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

Renal Failure Renal Failure andand

TreatmentTreatmentVicky Jefferson, RN, CNNVicky Jefferson, RN, CNN

Satellite DialysisSatellite Dialysis(modified by Kelle Howard, RN, MSN)(modified by Kelle Howard, RN, MSN)

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

Homer Homer Smith, Ph.D.Smith, Ph.D.

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REVIEWREVIEW

What are nephrons?What are nephrons?

What are the functions of the What are the functions of the kidneys?kidneys?

Normal creatinine & BUN?Normal creatinine & BUN?

Diagnostic toolsDiagnostic tools

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Functions of the KidneysFunctions of the Kidneys

Regulates ______ & _________ of Regulates ______ & _________ of extracellular fluid extracellular fluid

Regulates fluid & electrolyte balance Regulates fluid & electrolyte balance thruthru

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

Name some of the F & Es regulated by Name some of the F & Es regulated by kidneys kidneys ____________________________________

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Functions of the Kidneys Functions of the Kidneys (cont)(cont)

Regulates acid-base balance throughRegulates acid-base balance through HCO3 and H+HCO3 and H+

*Hormonal functions: *Hormonal functions: (BP control), (BP control), multisystem effect.multisystem effect. Renin ReleaseRenin Release

RAAS=

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Erythropoietin ReleaseErythropoietin Release If a patient has chronic renal If a patient has chronic renal

failure, what condition will occur?failure, what condition will occur? WHY???WHY???

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Activate Vitamin DActivate Vitamin D Necessary to absorb Calcium in the Necessary to absorb Calcium in the

GIGI

tract. tract.

If a patient has renal failure, what If a patient has renal failure, what will happen to the patient’s serum will happen to the patient’s serum calcium level? __________________calcium level? __________________

Functions of the KidneysFunctions of the Kidneys

______________________________ ______________________________ ______________________________

____________________________ ____________________________ ____________________________ ____________________________

Diagnostic Tools for Diagnostic Tools for Assessing Renal FailureAssessing Renal Failure

Blood TestsBlood Tests BUN BUN Creatinine Creatinine K+ K+ POPO4 4

Ca Ca UrinalysisUrinalysis

Specific gravitySpecific gravity ProteinProtein Creatinine clearanceCreatinine clearance

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BUNBUN

Normal 10-30 mg/dlNormal 10-30 mg/dl Nitrogenous waste product of Nitrogenous waste product of

protein metabolismprotein metabolism Unreliable in measurement of renal Unreliable in measurement of renal

functionfunction

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CreatinineCreatinine

A waste product of muscle A waste product of muscle metabolismmetabolism

Normal value 0.5 - 1.5 mg/dlNormal value 0.5 - 1.5 mg/dl 2 times normal = 50% damage 2 times normal = 50% damage 8 times normal = 75% damage8 times normal = 75% damage 10 times normal = 90% damage10 times normal = 90% damage Exception -_______________________ Exception -_______________________

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Diagnostic ToolsDiagnostic Tools

BiopsyBiopsy UltrasoundUltrasound X-RaysX-Rays

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Chronic Renal FailureChronic Renal Failure

Slow progressive renal disorder Slow progressive renal disorder related to nephron loss, occurring related to nephron loss, occurring over months to yearsover months to years

Culminates in End Stage Renal Culminates in End Stage Renal DiseaseDisease

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Characteristics of Characteristics of Chronic Renal FailureChronic Renal Failure

Cause & onset often unknownCause & onset often unknown Loss of function precedes lab Loss of function precedes lab

abnormalitiesabnormalities Lab abnormalities precede Lab abnormalities precede

symptomssymptoms Symptoms (usually) evolve in orderly Symptoms (usually) evolve in orderly

sequencesequence Renal size is usually decreasedRenal size is usually decreased

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Causes of Chronic Renal Causes of Chronic Renal FailureFailure

DiabetesDiabetes HypertensionHypertension GlomerulonephritisGlomerulonephritis Cystic disordersCystic disorders Developmental - CongenitalDevelopmental - Congenital Infectious DiseaseInfectious Disease

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Causes of Chronic Renal Causes of Chronic Renal Failure Failure

