Polycystic Kidney Disease

1
Polycystic Kidney Disease

• Definition
• 1. Hereditary disease characterized by cyst
  formation and massive kidney enlargement
• 2. Adult form of disorder is autosomal dominant
  polycystic kidney disease and accounts for 10 of
  persons in End Stage Renal Disease (ESRD)
• Pathophysiology
• 1. Renal cysts are fluid-filled sacs affecting
  nephrons cysts fill, enlarge, multiply thus
  compressing and obstructing kidney tissue renal
  parenchyma atrophies, becomes fibrotic
• 2. Cysts occur elsewhere in body including liver,
  spleen

2
Polycystic Kidney Disease

• Manifestations
• 1. Disease is slowly progressive symptoms
  develop in age 30 40s
• 2. Common manifestations include
• a. Flank pain
• b. Microscopic or gross hematuria
• c. Proteinuria
• d. Polyuria and nocturia (impaired ability to
  concentrate urine)
• e. UTI and renal calculi are common
• f. Hypertension from disrupted renal vessels
• g. Kidneys become palpable, enlarged, knobby
• h. Symptoms of renal insufficiency and chronic
  renal failure by age of 50 60

3
Polycystic Kidney Disease

• Collaborative Care Determine extent of
  polycystic kidney disease
• Diagnostic tests
• 1. Renal ultrasonography primary choice for
  diagnostic assesses kidney size, identifies and
  locates renal masses cysts, tumors, calculi
• 2. Intravenous pyelography (IVP) evaluate
  structure and excretory function of kidneys,
  ureters, bladder
• 3. CT scan of kidneys detects and differentiates
  renal masses

4
Polycystic Kidney Disease

• Management
• 1. Mainly supportive prevent further renal
  damage from UTI, nephrotoxic substances,
  obstruction, hypertension
• 2. Fluid intake of 2000 2500 mL to prevent UTI,
  calculi
• 3. Control of hypertension with ACE inhibitors
  and other antihypertensive agents
• 4. Eventually require dialysis or transplantation
  (typically good candidates)

5
Polycystic Kidney Disease

• Nursing Care and Nursing Diagnoses
• 1. Risk for Ineffective Coping address genetic
  counseling and screening for family members
• 2. Excess Fluid Volume
• 3. Anticipatory Grieving
• 4. Knowledge Deficit of measures to preserve
  kidney function

6
Clients with Renal Failure

• Definition
• 1. Condition in which kidneys are unable to
  remove accumulated metabolites from blood leads
  to altered fluid, electrolyte and acid-base
  balance
• 2. May be due to kidney (primary disorder) or
  resulting from another disease in another organ
  or systemic (secondary disorder)
• 3. Classified as acute (abrupt onset and may be
  reversible) or chronic (develops slowly and
  insidiously with few symptoms until kidneys are
  severely damaged and unable to meet bodys
  excretory needs)
• 4. Common and costly disease with people with End
  Stage Renal Disease requiring dialysis or
  transplant to live
• 5. 5 year survival rate for clients on dialysis
  is 31.3

7
Clients with Renal Failure

• Acute Renal Failure (ARF)
• 1. Definition
• a. Rapid decline in renal function with azotemia
  fluid and electrolyte imbalances
• b. High mortality rate but is related to clients
  being seriously ill and aged
• Risk Factors
• a. Major surgery or trauma
• b. Infection
• c. Hemorrhage
• d. Severe heart failure, liver disease
• e. Lower urinary tract obstruction
• f. Use of nephrotoxic contrast media and
  medications

8
Clients with Renal Failure

• Pathophysiology involved with cause categories
• a. Prerenal
• 1. 55 60 cases of ARF
• 2. Cause Conditions that affect renal blood flow
  and perfusion
• A .Decrease vascular volume
• B .Decrease cardiac output
• C .Decrease vascular resistance
• b. Intrarenal
• 1. 35-40 cases of ARF
• 2. Cause Acute damage to renal parenchyma and
  nephron
• a. Acute glomerulonephritis
• b. Vascular disorders including vasculitis,
  malignant hypertension, arterial or venous
  occlusion

