CHRONIC RENAL FAILURE, SURGICAL

MANAGEMENTMOKGWANE EUTLWETSE SPARKS

5TH YEAR MED STUDENTUWI,,NASSAU CAMPUS

PROTOCOL

DEFINITION CLASSIFICATION INCIDENCE AETIOLOGGY CLINICAL PRESENTATION INVESTIGATION SURGICAL MANAGEMENT COMPLICATIONS SUMMARY REFERENCES

DEFINITION

Chronic renal failure (CRF) is a progressive decrease in renal function (CFR <60 ml/min for ≥3 mo) with subsequent accumulation of waste products in the blood, electrolyte abnormalities, and anemia.

Ferri: Ferri's Clinical Advisor 2008, 10th ed.

CLASSIFICATION

INCIDENCE

Number of patients with ESRD is increasing at the rate of 7% to 9%/yr in the U.S.

Each year 2/10,000 persons develop end-stage CRF.

In the U.S., >250,000/yr receive dialysis treatment for ESRD.

INCIDENCE

15 million dollars annually to provide free dialysis treatment to 330 persons with kidney disease.

 costs a whopping $45,000 per patient per year.

Recent data confirms that there are more than 330 persons in The Bahamas receiving free dialysis treatment as a result of kidney disease.

The total cost to treat those persons: $14,850,000.

INCIDENCE

Estimated figures will increase by some 60 % to 80 % above current levels in all countries by the year 2020.

Diabetes is by far the single largest contributor to causes of kidney failure, accounting for some 47% of diagnoses in the United States as reflected in the USRDS statistics for 2011.

Hypertension (high blood pressure) is second, accounting for some 25-30%.

HEAMODIALYSIS MONTHLY STATS 2012- PMH

MONTH

NEW PTS

ACUTE PTS

TRANSIENT PTS

TOT PTS

TOT Rx

DEATHS

JAN 11 1 3 139 1569 2

FEB 3 5 5 139 1628 5

MARCH 4 0 1 142 1722 3

APRIL 3 3 7 142 1527 3

MAY 6 2 3 150 1698 2

JUNE 2 0 5 157 1754 0

JULY 3 2 4 159 1750 2

AUG 7 0 7 163 1902 3

SEP 9 0 10 153 1624 0

OCT 3 2 6 156 1814 0

NOV 1 0 8 157 1611 0

DEC 3 0 2 155 1503 6

AETIOLOGY

Diabetes (37%)

Hypertension (30%)

Chronic glomerulonephritis (12%)

Polycystic kidney disease

Tubular interstitial nephritis (e.g., drug hypersensitivity, analgesic nephropathy)

Obstructive nephropathies (e.g., nephrolithiasis, prostatic disease)

Vascular diseases (renal artery stenosis, hypertensive nephrosclerosis)

CLINICAL PRESENTATION

The clinical presentation varies with the degree of renal failure and its underlying etiology.

Skin pallor, Ecchymoses Edema Hypertension Emotional lability depression

Common symptoms are generalized fatigue, nausea, anorexia, pruritus, insomnia, taste disturbances

INVESTIGATION

LABORATORY EVALUATION

IMAGING STUDIES

KIDNEY BIOPSY

INVESTIGATION

LABORATORY EVALUATION

Urinalysis: may reveal proteinuria, RBC casts Serum chemistry: elevated BUN and creatinine, hyperkalemia,

hyperuricemia, hypocalcemia, hyperphosphatemia, hyperglycemia, decreased bicarbonate

Urinary protein excretion. Ratio of protein to creatinine of >1000 mg/g suggests the presence of glomerular disease

Cystatin C is a cysteine proteinase inhibitor produced by all

nucleated cells, freely filtered at the glomerulus but not secreted by tubular cells. Given these characteristics, it may be superior to creatinine concentration both in kidney disease and as a marker of acute kidney injury.

INVESTIGATION

IMAGING STUDIES- ULTRA SOUND

SURGICAL MANAGEMENT

People with chronic kidney failure have three treatment choices.

