Detoxification

what is detoxification?

removal of toxic substance from the human organism to promote homeostasis

what are the attributes of detox?

hepatic and renal

what is the scope of detox

← impaired detox — normal function — hyperfunction (too good in metabolizing)

What does renal function regulate?

• fluid volume

• acid-base balance

• electrolytes

• removes of wastes and urine production

what else can renal function affect?

hormones and immune regulation

what does hepatic function regulate?

• breakdown of toxins, chemicals, medications, hormones

• metabolism of cards, fats, proteins

• production of clotting factors → storage of vitamins

• bile secretions

What is nitrogenous waste?

ammonia → urea (excreted) → uric acid (excreted)

azotemia

build up of BUN and creatinine

uremia

buildup of all wastes

Liver → detox and convert

• ammonia → urea

• drugs → metabolites

• hemoglobin → bilirubin

  • into water-soluble wastes

bloodstream → filter and remove

• filter blood (glomerulus

• keep what body needs

• sends waste to urine

if problem is in the liver:

toxins not converted, findings:

• high ammonia → confusion

• high bilirubin → jaundice

if problem is in the kidneys

wastes NOT excreted, findings:

• high BUN/creatinine

• low urine output

if both fail in liver and kidneys

• rapid toxin build up → emergency

  • no → liver problem

• is the toxin being eliminated

  • no → kidney problem

problems with the liver

ammonia accumulates → not converted to urea

problems with the kidneys

urea and creatinine accumulate → not eliminated from the body

waste products can be

toxic to the body in high concentrations

infants/toddlers/ children

• immature systems, may see jaundice

• child dosing of meds, some meds avoid

older adults

• organ function declines at 40 yrs

• increase r/o of issues with meds (nephro and hepatotoxicity)

what are diseases of liver or the kidneys

cirrhosis, hepatitis and chronic kidney disease

Chronic conditions that may damage liver/kidneys

• heart failure, diabetes → kidneys

• medications (nephro and hepato toxicity)

• chronic alcohol use

Ammonia is easy to cross

blood-brain barrier and cause neuron dysfunction (hepatic encephalopathy)

Ammonia can cause

asterixis, changes in personality, agitation, restlessness, impaired judgement, slurred speech → incoherence, confusion, disorientation

early signs of uremia?

nausea, apathy, weakness, fatigue

what can urea/creatinine lead to

mental status changes, decline in cell/organ function, and multisystem effect

What are primary preventions that could help

hydrate, don’t hold your pee, and manage hypertension and diabetes

what secondary screenings that help

routine lab work (BUN/creatinine) and metabolic Panel and LFTs

what are the most common strategies

nutritional support (hydration), invasive procedures (kidney stones), pharmacotherapy

What is dialysis for

method to remove waste products from the body

how does dialysis help in end stage renal disease?

replaces function of the kidney → removes: urea, creatinine, fluid; balances electrolytes and acid base

how does dialysis help with cirrhosis

removes ammonia, typically reserved for hepatic encephalopathy flares

what is dialysis

diffusion/osmosis to filter blood

by machine

hemodialysis

internally

peritoneal dialysis

what to do for hemodialysis

• assessment of fistula

• palpate to feel “thrill”

• auscultate to hear the bruit

• exam the site visually for signs of infection/bleeding

what to do for peritoneal dialysis

• inspect catheter insertion site

• looks for signs of inflammation/infection

• inspect drainage, cloudy is abnormal

what are pros to hemodialysis

• no self treatment

• care team available

• good for those who can’t do it at home

• 3x/week

• good for acute toxicity

what are cons for hemodialysis

• go to hospital

• time consuming

• diet and fluid restriction

what are pros to peritoneal dialysis

• can be done at home

• no liquid/food restriction

• easier to travel, self-manage

• can be done while sleeping

what are the cons to peritoneal dialysis

• bloated

• has to be done every day

• risk for infection

• harder to manage for those managing their own care

what is lactulose for?

works to decrease ammonia production and traps it in the GI tract as well as treat constipation (osmotic laxative)

what does toxic accumulation of ammonia cause?

hyperammonemia → brain toxicity → coma and death

what are assessments for lactulose?

• is med appropriate?

• labs: liver function, ammonia

what is a side effect of lactulose?

diarrhea

what to monitor for lactulose

GI output

what are patient teaching for lactulose?

• causes frequent loose stools

• difference: decrease ammonia vs. improve constipation

• pts in liver failure make need to take this forever