Class 15: End stage renal disease

The kidney

• Remove waste products and fluid from the body through urine

• Production of Vitamin D to help form Red Blood Cells, and regulate blood pressure

The nephrons

• Major power unit of the kidney

• Has millions of filters in them help remove harmful waste from your body

• Wastes then move to tubules that remove the wastes through urine

Normal urine output

≥ 2 L, at least 2L of urine per day

End-stage renal disease urine output

• ≤ 200 ml or less

• some patients have none at all

Electrolytes

• Electrolytes get excreted as wastes by the kidney

  • Get a build-up in blood when kidneys aren't functioning well

• Na: Sodium 

• K: Potassium

  • Abnormal values can have an effect on the heart

• Ca: Calcium 

• P: Phosphorus

End-stage renal disease

• When a person’s GFR or renal function is less than 15 ml/min

• Symptoms include: Fatigue, electrolyte imbalances, hypertension, and decreased urine output

  • With fluid retention, we’re likely to have an increase in BP and our heart is working harder

Causes of kidney disease can be

Acute or chronic

Acute condition causing kidney disease

• Major illness

• MI

• Strep Throat

• IGA Nephropathy

  • Body rejects its own kidney

• Sepsis

• Congestive Heart Failure

• Acute Tubular Necrosis

• Kidney Stones or Kidney Obstruction

Chronic kidney failure is caused by

• Diabetes

• Hypertension

• Polycystic Kidney Disease

Acute vs chronic kidney disease

Acute can be reversible but chronic is irreversible

Detection of kidney disease

• Blood work

  • BUN, GFR, creatinine

• Decreased urine output

• Renal Ultrasound

• CT scan of Abdomen

• Renal Biopsy

• No single test is really used alone

Stages of end-stage renal disease

• For stage 1 the eGFR is greater than or equal to 90

• Stage 5 eGFR is less than 15

Effects of End-Stage Renal Disease

• Cardiovascular Issues

  • (Hypo/Hyperkalemia, Hypertension)

• Infertility

• Integumentary 

  • (Café Olay Color, dryness, edema)

• Respiratory 

  • (SOB related to fluid retention)

• Neurologic

• Musculoskeletal 

  • (calcium and phosphorus are altered in these patients, impacts bone)

Neurological Effects of End-Stage Renal Disease

• Kidney brain, anxiety is a big component, fear of the unknown

• Dialysis can provide a poorer QOL, loss of control

Treatments for End Stage Renal Disease

• Hemodialysis

• Peritoneal Dialysis

• Transplant

Kidney transplant

• Most favorable renal replacement option

  • Can be through live donation or deceased donation

  • Patients must meet specific criteria to be a transplant candidate

  • Donors must meet specific criteria to donate to a person with end stage renal disease

  • Anti-rejection drugs

Anti-rejection drugs for kidney transplant

• Myfortic, Neoral, Advagraf, Prograf, Predisone

• You have to take it for the remainder of your life, as long as you have that kidney; if you don't take it, your kidney is gonna fail

• Prednisone can cause fluid retention, more prominent at the beginning of transplant

• These drugs can cause cancer, huge skin warts on the face

Hemodialysis

• Can be done at home, in center, or outpatient

• In center or outpatient is 3-4 times per week for 2.5-4 hours

• Home is usually done at night (nocturnal)

• Fresenius Machine is currently being used

Stages of hemodialysis

• AV fistula or tunneled line

1. Blood is taken from the body via vascular access device

2. Blood is filtered through an artificial dialyzer

3. Solutes are removed through diffusion high concentration gradient to low concentration gradient (from blood to dialysate or dialysate to blood)

4. Temperature, pore size, particle size, and concentration differences impact the rate of diffusion

5. Fluid is removed through ultrafiltration (fluid is removed due to a difference in the pressure gradient of the blood and dialysate) low concentration to high concentration to equalize the pressure and lead to homeostasis

6. Waste products and fluid is removed

7. Blood is then returned to the body

Components of hemodialysis

• Patients are given a prescription

  • Dry Weight 

    • We have to develop a dry weight. We have a first dialysis and weigh you and assess you. At this time, very little fluid is being held; they feel well, no SOB. 