9
Clients with Renal Failure

• c. Acute Tubular Necrosis (ATN) Destruction of
  tubular epithelial cell with abrupt decline in
  renal function from
• 1. Prolonged ischemia (gt2 hours) as with surgery,
  severe hypovolemia, sepsis, trauma, burns
• 2. Nephrotoxins
• a. Aminoglycoside antibiotics
• b. Radiologic contrast media
• c. Other potential drugs NSAIDs, heavy metals,
  ethylene glycol (antifreeze)
• 3. Nephrotoxins have increased risk with clients
  with preexisting renal insufficiency or state of
  dehydration
• 4. Rhabdomyolysis excess myoglobin from skeletal
  muscle injury clogs renal tubules (muscle trauma,
  drug overdose, infection)
• 5. Hemolysis red blood cell destruction

10
Clients with Renal Failure

• Postrenal
• 1. lt5 cases of ARF
• 2. Cause Obstructive prevents urine excretion
• a. Benign prostatic hypertrophy
• b. Renal or urinary tract calculi or tumors

11
Clients with Renal Failure

• Course and Manifestations of ARF in 3 phases
• a. Initiation Phase
• 1. Lasts hours to day
• 2. Begins with initiating event ends when
  maintenance phase begins
• 3. Good prognosis if treated at this phase
• 4. Few manifestations identified when
  maintenance phase begins
• b. Maintenance Phase
• 1. Characterized by significant fall in GFR and
  tubular necrosis
• 2. Oliguric or non-oliguric but kidneys not
  eliminating wastes, water, electrolytes, acids
  azotemia, fluid retention, electrolyte imbalances
  (hyperkalemia, hypocalcemia, hyperphosphatemia),
  acidosis (impaired hydrogen ion elimination)
• 3. Anemia after several days due to suppressed
  erythropoetin secretion impaired immune function

12
Clients with Renal Failure

• 4. Salt and water retention leading to
  hypertension and risk for heart failure and
  pulmonary edema
• 5. Hyperkalemia cardiac dysrhythmias and EKG
  changes, muscle weakness, nausea, diarrhea
• 6. Confusion, disorientation, agitation or
  lethargy, hyperreflexia, possible seizures, coma
• 7. Vomiting, decreased or absent bowel sounds
• c. Recovery Phase
• 1. Progressive tubule cell repair and
  regeneration return of GFR to pre-ARF levels
• 2. Diuresis occurs as kidney recover but BUN,
  Creatinine, potassium and phosphate remain high
• 3. Renal function improves rapidly first 5 25
  days but improvement may continue for up to a
  year

13
Clients with Renal Failure

• Collaborative Care
• a. Prevention of ARF is goal for all clients,
  especially those at high-risk
• 1. Preserve kidney perfusion by adequate vascular
  volume, cardiac output and blood pressure
• 2. Limiting use of nephrotoxic medications or
  using minimal effective dose, maintaining
  hydration, monitoring renal function tests
• b. Treatment goals
• 1. Identify and correct underlying cause
• 2. Prevent additional renal damage
• 3. Restore urine output and kidney function
• 4. Compensate for impaired renal function
  maintain fluid and electrolyte balance

14
Clients with Renal Failure

• Diagnostic tests to identify ARF
• a. Urinalysis
• 1. Fixed specific gravity 1.010 (low)
• 2. Proteinuria, if glomerular damage
• 3. Presence of red blood cells (glomerular
  dysfunction), white blood cells (inflammation),
  renal tubule epithelial cells (ATN)
• 4. Cell casts (protein and cellular debris molded
  in shape of tubular lumen) brown color may
  indicate hemoglobinuria or myoglobinuria
• b. Serum BUN and creatinine
• 1. Creatinine rises rapidly (24 48 hours) and
  peaks in 5 10 days rise is slower if output
  maintained
• 2. Halt in rise of BUN and Creatinine signals
  onset of recovery