DIALYSIS

RENAL TRANSPLANT

CONSERVATIVE TREATMENT

DIALYSIS

a method of removing toxic substances (impurities or wastes) from the blood when the kidneys are unable to do so.

most frequently used for patients who have kidney failure, but may also be used to quickly remove drugs or poisons in acute situations.

This technique can be life saving in people with acute or chronic kidney failure.

2 methods: hemodialysis and peritoneal dialysis

DIALYSIS- METHODS

Hemodialysis Peritoneal Dialysis

HEMODIALYSIS

A dialysis process which requires a machine to transport the blood and dialysing fluid on either side of a semi-permeable membrane to effect the removal of toxic metabolites and excess water

Hemodialysis Treatment with the new dialysis machine

HEMODIALYSIS

4-6 hours

SUBCLAVIAN VEIN CATHETER

may be inserted for short term or temporary use in acute renal failure

usually filled w/ heparin & capped to maintain patency between dialysis treatments

may be left in place

for up to 6 wks if complications do not occur

FEMORAL VEIN CATHETER

may be inserted for short term or temporary use in acute renal failure

client should not sit up more than 45° or lean forward, or the catheter may kink & occlude.

an IV infusion pump w/ microdrip tubing should be used if a heparin infusion through the catheter is prescribed

SUBCLAVIAN & FEMORAL INTERVENTIONS

Assess insertion site for hematoma, bleeding, dislodging, and infection.

Do not use these catheters for any reason other than dialysis.

Maintain an occlusive dressing.

EXTERNAL AV SHUNT

Access is formed by the surgical insertion of 2 silastic cannulas into an artery or vein in the forearm or leg to form an external blood path.

EXTERNAL AV SHUNT

ADVANTAGES DISADVANTAGES

Can be used immediately after insertion

No venipuncture necessary for dialysis

External danger of disconnecting or dislodging the shunt Risk of hemorrhage, infection or clotting Skin erosion around the catheter site

EXTERNAL AV SHUNT- INTERVENTIONS

Avoid wetting the shunt. A dressing is wrapped completely around the shunt & kept

dry & intact. Cannula clamps need to be available at the client’s

bedside. Do not take BP, draw blood, place an IV line, or administer

injections in the shunt extremity. Monitor for hemorrhage, infection and clotting. Monitor skin integrity around the insertion site. Note that the shunt is patent if it is warm to touch. Auscultate & palpate for a bruit, although a bruit may not

be heard & is not always with the shunt. Notify the physician immediately if signs of clotting,

hemorrhage, or infection occur.

INTERNAL AV FISTULA for chronic dialysis

clients created surgically by

anastomosis of a large artery & a large vein in the arm

Maturity: veins become engorged due to the flow of arterial blood into the venous system; takes 1-2 wks.

Maturity is required before the fistula can be used

INTERNAL AV FISTULA

Preferred form of dialysis access Types

Radiocephalic (first choice) Brachiocephalic (second choice) Brachiobasilic (third choice, requires

superficialization of basilic vein, i.e. transposition)

Lower extremity fistulae are rare

INTERNAL AV FISTULA

ADVANTAGES DISADVANTAGES

Less danger of clotting and bleeding Can be used indefinitely Decreased incidence of infection No external dressing required Freedom of movement

Cannot be used immediately after insertion Venipuncture is required for dialysis Infiltration of needles → hematoma Aneurysm in the fistula Arterial steal syndrome Congestive heart failure

INTERNAL AV GRAFT for chronic dialysis clients

who do not have adequate blood vessels for the creation of a fistula

Gore-Tex or a bovine (cow) carotid artery as artificial vein for blood flow

Procedure involves the anastomosis of the graft to the artery, a tunneling under the skin, and anastomosis to a vein.

can be used 2 wks after insertion

Complications: clotting, aneurysms and infection

INTERNAL AV GRAFT

Synthetic conduit, usually polytetrafluoroethylene (PTFE, aka Gortex), between an artery and a vein

Either straight or looped

Common sites Straight forearm : Radial artery to cephalic vein Looped forearm : brachial artery to cephalic vein Straight upper arm : brachial artery to axillary vein Looped upper arm : axillary artery to axillary vein

INTERNAL AV GRAFT

ADVANTAGES DISADVANTAGES

Less danger of clotting and bleeding Can be used indefinitely Decreased incidence of infection No external dressing required Freedom of movement

Cannot be used immediately after insertion Venipuncture is required for dialysis Infiltration of needles → hematoma Aneurysm in the fistula Arterial steal syndrome Congestive heart failure

INTERNAL AV FISTULA & GRAFT- INTERVENTIONS

Do not measure BP, draw blood, place an IV line, or administer injections in the fistula or graft extremity.

