Focus on Dialysis and Kidney Transplant Relates to

Focus on Dialysis and Kidney Transplant (Relates to Chapter 47, “Nursing Management: Acute Renal Failure and Chronic Kidney Disease, ” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Dialysis • Movement of fluid/molecules across a semipermeable membrane from one compartment to another • Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure • Treat drug overdoses Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Dialysis • Two methods of dialysis available • Peritoneal dialysis (PD) • Hemodialysis (HD) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Dialysis • Begun when patient’s uremia can no longer be adequately managed conservatively • Initiated when GFR (or creatinine clearance) <15 ml/min Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Dialysis • Certain uremic complications also indicate a need • Encephalopathy, pericarditis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

General Principles of Dialysis • Diffusion • Movement of solutes from an area of greater concentration to an area of lesser Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

General Principles of Dialysis • Osmosis • Movement of fluid from an area of lesser to area of greater concentration of solutes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

General Principles of Dialysis • Ultrafiltration • Water and fluid removal • Results when there is an osmotic gradient across the membrane Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Osmosis and Diffusion Across Semipermeable Membrane Fig. 47 -7 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis • Peritoneal access is obtained by inserting a catheter through the anterior wall • Technique for catheter placement varies • Usually done via surgery Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis • After catheter inserted, skin is cleaned with antiseptic solution and sterile dressing applied • Connected to sterile tubing system • Secured to abdomen with tape • Catheter irrigated immediately Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis • Waiting period of 7 to 14 days preferable • 2 to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness • Once site healed patient may shower and pat dry Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Tenckhoff Catheter Fig. 47 -8 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fig. 47 -9 and Fig. 47 -10 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Solutions and Cycles • Available in 1 - or 2 -L plastic bags with glucose concentrations of 1. 5%, 2. 5%, and 4. 25% • Electrolyte composition similar to plasma • Solution warmed to body temperature Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Solutions and Cycles • Three phases of PD cycle • Called an exchange • Inflow (fill) • Dwell (equilibration) • Drain Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Solutions and Cycles • Inflow • Prescribed amount of solution infused through established catheter over about 10 minutes • After solution infused, inflow clamp closed to prevent air from entering tubing Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Solutions and Cycles • Dwell • Diffusion and osmosis occur between patient’s blood and peritoneal cavity • Duration of time varies depending on method Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fig. 47 -12 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Solutions and Cycles • Drain • 15 to 30 minutes • May be facilitated by gently massaging abdomen or changing position Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Systems • Automated peritoneal dialysis (APD) • Cycler delivers the dialysate • Times and controls fill, dwell, and drain • Continuous ambulatory peritoneal dialysis (CAPD) • Manual exchange Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Complications • • • Exit site infection Peritonitis Abdominal pain Outflow problems Hernias Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Complications • • Lower back problems Bleeding Pulmonary complications Protein loss Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Complications • Carbohydrate and lipid abnormalities • Encapsulating sclerosing peritonitis • Loss of ultrafiltration Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Peritoneal Dialysis Effectiveness and Adaptation • • • Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Vascular Access Sites • Obtaining vascular access is one of most difficult problems • Types of access include • Shunts • Internal arteriovenous fistulas and grafts • Temporary vascular access Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Vascular Access for Hemodialysis Fig. 47 -13 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fig. 47 -13 -D Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Dialyzers • Long plastic cartridge that contains thousands of parallel hollow tubes or fibers • Fibers are the semipermeable membrane Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis System Fig. 47 -16 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Procedure • Two needles placed in fistula or graft • Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer • Blood returned from dialyzer to patient through second needle or blue catheter Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Procedure • Dialyzer/blood lines primed with saline solution to eliminate air • Heparin added to blood as it flows to dialyzer • Terminated by flushing dialyzer with saline to remove all blood • Needles removed and firm pressure applied Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Procedure • Before treatment nurse should • Complete assessment of fluid status, condition of access, temperature, skin condition • During treatment nurse should • Be alert to changes in condition • Perform vital signs every 30 to 60 minutes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fig. 47 -17 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Complications • • • Hypotension Muscle cramps Loss of blood Hepatitis Sepsis Disequilibrium syndrome Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Hemodialysis Effectiveness and Adaptation • Cannot fully replace metabolic and hormonal functions of kidneys • Can ease many of the symptoms • Can prevent certain complications Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • Alternative or adjunctive method for treating ARF • Means by which uremic toxins and fluids are removed • Acid–base status/electrolytes adjusted slowly and continuously Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • Can be used in conjunction with HD • Contraindication • Presence of manifestations of uremia requiring rapid resolution • • Continued for 30 to 40 days Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow Specimens may be obtained for evaluation Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • Two types of CRRT • Continuous arteriovenous therapies (CAVTs) • Continuous venous therapies (CVVTs) • Most commonly used Ø Continuous venous hemofiltration (CVVH) Ø Continuous venous hemodialysis (CVVHD) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • Continuous venous hemofiltration (CVVH) • Large volumes fluid removed hourly, then replaced • Fluid replacement dependent on stability/individualized needs of patient Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • Continuous venous hemodialysis (CVVHD) • Uses dialysate • Dialysate bags attached to distal end of hemofilter • Fluid pumped countercurrent to blood flow • Ideal treatment for patient who needs fluid/solute