated peritoneal dialysis (APD)◦ Cycler delivers the dialysate.◦ Times and controls fill, dwell, and drain.

Continuous ambulatory peritoneal dialysis (CAPD)◦ Manual exchange

Peritoneal DialysisSystems


Automated Peritoneal Dialysis


Exit site infection Peritonitis Hernias

Peritoneal DialysisComplications


Lower back problems Bleeding Pulmonary complications Protein loss

Peritoneal DialysisComplications


Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD

Peritoneal DialysisEffectiveness and Adaptation


The patient diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse?◦ A. The ability to auscultate a bruit over the

fistula.◦ B. The dialysate instilled was 1,500 ml and

removed was 1,500 ml.◦ C. The dialysate being removed from the client’s

abdomen is clear.◦ D. The client’s abdomen is soft, is nontender, and

has bowel sounds.

Question

Obtaining vascular access is one of the most difficult problems.◦ Types of access include

Arteriovenous fistulae and grafts Temporary vascular access

HemodialysisVascular Access Sites


Vascular Access for Hemodialysis

117

Fig. 47-8. Vascular access for hemodialysis. A, Arteriovenous fistula. B, Arteriovenous graft.


Arteriovenous Fistula

Fig. 47-9. Arteriovenous fistula created by anastomosing an artery and vein.


Vascular Access Catheter

Fig. 47-10. Temporary double-lumen vascular access catheter for acute hemodialysis. A, Soft, flexible double-lumen tube is attached to a Y hub. B, The distance between the arterial intake and the venous return lumina typically provides recirculation rates of 5% or less.


Vascular Access Catheter

Fig. 47-11. A, Right internal jugular placement for a tunneled, cuffed semipermanent catheter.B, Temporary hemodialysis catheter in place. C, Long-term cuffed hemodialysis catheter.


Long plastic cartridge that contains thousands of parallel hollow tubes or fibers

Fibers are the semipermeable membrane.

HemodialysisDialyzers


Two needles placed in fistula or graft

Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer.

Blood is returned from dialyzer to patient through second needle or blue catheter.

HemodialysisProcedure


Components of Hemodialysis

Fig. 47-12. Components of a hemodialysis system. Blood is removed via a needle inserted in a fistula or viacatheter lumen. It is propelled to the dialyzer by a blood pump. Heparin is infused either as a bolus predialysis or through a heparin pump continuously to prevent clotting. Dialysate is pumped in andFlows in the opposite direction of the blood. The dialyzed blood is returned to the patient through aSecond needle or catheter lumen. Old dialysate and ultrafiltrate are drained and discarded.


Dialyzer/blood lines primed with saline solution to eliminate air

Terminated by flushing dialyzer with saline to remove all blood

Needles removed and firm pressure applied



Before treatment, nurse should◦ Complete assessment of fluid status, condition of

access, temperature, and skin condition During treatment, nurse should

◦ Be alert to changes in condition◦ Perform vital signs every 30 to 60 minutes



The patient is receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first?◦ A. Place the patient in the Trendelenburg

position.◦ B. Turn off the dialysis machine immediately.◦ C. Bolus the client with 500ml of NS◦ D. Notify the health-care provider as soon as

possible.

Question

Hypotension Muscle cramps Loss of blood Hepatitis

HemodialysisComplications


Cannot fully replace metabolic and hormonal functions of kidneys

Can ease many of the symptoms Can prevent certain complications

HemodialysisEffectiveness and Adaptation


The patient receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the patient?◦ A. Encourage significant other to make decisions

for the client.◦ B. Keep fingernails short and try not to scratch

the skin.◦ C. Apply ice to the access site if it starts bleeding

at home.◦ D. Notify the HCP if oral temperature is 102 F or

greater.

Question

Alternative or adjunctive method for treating AKI

Means by which uremic toxins and fluids are removed

Acid-base status/electrolytes adjusted slowly and continuously

Continual Renal Replacement Therapy (CRRT)


Can be used in conjunction with HD Contraindication

◦ Presence of manifestations of uremia requiring rapid resolution

Continued for 30 to 40 days



Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow. Specimens may be obtained for evaluation.