NeoplasmsNeoplasms Obstructive disordersObstructive disorders Autoimmune diseasesAutoimmune diseases Hepatorenal failureHepatorenal failure SclerodermaScleroderma AmyloidosisAmyloidosis Drug toxicityDrug toxicity

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Glomerular Filtration RateGlomerular Filtration RateGFRGFR

24 hour urine for creatinine clearance24 hour urine for creatinine clearance Most accurate indicator of Renal FunctionMost accurate indicator of Renal Function Reflects GFRReflects GFR Formula:Formula:

urine creatinine X urine volumeurine creatinine X urine volume

serum creatinineserum creatinine

Can estimate creatinine clearance by:Can estimate creatinine clearance by:

Men: {Men: {140 – age} x IBW (kg) 140 – age} x IBW (kg)

72 x serum creatinine72 x serum creatinine

Women: {Women: {140 – age} x IBW (kg) 140 – age} x IBW (kg)

85 x serum creatinine85 x serum creatinine

What is a normal GFR?What is a normal GFR?

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Stages of Chronic Renal Stages of Chronic Renal FailureFailure

Old SystemOld System Reduced Renal ReserveReduced Renal Reserve

Renal InsufficiencyRenal Insufficiency

End Stage Renal Disease (ESRD)End Stage Renal Disease (ESRD)

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NKF Classification SystemNKF Classification System

Stage 1: Stage 1:

GFR >/= 90 ml/min despite GFR >/= 90 ml/min despite kidney damagekidney damage

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NKF Classification SystemNKF Classification SystemStage 2:Stage 2: Mild reduction Mild reduction

(GFR 60 – 89 ml/min)(GFR 60 – 89 ml/min)

1. GFR of 60 may represent 1. GFR of 60 may represent 50% 50% loss in loss in function.function.

2. Parathyroid hormones 2. Parathyroid hormones starts to starts to increase. increase.

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During Stage 1 - 2During Stage 1 - 2

No symptomsNo symptoms

Serum creatinine doublesSerum creatinine doubles

Up to 50% nephron lossUp to 50% nephron loss

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NKF Classification SystemNKF Classification SystemStage 3:Stage 3: Moderate reduction Moderate reduction

(GFR 30 – 59 ml/min)(GFR 30 – 59 ml/min)1. Calcium absorption 1. Calcium absorption

decreases decreases

2. Malnutrition onset2. Malnutrition onset

3. Anemia3. Anemia

4. Left ventricular 4. Left ventricular hypertrophyhypertrophy

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NKF Classification SystemNKF Classification SystemStage 4:Stage 4: Severe reduction Severe reduction

(GFR 15 – 29 ml/min)(GFR 15 – 29 ml/min)

1. Serum triglycerides 1. Serum triglycerides increaseincrease

2. Hyperphosphatemia2. Hyperphosphatemia

3. Metabolic acidosis3. Metabolic acidosis

4. Hyperkalemia4. Hyperkalemia

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During Stage 3 - 4During Stage 3 - 4

Signs and symptoms worsen if Signs and symptoms worsen if kidneys are stressedkidneys are stressed

Decreased ability to maintain Decreased ability to maintain homeostasishomeostasis

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During stages 3 - 4During stages 3 - 4

75% nephron loss 75% nephron loss Decreased: glomerular filtration Decreased: glomerular filtration

rate, solute clearance, ability to rate, solute clearance, ability to concentrate urine and hormone concentrate urine and hormone secretionsecretion

Symptoms: elevated BUN & Symptoms: elevated BUN & Creatinine, mild azotemia, anemiaCreatinine, mild azotemia, anemia

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NKF Classification SystemNKF Classification System

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

1. Azotemia1. Azotemia

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During Stage 5During Stage 5End Stage Renal DiseaseEnd Stage Renal Disease

Residual function < 15% of normalResidual function < 15% of normal Excretory, regulatory and hormonal Excretory, regulatory and hormonal

functions severely impaired. functions severely impaired. Metabolic acidosisMetabolic acidosis Marked increase in: BUN, Marked increase in: BUN,

Creatinine, PhosphorousCreatinine, Phosphorous Marked decrease in: Hemoglobin, Marked decrease in: Hemoglobin,