  • Pre and Post Weight

  • Dialyzer 

  • Dialysate (dialysis bath) K Ca

  • Temperature 

  • Sodium 

  • Dialysis Time

    • Can be 5 hours, can be 2, depends on patient 

Vascular access for hemodialysis

• AV Fistula

• Central Line

• Graft

AV fistula

• Surgical connection of an artery and a vein (anastomosis) 

• Takes time to heal and develop (6 weeks)

  • Don't want to needle it until its strong

• Monitored through Ultrasound

• Usually inserted in advance (stage 4 end stage renal disease)

• Cannulated with 2 15G needles 

• Buttonhole or rope and ladder

Button hole fistula

• Pick scab off and wiggle needle in; you're creating a tunnel. Over time, you don't have feeling in that needle bc of scar tissue. Higher risk of infection

Rope and ladder fistula

you're moving sites; ensure no aneurysms. What we typically like.

Why may an AV fistula not work

• Patient does not have good vascularity

• Doesn’t grow

• Development of aneurysm

• Poor assessment

AV Fistula care

• Look, listen, and feel

• Bruit and thrill

• Redness, Swelling, bruising, tenderness

Nursing Considerations when accessing AV Fistula

• Fear of needles

• Relationship with patient

• Anxiety 

• Fear of what is to come

• Vasovagal Response

Hemostasis

• Patient education is very important

• Arms needs to be held for at least 10 minutes using direct pressure

  • Very firm pressure

• Fistula needs to be protected

  • Wear long sleeves, don't go swimming around sharp rocks

Central line

• Inserted into a major vein and provides immediate access

• Tunneled 

• Very common in acute situations

• Patients made start off with a temporary line 1st

• Always monitor for signs of infection

Graft

• Made of synthetic material

  • Like a straw. Like a last resort where a fistula won't work, a line won't work.

  • Infection risk huge; doesn't last long

• Placed between an artery and a vein

• Usually placed in people with vascular issues as a last resort

  • Life line

Peritoneal dialysis

• Is a form of home dialysis (usually daily)

• Uses the patients own peritoneal membrane instead of the kidney to excrete wastes and fluids

• Fluid and waste products move from the blood to the peritoneal cavity

• A PD catheter is inserted through surgery and used for access

• Occurs through osmosis, diffusion, and ultrafiltration

• The catheter inserts dialysate into the peritoneal cavity

• The dialysate stays insitu for 4-6 hours

• The dialysate is then drained by gravity

Benefits of peritoneal dialysis

• Can be done at home

• More freedom for patient/patient is in control

• Support from family members 

• Can be done anywhere

Risks of peritoneal dialysis

• Infection (Peritonitis)

• Weight Gain

• Aseptic technique is required 

  • Aseptic technique can be a challenge when patients perform their own care

Signs of peritonitis

• Tenderness in abdomen

• Swelling in abdomen

• Nausea and vomiting

• Abdominal bloating or distension

Eprex

Produce RBC in pts with end stage renal disease 

Heparin

Prevent clotting

Aranesp

Produce RBC

Gravol

• Nausea common in the beginning and anxiety which can give nausea

Tums

• Kidneys cannot filter and remove phosphorus properly; calcium in Tums binds with the phosphorus to help remove

Keflex

Dialysis pts when they develop infections

Vancomycin

• Hospital-acquired infections

Replavites

• Vitamin B C complex helps with overall well-being

Ferriecit

• Given for anemia usually given IV

Complications of dialysis treatment

• Hypotension/Hypertension 

• Air Embolism

• Peritonitis 

• Infection

• Nausea 

• Muscle Cramping

  • Too much fluid is being removed or being removed too quickly

• Vascular Access dysfunction
  
  

End-stage renal patients diet

• Stay away from high potassium foods (Tomato, banana, potato, orange juice, oranges, ketchup, chocolate, gravy, milk, etc)

• Need less protein in their diets since end stage renal patients cannot excrete protein (Fish, eggs, and poultry)

• Avoid Foods high in calcium and phosphorus or hyperparathyroidism can result (milk, cheese, colas, chocolate, oatmeal, etc)

• Avoid High sodium foods (canned, frozen, added salt)

• Watch fluid intake 1 litre per day

Overall nursing considerations

• Major life transition for the patient 

• Loss of Control

• Risk of infection 

• Compliance Issues/Denial

• Support

• Monitoring (BP, nausea, fluid overload, too much fluid removal)

• Regular Blood work