Dialysis

Pharmacological therapy

- many medications are removed from the blood during hemodialysis; therefore, the physician may need to adjust the dosage. Metabolites of drugs that are bound to protein are not removed during dialysis - patients undergoing hemodialysis who require medications (e.g., cardiac glycosides, antibiotic agents, antiarrhythmic medications, antihypertensive agents) are monitored closely to ensure that blood and tissue levels of these medications are maintained without toxic accumulation.

Assessing the patient for transplant rejection

- oliguria, edema, fever, increasing blood pressure, weight gain, and swelling or tender- ness over the transplanted kidney or graft - pts receiving cyclosporine may not exhibit the usual s/s of acute rejection; only sign may be rise in the serum creatinine level (more than a 20% rise is considered acute rejection)

A kidney from a cadaver donor may undergo acute tubular necrosis and therefore may not function for

2 or 3 weeks, during which time anuria, oliguria, or polyuria may be present

Renal transplantation

(1) The diseased kidney may be removed and the renal artery and vein tied off. (2) The transplanted kidney is placed in the iliac fossa. (3) The renal artery of the donated kidney is sutured to the iliac artery, and the renal vein is sutured to the iliac vein (4) The ureter of the donated kidney is sutured to the bladder or to the patient's ureter.

Approaches

- Acute intermittent peritoneal dialysis - Continuous Ambulatory Peritoneal Dialysis (CAPD) - Continuous Cyclic Peritoneal Dialysis (CCPD) *see handout

Monitor fluid balance indicators and monitor IV therapy carefully

keep accurate I&O and IV administration pump records. Because patients on dialysis cannot excrete water, rapid or excessive administration of IV fluid can result in pulmonary edema.

Continuous Renal Replacement Therapies (CRRT) indicated for:

- acute or chronic renal failure who are too clinically unstable for traditional hemodialysis - fluid overload secondary to oliguric (low urine output) renal failure - kidneys cannot handle their acutely high metabolic or nutritional needs - does not produce rapid fluid shifts, does not require dialysis machines or dialysis personnel to carry out the procedures, and can be initiated quickly in hospitals without dialysis facilitates - they require access to the circulation and blood to pass through an artificial filter. A hemofileter (an extremely porous blood filter containing a semi permeable membrane) is used.

Monitoring urinary function

- after successful renal transplantation, vascular access device may clot; Hemodialysis may be necessary postoperatively to maintain homeostasis until the transplanted kidney is functioning well

Medical Management:

A complete physical examination is performed to detect and treat any conditions that could cause complications after transplantation. Tissue typing, blood typing, and antibody screening are performed to determine compatibility of the tissues and cells of the donor and recipient. Other diagnostic tests must be completed to identify conditions requiring treatment before transplantation. The lower urinary tract is studied to assess bladder neck function and to detect ureteral reflux. The patient must be free of infection at the time of renal transplantation because after surgery medications to prevent transplant rejection will be prescribed. These medications suppress the immune response, leaving the patient immunosuppressed and at risk of infection. Therefore, the patient is evaluated and treated for any infections, including gingival (gum) disease and dental caries. A psychosocial evaluation is conducted to assess the patient's ability to adjust to the transplant, coping styles, social history, social support available, and financial resources. A history of psychiatric illness is important to obtain because psychiatric conditions are often aggravated by the corticosteroids needed for immunosuppression after transplantation. If a dialysis routine has been established, hemodialysis is often performed the day before the scheduled transplantation procedure to optimize the patient's physical status. However, it is preferable to avoid initiation of dialysis before transplantation when a donor kidney is available

Administering Medications

All medications and the dosage prescribed for any patient on dialysis must be closely monitored to avoid those that are toxic to the kidneys and may threaten remaining renal function. Medications are also scrutinized for potassium and magnesium content, because medications containing potassium or magnesium must be avoided. Care must be taken to evaluate all problems and symptoms that the patient reports without automatically attributing them to renal failure or to dialysis therapy.