Hematocrit, CalciumHematocrit, Calcium Fluid overloadFluid overload

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During Stage 5During Stage 5

Uremic syndrome develops affecting Uremic syndrome develops affecting all body systemsall body systems can be diminished with early diagnosis can be diminished with early diagnosis

& treatment& treatment

Last stage of progressive CRFLast stage of progressive CRF Fatal if no treatmentFatal if no treatment

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Manifestations of Manifestations of Chronic UremiaChronic Uremia

Fig. 47-5

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What happens when the What happens when the kidneys don’t function kidneys don’t function

correctly?correctly?

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Manifestations of CRF Manifestations of CRF Nervous SystemNervous System

Mood swingsMood swings Impaired judgmentImpaired judgment Inability to concentrate and perform Inability to concentrate and perform

simple math functionssimple math functions Tremors, twitching, convulsionsTremors, twitching, convulsions Peripheral NeuropathyPeripheral Neuropathy

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Manifestations of CRFManifestations of CRFSkinSkin

Pale, grayish-bronze colorPale, grayish-bronze color Dry scalyDry scaly Severe itchingSevere itching Bruise easilyBruise easily Uremic frostUremic frost

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Manifestations of CRFManifestations of CRFEyesEyes

Visual blurringVisual blurring BlindnessBlindness

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Manifestations of CRF Manifestations of CRF Fluid - Electrolyte - pHFluid - Electrolyte - pH

Volume expansion and fluid overloadVolume expansion and fluid overload Metabolic AcidosisMetabolic Acidosis Change in urine specific gravityChange in urine specific gravity Electrolyte ImbalancesElectrolyte Imbalances

PotassiumPotassium MagnesiumMagnesium SodiumSodium

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Manifestations of CRFManifestations of CRFGI TractGI Tract

Uremic fetorUremic fetor Anorexia, nausea, vomitingAnorexia, nausea, vomiting GI bleedingGI bleeding

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Manifestations of CRF Manifestations of CRF HematologicHematologic

AnemiaAnemia Platelet dysfunctionPlatelet dysfunction

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Manifestations of CRF Manifestations of CRF MusculoskeletalMusculoskeletal

Muscle crampsMuscle cramps Soft tissue calcificationsSoft tissue calcifications WeaknessWeakness Related to calcium phosphorous Related to calcium phosphorous

imbalancesimbalances RENAL OSTEODYSTROPHYRENAL OSTEODYSTROPHY

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Calcium-Phosphorous Calcium-Phosphorous BalanceBalance

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Manifestations of CRFManifestations of CRFHeart - LungsHeart - Lungs

HypertensionHypertension Congestive heart failureCongestive heart failure PericarditisPericarditis Pulmonary edemaPulmonary edema Pleural effusionsPleural effusions Atherosclerotic vascular disease*Atherosclerotic vascular disease* Cardiac dysrhythmiasCardiac dysrhythmias

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Manifestations of CRF Manifestations of CRF Endocrine - MetabolicEndocrine - Metabolic

Erythropoietin production decreasedErythropoietin production decreased HypothyroidismHypothyroidism Insulin resistanceInsulin resistance Growth hormone decreasedGrowth hormone decreased Gonadal dysfunctionGonadal dysfunction Parathyroid hormone and Vitamin DParathyroid hormone and Vitamin D33

HyperlipidemiaHyperlipidemia

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Treatment OptionsTreatment Options

Conservative TherapyConservative Therapy HemodialysisHemodialysis Peritoneal DialysisPeritoneal Dialysis TransplantTransplant NothingNothing

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Conservative Treatment Conservative Treatment GoalsGoals

GOALS:GOALS: Detect & treat potentially reversible Detect & treat potentially reversible

causes of renal failurecauses of renal failure Preserve existing renal functionPreserve existing renal function Treat manifestationsTreat manifestations Prevent complicationsPrevent complications Provide for comfortProvide for comfort

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Conservative TreatmentConservative Treatment

