Chronic Renal Failure

Prepared by D. ChaplinPrepared by D. Chaplin

Chronic Renal Failure




Progressive, irreversible damage to the nephrons and glomeruli

Regardless of the cause: Decreased: GFR, tubular function & tubular reabsorption capabilities. Dysfunction fluids & electrolytes, acid base disturbances, & systemic problems develops

Progressive, irreversible damage to the nephrons and glomeruli

Regardless of the cause: Decreased: GFR, tubular function & tubular reabsorption capabilities. Dysfunction fluids & electrolytes, acid base disturbances, & systemic problems develops



Cause:- most frequent cause of CKD is diabetic nephropathy, most often secondary to type 2 diabetes mellitus - Hypertensive nephropathy is a common cause of CKD in the elderly

Cause:- most frequent cause of CKD is diabetic nephropathy, most often secondary to type 2 diabetes mellitus - Hypertensive nephropathy is a common cause of CKD in the elderly


RISK FACTORS hypertension, diabetes mellitus, autoimmune disease, older age, African ancestry, a family history of renal disease, a previous episode

of acute renal failure presence of proteinuria, abnormal urinary sediment,

or structural abnormalities of the urinary tract


Chronic Renal FailureEnd Stage Renal Disease (ESRD)

Protein and waste metabolism accumulates in the blood (azotemia)

90% of kidney function is lost (kidney cannot adequately function)

Hypothesis: Nephrons remains intact, others progressively destroyed.

Adaptive response maintains function until ¾ are destroyed

Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately

Protein and waste metabolism accumulates in the blood (azotemia)

90% of kidney function is lost (kidney cannot adequately function)

Hypothesis: Nephrons remains intact, others progressively destroyed.

Adaptive response maintains function until ¾ are destroyed

Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately


ESRD

Polyuria is perhaps early sign of ESRD

As the disease progress – unable to rid the body of excess waste products via kidneys –uremia results – eventually other systems affected

When the creatinine clearance falls below 10 ml/min (average), GFR < 5ml/min (average) = dialysis

Other symptoms Nocturia, oliguria/anuria, increased K+, Mg++, PO4 and decrease Ca++, Neurological changes, CV changes, etc.

Polyuria is perhaps early sign of ESRD

As the disease progress – unable to rid the body of excess waste products via kidneys –uremia results – eventually other systems affected

When the creatinine clearance falls below 10 ml/min (average), GFR < 5ml/min (average) = dialysis

Other symptoms Nocturia, oliguria/anuria, increased K+, Mg++, PO4 and decrease Ca++, Neurological changes, CV changes, etc.


Stages of Chronic Renal Failure

Diminished Renal Reserve Normal BUN, and serum creatinine absence of symptoms

Renal Insufficiency GFR is about 25% of normal, BUN Creatinine levels increased

Renal Failure GFR <25% of normal increasing symptoms

ESRD or Uremia GFR < 5-10% normal, creatinine clearance <5-10 ml/min

resulting in a cumulative effect

Diminished Renal Reserve Normal BUN, and serum creatinine absence of symptoms

Renal Insufficiency GFR is about 25% of normal, BUN Creatinine levels increased

Renal Failure GFR <25% of normal increasing symptoms

ESRD or Uremia GFR < 5-10% normal, creatinine clearance <5-10 ml/min

resulting in a cumulative effect



Approach to patient

Identify if it is ACUTE RENAL FAILURE or CHRONIC.

Findings that suggest chronic kidney disease include anemia, evidence of renal osteodystrophy (radiologic or laboratory), and small scarred kidneys


Treatment Modalities

Decrease fluid 1000ml/day

Decrease protein (.5-1kg body weight)

Decrease sodium (1-4gm variable)

Decrease potassium

Decrease phosphorous (<1000mg/day)

Dialysis (periotoneal, hemodialysis)

RBC, Vitamin D (calcitrol replacement) etc.

Decrease fluid 1000ml/day

Decrease protein (.5-1kg body weight)

Decrease sodium (1-4gm variable)

Decrease potassium

Decrease phosphorous (<1000mg/day)

Dialysis (periotoneal, hemodialysis)

RBC, Vitamin D (calcitrol replacement) etc.


Dialysis Hemodialyis(Hemo)Peritoneal (PD)

General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another

Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)

Peritoneal – Peritoneal membrane is the semi permeable membrane

General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another

Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)

Peritoneal – Peritoneal membrane is the semi permeable membrane


Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through

Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment

Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through

Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment

Osmosis - movement fluid from an area of < to > concentration of solutes (particles)

Osmosis - movement fluid from an area of < to > concentration of solutes (particles)

Osmosis-Diffusion-Ultrafiltration


Peritoneal Dialysis

Catheter placement – anterior abdominal wallTenckoff (25cm length with cuff anchor and

migration)Dialysis solution (1-2 liters sometimes smaller)Three phases of PD

Inflow (fill) approximately 10 minutes, could be in cycles)

Dwell (equilibration) (approximately 20-30 min or 8 hours+)

Drain (approximately 15 minutes) These 3 phases are called Exchanges

Catheter placement – anterior abdominal wallTenckoff (25cm length with cuff anchor and

migration)Dialysis solution (1-2 liters sometimes smaller)Three phases of PD

Inflow (fill) approximately 10 minutes, could be in cycles)

Dwell (equilibration) (approximately 20-30 min or 8 hours+)

