1. Prepared by D. ChaplinPrepared by D. Chaplin
Chronic Renal
Failure

2. Prepared by D. ChaplinPrepared by D. Chaplin
Chronic Renal Failure
Progressive, irreversible damage to the nephrons
and glomeruli
Causes: recurrent kidney infections, vascular
changes (Diabetes/Hypertension) etc.
May be diffuse or limited to one kidney
Regardless of the cause: Decreased: GFR,
tubular function & tubular reabsorption
capabilities. Dysfunction fluids & electrolytes,
acid base disturbances, & systemic problems
develops

3. Prepared by D. ChaplinPrepared by D. Chaplin
Chronic Renal Failure
End Stage Renal Disease (ESRD)
Protein and waste metabolism accumulates in
the blood (azotemia)
90% of kidney function is lost (kidney cannot
adequately function)
Hypothesis: Nephrons remains intact, others
progressively destroyed.
Adaptive response maintains function until ¾
are destroyed
Hypertrophy continues kidneys begin to lose
their ability to concentrate the urine
adequately

4. Prepared by D. ChaplinPrepared by D. Chaplin
ESRD
Polyuria is perhaps early sign of ESRD
As the disease progress – unable to rid the body
of excess waste products via kidneys –uremia
results – eventually other systems affected
When the creatinine clearance falls below 10
ml/min (average), GFR < 5ml/min (average) =
dialysis
Other symptoms Nocturia, oliguria/anuria,
increased K+
, Mg++
, PO4and decrease Ca++
,
Neurological changes, CV changes, etc.

5. Prepared by D. ChaplinPrepared by D. Chaplin
Stages of Chronic Renal Failure
Diminished Renal Reserve Normal BUN,
and serum creatinine absence of symptoms
Renal Insufficiency GFR is about 25% of
normal, BUN Creatinine levels increased
Renal Failure GFR <25% of normal
increasing symptoms
ESRD or Uremia GFR < 5-10% normal,
creatinine clearance <5-10 ml/min
resulting in a cumulative effect

6. Prepared by D. ChaplinPrepared by D. Chaplin
Treatment Modalities
Decrease fluid 1000ml/day
Decrease protein (.5-1kg body weight)
Decrease sodium (1-4gm variable)
Decrease potassium
Decrease phosphorous (<1000mg/day)
Dialysis (periotoneal, hemodialysis)
RBC, Vitamin D (calcitrol replacement) etc.

7. Prepared by D. ChaplinPrepared by D. Chaplin
Dialysis Hemodialyis(Hemo)Peritoneal (PD)
General Principal: Movement of fluid and
molecules across a semi permeable membrane
from one compartment to another
Hemodialysis – Move substances from blood
through a semi permeable membrane and into a
dialysis solution (dialysate –bath) (synethetic
membrane)
Peritoneal – Peritoneal membrane is the semi
permeable membrane

8. Prepared by D. ChaplinPrepared by D. Chaplin
Diffusion - movement of solutes (particles) from an
area of > concentration to area of < concentration
[Remove urea, creatinine, uric acid and electrolytes,
from the blood to the dialystate bath] RBC, WBC,
Large plasma proteins do not go through
Ultrafiltration – Water and fluid removed when the
pressure gradient across the membrane is created,
by increase pressure in the blood compartment &
decrease pressure in the dialysate compartment
Osmosis - movement fluid from an area of < to >
concentration of solutes (particles)
Osmosis-Diffusion-Ultrafiltration

9. Prepared by D. ChaplinPrepared by D. Chaplin
Peritoneal Dialysis
Catheter placement – anterior abdominal wall
Tenckoff (25cm length with cuff anchor and
migration)
Dialysis solution (1-2 liters sometimes smaller)
Three phases of PD
Inflow (fill) approximately 10 minutes, could
be in cycles)
Dwell (equilibration) (approximately 20-30
min or 8 hours+)
Drain (approximately 15 minutes)
These 3 phases are called Exchanges

10. Prepared by D. ChaplinPrepared by D. Chaplin
Peritoneal Dialysis

11. Prepared by D. ChaplinPrepared by D. Chaplin
Hemodialysis
Vascular access for high blood flow
Shunts, (telfon, external)
Arteriovenous fistulas and grafts (AV)
Anastomosis between an artery and vein
Fistulas are native vessels (4-6 wks
maturity)
Grafts are artificial/synthetic material

12. Prepared by D. ChaplinPrepared by D. Chaplin
Hemodialysis
AV Fistula Communication
AV Graph Access

13. Prepared by D. ChaplinPrepared by D. Chaplin
Hemodialysis
Hemodialysis MachineHemodialysis Circuit

14. Prepared by D. ChaplinPrepared by D. Chaplin
PD Advantages and Disadvantages
Immediate initiation
Less complicated
Portable (CAPD)
Fewer dietary
restrictions
Short training time
Less cardio stress
Choice for diabetics
Bacterial/chemical
periotonitis
Protein loss
Exit site of catheter
Self image
Hyperglycemia
Surgical placement of
catheter
Multiple abdominal
surgery
Advantages Disadvantages