Control Control HyperkalemiaHyperkalemia HypertensionHypertension HyperphosphatemiaHyperphosphatemia HyperparthryoidismHyperparthryoidism HyperglycemiaHyperglycemia AnemiaAnemia DyslipidemiaDyslipidemia HypothyroidismHypothyroidism NutritionNutrition

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HemodialysisHemodialysis

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

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HistoryHistory

Early animal experiments began Early animal experiments began 19131913

1st human dialysis 1940’s by Dutch 1st human dialysis 1940’s by Dutch physician Willem Kolff (2 of 17 physician Willem Kolff (2 of 17 patients survived)patients survived)

Considered experimental through Considered experimental through 1950’s, No intermittent blood 1950’s, No intermittent blood access; for acute renal failure only. access; for acute renal failure only.

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History cont’dHistory cont’d

1960 Dr. Scribner developed 1960 Dr. Scribner developed Scribner ShuntScribner Shunt

1960’s Machines expensive, scarce, 1960’s Machines expensive, scarce, no funding.no funding.

““Death Panels” panels within Death Panels” panels within community decided who got to community decided who got to dialyze.dialyze.

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Hemodialysis ProcessHemodialysis Process

Blood removed from patient into the Blood removed from patient into the extracorporeal circuit. extracorporeal circuit.

Diffusion and ultrafiltration take Diffusion and ultrafiltration take place in the dialyzer. place in the dialyzer.

Cleaned blood returned to patient. Cleaned blood returned to patient.

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Extracorporeal CircuitExtracorporeal Circuit

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How Hemodialysis How Hemodialysis WorksWorks

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Vascular AccessVascular Access

Arterio-venous shunt (Scribner Arterio-venous shunt (Scribner External Shunt)External Shunt)

Arterio-venous (AV) FistulaArterio-venous (AV) Fistula PTFE GraftPTFE Graft Temporary cathetersTemporary catheters ““Permanent” cathetersPermanent” catheters

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Scribner ShuntScribner Shunt

External- one end External- one end into artery, one into into artery, one into vein. vein.

AdvantagesAdvantages place at bedsideplace at bedside use immediatelyuse immediately

DisadvantagesDisadvantages infectioninfection skin erosionskin erosion accidental separation accidental separation limits use of limits use of

extremityextremity

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Arterio-venous (AV) Arterio-venous (AV) FistulaFistula

Primary FistulaPrimary Fistula Patients own artery and vein surgically Patients own artery and vein surgically

anastomosed.anastomosed. AdvantagesAdvantages

patients own veinpatients own vein longevitylongevity low infection and thrombosis rateslow infection and thrombosis rates

DisadvantagesDisadvantages long time to mature, 1- 6 monthslong time to mature, 1- 6 months ““steal” syndrome steal” syndrome requires needle sticks requires needle sticks

devita.com devita.com

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PTFE PTFE (Polytetrafluoroethylene) (Polytetrafluoroethylene)

GraftGraft Synthetic “vessel” anastomosed into an artery and Synthetic “vessel” anastomosed into an artery and

vein.vein. AdvantagesAdvantages

for people with inadequate vesselsfor people with inadequate vessels can be used in 1-4 weekscan be used in 1-4 weeks prominent vesselsprominent vessels

DisadvantagesDisadvantages clots easilyclots easily ““steal” syndrome more frequentsteal” syndrome more frequent requires needle sticksrequires needle sticks infection may necessitate removal of graftinfection may necessitate removal of graft

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Temporary CathetersTemporary Catheters Dual lumen catheter placed into a central vein-Dual lumen catheter placed into a central vein-

subclavian, jugular or femoral.subclavian, jugular or femoral. AdvantagesAdvantages

immediate useimmediate use no needle sticksno needle sticks

DisadvantagesDisadvantages high incidence of infectionhigh incidence of infection subclavian vein stenosissubclavian vein stenosis poor flow-inadequate dialysispoor flow-inadequate dialysis clottingclotting restricts movement restricts movement

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Cuffed Tunneled Cuffed Tunneled CathetersCatheters

Dual lumen catheter with Dacron Dual lumen catheter with Dacron cuff surgically tunneled into cuff surgically tunneled into subclavian, jugular or femoral subclavian, jugular or femoral vein.vein.

