CKD/ESRD & Management

1
CKD/ESRDManagement
Note-when viewing lab values in PPT-note that
values are given as both as common values as
also the specific values given in textbook
(remember, sources vary slightly-think
ranges.)2010
2

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

3
REVIEW

• Recall functions of the kidneys?
• Recall normal creatinine BUN other lab tests?
• Review Diagnostic Tools

4
CKD- Elderly Risk (Review)

• Older Adult-normal aging (plus co-morbidities) gt
  risk kidney dysfunction/renal failure
• Must
• Identify/prevent damage
• Monitor/risk multiple RX/OTC meds (altered renal
  blood flow/dec. renal clearance etc)
• Monitor/risk associated with dehydration (ie
  diuretics)
• Monitor/risk with dec ability to respond to
  changes to fluid/electrolyte status
  (manifestation may be atypical

5
Functions of the Kidneys

• Regulates volume and composition of extracellular
  fluid
• Excretion of nitrogenous waste products
• BP control via renin-angiotensin-aldosterone
  system- Recall RAAS

• Vitamin D activation
• Acid-base balance (HCO3 H) regulation through
  process of _____, ____ and ______.
• Prostaglandin synthesis
• Erythropoietin production

filtration, secretion, reabsorpton
6
Functions of the Kidneys (cont)

• Erythropoietin Release
• If a patient has chronic renal failure, what
  condition will occur?
• WHY???

EPO- glycoprotein hormone that controls
erythropoiesis, or red blood cell production
1/24/2013
6
7
Diagnostic Tools for Assessing Renal Failure

• Blood Tests
• BUN elevated (norm 10-20 mg/dl) (text 10-30mg/dl)
• Creatinine elevated (norm 0.6 - 1.2 mg/dl) (text
  0.5-1.5mg/dl)
• K elevated (text norm 3.5-5.0 mEq/L)
• PO4 elevated (text norm 2.8-4.5mg/dl)
• Ca decreased (text norm 9-11mg/dl)
• Urinalysis
• Specific gravity (text norm 1.003-1.030
• Protein (text norm 0-trace)
• Creatinine clearance (text norm 85-135ml/min)

8
BUN

• Normal 8 - 20 mg/dl (text 10-30mg/dl)
• Nitrogenous waste product of protein metabolism
• Unreliable in measurement of renal function
• Relevance assessed in conjunction with serum
  creatinine

9
Creatinine

• A waste product of muscle metabolism
• Normal value 0.6 - 1.2 mg/dl (text 0.5-1.5mg/dl)
• 2 times normal 50 damage
• 8 times normal 75 damage
• 10 times normal 90 damage
• Exception -

severe muscular disease can greatly ? serum
creatinine levels
10
Diagnostic Tools

• Ultrasound
• X-Rays
• Biopsy most definitive

11
Chronic Renal Failure/ Chronic Kidney Disease
(CKD)

• Slow progressive renal disorder related to
  nephron loss, occurring over months to years
• Culminates in End Stage Renal Disease (ESRD)

12
Characteristics of CKD gt ESRD

• Cause onset often unknown
• Loss of function precedes lab abnormalities
• Lab abnormalities precede symptoms
• Symptoms (usually) evolve in orderly sequence
• Renal size is usually decreased

13
Causes of CKD

• Diabetes
• Hypertension
• Glomerulonephritis
• Cystic disorders
• Developmental - Congenital
• Infectious Disease

• Neoplasms
• Obstructive disorders
• Autoimmune diseases (lupus)
• Hepatorenal failure
• Scleroderma
• Amyloidosis
• Drug toxicity-(overuse some common drugs, as
  aspirin, NSAID as ibuprofen, cocaine and
  acetaminophen)

NSAIDs-cause prerenal ARF by blocking
prostaglandin production gt also alters local
glomerular arteriolar perfusion (reduces renal
blood flow)
14
Glomerular Filtration Rate (GFR)-determine stage
CKD (most accurate evaluation)

• 24 hour urine for creatinine clearance
• Formula- urine creatinine X urine volume
• serum creatinine
• Can estimate creatinine clearance by
• 140 age x weight (kg)
• 72 x serum creatinine
• What is normal GFR?