Complications such as pruritis and pain secondary to neuropathy must be managed

Antihistamine agents (Benadryl) are commonly used and analgesic medications may be prescribed. Medication dosages may need to be adjusted because elimination of the metabolites of meds occurs during dialysis. Keeping the skin clean and well moisturized using bath oils, super fatted soap, and creams or lotions help promote comfort and reduce itching. Teach patients to keep nails trimmed to avoid scratching and excoriation and apply lotion to the skin instead of scratching.

Continuous Venovenous Hemodilaysis (CVHHD)

Blood is pumped from a double-lumen venous catheter through a hemofilter and returned to the patient through the same catheter. In addition to the benefits of ultra filtration, CVVHD uses a concentration gradient to facilitate the removal of uremic toxins and fluid by adding a dialysate solution into the circiut. A dual lumen catheter is required,. hemodynamic effects are usually mild, and critical care nurses can set up, initiate, maintain and terminate the system with the support of the nephrology nursing staff.

Meds

Cyclosporines (Neoral®, Gengraf®, Sandimmune®) Tacrolimus (Prograf®, FK506) Mycophenolate mofetil (CellCept®) Prednisone Azathioprine (Imuran®) Sirolimus (Rapamune®) Daclizumab and Basiliximab (Zenapax® and Simulect®) OKT3® (monoclonal antibody) Anti-Fungal Medications (Mycelex Troche®, Nystatin® Swish and Swallow, and Diflucan®) Antiviral Medications (Zovirax® (acyclovir), Cytovene® (ganciclovir), and Valcyte® (valganciclovir)) Diuretics (Lasix® (furosemide)) Antibiotics (Bactrim® (septra)) Anti-Ulcer Medications (Prilosec® (omeprazole), Prevacid® (lansoprazole), Zantac® (ranitidine), Axid® (nizatidine), Carafate®(sucralfate), Pepcid®)

Acute Complications: Leakage

leakage of dialysate through the catheter site may occur immediately after the catheter is inserted. Usually, the leak stops spontaneously if the incision and exit site is given time to heal. During this time it is important to reduce factors that may delay healing, such as undue abdominal muscle activity and straining during BM. Leakage through the exit site or into the abdominal wall can occur for months to years after catheter placement. In many cases, leakage can be avoided by using small volumes (500mL) of dialysate, gradually increasing the volume up to 2000-3000 mL.

Hypotension

may occur during treatment as fluid is removed. n/v, diaphoresis, tachycardia, dizziness are common signs of hypotension in HD.

Chest pain

may occur in patients with anemia or arteriosclerotic heart disease.

Goals of nutritional therapy are to:

Diet is an important factor for patients on hemodialysis because of the effects of uremia. - minimize uremic symptoms and fluid and electrolyte imbalances - restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months - restriction of fluid is also part of the dietary prescription because fluid accumulation may occur, leading to weight gain, heart failure, and pulmonary edema. - with the initiation of hemodialysis, the patient usually requires some restriction of dietary protein, sodium, potassium, and fluid intake. Protein intake is restricted to about 1.2 to 1.3 g/kg/day ideal body weight per day; therefore, protein must be of high biologic quality and consist of the essential amino acids to prevent poor protein use and to maintain a positive nitrogen balance. - Examples of foods high in biologic protein content include eggs, meat, milk, poultry, and fish. Sodium is usually restricted to 2 to 3 g/day; fluids are restricted to an amount equal to the daily urine output plus 500 mL/day. - keep their interdialytic (between dialysis treatments) weight gain under 1.5 kg. Potassium restriction depends on the amount of residual renal function and the frequency of dialysis. - if the restrictions are ignored, hyperkalemia and pulmonary edema, may result

chronic need

ESRD, presence of uremic S&S affecting all body systems, hyperkalemia, fluid overload not responding to diuretics, fluid restriction and general lack of well-being

Managing complications

GI ulceration and corticosteroid-induced bleeding may occur. Fungal colonization of the GI tract (especially the mouth) and urinary bladder may occur secondary to corticosteroid and anti-biotic therapy. Closely monitoring the patient and notifying the physician about the occurrence of these complications are important nursing interventions. In addition, the patient is monitored closely for signs and symptoms of adrenal insufficiency if the treatment has included use of corticosteroids

Objective

to extract toxic nitrogenous substances from the blood and to remove excess H2O - the patients blood is diverted to a machine (dialyzer) where toxins are removed, then the blood is returned to the patient.

definition

used to remove fluid and uremic waste products from the body when the kidneys are unable to do so.