AdvantagesAdvantages immediate useimmediate use can be used for patients that can be used for patients that

can have no other permanent can have no other permanent accessaccess

no needle sticksno needle sticks DisadvantagesDisadvantages

high incidence of infectionhigh incidence of infection poor flows result in inadequate poor flows result in inadequate

dialysisdialysis clottingclotting

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Care of Vascular AccessCare of Vascular Access

NONO BP’s, needle sticks to arm with BP’s, needle sticks to arm with vascular access. This includes finger vascular access. This includes finger sticks.sticks.

Place ID bands on other arm Place ID bands on other arm whenever possible.whenever possible.

Palpate thrill and listen for bruit.Palpate thrill and listen for bruit. Teach patient nothing constrictive.Teach patient nothing constrictive.

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Potential Potential Complications of Complications of

HemodialysisHemodialysis During dialysisDuring dialysis Fluid and electrolyte related Fluid and electrolyte related

hypotensionhypotension CardiovascularCardiovascular

arrythmiasarrythmias Associated with the extracorporeal circuitAssociated with the extracorporeal circuit

exsanguinationexsanguination NeurologicNeurologic

Disequilibrium Syndrome & seizuresDisequilibrium Syndrome & seizures MusculoskeletalMusculoskeletal

crampingcramping OtherOther

fever & sepsisfever & sepsis blood born diseasesblood born diseases

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Potential Potential Complications of Complications of

Hemodialysis Hemodialysis Between treatmentsBetween treatments Hypertension/HypotensionHypertension/Hypotension EdemaEdema Pulmonary edemaPulmonary edema HyperkalemiaHyperkalemia BleedingBleeding Clotting of accessClotting of access

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Complications of Complications of Hemodialysis cont’dHemodialysis cont’d

Long termLong term MetabolicMetabolic

hyperparathyroidismhyperparathyroidism diabetic complicationsdiabetic complications

*Cardiovascular*Cardiovascular CHFCHF AV access failureAV access failure cardiovascular diseasecardiovascular disease

RespiratoryRespiratory pulmonary edemapulmonary edema

NeuromuscularNeuromuscular neuropathyneuropathy

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Complications of Complications of HemodialysisHemodialysis

cont’dcont’d Long term cont’dLong term cont’d

HematologicHematologic anemiaanemia

GIGI bleedingbleeding

DermatologicDermatologic calcium phosphorous depositscalcium phosphorous deposits

RheumatologicRheumatologic amyloid depositsamyloid deposits

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Complications of Complications of Hemodialysis cont’dHemodialysis cont’d

Long term cont’dLong term cont’d GenitourinaryGenitourinary

infectioninfection sexual dysfunctionsexual dysfunction

PsychiatricPsychiatric depressiondepression

*Infection*Infection blood borne pathogensblood borne pathogens

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Dietary Restrictions on Dietary Restrictions on HemodialysisHemodialysis

Fluid restrictionsFluid restrictions Phosphorous restrictionsPhosphorous restrictions Potassium restrictionsPotassium restrictions Sodium restrictionsSodium restrictions Protein to maintain nitrogen balanceProtein to maintain nitrogen balance

too high - waste productstoo high - waste products too low - decreased albumin, increased too low - decreased albumin, increased

mortalitymortality Calories to maintain or reach ideal weightCalories to maintain or reach ideal weight

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Peritoneal DialysisPeritoneal Dialysis

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

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Types of Peritoneal Types of Peritoneal DialysisDialysis

CAPD: CAPD: Continuous ambulatory peritoneal Continuous ambulatory peritoneal dialysisdialysis

CCPDCCPD: Continuous cycling peritoneal : Continuous cycling peritoneal dialysis dialysis Aka. APD – Automated Peritoneal DialysisAka. APD – Automated Peritoneal Dialysis

IPD: IPD: Intermittent peritoneal dialysisIntermittent peritoneal dialysis

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CAPDCAPD

Catheter into peritoneal cavityCatheter into peritoneal cavity Exchanges 4 - 5 times per dayExchanges 4 - 5 times per day Treatment 24 hours; 7 days a weekTreatment 24 hours; 7 days a week Solution remains in peritoneal cavity Solution remains in peritoneal cavity

except during drain timeexcept during drain time Independent treatmentIndependent treatment