Monitor for clotting. Monitor for arterial steal syndrome. Palpate or auscultate for bruit or thrill over the fistula

or graft. Palpate pulses below the fistula or graft, and monitor

for hand swelling as an indication of ischemia. Note temperature and capillary refill of the extremity. Monitor for infection. Monitor lung and heart sound for signs of CHF. Notify the physician immediately if sings of clotting,

infection, or arterial steal syndrome occur.

DIALYSIS METHODS

Hemodialysis Peritoneal Dialysis

PERITONEAL DIALYSIS

A dialysis process which requires the introduction of peritoneal dialysis solution (dialysate) into the peritoneal cavity via gravity or a cycler.

A soft, elastic tube (catheter) inside the abdomen is inserted through a minor surgical operation.

HOW IT WORKS…?

Peritoneum – semi-permeable; rich blood supply

When a dialysate is put into the peritoneal cavity, the dialysate gently pulls the small pieces of waste products & water from the blood into the dialysate via the semi-permeable membrane. (diffusion & osmosis)

THE PERITONEAL CYCLE

TYPES OF PR DIALYSIS…

Continuous Ambulatory Peritoneal Dialysis (CAPD)

Automated Peritoneal Dialysis (APD)

CONTINUOS AMBULATORY PD

A dialysis treatment carried out continuously 24/7 without the use of a dialysis machine

Remember: Warm solution bag to avoid stomach pain. This may be done by wrapping solution bag w/in an electric blanket set on ‘low’ or by wrapping w/in a towel under a heat lamp.

CAPD Solution Baghas 2 short tubes at the bottom end:

Shorter tube w/ aluminum cap: for adding medicationLonger tube w/ connector: for connection w/ the Y-Set

Always check the ff before use:Strength: 1.5 GLU to 4.25 GLUClarity: clear & w/o particlesAmount: 1L to 2LLeakage: no leaking bagsExpiry Date: do not use after expiry date

CAPD- EQUIPMENTS

CAPD Y-Set Connection for the patient line, new solution bag and empty bag

Patient Line Attached to the catheter Reduces exit site infection

White Caps Used to cover the end of the patient line after an exchange

Braunoderm (Skin disinfectant) For disinfection

Masks Protection for both the nurse and equipment

CAPD- EQUIPMENTS

CAPD CYCLE…

1. The dialysate is instilled into the peritoneal cavity through an implant catheter attached to a transferline, which is attached to a bag of dialysate.

2. Once the fluid has been instilled completely into the peritoneal cavity, the empty bag and transferline are folded up and worn in a cloth pouch beneath the clothing. Thus, the patient is free to ambulate and resume his normal daily activities.

CAPD CYCLE…

3.When it is time to drain off the effluent, the bag is unfolded, placed on the floor and drainage is achieved by gravity. A new bag of dialysate is then attached to the transferline and the process is repeated. Usually the solution exchange procedure takes about 15 minutes.

TYPES OF PR DIALYSIS

Continuous Ambulatory Peritoneal Dialysis (CAPD)

Automated Peritoneal Dialysis (APD)

AUTOMATED PERITONEAL DIALYSIS

Similar to CAPD Requires a peritoneal

cycling machine called a cycler

Can be done as intermittent peritoneal dialysis, continuous cycling peritoneal dialysis, or nightly peritoneal dialysis

PR COMPLICATIONS

Peritonitis Signs: cloudy bag, stomach pain, fever If suspected, obtain a culture of the outflow to determine the infective

organism

Abdominal Pain Pain during inflow is common during the 1st few exchanges & usually

disappears 1 to 2 wks of dialysis treatments Place heating pad

Insufficient Outflow Check for kinks and placement; refer to physician Encourage high-fiber diet

