Dialysis and Renal Transplant
How does peritoneal dialysis work?
-1-2L of dialysate -fluid stays in abdomen for given time period: 20-30 minutes -then drained off by gravity -goes in and out same catheter
How long can double lumen catheter be used for hemodialysis?
-1-3 weeks
How long does hemodialyis take?
-12 hours per week -divided into three 4 hours treatments
When does acute transplant rejection occur?
-3-14 days to 3 months after transplant -vaires
How often is intermittent peritoneal dialysis (IPD) done?
-3-5 times per week for 8-12 hours
How many times is continuous amulatory peritoneal dialysis (CAPD) system opened?
-3-6 times per day
When does hyperacute transplant rejection occur?
-5-10 minutes and up to 24 hours
What is criteria for receiving kidney transplant?
-ESRD -<70 yo -patent and functional lower urinary tract -free of CF complications -free of extensive vascular disorders -free of malignancies -free of chronic respiratory disease -no ongoing alcohol or drug abuse
What are other complication mostly due to meds after kidney transplant?
-GI ulceration -suprainfection: thrush, vaginal infection -thrombocytopenia
What are the SE of cyclosporine?
-HTN -N&V -diarrhea -infection -gingival hyperplasia -hirsutissm -nephrotoxicity -liver failure
What is given to decrease ICP during disequilibrium syndrome?
-Mannitol
What is key physical finding of arterial steal syndrome?
-absent radial pulse -always check pulse below graft and compare with the other side
When are lumen catheters used for hemodialysis?
-acute situation -or until permanant access matures
How to prevent disequilibrium syndrome?
-administer dialysis for shorter time -decrease blood flow rate
What is peritoneal dialysis?
-allows exchange of wastes, fluids, and electrolytes to occur in peritoneal cavity -slower than hemodialysis -takes more time to achieve same effect
What is needed during hemodialysis treatments to prevent blood clots?
-anticoagulation: heparin
What does dialyzer act as?
-artificial kidney
What kind of technique is used with peritoneal dialysis?
-aseptic technique -sterile everything
What must be tested with blood when transplanting kidney?
-blood type -Rh type -human leukocyte antigen(HLA)
What are the manifestations for disequilibrium syndrome?
-cerebral edema leading to decreased LOC -heart attack -blurred vision -disorientation -seizures -N&V
What are the manifestations for infection after kidney transplant?
-chills -fever -tachycardia -increased or decreased WBC
What can cause pain on inflow with peritoneal dialysis?
-cold dialysate -too rapid infusion -catheter position
S&S of arterial steal syndrome?
-cold hand -pain in hand -weakness, reduced function
How deos intermittent peritoneal dialysis(IPD) work?
-combines osmotic pressure gradients with true dialysis -done while patient sleeps
What is arterial steal syndrome?
-complication with internal av fistula or graft -extremity ischemia -imbalance in low resistance outflow access and high resistance vascular
How does osmosis work with dialysis?
-contains glucose which makes it hyperosmolar -pulls H2O from patient's blood into dialysate -more glucose equals greater osmotic gradient
How does continuous ambulatory peritoneal dialysis(CAPD) work?
-continuous dialysate dwells 4-8 hours -bad remains attached during dwell time -after draining patient removes bag and connects a new bag to repeat process
What are some examples of food high in phosphorus?
-dairy -nuts and peanut butter -dried beans -dark cola drinks
How long does it take for a fistula to be ready to use for dialysis?
-depends on the patient -may take as long as 4-6weeks
What is dialysate?
-dialyzing solution -flow in opposite direction across an enclosed -semipermeable membrane -process of exchanging electrolytes
What are the 3 basic principals of dialysis?
-diffusion -osmosis -ultra-filtration
What process allows peritoneal dialysis to work?
-diffusion and osmosis across the semipermealble peritoneal membrane and capillaries -allows solutes and water to move from an area of highter concentration into th eblood to area of lower concentration in dialyzing fluid
Where not to take IV's and venipuntures on someone with CRF?
-don't use cephalic veins on non-dominant arm because that is the first choice for the placement of the av fistula or graft
What gives temporary access for hemodialysis?
-double lumen catheter into subclavian, femoral , or jugular vein
What is post dialysis weight referred to as?
-dry weight
How does diffusion work with dialysis?
-electrolytes, urea, creatine, and uric acid move to or from blood into dialysate
What is fecal effluent with peritoneal dialysis?
-emergency -bowel perforation
When must transplant recipient report for temperature?
-even slight elevation in temp must be reported
When is peritoneal dialysis contraindicated?
-extensive abdominal surgery -colostome
How does Continuous Renal Replacement Therapy(CCRT) work?
-fluid and solutes removed by convection because hydostatic pressure through a filter -patiet's pressure drives
How does ultra-filtration work with dialysis?
-fluid drawn across membrane from area of higher hydrostatic pressure to area of lower one -can be artificially included -can rely on patient's pressure
What type nutrient to avoid when on peritoneal dialysis?
-foods high in phosphorus
What is important to teach for preventing infection after kidney transplant?
-frequent urine cultures taken -handwashing
What can effect the osmotic gradient of dialysate for peritoneal dialysis?
-glucose concentration determines gradient
What drink must be avoided with cyclosporine?
-grapefruit juice
What are the disadvantages for peritoneal dialysis?
-greater chance for hyperglycemia -daily treatment
What puts patients at risk for hemorrhaging during and immediately after hemodialysis treatment?
-heparin remains active in the body for 4-6 hours after dialysis
What id dialysis used with ARF?
-hyperkalemia -fluid overload -acidosis -drug overdose
What to monitor for during dialysis?