15
Clients with Renal Failure

• Serum Electrolytes
• 1. Monitored to determine whether to initiate
  dialysis
• 2. Moderate rise in potassium
• 3. Hyponatremia related to water excess
• d. CBC showed moderate anemia and low hematocrit
  (Iron and folate may be low and add to anemia)
• e. Renal ultrasound used to identify any
  obstruction, identify acute from chronic renal
  failure
• f. CT scan identify obstruction and kidney size
• g. IVP, retrograde pyelography, or antegrade
  pyelography
• 1. Assess renal structure and function
• 2. Retrograde and antegrade testing less toxicity
  from contrast media
• h. Renal biopsy determine cause, differentiate
  acute from chronic

16
Clients with Renal Failure

• Medications
• a. Intravenous fluids and blood volume expanders
  to restore renal perfusion
• b. Low dose Dopamine (Intropin) intravenous
  infusion to increase renal blood flow and improve
  cardiac output
• c. Diuretic Furosemide (Lasix) or osmotic
  diuretic such as mannitol along with intravenous
  fluids washes out nephrons prevents oliguria
  reducing azotemia and electrolyte imbalance
• d. Antihypertensive medications including ACE
  inhibitors to limit renal injury

17
Clients with Renal Failure

• Medications to prevent possible complications
• 1. Prevention of gastrointestinal bleeding (at
  risk due to stress, impaired platelet function)
• a. Antacids
• b. H2 receptor antagonists
• c. Proton-pump inhibitors
• 2. Hyperkalemia serum K gt 6.5 mEq/L puts client
  at risk for cardiac arrest
• a. Calcium chlorides
• b. Bicarbonate
• c. Insulin and glucose

18
Clients with Renal Failure

• d. Sodium polystyrene sulfonate (Kayexalete)
• 1. Removes potassium from body primarily in large
  intestine
• 2. If given orally, is combined with sorbitol
• 3. May be given as retention enema with tap water
  enema to follow after 30 60 minutes
• 3. Hyperphosphatemia
• a. Aluminum hydroxide (AlternaGEL, Amphojel,
  Nephrox)
• b. Binds with phosphates in GI tract and is
  eliminated from bowel

19
Clients with Renal Failure

• Fluid Management
• a. Once vascular volume and renal perfusion
  restored, fluids are restricted
• b. Often intake is calculated by adding output
  from previous 24 hours and 500 ml for insensible
  losses
• c. Fluid balance monitored by daily weights and
  serum Na level

20
Clients with Renal Failure

• Dietary Management
• a. Renal insufficiency and underlying disease
  creates increased rate of catabolism (breakdown
  of body proteins) and decreased rate of anabolism
  (tissue repair)
• b. Client needs adequate nutrition and calories
  to prevent catabolism but protein intake needs to
  be limited to minimize azotemia
• c. Protein limited to 0.6g/kg body weight per
  day protein should be of high biologic value
  (contains essential amino acids)
• d. Carbohydrate intake is increased for adequate
  calories and protein-sparing effect

21
Clients with Renal Failure

• Dialysis
• a. Dialysis is the diffusion of solute molecules
  across semipermeable membrane from area of higher
  solute concentration to lower concentration
• b. Dialysis used to remove excess fluid, waste
  products from client with renal failure can
  rapidly remove nephrotoxins from blood

22
A hemodialysis system
23
Continuous arteriovenous hemofiltration (CAVH)
24
An arteriovenous fistula
25
An arteriovenous shunt in the forearm
26
Options for long-term vascular access for
hemodialysis
27
Peritoneal dialysis
28
Manual peritoneal dialysis via an implanted
abdominal catheter (Tenckhoff catheter)
29
Clients with Renal Failure

• Hemodialysis Dialysis process
• a. In this type of dialysis, blood is taken from
  client via vascular access and pumped into a
  dialyzer blood is separated from the dialysate
  (dialysis solution) by semipermeable membrane
• b. Processes of diffusion and ultrafiltration
  remove waste products, electrolytes, excess water
• c. Glucose, electrolytes, water can pass through,
  but larger molecules (protein, red blood cells)
  are blocked
• d. Substances can be added to dialysate to
  diffuse into the blood of the client
• e. Client with ARF may undergo hemodialysis daily
  initially, then 3 4 times/week according to
  client condition 3 4 hours at a time