Drain (approximately 15 minutes) These 3 phases are called Exchanges


Peritoneal Dialysis


Hemodialysis

Vascular access for high blood flow

Shunts, (telfon, external)

Arteriovenous fistulas and grafts (AV)

Anastomosis between an artery and vein

Fistulas are native vessels (4-6 wks maturity)

Grafts are artificial/synthetic material

Vascular access for high blood flow

Shunts, (telfon, external)

Arteriovenous fistulas and grafts (AV)

Anastomosis between an artery and vein

Fistulas are native vessels (4-6 wks maturity)

Grafts are artificial/synthetic material


Hemodialysis

AV Fistula CommunicationAV Fistula Communication

AV Graph AccessAV Graph Access


Hemodialysis

Hemodialysis MachineHemodialysis MachineHemodialysis CircuitHemodialysis Circuit


PD Advantages and Disadvantages

Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Bacterial/chemical periotonitis

Protein lossExit site of catheterSelf imageHyperglycemiaSurgical placement of

catheterMultiple abdominal

surgery

Bacterial/chemical periotonitis

Protein lossExit site of catheterSelf imageHyperglycemiaSurgical placement of

catheterMultiple abdominal

surgery

AdvantagesAdvantages DisadvantagesDisadvantages


Hemo Advantages & Disadvantages

Rapid fluid removalRapid removal of urea &

creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at the

bedside

Rapid fluid removalRapid removal of urea &

creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at the

bedside

Vascular access problems

Dietary & fluid restrictions

HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist

Vascular access problems

Dietary & fluid restrictions

HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist

AdvantagesAdvantages DisadvantagesDisadvantages


Disequalibrium Syndrome

Fluid removal and decrease in BUN during hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures

Treatment: Hypertonic saline, Normal saline

Fluid removal and decrease in BUN during hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures

Treatment: Hypertonic saline, Normal saline


Nursing Care Pre, Post Dialysis

Weigh before & after

Assess site before & after (bruit, thrill, infection, bleeding etc.)

Medications (precautions before & after)

Vital signs before and after etc.

Weigh before & after

Assess site before & after (bruit, thrill, infection, bleeding etc.)

Medications (precautions before & after)

Vital signs before and after etc.


Renal Transplant

Living and Cadaveric donors

Predialysis: obtain a dry weight free of excess fluids and toxins

More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement

Delay may increase ATN

Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)

Living and Cadaveric donors

Predialysis: obtain a dry weight free of excess fluids and toxins

More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement

Delay may increase ATN

Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)


Immunological Compatibility of Donor and Recipient

Done to minimize the destruction (rejection) of the transplanted kidney

HUMAN LEUKOCYTE ANTIGEN (HLA)

This gives you your genetic identity (twins share identical HLA)

HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.

Done to minimize the destruction (rejection) of the transplanted kidney

HUMAN LEUKOCYTE ANTIGEN (HLA)

This gives you your genetic identity (twins share identical HLA)

HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.


Immunological Analysis

WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney

A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation

WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney

A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation


Immulogical Analysis

MIXED LYMPHOCYTE CULTURE

The donor and recipient lymphocytes are mixed. Result = HIGH SENTIVITY, this is

contraindicated for renal transplantation.

ABO BLOOD GROUPING

ABO blood group must be compatible

MIXED LYMPHOCYTE CULTURE

The donor and recipient lymphocytes are mixed. Result = HIGH SENTIVITY, this is

contraindicated for renal transplantation.

ABO BLOOD GROUPING

ABO blood group must be compatible


Surgery

LLQ of the abdomen outside of the peritoneal cavity

Renal artery and vein anastomosed to the corresponding iliac vessels

Donor ureters are tunneled into the recipients’ bladder.

LLQ of the abdomen outside of the peritoneal cavity

Renal artery and vein anastomosed to the corresponding iliac vessels

Donor ureters are tunneled into the recipients’ bladder.


Complications Post Transplant

Rejection is a major problem

Hyperacute rejection: occurs within minutes to hours after transplantation

Renal vessels thrombosis occurs and the kidney dies

There is no treatment and the transplanted kidney is removed

Rejection is a major problem

Hyperacute rejection: occurs within minutes to hours after transplantation

Renal vessels thrombosis occurs and the kidney dies

There is no treatment and the transplanted kidney is removed



Acute Rejection: occurs 4 days to 4 months after transplantation

It is not uncommon to have at least one rejection episode

Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)

Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys

Acute Rejection: occurs 4 days to 4 months after transplantation

It is not uncommon to have at least one rejection episode

Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)

Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys



Chronic Rejection: occurs over months or years and is irreversible.

The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury

Gradual occlusion renal blood vessels

Signs: proteinuria, HTN, increase serum creatinine levels

Supportive treatment, difficult to manage

Replace on transplant list

Chronic Rejection: occurs over months or years and is irreversible.

The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury

Gradual occlusion renal blood vessels

Signs: proteinuria, HTN, increase serum creatinine levels

Supportive treatment, difficult to manage

Replace on transplant list



InfectionHypertensionMalignancies (lip, skin,

lymphomas, cervical)Recurrence of renal diseaseRetroperiotneal bleedArterial stenosisUrine leakage

InfectionHypertensionMalignancies (lip, skin,

lymphomas, cervical)Recurrence of renal diseaseRetroperiotneal bleedArterial stenosisUrine leakage

Date post:	01-Jan-2016
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Chronic Renal Failure

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