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Phases of A Peritoneal Phases of A Peritoneal Dialysis ExchangeDialysis Exchange

Fill: fluid infused into peritoneal Fill: fluid infused into peritoneal cavitycavity

Dwell: time fluid remains in Dwell: time fluid remains in peritoneal cavityperitoneal cavity

Drain: time fluid drains from Drain: time fluid drains from peritoneal cavityperitoneal cavity

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Complications of Complications of Peritoneal DialysisPeritoneal Dialysis

InfectionInfection peritonitisperitonitis tunnel infectionstunnel infections catheter exit site catheter exit site

HypervolemiaHypervolemia hypertensionhypertension pulmonary edemapulmonary edema

HypovolemiaHypovolemia hypotensionhypotension

HyperglycemiaHyperglycemia MalnutritionMalnutrition

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Complications of Complications of Peritoneal Dialysis cont’dPeritoneal Dialysis cont’d ObesityObesity HypokalemiaHypokalemia HerniaHernia Cuff erosionCuff erosion Low back painLow back pain HyperlipidemiaHyperlipidemia

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Advantages of CAPDAdvantages of CAPD

Independence for patientIndependence for patient No needle sticksNo needle sticks Better blood pressure controlBetter blood pressure control Some diabetics add insulin to solutionSome diabetics add insulin to solution Fewer dietary restrictionsFewer dietary restrictions

protein loses in dialysateprotein loses in dialysate generally need increased potassiumgenerally need increased potassium less fluid restrictionsless fluid restrictions

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Peritoneal Catheter Exit Peritoneal Catheter Exit SiteSite

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Medications Common to Medications Common to Dialysis PatientsDialysis Patients

Vitamins - water solubleVitamins - water soluble Phosphate binder ---- GIVE WITH MEALSPhosphate binder ---- GIVE WITH MEALS

Phoslo (calcium acetate)Phoslo (calcium acetate) Renagel (sevelamere hydrochloride)Renagel (sevelamere hydrochloride) Caltrate (calcium cabonate) Caltrate (calcium cabonate) Amphojel (aluminum hydroxide)Amphojel (aluminum hydroxide)

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

Antihypertensives - hold prior to dialysisAntihypertensives - hold prior to dialysis

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Medications Common to Medications Common to Dialysis Patients cont’dDialysis Patients cont’d

ErythropoietinErythropoietin Calcium SupplementsCalcium Supplements

BetweenBetween meals, meals, notnot with iron with iron

Activated Vitamin DActivated Vitamin D3 3

aids in calcium absorptionaids in calcium absorption Antibiotics Antibiotics

hold dose prior to dialysis if it dialyzes hold dose prior to dialysis if it dialyzes outout

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MedicationsMedications

Many drugs or their metabolites are Many drugs or their metabolites are excreted by the kidneyexcreted by the kidney

Dosages Dosages many change when used in renal failure many change when used in renal failure

patientspatients Dialyzability Dialyzability

many removed by dialysis varies many removed by dialysis varies between HD and PDbetween HD and PD

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Patient EducationPatient Education

Alleviate fearAlleviate fear Dialysis processDialysis process Fistula/catheter careFistula/catheter care Diet and fluid restrictionsDiet and fluid restrictions MedicationMedication Diabetic teachingDiabetic teaching

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TransplantationTransplantation

TreatmentTreatment not not curecure

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Kidney Awaiting Kidney Awaiting TransplantTransplant

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Transplanted KidneyTransplanted Kidney

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AdvantagesAdvantages

Restoration of “normal” renal Restoration of “normal” renal functionfunction

Freedom from dialysisFreedom from dialysis Return to “normal” lifeReturn to “normal” life Reverses pathophysiological Reverses pathophysiological

changes related to Renal Failurechanges related to Renal Failure Less expensive than dialysis after 1Less expensive than dialysis after 1stst

yearyear

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DisadvantagesDisadvantages

Life long medicationsLife long medications Multiple side effects from Multiple side effects from

medicationmedication Increased risk of tumorIncreased risk of tumor Increased risk of infectionIncreased risk of infection Major surgeryMajor surgery