Two types of CRRT◦ Venous access◦ Arterial access



Most common: Venovenous approaches ◦ Continuous venovenous hemofiltration (CVVH)◦ Continuous venovenous hemodialysis (CVVHD)



Continuous Vevovenous Therapies

Fig. 47-14. Basic schematic of continuous venovenous therapies. Blood pump is required to pump blood through the circuit. Replacement ports are used for instilling replacement fluids and can be given prefilteror postfilter. Dialysate port is used for infusing distillate. Regardless of modality, ultrafiltrate is drainedvia the ultrafiltration drain port.


Continuous venovenous hemofiltration (CVVH)◦ Large volumes of fluid removed hourly, then

replaced◦ Fluid replacement dependent on

stability/individualized needs of patient



Continuous venovenous hemodialysis (CVVHD)◦ Uses dialysate◦ Dialysate bags attached to distal end of

hemofilter



Continuous venovenous hemodialysis (CVVHD)◦ Fluid pumped countercurrent to blood flow◦ Ideal treatment for patient who needs fluid/solute

control but cannot tolerate rapid fluid shifts with HD



Highly permeable, hollow fiber hemofilter Uses double-lumen catheter placed in

femoral, jugular, or subclavian vein. Removes plasma water and nonprotein

solutes



CRRT versus HD◦ Continuous rather than intermittent◦ Solute removal by convection (no dialysate

required), in addition to osmosis and diffusion◦ Less hemodynamic instability



CRRT versus HD (cont’d)◦ Does not require constant monitoring by HD nurse◦ Does not require complicated HD equipment



When implementing care for the patient on peritoneal dialysis, the nurse recognizes that dietary needs include an increased quantity of:

1. Fat.2. Protein.3. Calories.4. Carbohydrates.

Question

142Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study

143Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

65-year-old woman with history of progressive renal failure for 5 years

Diagnosed with type 1 diabetes mellitus when 15 years old

Case Study


She has diabetic retinopathy with macular degeneration.

Gives herself insulin using an insulin pen

Case Study


Lab values◦ BUN 72 mg/dL◦ Serum creatinine 7.5 mg/dL◦ GFR 12 mL/min

Case Study

1. What are her options for renal replacement therapy?

2. Which one would be the best choice for her?


Focus on Kidney Transplant

Kidney Transplantation More than 75,000 patients are currently

awaiting kidney transplants. Less than ¼ ever receive a kidney.

Kidney Transplantation Extremely successful 1-year graft survival rate

◦ 90% for cadaver transplants◦ 95% for live donor transplants

Kidney Transplantation Advantages of kidney transplant compared

with dialysis◦ Reverses many of the pathophysiologic changes

associated with renal failure◦ Eliminates dependence on dialysis◦ Less expensive than dialysis after the first year

Kidney TransplantationRecipient Selection Candidacy determined by a variety of

medical and psychosocial factors that vary among transplant centers.

Kidney TransplantationRecipient Selection Contraindications to

transplantation◦ Disseminated malignancies◦ Untreated cardiac disease◦ Chronic respiratory failure◦ Extensive vascular disease◦ Chronic infection◦ Unresolved psychosocial disorders

Kidney TransplantationHistocompatibility Studies Purpose of testing is to identify the HLA

antigens for both donors and potential recipients.

Kidney TransplantationDonor Sources Compatible blood type deceased donors Blood relatives Emotionally related living donors Altruistic living donors Paired organ donation

Kidney TransplantationSurgical Procedure Live donor

◦ Nephrectomy performed by a urologist or transplant surgeon

◦ Begins an hour or two before the recipient’s surgery is started

◦ Rib may need to be removed for adequate view ◦ Takes about 3 hours

Kidney TransplantationSurgical Procedure Live donor

◦ Laparoscopic donor nephrectomy Alternative to conventional nephrectomy Most common approach of live kidney procurement

Kidney TransplantationSurgical Procedure Kidney transplant recipient

◦ Usually placed extraperitoneally in the iliac fossa◦ Right iliac fossa is preferred.

Kidney Transplant

Fig. 47-15. A, Surgical incision for a renal transplant. B, Surgical placement of transplanted kidney.

Kidney Transplantation Surgical ProcedureKidney transplant recipient Before incision

◦ Urinary catheter placed into bladder◦ Antibiotic solution instilled

Distends the bladder Decreases risk of infection

◦ Crescent-shaped incision

Kidney Transplantation Surgical ProcedureKidney transplant recipient Rapid revascularization critical Donor artery anastomosed to recipient

internal/external iliac artery Donor vein anastomosed to recipient

external iliac vein

Kidney Transplantation Surgical ProcedureKidney transplant recipient When anastomoses complete,

clamps released and blood flow reestablished

Urine may begin to flow, or diuretic may be given.