Leakage around the catheter site May take up to 2 wks for client to tolerate a full 2L exchange w/o

leaking around the catheter site

Bladder or Bowel Perforation

NURSING INTERVENTIONS Monitor vital signs. Monitor for signs of infection. Monitor for respiratory distress, pain, or discomfort. Monitor signs of pulmonary edema. Monitor for hypotension & hypertension. Monitor for malaise, nausea, vomiting. Assess the catheter sit dressing for wetness or bleeding. Monitor dwell time as prescribed by the physician & initiate flow. Do not allow dwell time to extend beyond the physician’s order

because this increases the risk for hyperglycemia. Turn the client from side to side if the outflow is slow to start. Monitor outflow, which should be a continuous stream after the

clamp is opened. Monitor outflow for color & clarity. Monitor intake & output accurately. If outflow < inflow, inflow – outflow = amt absorbed/retained by

the client during dialysis and should be counted as intake.

RENAL TRANSPLANTATION

Annual mortality rates for patients under dialysis range from 21%-25%, but <8% with cadaveric and <4% with living-related transplant recipients.

Healthier patients generally are selected for transplantation.

The benefit of transplantation is most notable in young people and in those with diabetes mellitus.

Projected years of life for patients 20-39 years old:

Dialysis Transplant

Non diabetic 20 31 years

Diabetic 825years

INDICATIONS & CONTRAINDICATIONS

INDICATIONS CONTRAINDICATIONS

All patients with ESRD are candidates for KT

Absolute : Severe vascular

disease.

Relative : Recent malignancy. Coronary artery

disease. Active bacterial,

fungal, or viral disease.

HIV positivity. Social conditions.

CRITERIA FOR LIVING DONOR SELECTION

- Blood relative.- Highly motivated.- ABO blood group-compatible.- HLA-identical or haploidentical with

negative cross-match.- Excellent medical condition with normal

renal function.

CRITERIA FOR CADAVER DONOR SELECTION

- Irreversible brain damage.- Normal renal function appropriate for age.- No evidence of preexisting renal disease.- No evidence of transmissible diseases.- ABO blood group-compatible.- Negative cross-match.- Best HLA match possible, particularly at

the DR and B loci.

SURGICAL PROCEDURE

Wet ischemia time (time from cessation of circulation to removal of organ and its placement in cold storage) should not exceed 30 mins.

Living donor transplants function immediately after transplant, +/- 30% of cadaveric transplants have delayed graft function because of more prolonged ischemic cold preservation. These pts need continued dialysis support until the kidney starts to function.

SURGICAL PROCEDURE

GRAFT PROGNOSIS

Directly related to source of donor kidney. Recipients of cadaveric kidneys have

more episodes of rejection and lower graft survival rates.

Graft survival rates for kidneys from living donor is 95% @ 1 yr and 76% @ 5 yrs vs graft survival from a cadaveric kidney donor is 89% @ 1 yr and 61% @ 5 yrs.

COMPLICATIONS

Usual postop generic complications: Atelectasis Pneumonia Haemorrhage Venous thromboembolism Transplant rejection

(hyeracute,acute,chronic) Wound infection Fever

COMPLICATIONS

I. Acute occlusion of transplant renal a or v.II. Electrolyte imbalanceIII. Peritransplant haematomaIV. Urinary LeakV. Obstructive uropathyVI. Renal artery stenosis

SUMMARY

Chronic renal failure is a debilitating condition.

Urgent appropriate intervention tends to prolong life and prevent a sequel of complications

Renal transplantation is superior compared to dialysis

Transplant tends to prolong life more compared to dialysis

REFERENCES

Ferri: Ferri's Clinical Advisor 2008, 10th ed.

Principles of Surgical Patient Care, 2nd edition, CJ Mieny + V Mennen, 2003.

Emedicine, Transplant, Renal, Richard Sinert + Mert Erogul.

Special thanks to Dialysis Unit PMH Special thanks to Dr McPhee