30
Clients with Renal Failure

• Complications associated with hemodialysis
• a. Hypotension, most common, related to changes
  in osmolality, rapid removal from vascular
  department, vasodilation
• b. Bleeding related to platelet function and use
  of heparin during dialysis
• c. Infection, local or systemic Staphylococcus
  aureus septicemia associated with infected
  vascular access site higher rates of hepatitis B
  and C, cytomegalovirus, HIV in hemodialysis
  clients

31
Clients with Renal Failure

• 13. Continuous Renal Replacement Therapy (CRRT)
• a. Technique used, which allows more gradual
  fluid and solute removal than hemodialysis used
  for clients with ARF unable to tolerate
  hemodialysis
• b. Done over period of 12 hours or more
• 14. Vascular Access for Hemodialysis
• a. Acute or temporary access is gained inserting
  double lumen catheter into subclavian, jugular,
  or femerol vein
• b. Blood is drawn from proximal portion of
  catheter and returned to circulation through
  distal end of catheter

32
Clients with Renal Failure

• Arteriovenous (AV) fistula created for longer
  term access for dialysis
• 1. Surgical anastomosis of artery and vein in
  non-dominant arm, usually radial artery and
  cephalic vein
• 2. Usually cannot use fistula for hemodialysis
  access for a month while it matures
• 3. Nurse or client can assess functional fistula
  for complications
• a. Thrombosis (clotted off) check for palpable
  thrill, audible bruit
• b. Infection check for redness, drainage
• 4. Venipunctures and blood pressures should not
  be done in arm with the AV fistula
• 5. AV fistulas are commonly used for vascular
  access for dialysis clients with chronic renal
  failure

33
Clients with Renal Failure

• Peritoneal dialysis process involves
• a. Peritoneal membrane of client is used as
  dialyzing surface
• b. Warmed sterile dialysate instilled into
  peritoneal cavity through a catheter that has
  been inserted into peritoneal cavity
• c. Metabolic waster products and excessive
  electrolytes diffuse into dialysate while it
  remains in abdomen
• d. Water diffusion is controlled by glucose in
  the dialysate which acts as an osmotic agent
• e. Fluid is drained off by gravity into sterile
  bag at set intervals, thus removing waste
  products and excess fluid

34
Clients with Renal Failure

• Disadvantages of peritoneal dialysis
• a. Dialysis is more gradual and may be slow for
  ARF
• b. Risk of peritonitis
• c. Contraindicated for clients with abdominal
  surgery, peritonitis, significant lung disease
• Health Promotion Prevention of ARF
• a. Maintenance of fluid volume and cardiac output
• b. Reduce risk of exposure to nephrotoxins
• c. Report output lt 30 ml per hour in clients at
  risk
• d. Report dehydration, monitor renal function
  tests in clients receiving nephrotoxic
  medications

35
Clients with Renal Failure

• Nursing Diagnoses for clients in ARF
• a. Excess Fluid Volume
• b. Imbalanced Nutrition Less than body
  requirements
• c. Deficient Knowledge
• Home care Client who is recovering from ARF
  will need teaching for prescribed diet and fluid
  intake, avoidance of nephrotoxins, prevention of
  infection, continue under medical supervision

36
Clients with Renal Failure

• Client with Chronic Renal Failure (CRF)
• Definition
• a. Progressive renal tissue destruction and loss
  of function
• b. May progress over many years without being
  recognized until kidneys are unable to excrete
  metabolic wastes and regulate fluid and
  electrolytes End-stage Renal Disease (ESRD)
• c. Incidence is increasing especially in older
  adults higher in African Americans, Native
  Americans
• d. Conditions causing chronic renal failure
  diffuse bilateral disease of kidneys with
  progressive destruction and scarring diabetes is
  leading cause of ESRD then hypertension

37
Clients with Renal Failure

• Pathophysiology and Manifestations of Stages
• a. Decreased Renal Reserve Early Stage
• 1. Unaffected nephrons compensate for lost
  nephrons
• 2. GFR is about 50 of normal
• 3. Client is asymptomatic
• 4. BUN and serum creatinine are normal
• b. Renal Insufficiency
• 1. GRF falls to 20 50 of normal
• 2. Azotemia and some manifestations
• 3. Insult to kidneys could precipitate onset
  renal failure (infection, dehydration, exposure
  to nephrotoxins, urinary tract obstructions)