90 - 120 mL/min
15
Stages of CKD (old terminology)

• Reduced Renal Reserve
• Renal Insufficiency
• End Stage Renal Disease (ESRD)

16
Stages of CKDNKF Classification System

• Stage 1 GFR gt 90 ml/min despite kidney
  damage
• Stage 2 Mild reduction (GFR 60 89 ml/min)
• 1. GFR of 60 may represent 50
  loss in function.
• 2. Parathyroid hormones starts to
  increase. (why?)

kidneys unable to reabsorb calcium, blood
calcium levels fall, stimulating continual
secretion of parathyroid hormone to maintain
normal calcium levels in blood.
17
During Stage 1 - 2

• No symptoms
• Serum creatinine doubles
• (Up to 50 nephron loss

FYI-older adult- may impaired renal function even
in presence of normal serum creatinine
18
Stages of CKDNKF Classification System

• Stage 3 Moderate reduction (GFR 30 59
  ml/min)
• 1. Calcium absorption decreases
• (from the GI tract)
• 2. Malnutrition onset
• 3. Anemia
• 4. Left ventricular hypertrophy

19
Stages of CKDNKF Classification System

• Stage 4 Severe reduction (GFR 15 29 ml/min)
• 1. Serum triglycerides
• 2. Hyperphosphatemia
• 3. Metabolic acidosis
• 4. Hyperkalemia

Oops-trouble!
K Effect EKG
20
During Stage 3 - 4

• Signs and symptoms worsen if kidneys stressed
• ability to maintain homeostasis
• 75 nephron loss
• glomerular filtration rate, solute
  clearance, ability to concentrate urine and
  secrete hormone
• Symptoms BUN Creatinine, mild azotemia,
  anemia

21
Stages of CKD-NKF Classification System

• Stage 5 Kidney failure (GFR lt 15 ml/min)
• Azotemia
• Residual function lt 15 of normal
• Excretory, regulatory, hormonal functions
  severely impaired
• Metabolic acidosis (Kussmaul breathing)
• Marked BUN, Creatinine, Phosphorous
• Marked Hemoglobin, Hematocrit, Calcium
• Fluid overload

ESRD!!!
22
During Stage 5

• Uremic syndrome develops- affecting all body
  systems
• can be diminished with early diagnosis
  treatment
• Last stage of progressive CKD
• Fatal if no treatment

23
Manifestations of Chronic Uremia
Syndrome- combination of common symptoms greater
build-up waste products greater symptoms
Fig. 47-5
24
What happens when kidneys dont function
correctly?
25
Manifestations of CKD -Nervous System

• Mood swings
• Impaired judgment
• Inability to concentrate and perform simple math
  functions
• Tremors, twitching, convulsions
• Peripheral Neuropathy
• restless legs
• foot drop

Manifestations due to inc nitrogenous waste
products, electrolyte imbalances, metabolic
acidosis and axonal atrophy and demyelination of
nerve fibers dec erythropoietin
26
Manifestations of CRFSkin

• Pale, grayish-bronze color
• Dry scaly
• Severe itching
• Bruise easily, petechiae, ecchymosis
• Uremic frost

Manifestations due tocalcium-phosphate
deposition in skin, sensory neuropathy, platelet
abnormalities urea crystallizes (uremic frost)
gtif BUN extremely high
27
Medical Mystery? What do lab studies, etc
indicate ? What causes uremic frost?
57-year-old with HTN and CKD (Stage 5), refused
dialysis found in respiratory distress after week
of upper respiratory symptoms due to viral
infection
Before admission to hospital gtdeveloped
asystolic cardiac arrest, was resuscitated by
EMT, admitted to ICU, required vasopressor
support. PE- diffuse deposits tiny white
crystalline material on skin gt lab studies- BUN
208 mg/dl creatinine 15 mg/dl bicarbonate level
5 mmol per liter anion gap-26 arterial pH of
6.74, and arterial partial pressure of carbon
dioxide of 50 mm Hg. Blood cultures-
revealed-Staphylococcus aureus pneumonia, likely
due to prior influenza infection. Aggressive
care measures withdrawn after consultation with
patient's family gtpatient died.
Walsh S and Parada N. N Engl J Med 2005352e13
Uremic frost- uncommon skin manifestation due to
profound azotemia occurs when urea and other
nitrogenous waste products accumulate in sweat
and crystallize after evaporation.
28
Manifestations of CKDEyes

