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Renal Failure and Treatment

Renal Failure and Treatment. Vicky Jefferson, RN, CNN. 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. History.

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Renal Failure and Treatment

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  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

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

  36. 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

  37. External (Scribner) Shunt

  38. 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

  39. AV Fistula

  40. 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

  41. PTFE Graft

  42. 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

  43. 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

  44. Cuffed TunneledCatheter

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

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

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

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

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

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