Surgery takes 3 to 4 hours.

Kidney TransplantationNursing Management Preoperative care

◦ Emotional and physical preparation◦ Immunosuppressive drugs◦ ECG◦ Chest x-ray◦ Laboratory studies

Kidney TransplantationNursing Management Postoperative care

◦ Live donor Care is similar to laparoscopic nephrectomy. Close monitoring of renal function Close monitoring of hematocrit

Kidney TransplantationNursing Management Postoperative care (cont’d)

◦ Recipient Maintenance of fluid and electrolyte balance is first

priority. Large volumes of urine soon after transplanted

kidney placed due to New kidney’s ability to filter BUN Abundance of fluids during operation Initial renal tubular dysfunction

Kidney TransplantationNursing Management Postoperative care (cont’d)

◦ Recipient Urine output replaced with fluids milliliter by milliliter

hourly Urine output closely measured

Acute tubular necrosis can occur. May need dialysis

Maintain catheter patency.

Kidney TransplantationImmunosuppressive Therapy Goals

◦ Adequately suppress the immune response.◦ Maintain sufficient immunity to prevent

overwhelming infection.

Kidney TransplantationComplications Rejection

◦ Hyperacute (antibody-mediated, humoral) rejection Occurs minutes to hours after transplantation

Kidney TransplantationComplications Rejection (cont’d)

◦ Acute rejection Occurs days to months after transplantation

Kidney TransplantationComplications Rejection (cont’d)

◦ Chronic rejection Process that occurs over months or years and is

irreversible

Kidney TransplantationComplications

Infection◦ Most common infections observed in the first

month Pneumonia Wound infections IV line and drain infections

Kidney TransplantationComplications Infection (cont’d)

◦ Fungal infections Candida Cryptococcus Aspergillus Pneumocystis jiroveci

Kidney TransplantationComplications Infection (cont’d)

◦ Viral infections CMV

One of the most common Epstein-Barr virus Herpes simplex virus

Kidney TransplantationComplications Cardiovascular disease

◦ Transplant recipients have increased incidence of atherosclerotic vascular disease.

◦ Immunosuppressant can worsen hypertension and hyperlipidemia.

◦ Adhere to antihypertensive regimen.

Kidney TransplantationComplications Malignancies

◦ Primary cause is immunosuppressive therapy.◦ Regular screening is important preventive care.

Kidney TransplantationComplications Recurrence of original renal disease

◦ Glomerulonephritis◦ IgA nephropathy◦ Diabetes mellitus◦ Focal segmental sclerosis

Kidney TransplantationComplications Corticosteroid-related complications

◦ Aseptic necrosis of the hips, knees, and other joints

◦ Peptic ulcer disease◦ Glucose intolerance and diabetes

Kidney Transplantation Complications Corticosteroid-related complications

(cont’d)◦ Dyslipidemia◦ Cataracts◦ Increased incidence of infection and malignancy ◦ Close monitoring of side effects

Nursing ManagementEvaluation Maintenance of ideal body weight Acceptance of chronic disease No infection No edema Hematocrit, hemoglobin, and serum

albumin levels in acceptable range

Six days after a kidney transplant from a deceased donor , the patient develops a temperature of 101.2° F (38.5°C), tenderness at the transplant site, and oliguria. The nurse recognizes that these findings indicate:

1. Acute rejection, which is not uncommon and is usually reversible.2. Hyperacute rejection, which will necessitate removal of the transplanted kidney.3. An infection of the kidney, which can be treated with intravenous antibiotics.4. The onset of chronic rejection of the kidney with eventual failure of the kidney.

Question

180

Case Study

181

Case Study (same patient as in dialysis presentation) 65-year-old woman with history of

progressive renal failure for 5 years

Diagnosed with type 1 diabetes mellitus when 15 years old

Case Study (same patient as in dialysis presentation) After waiting for 9 months, she is notified

that a diseased (cadaver) kidney has become available.

The kidney transplant is done.


1. She does very well postoperatively and is ready for discharge. What are the priority teaching interventions?


2. Because she is a diabetic individual, what are her special needs?

Documents

Jules Brinley, RN, MSN/Ed, CNE. Which statement does not accurately characterize the kidneys: ◦ A. Each kidney contains millions of nephrons, which