• Visual blurring
• Occasional blindness
• Red eye

Due to calcium-phosphate deposits in eyes
29
Manifestations of CKD Fluid - Electrolyte - pH

• Volume expansion and fluid overload
• Metabolic Acidosis
• Electrolyte Imbalances
• Potassium
• Magnesium
• Sodium

Due to impaired kidneys unable to excrete acid
load (mostly from NH3) defective
reabsorption/regeneration of HCO3.
Due to dec excretion by kidneys, breakdown of
cellular protein, bleeding, metabolic acidosis,
food, drugs, etc
Kidneys unable to excrete (too much magnesium
causes hyporeflexia and can lead to cardiac
arrest)
Kidneys retain gt water retentiongt fluid overload
30
Manifestations of CKDGI Tract/Bleeding Risk

• Uremic fetor
• Anorexia, nausea, vomiting
• GI bleeding
• Anemia
• Platelet dysfunction

Due to GI irritation, platelet defect diarrhea
from hyperkalemia
Anemia-due to insufficient production of
erythropoietin, protein naturally produced in
functioning kidneyscirculates through
bloodstream to bone marrow, stimulating
production of RBCs.
Platelet dysfunction-subnormal platelet
aggregation -due to fibrinogen fragments, usually
absent in normal human blood but present in
uremic plasma may lead to platelet dysfunction in
uremia.
31
Manifestations of CKD-Musculoskeletal

• Muscle cramps
• Soft tissue calcifications
• Weakness
• Related to calcium phosphorous imbalances
• RENAL OSTEODYSTROPHY
• Fracture risk!

32
Manifestations of CKD- Heart Lungs

• Hypertension
• Heart failure gt pulmonary edema
• Pericarditis due to uremia
• Pulmonary edema
• Pleural effusions- Uremic Lung
• Atherosclerotic vascular disease
• Cardiac dysrhythmias (from HF, electrolyte
  imblaances)

Major Problem!
33
Manifestations of CKD- Endocrine - Metabolic

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

34
Treatment Options

• Conservative Therapy (Severe restrictions,
  dietary, fluids maintain renal function as long
  as possible- if GFR gt 10ml/min)
• Hemodialysis
• Peritoneal Dialysis
• Transplant
• Nothing gt Death

35
Conservative Treatment Goals

• Detect/treat potentially reversible causes of
  renal failure
• Preserve existing renal function
• Treat manifestations
• Prevent complications
• Provide for comfort

36
Conservative Treatment

• Control
• Hyperkalemia
• Hypertension
• Hyperphosphatemia
• Hyperparthryoidism
• Anemia
• Hyperglycemia
• Dyslipidemia
• Hypothyroidism
• Nutrition Describe a renal diet?

Depends on lab values-usually low NA, K,
restricted protein, phosphorous, fluids (See
text)
37
Hemodialysis

• Removal of soluble substances and water from the
  blood by diffusion through a semi-permeable
  membrane.
• Early animal experiments began 1913
• 1st human dialysis 1940s by Dutch physician
  Willem Kolff (2 of 17 patients survived)
• Considered experimental through 1950s, No
  intermittent blood access for acute renal
  failure only.
• 1960 Dr. Scribner developed Scribner
  Shunt-1960s machines expensive, scarce, no
  funding.
• Death Panels panels within community decided
  who got to dialyze.

38
Hemodialysis Process

• Blood removed from patient into extracorporeal
  circuit.
• Diffusion and ultrafiltration take place in
  dialyzer.
• Cleaned blood returned to patient.

39
Extracorporeal Circuit
40
How Hemodialysis Works
41
.                                           
                                                  
                                                  
          
How Dialysis Works-Interactive! An Introduction
to Dialysis-How Stuff Works! (Step by
Step) YouTube- Hemodialysis! Great!
42
Vascular Access (click)

• Arterio-venous shunt (External Shunt) used now
  for Continuous Renal Replacement Therapy
  (CRRT)-temporary access
• Arterio-venous (AV) Fistula (AKA-native or
  primary fistula)
• PTFE Graft
• Temporary catheters
• Permanent catheters

43
External Shunt (Schribner Shunt)

• External- one end into artery, one into vein.
• Advantages
• place at bedside
• use immediately
• Disadvantages
• infection
• skin erosion
• accidental separation
• limits use of extremity
• Used now only for CRRT-temporary

