NUR 544 -- Dialysis and Kidney Transplantation

Indication for Dialysis

To remove waste products for patients in renal failure

Used to correct fluid/electrolyte imbalances (fluid volume overload or elevated K levels)

For those who have metabolic acidosis

For those who have elevated BUN: > 120 mg/dL

If a patient has increased uremia and significant mental health changes.

What is Dialysis?

Movement of fluid/molecules across a semipermeable membrane from one compartment to another

What are the types of dialysis?

PD (Peritoneal Dialysis)

HD (Hemodialysis)

Peritoneal Dialysis (PD)

Peritoneal membrane acts as the semipermeable membrane

That has a catheter that is inserted into the anterior abdominal wall

Hemodialysis (HD)

Artificial membrane is used as the semipermeable membrane and is in contact with the patient's blood

A patient is put on dialysis because...

The patient's uremia can no longer be adequately managed

-BUN and creatinine are progressively getting higher

-GFR is less than 15 mL/min (normal GFR is 125 mL/min) -->they're not urinating

ESKD (End-Stage Kidney Disease) is treated with dialysis because...

-Lack of donated organs

-Physically or mentally unsuitable for transplant (can't follow directions post-transplant)

-Transplant refusal for patient!

Principles for Dialysis

Diffusion: Solutes from an area of higher concentration to an area of lower concentration

Osmosis: Fluid from an area of lower concentration of solutes to an area of higher concentration

Ultrafiltration:

-Water and fluid removal

-Results when there is an osmotic gradient across the membrane

Peritoneal Dialysis:

How is it inserted?

What do you do after insertion?

How long is the use post placement?

It's the insertion of a catheter through the anterior abdominal wall

After insertion, sterile dressing is applied:

-connected to sterile tubing system

-secured to abdomen with tape

Use 7-14 days post placement

2-4 weeks: site free from redness/tenderness

Peritoneal Dialysis involves what?

It involves instillation of a hypertonic dialysate solution into the peritoneal cavity (1-2L bags that keep dialysis in it. It has glucose concentration in it).

The peritoneal cavity serves as the filtration membrane

Indications for PD (Peritoneal Dialysis) (why are patient's on it?)?

Unable to tolerate anticoagulation

Chronic infections

Pt's who do not want HD or kidney transplant (HD means you have to go somewhere and sit for a while to have it done)

Those who cannot tolerate rapid fluid shifts

Phases of PD (Peritoneal Dialysis)

Inflow (fill)

Dwell (equilibrium)

Drain

Inflow Phase of PD

The "fill" where we actually infuse the solution through catheter over 10 minutes

-after solution infused, inflow clamp closed to prevent from air entering the tubing

The whole system is kept closed and sterile

Dwell Phase of PD

The equilibrium phase. During that time diffusion and osmosis occur between the pt's blood and peritoneal cavity

duration of time varies depending on method (sometimes it's several hours, or overnight, it depends)

Drain Phase of PD

Once the dialysis has dwelled, then we have to drain it.

Lasts 15 to 30 minutes (all that infusion that went in is coming out of patient)

May be facilitated by gently massaging abdomen or changing position

-When dialysate goes in it's clear, when it comes out it has a tint of yellow (that's normal)

With PD they can have automated PD (APD):

In this what delivers dialysis?

When can you do this?

A cylinder delivers dialysate

This can be done while the patient is sleeping overnight

Times and controls fill, dwell, and drain is done by a machine

With PD they can also have Continuous Ambulatory Peritoneal Dialysis (CAPD). What is this?

Manual exchange. Pt is actually exchanging dialysis bags manually. They'll control the fill time, dwell time, and will manually drain it from abdominal cavity to drainage bag.

PD Complications

-Site infection

-Peritonitis (from tunneling infection)

-Hernias

-Lower back problems (because of increased abd pressure)

-Bleeding

-Pulmonary complications (repeated upward displacement of diaphragm -- impedes lung expansion)

-Protein loss (protein can inadvertently be removed with other stuff)

-Poor dialysate inflow or outflow (may be caused by constipation or position of catheter. Monitor pt's bowel pattern)

Hemodialysis (HD) Vascular Access

Arteriovenous Fistulas (AVFs)

Arteriovenous Grafts (AVGs)

Temporary Vascular

Hemodialysis (HD) Vascular Access:

Arteriovenous Fistulas (AVFs)

Where is it?

How do we know if it's working properly?

What do we make sure not to do?

Anastomosis between an artery and a vein

We know it's working properly if there's a bruit and thrill (listen over the fistula for bruit and feel for thrill)

Make sure there are no blood pressures in that arm which has a AVF

Hemodialysis (HD) Vascular Access:

Arteriovenous Grafts (AVGs)

What is it?

What's a possible complication for this?

Synthetic material forms anastomosis between arterial and venous blood supplies.

Possible complication is Steal syndrome: shunted arterial blood. There's a development of distal ischemia and pain. Pt may have pain distal to access site, numbness or tingling, poor cap refill.

Hemodialysis (HD) Vascular Access:

Temporary Vascular (aka Quinton cath)

What is it?

Where is it placed

Why is it used?

It's a long-term cuff catheter

Usually placed in upper chest wall (tunneled in subclavian to jugular. Tip is in right atrium)

Used if the patient is waiting for a fistula placement, or as a long-term access while other accesses have failed.

What are Dialyzers in HD?

How do they work?