38
Clients with Renal Failure

• c. Renal failure
• 1. GRF lt 20 of normal
• 2. BUN and serum creatinine rise sharply
• 3. Oliguria, manifestations of uremia
• d. End-stage renal disease (ESRD)
• 1. GRF lt 5 of normal
• 2. Renal replacement therapy necessary to sustain
  life

39
Clients with Renal Failure

• ESRD Uremia (urine in blood)
• a. Early manifestations
• 1. Nausea, apathy, weakness, fatigue
• 2. Progresses to frequent vomiting, increasing
  weakness, lethargy, confusion
• b. Fluid and electrolyte effects
• 1. Urine less concentrated with proteinuria and
  hematuria
• 2. Sodium and water retention
• 3. Hyperkalemia (Muscle weakness, paresthesia,
  EKG changes)
• 4. Hyperphosphatemia, hypocalcemia,
  hypermagesemia
• 5. Metabolic acidosis

40
Clients with Renal Failure

• Cardiovascular effects
• 1. Systemic hypertension
• 2. Edema and heart failure pulmonary edema
• 3. Pericarditis metabolic toxins irritate
  pericardial sac less often now with dialysis
• 4. Cardiac tamponade fluid in pericardial sac
• Hematologic effects
• 1. Anemia contributing to fatigue, weakness,
  depression, impaired cognition, impaired cardiac
  function
• 2. Impaired platelet function
• Immune system effects
• 1. WBC declines
• 2. Humoral and cell-mediated immunity impaired
• 3. Fever suppressed

41
Clients with Renal Failure

• Gastrointestinal effects
• 1. Anorexia, nausea, vomiting, hiccups
• 2. GI ulcerations, increased risk for GI bleeding
• 3. Uremic fetor urinelike breath odor
• Neurologic effects
• 1. Changes in mentation, poor concentration
• 2. Fatigue, insomnia
• 3. Psychotic symptoms, seizures, coma
• 4. Peripheral neuropathy restless leg
  syndrome, sensations of crawling, prickling
• 5. Muscle weakness, decreased deep tendon
  reflexes, gait disturbances

42
Clients with Renal Failure

• Musculoskeletal effects
• 1. Renal osteodystrophy (renal rickets)
  characterized by osteomalacia (bone softening)
  and osteoporosis
• 2. Bone tenderness and pain
• Endocrine and metabolic effects
• 1. Elevated uric acid levels risk for gout
• 2. Resistance to insulin, glucose intolerance
• 3. High triglyceride and lt HDL levels resulting
  in accelerated atherosclerotic process
• 4. Menstrual irregularities reduced testosterone
  levels
• Dermatologic effects
• 1. Yellowish hue to skin
• 2. Dry skin with poor turgor
• 3. Pruritis due to metabolic wastes deposited in
  skin
• 4. Uremic frost crystallized deposits of urea on
  skin

43
Clients with Renal Failure

• Collaborative Care
• a. Eliminate factors that further decrease renal
  function
• b. Maintenance of nutritional status with minimal
  toxic waste products
• c. Identify and treat complications of CRF
• d. Preparation for dialysis or renal
  transplantation

44
Clients with Renal Failure

• Diagnostic Tests Identify CRF and monitor renal
  function by following levels of metabolic wastes
  and electrolytes
• a. Urinalysis fixed specific gravity at 1.010
  excess protein, blood cells, cellular casts
• b. Urine culture identify infection
• c. BUN and serum creatinine evaluate kidney
  function
• 1. BUN levels
• a. Mild azotemia 20 50 mg/dL
• b. Severe renal impairment gt 100 mg/dL
• c. Uremic symptoms gt 200mg/dL
• 2. Creatinine levels gt4 mg/dL indicate serious
  renal impairment
• d. Creatinine Clearance evaluates GFR and renal
  function
• 1. Decreased renal reserve 32.5 130 mL/min
• 2. Renal insufficiency 10 30 mL/min
• 3. ESRD 5 10 mL/min