control but cannot tolerate rapid fluid shifts with HD Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • Highly permeable, hollow fiber hemofilter • Uses double-lumen catheter placed in femoral, jugular, or subclavian vein • Removes plasma water and nonprotein solutes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • CRRT versus HD • Continuous rather than intermittent • Solute removal by convection (no dialysate required) in addition to osmosis and diffusion • Less hemodynamic instability Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Continual Renal Replacement Therapy (CRRT) • CRRT versus HD (cont’d) • Does not require constant monitoring by HD nurse • Does not require complicated HD equipment Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation • More than 66, 000 patients currently awaiting deceased (cadaveric) kidney transplants • 19, 549 kidneys were transplanted in 2004 • More than 6990 living donor transplants in 2004 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation • Extremely successful • 1 -year graft survival rate • 90% for cadaver transplants • 95% for live donor transplants Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation • Advantages of kidney transplant compared with dialysis • Reverses many of the pathophysiologic changes associated with renal failure • Eliminates the dependence on dialysis • Less expensive than dialysis after the first year Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Recipient Selection • Candidacy determined by a variety of medical and psychosocial factors that vary among transplant centers Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Recipient Selection • Contraindications to transplantation • Disseminated malignancies • Cardiac disease • Chronic respiratory failure • Extensive vascular disease • Chronic infection • Unresolved psychosocial disorders Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Histocompatibility Studies • Purpose of testing is to identify the HLA antigens for both donors and potential recipients Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Donor Sources • Compatible blood type deceased donors • Blood relatives • Emotionally related living donors • Altruistic living donors Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Surgical Procedure Live donor • Nephrectomy performed by a urologist • • • or transplant surgeon Begins an hour or two before the recipient’s surgery is started Rib may need to be removed for adequate view Takes about 3 hours Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Surgical Procedure Live donor • Laparoscopic donor nephrectomy • Alternative to conventional nephrectomy • Primary method of live kidney procurement Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Surgical Procedure Kidney transplant recipient • Usually placed extraperitoneally in the iliac fossa • Right iliac fossa is preferred Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Fig. 47 -19 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Surgical Procedure Kidney transplant recipient • Before incision • Urinary catheter placed into bladder • Antibiotic solution instilled • Distends the bladder • Decreases risk of infection • Crescent-shaped incision Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Surgical Procedure Kidney transplant recipient • Rapid revascularization critical • Donor artery anastomosed to recipient internal/external iliac artery • Donor vein anastomosed to recipient external iliac vein Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Surgical Procedure Kidney transplant recipient • When anastomoses complete, clamps released and blood flow reestablished • Urine may begin to flow or diuretic may be given • Surgery takes 3 to 4 hours Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Nursing Management • Preoperative care • Emotional and physical preparation • Immunosuppressive drugs • ECG • Chest x-ray • Laboratory studies Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Nursing Management • Postoperative care • Live donor • Care is similar to laparoscopic nephrectomy • Close monitoring of renal function • Close monitoring of hematocrit Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Nursing Management • Postoperative care (cont’d) • Recipient • Maintenance of fluid and electrolyte balance is first priority • Large volumes of urine soon after transplanted kidney placed due to Ø New kidney’s ability to filter BUN Ø Abundance of fluids during operation Ø Initial renal tubular dysfunction Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Nursing Management • Postoperative care (cont’d) • Recipient • Urine output replaced with fluids milliliter by milliliter hourly Ø Urine output closely measured • Acute tubular necrosis can occur Ø May need dialysis • Maintain catheter patency Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Immunosuppressive Therapy • Goals • Adequately suppress the immune response • Maintain sufficient immunity to prevent overwhelming infection Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Rejection • Hyperacute (antibody-mediated, humoral) rejection • Occurs minutes to hours after transplantation Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Rejection (cont’d) • Acute rejection • Occurs days to months after transplantation Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Rejection (cont’d) • Chronic rejection • Process that occurs over months or years and is irreversible Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Infection • Most common infections observed in the first month • Pneumonia • Wound infections • IV line and drain infections Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Infection (cont’d) • Fungal infections • Candida • Cryptococcus • Aspergillus • Pneumocystis jiroveci Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Infection (cont’d) • Viral infections • CMV Ø One of the most common • Epstein-Barr virus • Herpes simplex virus Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Cardiovascular disease • Transplant recipients have increased incidence of atherosclerotic vascular disease • Immunosuppressant can worsen hypertension and hyperlipidemia • Adhere to antihypertensive regimen Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Malignancies • Primary cause is immunosuppressive therapy • Regular screening important preventive care Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Recurrence of original renal disease • Glomerulonephritis • Ig. A nephropathy • Diabetes mellitus • Focal segmental sclerosis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Corticosteroid-related complications • Aseptic necrosis of the hips, knees, and other joints • Peptic ulcer disease • Glucose intolerance and diabetes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Kidney Transplantation Complications • Corticosteroid-related complications (cont’d) • Hyperlipidemia • Cataracts • Increased incidence of infections and malignancies • Close monitoring of side effects Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Kidney Disease Gerontologic Considerations • About 35% of ESRD patients are 65 or older • Most common diseases leading to renal failure in the older adult • Hypertension • Diabetes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Management Evaluation • • • Maintenance of ideal body weight Acceptance of chronic disease No infections No edema Hematocrit, hemoglobin and serum albumin levels in acceptable range Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.