Chronic Renal Failure

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Chronic Renal Failure
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Chronic Renal Failure

• Progressive, irreversible damage to the nephrons
  and glomeruli
• Causes recurrent kidney infections, vascular
  changes (Diabetes/Hypertension) etc. May
  be diffuse or limited to one kidney
• Regardless of the cause Decreased GFR, tubular
  function tubular reabsorption capabilities.
  Dysfunction fluids electrolytes, acid base
  disturbances, systemic problems develops

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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

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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 lt 5ml/min (average)
  dialysis
• Other symptoms Nocturia, oliguria/anuria,
  increased K, Mg, PO4 and decrease Ca,
  Neurological changes, CV changes, etc.

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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 lt25 of normal increasing
  symptoms
• ESRD or Uremia GFR lt 5-10 normal, creatinine
  clearance lt5-10 ml/min
• resulting in a cumulative effect

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Treatment Modalities

• Decrease fluid 1000ml/day
• Decrease protein (.5-1kg body weight)
• Decrease sodium (1-4gm variable)
• Decrease potassium
• Decrease phosphorous (lt1000mg/day)
• Dialysis (periotoneal, hemodialysis)
• RBC, Vitamin D (calcitrol replacement) etc.

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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

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Osmosis-Diffusion-Ultrafiltration
Osmosis - movement fluid from an area of lt to gt
concentration of solutes (particles)

• Diffusion - movement of solutes (particles)
  from an area of gt concentration to area of lt
  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

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Peritoneal Dialysis

• Catheter placement anterior abdominal wall
• Tenckoff (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

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Peritoneal Dialysis
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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

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Hemodialysis
AV Fistula Communication
AV Graph Access
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Hemodialysis
Hemodialysis Machine
Hemodialysis Circuit
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PD Advantages and Disadvantages
Advantages
Disadvantages

• Bacterial/chemical periotonitis
• Protein loss
• Exit site of catheter
• Self image
• Hyperglycemia
• Surgical placement of catheter
• Multiple abdominal surgery

• Immediate initiation
• Less complicated
• Portable (CAPD)
• Fewer dietary restrictions
• Short training time
• Less cardio stress
• Choice for diabetics

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Hemo Advantages Disadvantages
Advantages
Disadvantages

• Rapid fluid removal
• Rapid removal of urea creatinine
• Effective K removal
• Less protein loss
• Lower triglycerides
• Home dialysis possible
• Temporary access at the bedside

• Vascular access problems
• Dietary fluid restrictions
• Heparinization
• Extensive equipment
• Hypotension
• Added blood lost
• Trained specialist

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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

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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.

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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)

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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.

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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

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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

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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.

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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

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Complications Post Transplant

• 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

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Complications Post Transplant

• 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

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Complications Post Transplant

• Infection
• Hypertension
• Malignancies (lip, skin, lymphomas, cervical)
• Recurrence of renal disease
• Retroperiotneal bleed
• Arterial stenosis
• Urine leakage