Implement stringent infection control measures

Patients with ESRD commonly have low WBC counts (decreased phagocytic ability), low RBC's (anemia) and impaired platelet function. These pose a risk for infection and potential for bleeding even after minor trauma. Preventing and controlling infection are essential because the incidence of infection is high. Infection of the vascular access site and pneumonia are common. Patients receiving CAPD usually know how to care for the catheter site; however, the hospital stay should be an opportunity to assess catheter care technique and correct misperceptions or deviations from recommended technique. Recommended daily or three-or-four-times-weekly routine catheter site care is typically performed during showering or bathing. The exit site should not be submerged in bath water. The most common cleaning method is soap and water; liquid soap is recommended. During care, the nurse and patient need to make sure that the catheter remains secure to avoid tension and trauma. The patient may wear a gauze or semitransparent dressing over the exit.

Preoperative Management

Preoperative management goals include bringing the patient's metabolic state to a level as close to normal as possible, making sure that the patient is free of infection, and preparing the patient for surgery and the postoperative course.

Procedure

Preparing the patient Preparing the equipment Inserting the catheter Performing the exchange *handout

All IV Fluids and medications to be administered are evaluated for their electrolyte content

Serum laboratory values are assessed daily. If blood transfusions are required, they must be administered during hemodialysis if possible, so that excess potassium can be removed. Dietary intake must also be monitored. Hypoalbuminemia is an indicator of malnutrition in patients undergoing LT or maintenance dialysis. Monitor all medications and medication dosages carefully; avoid medications containing potassium and magnesium.

Postoperative Management

The goal of care is to maintain homeostasis until the transplanted kidney is functioning well. The patient whose kidney functions immediately has a more favorable prognosis than the patient. whose kidney does not.

Nursing Management

The nursing aspects of preoperative care for the patient undergoing renal transplant are similar to those for patients undergoing other types of elective abdominal surgery. Preoperative teaching can be conducted in a variety of settings, including the outpatient preadmission area, the hospital, or the transplantation clinic during the preliminary workup phase. Patient teaching addresses postoperative pulmonary hygiene, pain management options, dietary restrictions, IV and arterial lines, tubes (indwelling catheter and possibly a nasogastric tube), and early ambulation. The patient who receives a kidney from a living related donor may be concerned about the donor and how the donor will tolerate the surgical procedure. Most patients have been on dialysis for months or years before transplantation. Many have waited months to years for a kidney transplant and are anxious about the surgery, possible rejection, and the need to return to dialysis. Helping the patient to deal with these concerns is part of the nurse's role in preoperative management, as is teaching the patient about what to expect after surgery.

Continuous Venovenous Hemofiltration (CVVH)

Used to manage acute kidney disease. Blood from a double-lumen venous catheter is pumped (using a small blood pump) through a hemofilter and then returned to the patient through the same catheter. CVVH provides continuous slow fluid removal (ultra filtration); therefore, hemodynamic effects are mild and better tolerated by patients with unstable conditions. CVVH requires a dual lumen venous catheter and Critical care nurses trained in the management of therapy can set up, initiate, maintain and terminate the system. CC + nephrology nurisng staff in collaboration/

Hypertension in renal failure is common

Usually results from fluid overload and in part, over secretion of renin. Many patients undergoing hemodialysis receive some form of antihypertensive therapy.