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Care of the RecipientCare of the Recipient

Major surgery with general Major surgery with general anesthesiaanesthesia

Assessment of renal functionAssessment of renal function Assessment of fluid and electrolyte Assessment of fluid and electrolyte

balancebalance Prevention of infectionPrevention of infection Prevention and management of Prevention and management of

rejectionrejection

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FunctionFunction

ATN? (acute tubular necrosis) ATN? (acute tubular necrosis) 50% experience50% experience

Urine output >100 <500 cc/hrUrine output >100 <500 cc/hr BUN, creatinine, creatinine clearanceBUN, creatinine, creatinine clearance Fluid BalanceFluid Balance UltrasoundUltrasound Renal scansRenal scans Renal biopsyRenal biopsy

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Fluid & Electrolyte Fluid & Electrolyte BalanceBalance

Accurate I & OAccurate I & O CRITICAL TO AVOID DEHYDRATIONCRITICAL TO AVOID DEHYDRATION Output normal - >100 <500 cc/hr, could Output normal - >100 <500 cc/hr, could

be 1-2 L/hrbe 1-2 L/hr Potential for volume overload/deficitPotential for volume overload/deficit

Daily weightsDaily weights Postassium (K+)___________Postassium (K+)___________ Sodium (Na) _____________ Sodium (Na) _____________ Blood sugrar _____________Blood sugrar _____________

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Prevention of InfectionPrevention of Infection

Major complication of Major complication of transplantation due to transplantation due to immunosuppressionimmunosuppression

HANDWASHINGHANDWASHING Crowds, KidsCrowds, Kids Patient EducationPatient Education

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RejectionRejection

Hyperacute - preformed antibodies Hyperacute - preformed antibodies to donor antigento donor antigen function ceases within 24 hoursfunction ceases within 24 hours Rx = removalRx = removal

Accelerated - same as hyperacute Accelerated - same as hyperacute but slower, 1st week to monthbut slower, 1st week to month Rx = removalRx = removal

87

Rejection cont’dRejection cont’d

Acute - generally after 1st 10 days to Acute - generally after 1st 10 days to end of 2nd monthend of 2nd month 50% experience50% experience must differentiate between rejection must differentiate between rejection

and cyclosporine toxicityand cyclosporine toxicity Rx = steroids, monoclonal (OKTRx = steroids, monoclonal (OKT33), or ), or

polyclonal (HTG) antibodiespolyclonal (HTG) antibodies

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Rejection cont’dRejection cont’d

Chronic - gradual process of graft Chronic - gradual process of graft dysfunctiondysfunction Repeated rejection episodes that have Repeated rejection episodes that have

not been completely resolved with not been completely resolved with treatmenttreatment

4 months to years after transplant4 months to years after transplant Rx = return to dialysis or re-Rx = return to dialysis or re-

transplantationtransplantation

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Immunosuppressant Immunosuppressant DrugsDrugs

PrednisonePrednisone prevents infiltration of T lymphocytesprevents infiltration of T lymphocytes

Side effectsSide effects cushingnoid changescushingnoid changes avascular necrosisavascular necrosis GI disturbancesGI disturbances diabetesdiabetes infectioninfection risk of tumorrisk of tumor

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Immunosuppressant Immunosuppressant Drugs cont’dDrugs cont’d

Azathioprine (Imuran)Azathioprine (Imuran) Prevents rapid growing lymphocytesPrevents rapid growing lymphocytes

Side EffectsSide Effects bone marrow toxicitybone marrow toxicity hepatotoxicityhepatotoxicity hair losshair loss infectioninfection risk of tumorrisk of tumor

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CyclosporinCyclosporin Interferes with production of Interferes with production of

interleukin 2 which is necessary for interleukin 2 which is necessary for growth and activation of T lymphocytes.growth and activation of T lymphocytes.