-hypotension -angina -hemorrhage -muscle cramps -hemolysis -infection -seizures
What must kidney transplant recipient take for life?
-immunosuppressive therapy
What is a major cause of death after kidney transplant?
-infection
What can be added to dialysate for peritoneal dialysis?
-insulin -antibiotics -heparin
What is hemodialysis?
-involves passing the patient's blood through an artificial permeable membrane to perform the filtering and excretion of functions of the kidney in dialysis machine outside of patient -blood removed/returned via vascular system
What can cause outflow failure with peritoneal dialysis?
-kinks in tubing -full colon(constipation) -position of bag -position of client
What are some S&S of transplant rejection?
-lethargy -anorexia -tenderness over graft site -temerpature elevation -oliguria -hematuria -weight gain -edema -sudden change in BP -increased serum creatinine -decreased serum creatinine clearance
How does continuous cycle peritoneal dialysis (CCPD) work?
-machine used overnight for 3 exchanges -fourth exchange remains in patient throughout day -drained when clycler attached at night
Can drugs be given during hemodialysis?
-many drugs such as antibiotics are dialyzable -can be partially removed from blood during dialysis -should not be administered just before or during dialysis
What causes disequilibrium syndrome?
-may develop during or after hemodialysis -rapid decrease in fluid volume and BUN levels
Nursing Care for peritoneal dialysis?
-monitor daily weights -monitor vital signs -monitor lab values -assist to defecate prior -asses dialysate drainage -maintain asepsis -keep accurate record of exchanges
How to check permanent access av fistula or graft is okay?
-monitor of signs of infection -feel thrill at site -auscultate for bruit
What are the advantages of peritoneal dialysis?
-more gradual exchange of fluid -mimics action of kidney -advocated in children -advocated in those with CV disease -allows patient to participate in own care -less chance of disequilibrium -less chance of hemorrhage
Are people on peritoneal dialysis encouraged to eat more or less potassium?
-more potassium
What is osmosis?
-movement of H2O across a semipermeable membrane from lesser concentration of solute(blood) to area of higher level of solute(dialysate)
What is ultra-filtration?
-movement of fluid across semipermeable membrane due to pressure gradient
What is diffusion?
-movement of ions from area of high concentration (blood) to area of low concentration (dialysate)
What must check for during physical assessment pre-op kidney transplant?
-must be free of infection
When does chronic transplant rejection occur?
-occurs several months to years
Why is peritoneal dialysis often treatment of choice for older adults?
-offers more flexibility if his or her status changes frequently
How many times is continuous cycle peritoneal dislysis (CCPD) system opened?
-once
What does fluid removal depend on for peritoneal dialysis?
-osmotic gradient of dialysate
What are some complications with peritoneal diaslysis?
-pain on inflow -outflow failure -bloody effluent -fecal effluent -bleeding -electrolyte disorders -dyspnea -dysrhythmias -volume overload -volume depletion
What does peritoneal dialysis put patient at high risk for?
-peritoitis
What must be taken with all meals when on peritoneal dialysis?
-phosphorus binder -calcitrol
What electrolyte to especially to monitor in hemodialysis patient?
-potassium
What is dialysis?
-process of moving fluid and particles form one fluid compartment to another across semi-permeable membrane
Why is dialysis used with drug overdose?
-removes meds quickly from system
How does a dialysis machine work as an artificial kidney?
-removes waste product of protein metabolism -maintains F&E balance -restores acid-base balance
How to treat disequilibrium syndrome?
-restore volume with IV NS -decrease ICP: Mannitol -prevent seizures: dilantin
What could cause patient to be hemodynamically unstable so would require continuous renal replacement therapy(CRRT)?
-sepsis -shock
When is continuous renal replacement therapy(CRRT) used?
-standard treatment for ARF -used if patient hemodynanically unstable -usually seen in ICU or CCU
What is number 1 cause of access failure of av fistula or graft?
-stenosis
What is cyclosporine given with?
-steriod
What is an AV fistula?
-surgically connnecting an artery to a vein -radial or brachial artery with cephalic vein are most often used in the nondominant arm
What always must be available in the dialysis setting?
-the antidote to heprain: protamine sulfate
What can cause stenosis of av fistula or graft?
-thrombus -infection -anatomical dysfunction of vessels
Who is peritoneal dialysis ideal for?
-unstable -chronic kidney disease -can't handle anticoagulation -chronic kidney infection
When is dialysis used with ESRD?
-uremia can no longer be controlled with diet and medicaiton
Where to take IV's and venipuntures on someone witt CRF?
-use dorsum of dominant hand
Why is calcitrol prescribed when on peritoneal dialysis?
-vitamin D -helps to maintain calcium level which helps keep phosphorus and calcium balanced
What is a AV graft?
-when AV fistula doesn't work -synthetic material graft is used to connect artery and vein
What are 4 drugs for immunsuppressive therapy after kidney transplant?
1) cyclosporine 2) tacrolimus 3) prednisone 4) monolonal antibodies
What are the 3 types of dialysis?
1) hemodialysis 2) CRRT 3) Peritoneal
What are the 3 types of transplant rejections?
1) hyperacute 2) acute 3) chronic
What are the 3 types of peritoneal dialysis?
1)intermittent 2) continuous ambulatory 3) continuous cyclic
How much weight is lost from dialysis?
2-15 pounds
What level of GFR is dialysis used?
<5-10
What level of creatinine is dialysis used?
>10
What is the most common type of dialysis?
hemodialysis
What hemodialysis access carries higher incidence of infection?
internal AV graft
What is a major complication of kidney transplant?
rejection