45
Clients with Renal Failure

• e. Serum electrolytes monitored throughout
  course of CRF
• f. CBC moderately severe anemia with hematocrit
  20 30 low hemoglobin reduced RBCs and
  platelets
• g. Renal ultrasonography CRF decreased kidney
  size
• h. Kidney biopsy diagnose underlying disease
  process differentiate acute from chronic

46
Clients with Renal Failure

• Medications
• a. General effects of CRF on medication effects
• 1. Increased half-life and plasma levels of meds
  excreted by kidneys
• 2. Decreased drug absorption if phosphate-binding
  agents administered concurrently
• 3. Low plasma protein levels can lead to toxicity
  when protein-bound drugs are given
• 4. Avoid nephrotoxic meds or give with extreme
  caution
• b. Diuretics (furosemide, other loop diuretics)
• 1. Reduce edema
• 2. Reduce blood pressure
• 3. Lower potassium
• c. Antihypertensive medications ACE inhibitors
  preferred
• d. Sodium bicarbonate or calcium carbonate
  correct mild acidosis
• e. Oral phosphorus binding agents (calcium
  carbonate, calcium acetate) to lower phosphate
  levels and normalize calcium levels
• f. Aluminum hydroxide for acute treatment of
  hyperphosphatemia

47
Clients with Renal Failure

• g. Vitamin D supplements to improve calcium
  absorption
• h. To treat dangerously high potassium levels
• 1. Intravenous bicarbonate, insulin, glucose
• 2. Sodium polystyrene sulfonate (Kayexalate)
• i. Folic acid, iron supplements to combat anemia
• j. Multiple vitamin supplement
• Dietary and Fluid Management
• a. Early in course of CRF diet modifications to
  slow kidney failure, uremic symptoms, and
  complications
• b. Restrict proteins (40 gm/day) of high biologic
  value
• c. Increase carbohydrate intake (35kcal/kg/day)
• d. Limit fluid to 1 2 L per day limit sodium
  to 2 g/day
• e. Restrict potassium (60 -70 mEq/day) no salt
  substitutes
• f. Restrict phosphorus foods (meat, eggs, dairy
  products)

48
Clients with Renal Failure

• Renal Replacement Therapies considered when
  medications and dietary modifications are no
  longer effective
• a. Hemodialysis establish vascular access
  (create AV fistula) months ahead
• b. Peritoneal dialysis can be initiated when
  indicated training client and/or family involved
• c. Transplantation tissue typing and
  identification of living related potential donors
  including health assessment of donor
• Dialysis
• a. Considerations
• 1. Dialysis manages ESRD, but does not cure it
• 2. Hemodialysis or peritoneal dialysis is
  constant factor of life
• 3. Depending on individual client situation and
  total health, client may prefer death to dialysis

49
Clients with Renal Failure

• Hemodialysis for ESRD
• 1. Treatments are 3 times per week for 9 12
  hours
• 2. Specific dialysis orders according to body
  size, residual renal function (based on that
  days current lab test results), dietary intake,
  concurrent illnesses
• 3. Complications during treatment are hypotension
  and muscle cramps dialysis disequilibrium
  syndrome
• 4. Long term complications are infection and
  vascular access problems
• 5. Cardiovascular disease is leading cause of
  death for hemodialysis clients higher death rate
  than clients on peritoneal dialysis or
  transplanted

50
Clients with Renal Failure

• Peritoneal Dialysis for ESRD
• 1. Continuous ambulatory peritoneal dialysis
  (CAPD) most common
• 2. 2 liters of dialysate instilled into
  peritoneal cavity and catheter sealed empty and
  replace every 4 6 hours
• 3. Continuous cyclic peritoneal dialysis (CCPD)
  uses delivery device during nighttime hours and
  continuous dwell during day
• Advantages over hemodialysis
• a. Eliminates vascular access and heparinization
• b. Avoids rapid fluctuation in extracellular
  fluid
• c. Diet intake is more liberal with fluids and
  nutrients
• d. Regular insulin can be added to dialysate to
  manage hyperglycemia for diabetics
• e. Client more able to self-manage

