Renal Failure and Treatment

1. Renal Failure andTreatment Vicky Jefferson, RN, CNN

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, PhD

3. History • Early animal experiments began 1913 • 1st human dialysis 1940 by Dutch physician Willem Kolff (2 of 17 patients survived) • Considered experimental through 1950’s, No intermittent blood access; for acute renal failure only.

4. History cont’d • 1960 Dr. Scribner developed Scribner Shunt • 1960’s Machines expensive, scarce, no funding. • “Death Panels” panels within community decided who got to dialyze.

5. Normal Kidney Function • Fluid balance • Electrolyte regulation • Control acid base balance • Waste removal • Hormonal function • Erythropoietin • Renin • Active Vitamin D3 • Prostaglandins

6. Acute Renal Failure (ARF) • Sudden onset - hours to days • Often reversible • Severe - 50% mortality rate overall; generally related to infection.

7. Chronic Renal Failure (CRF) • Slow onset - years • Not reversible

8. Causes of Chronic Renal Failure • Diabetes • Hypertension • Glomerulonephritis • Cystic disorders • Developmental - Congenital • Infectious Disease

9. Causes of Chronic Renal Failure cont’d • Neoplasms • Obstructive disorders • Autoimmune diseases • Lupus • Hepatorenal failure • Scleroderma • Amyloidosis • Drug toxicity

10. Stages of Chronic Renal Failure • Reduced Renal Reserve • Renal Insufficiency • End Stage Renal Disease (ESRD)

11. Stage 1: Reduced Renal Reserve • Residual function 40 - 75% of normal • BUN and Creatinine normal (early) • No symptoms

12. Stage II: Renal Insufficiency • Residual function 20 - 40 % normal • Decreased: glomerular filtration rate, solute clearance, ability to concentrate urine and hormone secretion • Symptoms: elevated BUN & Creatinine, mild azotemia, anemia

13. Stage II: Renal Insufficiency cont’d • Signs and symptoms worsen if kidneys are stressed • Decreased ability to maintain homeostasis

14. Stage III: End Stage Renal Disease (ESRD) • Residual function < 15% of normal • Excretory, regulatory and hormonal functions severely impaired. • metabolic acidosis

15. Stage III: End Stage Renal Disease (ESRD) cont’d • Marked increase in: BUN, Creatinine, Phosphorous • Marked decrease in: Hemoglobin, Hematocrit, Calcium • Fluid overload

16. Stage III: End Stage Renal Disease (ESRD) cont’d • Uremic syndrome develops affecting all body systems • Last stage of progressive CRF • Fatal if no treatment

17. Diagnostic Tools for Assessing Renal Failure • Blood Tests • BUN elevated (norm 10-20) • Creatinine elevated (norm 0.7-1.3) • K elevated • PO4 elevated • Ca decreased • Urinalysis • Specific gravity • Protein • Creatinine clearance

18. Diagnostic Tools cont’d • Biopsy • Ultrasound • X-Rays

19. Manifestations of Chronic Renal Failure

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

21. Integumentary • Pale, grayish-bronze color • Dry scaly • Severe itching • Bruise easily • Uremic frost

22. Eyes • Visual blurring • Occasional blindness

23. Fluid - Electrolyte - PH • Volume expansion and fluid overload • Metabolic Acidosis • Electrolyte Imbalances • Hyperkalemia

24. GI Tract • Uremic fetor • Anorexia, nausea, vomiting • GI bleeding

25. Hematologic • Anemia • Platelet dysfunction

26. Musculoskeletal • Muscle cramps • Soft tissue calcifications • Weakness • Related to calcium phosphorous imbalances

27. Heart Lungs • Hypertension • Congestive heart failure • Pericarditis • Pulmonary edema • Pleural effusions

28. Endocrine/Metabolic • Erythropoietin production decreased • Hypothyroidism • Insulin resistance • Growth hormone decreased • Gonadal dysfunctions • Parathyroid hormone and Vitamin D3 • Hyperlipidemia

29. Treatment Options • Hemodialysis • Peritoneal Dialysis • Transplant

30. Hemodialysis • Removal of soluble substances and water from the blood by diffusion through a semi-permeable membrane.

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

32. Hemodialysis Process

33. HemodialysisCircuit

34. ExtracorporealCircuit

36. Vascular Access • Arterio-venous shunt (Scribner External Shunt) • Arterio-venous (AV) Fistula • PTFE Graft • Temporary catheters • “Permanent” catheters

37. Scribner 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

38. External (Scribner) Shunt

39. Arterio-venous (AV) FistulaPrimary Fistula • Patients own artery and vein surgically anastomosed. • Advantages • patients own vein • longevity • low infection and thrombosis rates • Disadvantages • long time to mature, 1- 6 months • “steal” syndrome • requires needle sticks

40. AV Fistula

41. PTFE (Polytetraflourethylene) Graft • Synthetic “vessel” anastomosed into an artery and vein. • Advantages • for people with inadequate vessels • can be used in 7-14 days • prominent vessels • Disadvantages • clots easily • “steal” syndrome more frequent • requires needle sticks • infection may necessitate removal of graft

42. PTFE Graft

43. 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

44. Cuffed Tunneled Catheters • Dual lumen catheter with Dacron cuff surgically tunneled into subclavian, jugular or femoral vein. • Advantages • immediate 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

45. Cuffed TunneledCatheter

46. Complications of Hemodialysis • During dialysis • Fluid and electrolyte related • hypotension • Cardiovascular • arrythmias • Associated with the extracorporeal circuit • exsanguination • Neurologic • seizures • other • fever

47. Complications of Hemodialysis cont’d • Between treatments • Hypertension/Hypotension • Edema • Pulmonary edema • Hyperkalemia • Bleeding • Clotting of access

48. Complications of Hemodialysis cont’d • Long term • Metabolic • hyperparathyroidism • diabetic complications • Cardiovascular • CHF • AV access failure • Respiratory • pulmonary edema • Neuromuscular • neuropathy

49. Complications of Hemodialysiscont’d • Long term cont’d • Hematologic • anemia • GI • bleeding • dermatologic • calcium phosphorous deposits • Rheumatologic • amyloid deposits

50. Complications of Hemodialysis cont’d • Long term cont’d • Genitourinary • infection • sexual dysfunction • Psychiatric • depression • Infection • bloodborne pathogens