44
Arterio-venous (AV) FistulaPrimary (native)
Fistula

• Patients own artery and vein surgically
  anastomosed.
• Advantages
• patients own vein/artery
• longevity
• low infection and thrombosis rates
• Disadvantages
• long time to mature, 1- 6 months
• steal syndrome
  
• requires needle sticks
  davita.com

45
PTFE (Polytetraflourethylene) Graft

• Synthetic vessel anastomosed into an artery and
  vein.
• Advantages
• for people with inadequate vessels
• can be used in 1-4 weeks
• prominent vessels
• Disadvantages
• clots easily
• steal syndrome more frequent
• requires needle sticks
• infection may necessitate removal of graft

46
Temporary Catheters

• Dual lumen catheter placed into a central
  vein-subclavian, jugular or femoral.
• Advantages
• immediate use
• no needle sticks
• Disadvantages
• high incidence of infection
• subclavian vein stenosis
• poor flow-inadequate dialysis
• clotting
• Restricts movement

47
Cuffed Tunneled Catheters (Dacron cuff)

• Dual lumen catheter with Dacron cuff surgically
  tunneled into subclavian, jugular or femoral
  vein.
• Advantages
• immediate use permanent/long term use
• can be used for patients that can have No other
  permanent access
• no needle sticks
• Disadvantages
• high incidence of infection
• poor flows result in inadequate dialysis
• clotting

48
Above Native fistula (in place for over 20
years) Remember- assess circulation-listen for
bruit, feel for thrill!
Temporary vascular access catheters- if
tunnelled, with Dacron cuff, can be used
long-term as Permacath, below.
Buttonhole technique-individual cannulates own
fistula for home dialysis YouTube video
49
Care of Vascular Access

• NO BPs, needle sticks to arm with vascular
  access. This includes finger sticks.
• Place ID bands on other arm whenever possible.
• Palpate thrill and listen for bruit.
• Teach patient nothing constrictive, feel for
  thrill.

50
Potential Complications of Hemodialysis

• During dialysis
• Fluid and electrolyte related
• hypotension
• Cardiovascular
• arrhythmias
• Associated with the extracorporeal circuit
• exsanguination
• Neurologic
• Disequilibrium Syndrome seizures
• Musculoskeletal
• cramping
• Other
• fever sepsis
• blood born diseases

51
Potential Complications of Hemodialysis

• Long term (due to disease process management)
• Metabolic
• Hyperparathyroidism
• Diabetic complications
• Cardiovascular
• CHF
• AV access failure
• Cardiovascular disease
• Respiratory
• Pulmonary edema
• Neuromuscular
• Neuropathy

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

52
Complications Hemodialysis- cont-long term, ESRD

• Long term contd
• Hematologic
• anemia
• GI
• bleeding
• dermatologic
• calcium phosphorous deposits
• Rheumatologic
• amyloid deposits

• Long term contd
• Genitourinary
• infection
• Sexual dysfunction
• Psychiatric
• depression
• Infection
• blood borne pathogens

53
Dietary Restrictions-Hemodialysis

• Fluid restrictions
• Phosphorous restrictions
• Potassium restrictions
• Sodium restrictions
• Protein to maintain nitrogen balance (complete)
• too high - waste products
• too low - decreased albumin, increased mortality
• Calories to maintain or reach ideal weight

Urine output 500-600
Approx 800-1200 mg/day
Approx 1-2 g/day 40 mg/kg/IBW
Approx 1-2 g/day
54
Peritoneal Dialysis

• Removal of soluble substances and water from
  blood by diffusion through a semi-permeable
  membrane (peritoneum) that is intracorporeal
  (inside body).
• Solution warmed to body temperature prior to
  instillation into peritoneal cavity via
  peritoneal catheter
• Metabolic waste products and excessive
  electrolytes diffuse into dialysate while it
  remains in abdomen
• Fluid removal controlled by glucose (dextrose)
  concentration in dialysate (acts as osmotic
  agent)
• Excess fluid/solutes removed- gradual/constant-
• Fluid drained by gravity into sterile bag at set
  intervals-
• Clear solution fills abdomen
• Yellow urine-like fluid drains out (like
  urine, clear)
• Types of Peritoneal Dialysis
• CAPD Continuous ambulatory peritoneal dialysis
• CCPD Continuous cycling peritoneal dialysis/Aka.
  APD Automated Peritoneal Dialysis
• IPD Intermittent peritoneal dialysis (also)