Long plastic cartridges that contain thousands of parallel hollow tubes or fibers

Fibers are semipermeable membranes

Blood is pumped into the top of the cartridge and is dispersed into all of the fibers

Dialysate is pumped into the bottom of the cartridge and washes the outside of the fibers with dialysis fluid

Procedure for placing Hemodialysis

Two needles are placed in fistula or graft

First needle: placed to pull blood from the circulation to the HD machine

-red catheter: attached to first needle

Second needle: used to return the dialyzed blood to the patient

-blue catheter: attached to second needle

Complications of HD

Hypotension

Muscle cramps

Loss of blood

For HD, Dialyzer/blood lines are primed with what?

Why is this?

Primed with saline to eliminate air

Once pt has HD, and treatment is terminated you flush the dialyzer with what?

Why do you do this?

Flush the dialyzer with saline to remove all blood

*needles are removed and firm pressure is applied

An individual could be on CRRT (Continual Renal Replacement Therapy) which is what?

Why is it done?

What does it use to work?

It's an alternative/adjunctive way to treat AKI

It's done to remove uremic toxins and fluids

It adjusts the acid-base status/electrolyte balance slowly and continuously

It uses a highly permeable, hollow-fiber hemofilter which removes plasma, water, and nonprotein solutes

CRRT can be done over what period of time?

Does it require constant monitoring?

What kind of patient is it used for?

It's contraindicated for?

It can be done over a period of days

It does NOT require constant monitoring

It's used in highly unstable patients. Pt's don't respond to diet or drug interventions. Mimics the body's way of eliminating waster over a 24 hour period

Contraindicated for anyone who has life-threatening uremia or hyperkalemia

*it's not a quick fix, it's slowly done!

Catheter is placed in jugular or femoral vein

Kidney Transplantation Advantages over dialysis

Reverses pathophysiologic changes associated with renal failure

Eliminates dependence on dialysis

Less expensive than dialysis after first year

Contraindications for a Kidney Transplant

-Disseminated malignancies

-Untreated cardiac disease

-Chronic respiratory failure

-Extensive vascular disease

-Chronic infection

-Unresolved psychosocial disorders

-Non-compliance

Kidney Transplant Donor Sources

-Deceased donors with compatible blood type (want to do it within 24 hours of a person being brain dead)

-Blood relatives

-Emotionally related living donors

-Altruistic living donors

-Paired organ donation

*live donors need to be in good health!

Surgery for Kidney Transplant

Nephrectomy (can be either open or laparoscopic)

Performed by a urologist or transplant surgeon

Begins 1 or 2 hours before the recipient's surgery is started

Rib may need to be removed for adequate view

Takes about 3 hours

Laparoscopic donor nephrectomy:

-most common approach for live kidney procurement

-->decreases hospital stay for donor

--> decreases blood loss

Nursing Management for the Live Donor of a Kidney Transplant

Monitor renal function: BUN, creatinine, urine output

-they're usually in the hospital for about 2-4 days

Monitor hematocrit

Donors have more pain than recipients, eval pain!

Nursing management for Recipient of Kidney Transplant

Maintenance of fluid and electrolyte balance is first priority

Large volumes of urine soon after transplanted kidney placed r/t:

-new kidney's ability to filter BUN

-abundance of fluids during operation

-initial renal tubular dysfunction

A Kidney Transplant patient will be on ________________ Therapy? What does it do?

They will be on immunosuppressive therapy

It adequately suppresses the immune response. The body senses it as a foreign body and will attack it. This is why you need immunosuppressive therapy

Maintain sufficient immunity to prevent overwhelming infection

Three types of complications for Kidney Transplantation

Rejection

Infection

Cardiovascular disease

Complications of Kidney Transplantation:

Three types of Kidney Transplant Rejection

Hyperacute

Acute

Chronic

Hyperacute Kidney Rejection

How long they take to occur?

What do they cause?

What do you do for this?

Clinical manifestations?

Occurs: Within first 48 hours of transplant

Causes a small blood clot to form in transplanted kidney. It can occlude vessels and cause cellular dysfunction

What to do: The kidney needs to be removed. It's irreversible

Clinical manifestations: fever, htn, severe pain at transplant site

Acute Kidney Rejection

How long they take to occur?

What do they cause?

Treatment?

Clinical manifestations?

Occurs one week to two years after surgery

It can be caused by an antibody mediated response/can cause vasculitis in kidney and cellular destruction.

Treatment: increasing dose of immunosuppressant medications.

Clinical manifestations: oliguria, anuria, low-grade fever, htn, tenderness over transplanted kidney area, lethargy, fluid retention.

Chronic Kidney Rejection

How long they take to occur?

What do they cause?

Clinical manifestations?

Occurs: gradually over several months to years

Caused by: blood vessel injury from an overgrowth of smooth muscles on blood vessels. This causes fibrotic tissue to replace normal tissue; this results in non-functioning kidney

Clinical manifestations: may have a gradual return of azotemia, higher levels of nitrogen compounds (urea, creatinine), fluid retention, electrolyte imbalances

Treatment: monitor kidney status and continue immunosuppressant meds until dialysis is needed.

Complications of Kidney Transplantation:

Infection

Wound infections

Fungal (Candida) and viral (CMV)

Complications of Kidney Transplantation:

Cardiovascular Disease

Increased incidence of atherosclerotic vascular disease

immunosuppressants can worsen htn and hld

Kidney Transplant Malignancies

Primary cause is immunosuppressive therapy. Hinders the body's ability to fight infection (though it helps the new kidney adapt)

Monitor for basal and squamous cell carcinoma of the skin (we may see this the most in these patients!).

Kidney Transplantation Nursing Management

-Patient education

-Maintain ideal body weight

-Acceptance of chronic disease

-Monitor for infection

-No edema

-Monitor laboratory values

--> Hct and Hgb

--> serum albumin levels

-Immunosuppressant medications