Monitor blood pressure

antihypertensive agents must be held on dialysis days to avoid hypotension. Cardiac and respiratory assessment must be conducted frequently. As fluid builds up, fluid overload, heart failure, and pulmonary edema develop. Crackles in the bases of the lungs may indicate pulmonary edema. Pericarditis (indicated by the patients report of substernal chest pain, low grade fever and pericardial friction rub; a pulsus paradoxus (decrease in BP of more than 10 mmHg during inspiration) may result from the accumulation of uremic toxins. If not detected and treated promptly, this complication may progress to pericardial effusion and cardiac tamponade (narrowing of the pulse pressure). Although these findings can be detected in an x-ray, astute nursing assessment is a priority.

Protect vascular access

assess site for patency and signs of potential infection, do not use it for blood pressure or blood draws; tight dressings, restraints or jewelry over the site must be avoided as well. The BRUIT and THRILL over the venous access site must be evaluated at least every 8 hours. Absence of a palpable thrill or audible bruit may indicate blockage or clotting in the vascular access. The nurse must assess the integrity of the dressing and change it as needed.

Exsanguinations

blood line separate or dialysis needle become dislodged.

Acute Complications: Bleeding

bloody effluent (drainage) my be observed occasionally, especially in young, menstruating women. The hypertonic fluid pulls blood from the uterus, through the opening in the fallopian tubes, into the peritoneal cavity. Bleeding is common during the first few exchanges after a new catheter insertion because some blood enters the abdominal cavity following insertion. In many cases, no cause can be found for the bleeding, although catheter displacement form the pelvis has occasionally been associated with bleeding. Some patients have bloody effluent after an enema or minor trauma. invariably, bleeding stops in 1-2 days and requires no specific intervention. More frequent exchanges during this time may be necessary to prevent blood clots from obstructing the catheter.

Areterivenous graft

created by subcutaneously interposing a biological, semi biologic or synthetic graft material between and artery and a vein. Access can be achieved in 10 days - used for patients with compromised vascular systems. Infection and thrombus the most common complications.

Dysrhythmias

electrolyte and pH changes or removal of antiarrhythmic meds during dialysis.

SOB complication

fluid accumulation between dialysis treatments

Mechanical problems

formation of clots in the catheter and constipation.

Left ventricular hypertrophy and dyslipidemias

from HTN and hypervolemia are the major causes of morbidity and mortality in PD patients with comorbidities such as DM and vascular disease. Because cardiovascular disease if the cause of death in ½ of all patients with ESRD, the adequacy of dialysis is determined by its effects on risk for CV disease.

Low back pain and anorexia

from fluid in the abdomen and a constant sweet taste related to glucose absorption.

methods include

hemodialysis, CRRT, PD

A kidney from a living donor related to the patient usually begins to function

immediately after surgery and may produce large quantities of dilute urine

acute need

increased levels of serum potassium, fluid overload, impending pulmonary edema, increased acidosis, pericarditis, and severe confusion

Acute Complications: Peritonitis

most common and serious complication of PD, although there has been a recent decrease. The organism responsible for peritoneal dialysis peritonitis is an important factor in the clinical outcome and the basis of treatment guidelines. Staphylococcus aureus and S. epidermidis remain the most common gram-positive organisms responsible for peritonitis. Pseudomonas aeruginosa, E. Coli and Klebsiella species are the most common causes of gram-negative peritonitis. Peritonitis is characterized by cloudy dialysate drainage, diffuse abdominal pain, and rebound tenderness. Hypotension and other signs of shock may occur if S. aureus is the responsible organism. The patient with peritonitis may be treated as an in or outpatient depending on the severity of the infection and the patients clinical status. Initially, one to three rapid exchanges with a 1.5% dextrose solution without added medications are completed to wash out causes of inflammation and to reduce abdominal pain. Drainage fluid is examined for cell count and Gram's stain and culture are used to id the organism and guide treatment. Antibiotic agents (amino glycosides or cephalosporin's) are usually added to the subsequent exchanges until cultures are available for appropriate antibiotic determination. Antibiotic therapy continues for 10-14 days. Careful calculation of antibiotic dosage to prevent nephrotoxicity and further complications of renal function. Peritonitis that is unresolved within 3 days of appropriate therapy may necessitate catheter removal. HD and systemic antibiotics for 1 month before a new catheter is inserted. Patients with peritonitis lose large amounts to protein through the peritoneum. Acute malnutrition and delayed healing may result, therefore treat promptly.