55
Phases of Peritoneal Dialysis Exchange
1. Fill (inflow) fluid infused into peritoneal
cavity (usually 10-15 min). 2. Dwell time
(equilibrium) time solution (dialysate) fluid
remains in peritoneal cavity (duration depends on
method- as CAPD 4-5 exchanges/day). 3. Drain
(equilibrium) time fluid drains from peritoneal
cavity by gravity flow (usually 20-30 min)
facilitate by gently massaging abdomen, changing
position.
CAPD
56
CAPD APD

• Automated Peritoneal Dialysis- fluid exchanges
  automatically by machine-(also known as
  continuous cycling peritoneal dialysis (CCPD),
  requires cycler machine- programmable- to
  automate filling and draining process.
• Treatment at home, typically at night (while
  sleeping-thus no fluid in the belly at daytime

• Catheter into peritoneal cavity
• Exchanges 4 - 5 times per day
• Treatment 24 hrs 7 days a week
• Solution remains in peritoneal cavity except
  during drain time
• Independent treatment

Click to play animation
Videos-Dialysis, all types! Click to locate
desired video
57
Complications of Peritoneal Dialysis

• Infection
• peritonitis
• tunnel infections
• catheter exit site
• Hypervolemia
• hypertension
• pulmonary edema
• Hypovolemia
• hypotension
• Hyperglycemia
• Malnutrition

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

58
Peritoneal Catheter Exit Site
59
Advantages of PD

• Independence for patient
• No needle sticks
• Better blood pressure control
• Some diabetics add insulin to solution
• Fewer dietary restrictions
• protein loses in dialysate
• generally need increased potassium
• less fluid restrictions

60
Multi-prong system occasionally used with PD
patients in hospital settings Which dialysis
bags have already been infused?
The yellow ones!- dialysis nurse sets up bags,
staff nurse infuses, drains according to schedule.
61
(No Transcript)
62
Medications - Dialysis Patients CKD (Stages
4-5)

• Vitamins - water soluble
• Phosphate binder - (Phoslo, Renagel, Calcium,
  Aluminum hydroxide-risks) Give with meals
• Iron - dont give with phosphate binder or
  calcium
• Antihypertensives typically hold prior to
  dialysis
• Erythropoietin
• Calcium Supplements - Between meals, not with
  iron
• Activated Vitamin D3 - aids in calcium absorption
• Antibiotics - hold dose prior to dialysis if it
  dialyzes out

63
Medications

• Many drugs or their metabolites are excreted by
  the kidney
• Dosages - many change when used in renal failure
  patients
• Dialyzability - many removed by dialysis varies
  between HD and PD

64
Patient Education

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

65
Case Study

• A 48 year old female with a history of
  uncontrolled diabetes presents to the ER. Her
  chief complaints are nausea, vomiting and
  fatigue.
• Lab BUN 100 Creatinine 10 HH 7.0/21.4
• K 6.0, PO4 5.5 Ca 7.5
• What do you suspect? How would she possibly be
  treated?
• Access Evolve Apply Case Study- Chronic Renal
  Failure
• Access Renal Case Study

66
Transplantation

• Treatment not cure

View also Organ Donation video
67
Kidney Awaiting Transplant
68
Old kidneys typically left in place
69
Advantages Disadvantages

• Restoration of normal renal function
• Freedom from dialysis
• Return to normal life
• Reverses pathophysiological changes related to RF
• Less expensive than dialysis after 1st year

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

70
Care of Recipient

• Major surgery with general anesthesia
• Assessment of renal function
• Assessment of fluid and electrolyte balance
• Prevention of infection
• Prevention and management of rejection

71
Post-op Care

• ATN? (acute tubular necrosis)
• 50 experience
• Urine output gt100 lt500 cc/hr
• BUN, creatinine, creatinine clearance
• Fluid Balance-careful monitor
• Ultrasound
• Renal scans
• Renal biopsy