Side EffectsSide Effects– NephrotoxicityNephrotoxicity– HTNHTN– HepatotoxicityHepatotoxicity– Gingival hyperplasiaGingival hyperplasia– InfectionInfection

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Cytoxan - in place of Imuran less Cytoxan - in place of Imuran less toxictoxic

FK506 - 100 x more potent than FK506 - 100 x more potent than CyclosporinCyclosporin

PrografPrograf CellceptCellcept

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OKTOKT33 - monoclonal antibody used to treat rejection - monoclonal antibody used to treat rejection or induce immunosuppressionor induce immunosuppression decreases CDdecreases CD3 3 cells within 1 hour cells within 1 hour

Side effectsSide effects anaphylaxisanaphylaxis fever/chillsfever/chills pulmonary edemapulmonary edema risk of infectionrisk of infection tumorstumors

1st dose reaction expected & wanted, pre-treat 1st dose reaction expected & wanted, pre-treat with Benadryl, Tylenol, Solumedrolwith Benadryl, Tylenol, Solumedrol

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Atgam - polyclonal antibody used to treat Atgam - polyclonal antibody used to treat rejection or induce immunosuppressionrejection or induce immunosuppression decreased number of T lymphocytesdecreased number of T lymphocytes

Side effectsSide effects anaphylaxisanaphylaxis fever chillsfever chills leukopenialeukopenia thrombocytopeniathrombocytopenia risk of infectionrisk of infection tumortumor

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Patient EducationPatient Education

Signs of infectionSigns of infection Prevention of infectionPrevention of infection Signs of rejectionSigns of rejection

decreased urine outputdecreased urine output increased weight gainincreased weight gain tenderness over kidneytenderness over kidney fever > 100 degrees Ffever > 100 degrees F

MedicationsMedications time, dose, side effectstime, dose, side effects

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Exclusion for TransplantExclusion for Transplant

Exclusion for Transplant not limited tooExclusion for Transplant not limited too Active vasculitis; Active vasculitis; oror Life threatening extrarenal congenital Life threatening extrarenal congenital

abnormalities; abnormalities; oror Untreated coagulation disorder; Untreated coagulation disorder; oror Ongoing alcohol or drug abuse; Ongoing alcohol or drug abuse; oror Age over 70 years with severe co-morbidities; Age over 70 years with severe co-morbidities; oror Severe neurological or mental impairment, in Severe neurological or mental impairment, in

persons without adequate social support, such persons without adequate social support, such that the person is unable to adhere to the that the person is unable to adhere to the regimen necessary to preserve the transplant.regimen necessary to preserve the transplant.

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Exclusion for TransplantExclusion for Transplant

Exclusion for Transplant not limited tooExclusion for Transplant not limited too Active vasculitis; Active vasculitis; oror Life threatening extrarenal congenital Life threatening extrarenal congenital

abnormalities; abnormalities; oror Untreated coagulation disorder; Untreated coagulation disorder; oror Ongoing alcohol or drug abuse; Ongoing alcohol or drug abuse; oror Age over 70 years with severe co-morbidities; Age over 70 years with severe co-morbidities; oror Severe neurological or mental impairment, in Severe neurological or mental impairment, in

persons without adequate social support, such persons without adequate social support, such that the person is unable to adhere to the that the person is unable to adhere to the regimen necessary to preserve the transplant.regimen necessary to preserve the transplant.

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Official Criteria for Official Criteria for Deceased DonorsDeceased Donors

Usually irreversible brain injuryUsually irreversible brain injury MVA, gunshot wounds, hemorrhage, anoxic MVA, gunshot wounds, hemorrhage, anoxic

brain injury from MIbrain injury from MI Must have effective cardiac functionMust have effective cardiac function Must be supported by ventilator to preserve Must be supported by ventilator to preserve

organsorgans Age 2-70Age 2-70 No IV drug use, HTN, DM, Malignancies, Sepsis, No IV drug use, HTN, DM, Malignancies, Sepsis,

diseasedisease Permission from legal next of kin & Permission from legal next of kin &

pronoucement of death made by MDpronoucement of death made by MD

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Official Criteria for Living Official Criteria for Living DonorsDonors

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 Nurses Role in Event of Potential DonationPotential Donation

Notify TOSA of possible organ Notify TOSA of possible organ donationdonation Identify possible donorsIdentify possible donors Make referral in timely mannerMake referral in timely manner

Do not discuss organ donation with Do not discuss organ donation with familyfamily

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

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Documents

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