51
Clients with Renal Failure

• Disadvantages of peritoneal dialysis
• a. Less effective metabolite elimination
• b. Risk for infection (peritonitis dialysate
  returns cloudy should be straw colored)
• c. Serum triglyceride levels increase
• d. Altered body image with peritoneal catheter

52
Clients with Renal Failure

• Kidney Transplant
• a. Background
• 1. Treatment of choice for ESRD
• 2. Primarily limited by availability of kidneys
• 3. Many persons on waiting list for kidney
• 4. Improves survival and quality of life for ESRD
  client
• b. Organ Donors
• 1. Majority are from cadavers
• 2. Transplants from living donors increasing
• 3. Close match between blood and tissue type
  desired HLA are compared 6 in common is perfect
  match
• 4. Living donors must be in good physical health
  nephrectomy is major surgery and remaining kidney
  must be healthy

53
Placement of a transplanted kidney.
54
Placement of a transplanted kidney in the right
iliac fossa
55
Clients with Renal Failure

• Cadaver donors
• 1. Cadaver kidney from persons who
• a. Meets criteria for brain death
• b. Are aged lt 65 years old
• c. Are free of systemic disease, malignancy, or
  infection including HIV, hepatitis B, C
• 2. Kidney removed and preserved by hypothermia
• a. Transplant in 24 48 hours
• b. Use technique continuous hypothermic
  pulsatile perfusion, and transplant up to 3 days
• 3. Donor kidney placed in lower abdominal cavity,
  renal artery, vein, and ureter are anastomosed

56
Clients with Renal Failure

• Immunosuppressive therapy
• 1. Necessary to block immune response that would
  reject transplanted organ
• 2. Medications include
• a. Glucocorticoids prednisone and
  methylprednisolone used for maintenance and
  treatment of acute rejection episodes
• b. Azathioprine inhibits cellular and humoral
  immunity metabolized by liver
• c. Mycophenolate mofetil more potent and minimal
  bone marrow suppression
• d. Cyclosporine affects cellular immunity is
  hepatotoxic and nephrotoxic

57
Clients with Renal Failure

• Rejection
• 1. Can occur at any time
• 2. Acute rejection
• a. Occurs within months of transplant
• b. Cellular immune response with T cells
• c. Few manifestations
• 1. Rise in serum creatinine
• 2. Possibly oliguria
• d. Treatment
• 1. Methylprednisolone
• 2. OKT3 monoclonal antibody
• 3. Chronic rejection
• a. Develops months to years post transplant
• b. Major cause of graft loss
• c. Involves both humoral and cellular immune
  response
• d. Manifestations (same as renal failure)
• 1. Progressive azotemia
• 2. Proteinuria
• 3. Hypertension

58
Clients with Renal Failure

• Complications of kidney transplant
• 1. Hypertension
• 2. Glomerular lesions with manifestations of
  nephrosis
• 3. Increased risk for myocardial infarction and
  stroke
• Complications associated with long-term
  immunosuppression
• 1. Infection bacterial, viral, fungal in blood,
  lung, CNS
• 2. Tumors carcinoma in situ in cervix,
  lymphomas, skin cancers
• 3. Steroid use leads to bone problems, peptic
  ulcer disease, cataract formation

59
Clients with Renal Failure

• Health Promotion
• a. Ensure all clients with impaired renal
  function are well hydrated, especially while
  receiving nephrotoxic drugs
• b. Encourage clients with ESRD to explore
  transplant options
• Nursing Diagnoses
• a. Impaired Tissue Perfusion renal
• b. Imbalanced Nutrition Less than body
  requirements
• c. Risk for Infection
• d. Disturbed Body Image

60
Clients with Renal Failure

• Home Care
• a. CRF and ESRD are long-term processes requiring
  client management
• b. Extensive teaching required
• 1. Monitoring health status
• 2. Compliance with fluid and dietary restriction
  and medications
• 3. Care involved with hemodialysis, peritoneal
  dialysis, or living with transplant