15. Prepared by D. ChaplinPrepared by D. Chaplin
Hemo Advantages & Disadvantages
Rapid fluid removal
Rapid removal of urea &
creatinine
Effective K+
removal
Less protein loss
Lower triglycerides
Home dialysis possible
Temporary access at the
bedside
Rapid fluid removal
Rapid removal of urea &
creatinine
Effective K+
removal
Less protein loss
Lower triglycerides
Home dialysis possible
Temporary access at the
bedside
Vascular access
problems
Dietary & fluid
restrictions
Heparinization
Extensive equipment
Hypotension
Added blood lost
Trained specialist
Vascular access
problems
Dietary & fluid
restrictions
Heparinization
Extensive equipment
Hypotension
Added blood lost
Trained specialist
Advantages Disadvantages

16. Prepared by D. ChaplinPrepared by D. Chaplin
Disequalibrium Syndrome
Fluid removal and decrease in BUN during
hemodilaysis which cause changes in blood
osmolarity.These changes trigger a fluid shift from
the vascular compartment into the cells. In the
brain, this can cause cerebral edema, resulting in
increase intracranial pressure and visible signs of
decreasing level of consciousness. Symptoms:
Sudden onset of headache, nausea and vomiting,
nervousness, muscle twitching, palpitation,
disorientation and seizures
Treatment: Hypertonic saline, Normal saline

17. Prepared by D. ChaplinPrepared by D. Chaplin
Nursing Care Pre, Post Dialysis
Weigh before & after
Assess site before & after (bruit, thrill,
infection, bleeding etc.)
Medications (precautions before & after)
Vital signs before and after etc.

18. Prepared by D. ChaplinPrepared by D. Chaplin
Renal Transplant
Living and Cadaveric donors
Predialysis: obtain a dry weight free of excess
fluids and toxins
More preparation time from a living donor vs.
cadaveric – transplant within 36 hours of
procurement
Delay may increase ATN
Pre-transplant: Immunotherapy (IV
methylprednisolone sodium succinate,
(A –methaPred, Solu-Medrol), cyclosporine
(Sandimmune and azathioprine ((Imuran)

19. Prepared by D. ChaplinPrepared by D. Chaplin
Immunological Compatibility
of Donor and Recipient
Done to minimize the destruction (rejection) of
the transplanted kidney
HUMAN LEUKOCYTE ANTIGEN (HLA)
This gives you your genetic identity (twins share
identical HLA)
HLA compatibility minimizes the recognition of
the transplanted kidney as foreign tissues.

20. Prepared by D. ChaplinPrepared by D. Chaplin
Immunological Analysis
WHITE CELL CROSS MATCH (the
recipient serum is mixed with donor
lymphocytes to test for performed
cytotoxic (anti-HLA) antibodies to the
potential donor kidney
A positive cross match indicates that the
recipient has cytotoxic antibodies to the
donor and is an absolute
contraindication to transplantation

21. Prepared by D. ChaplinPrepared by D. Chaplin
Immulogical Analysis
MIXED LYMPHOCYTE CULTURE
The donor and recipient lymphocytes are
mixed. Result = HIGH SENTIVITY,
this is contraindicated for renal
transplantation.
ABO BLOOD GROUPING
ABO blood group must be compatible

22. Prepared by D. ChaplinPrepared by D. Chaplin
Surgery
LLQ of the abdomen outside of the
peritoneal cavity
Renal artery and vein anastomosed to
the corresponding iliac vessels
Donor ureters are tunneled into the
recipients’ bladder.

23. Prepared by D. ChaplinPrepared by D. Chaplin
Complications Post Transplant
Rejection is a major problem
Hyperacute rejection: occurs within minutes
to hours after transplantation
Renal vessels thrombosis occurs and the
kidney dies
There is no treatment and the transplanted
kidney is removed

24. Prepared by D. ChaplinPrepared by D. Chaplin
Complications Post Transplant
Acute Rejection: occurs 4 days to 4 months after
transplantation
It is not uncommon to have at least one rejection
episode
Episodes are usually reversible with additional
immunosuppressive therapy (Corticosteroids,
muromonab-CD3, ALG, or ATG)
Signs: increasing serum creatinine, elevated BUN,
fever, wt. gain, decrease output, increasing BP,
tenderness over the transplanted kidneys

25. Prepared by D. ChaplinPrepared by D. Chaplin
Complications Post Transplant
Chronic Rejection: occurs over months or years and
is irreversible.
The kidney is infiltrated with large numbers of T
and B cells characteristic of an ongoing , low
grade immunological mediated injury
Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum creatinine
levels
Supportive treatment, difficult to manage
Replace on transplant list

26. Prepared by D. ChaplinPrepared by D. Chaplin
Complications Post Transplant
Infection
Hypertension
Malignancies (lip, skin,
lymphomas, cervical)
Recurrence of renal disease
Retroperiotneal bleed
Arterial stenosis
Urine leakage