72
Fluid Electrolyte Balance

• Accurate I O
• CRITICAL TO AVOID DEHYDRATION
• Output normal - gt100 lt500 cc/hr, could be 1-2
  L/hr
• Potential for volume overload/deficit
• Daily weights
• Hyper/Hypokalemia potential
• Hyponatremia
• Hyperglycemia

73
Prevention of Infection

• Major complication of transplantation due to
  immunosuppression
• HANDWASHING
• Avoid Crowds, Kids
• Patient Education

74
Rejection

• Hyperacute - preformed antibodies to donor
  antigen
• function ceases within 24 hours
• Rx removal
• Accelerated - same as hyperacute but slower, 1st
  week to month
• Rx removal
• Acute - generally after 1st 10 days to end of 2nd
  month
• 50 experience
• must differentiate between rejection and
  cyclosporine toxicity
• Rx steroids, monoclonal (OKT3), or polyclonal
  (HTG) antibodies
• Chronic - gradual process of graft dysfunction
• Repeat rejection episodes- not completely
  resolved with treatment
• 4 months to years after transplant
• Rx return to dialysis or re-transplantation

75
Immunosuppressant Drugs

• Cytoxic Agents-Azathioprine (Imuran)
  Mycophenolate (Cellcept), Cytoxin (less toxic
  than Imuran)
• Prevents rapid growing lymphocytes
• Side Effects
• bone marrow toxicity
• hepatotoxicity
• hair loss
• infection
• risk of tumor

• Corticosteroids-Prednisone
• Prevents infiltration of T lymphocytes
• Side effects
• cushingnoid changes
• Avascular Necrosis
• GI disturbances
• Diabetes
• infection
• risk of tumor

76
Immunosuppressant Drugs

• Monoclonal antibody- OKT3 - used to treat
  rejection/induce immunosuppression
• decreases CD3 cells within 1 hour
• Side effects
• anaphylaxis
• fever/chills
• pulmonary edema
• risk of infection
• tumors
• 1st dose reaction expected wanted, pre-treat
  with Benadryl, Tylenol, Solumedrol

• Calcineuin Inhibitors-Cyclosporin, Neoral,
  Prograft, FK506 (more potent than cyclosporin)
• Interferes with production of interleukin 2 which
  is necessary for growth and activation of T
  lymphocytes.
• Side Effects
• Nephrotoxicity
• HTN
• Hepatotoxicity
• Gingival hyperplasia
• Infection

77
Immunosuppressant Drugs contd

• Polyclonal antibody-Atgam-treat rejection or
  induce immunosuppression
• decreased number of T lymphocytes
• Side effects
• anaphylaxis
• fever chills
• leukopenia
• thrombocytopenia
• risk of infection
• tumor

78
Patient Education

• Signs of infection
• Prevention of infection
• Signs of rejection
• decreased urine output
• increased weight gain
• tenderness over kidney
• fever gt 100 degrees F
• Medications
• time, dose, side effects

79
TransplantsNotes from Organ Donation slides

• Exclusion for Transplant not limited too
• Active vasculitis or
• Life threatening extrarenal congenital
  abnormalities or
• Untreated coagulation disorder or
• Ongoing alcohol or drug abuse or
• Age over 70 years with severe co-morbidities or
• Severe neurological or mental impairment, in
  persons without adequate social support, such
  that the person is unable to adhere to the
  regimen necessary to preserve the transplant.

80
Official Criteria for Deceased Donors

• Usually irreversible brain injury
• MVA, gunshot wounds, hemorrhage, anoxic brain
  injury from MI
• Must have effective cardiac function
• Must be supported by ventilator to preserve
  organs
• Age 2-70
• No IV drug use, HTN, DM, Malignancies, Sepsis,
  disease
• Permission from legal next of kin pronoucement
  of death made by MD
• Brain Death is the complete cessation of all
  brain brainstem function. It is death.

81
Official Criteria for Living Donors

• Psychiatric evaluation
• Anesthesia evaluation
• Medical Evaluation
• Free from diseases listed under deceased donor
  criteria
• Kidney function evaluated
• Crossmatches done at time of evaluation and 1
  week prior to procedure
• Radiological evaluation

82
Nurses Role in Event of Potential Donation

• Notify TOSA of possible organ donation
• Identify possible donors
• Make referral in timely manner
• Do not discuss organ donation with family
• Offer support to families after referral is made
  donation coordinator has met with family

83
(No Transcript)