Hemodialysis

most common; used for patients who are acutely ill and require short term dialysis (days to weeks) or for pts with ESRD who require long term or permanent therapy (3-4 times/week for 3-4 hours/treatment).

Arteriovenous fistula

needs 14 days to mature. Encourage patient to exercise to increase the size of the vessels to accommodate large bore needles (14,15,16 French)

Muscle cramps

painful; usually late in dialysis as fluids and electrolytes rapidly leave the extracellular space.

Urgent indication for dialysis in patients with ESRD is

pericardial friction rub

Assess for signs and symptoms or uremia

pts whose metabolic rate accelerates (those receiving corticosteroid medications or parenteral nutrients, those with infection or bleeding disorders, those undergoing surgery) accumulate waste products more quickly and may require more dialysis.

Air embolism

rare by can occur if air enters the vascular system.

Peritoneal Dialysis

remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance PD may be the treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or renal transplant. PD with DM, CV disease, older patients and those who may be at risk for adverse affects of systemic heparin are candidates for PD. In PD the peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semi permeable membrane. The surface of the peritoneum constitutes a body surface area of about 22,000 cm2. sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal catheter at intervals. Urea and creatanine, metabolic end products normally excreted by the kidneys are cleared from the blood by diffusion and osmosis as waste products move from an area of higher concentat8on (peritoneal blood supply) to an area of lower concentration (lining of peritoneal cavity). EXCHANGE: Inflow (fill) Dwell (equilibrium) Drain

Abdominal hernias

resulting from continuously increased intraabdominal pressure.

Dialysis disequilibrium

results from cerebral fluid shift. S/S include n/v, headache, restlessness, decreased LOC, seizures. More likely to occur in ARF when BUN is > 150 mg/dL.

Dialyzer (artificial kidney)

serves as a synthetic semi-permeable membrane, replacing the renal glomeruli and tubules as the filter for impaired kidney function. Diffusion, osmosis, ultra filtration are the principles on which hemodialysis is based. Toxins and wastes in the blood are removed by diffusion - move from an area of higher concentration in the blood to an area of lower concentration in the dialysate - solution make up of all the important electrolytes in the ideal extracellular concentrations. The electrolyte level in the patients blood can be brought under control by properly adjusting the dialysate bath. The semi permeable membrane impedes the diffusion of large molecules, such as proteins and RBC's. Excess H2O is removed by osmosis in which water moves from an area of higher solute concentration (blood) to an area of lower solute concentration (dialysate bath). Ultra filtration - water moves from and are of increased pressure to an area of lower pressure. The body's buffer system is maintained using a dialysate bath made up of bicarbonate (most common) or acetate. The anticoagulant, Heparin, is administered to keep blood from clotting in the dialysis current.

Clinical manifestations of infection include

shaking chills, fever, rapid heartbeat and respirations (tachycardia and tachypnea), and either an increase or a decrease in WBCs (leukocytosis or leukopenia).

Medical Management

survival of a transplanted kidney depends on the ability to block the body's immune response to the transplanted kidney. To overcome or minimize the body's defense mechanism, immunosuppressive agents are administered. The use of corticosteroid agents is limited because of long-term side effects. Cyclosporine is available in a microemulsion form (Neoral) that delivers the medication reliably, thus producing a steady-state serum concentration. Tacrolimus (Prograf) is similar to cyclosporine and about 100 times more potent. Mycophenolate mofetil The following are a list of common post-transplant medications. Your nurse will check off the medications that you will be taking.

Vascular access devices (SC, internal jugular, femoral vein)

temporary - risk of hematoma, pneumothorax, infections, thrombosis, cannot be used for more that 3 weeks.

Long term complications: Hypertriglycertidemia

therapy may accelerate atherogenesis. The use of cardio protective medication is low, many patients have suboptimal blood pressure control. Given the high burden of disease in these patients, beta blockers and ACE-inhibitors should be used to control HTN or protect the heart and the use of aspirin and statins should be considered.