Dialysis Updated 2024 PDF

RENAL REPLACEMENT THERAPIES Mario R. Marasigan, RN, MAN, PhD Alexis Luigi Lorenzo C. Cresencia, RN, MD  D I A LY S I S A. Hemodialysis B. Peritoneal Dialysis C. Continuous Renal Replacement Therapy Acute/Urgent  High & Increasing K  Fluid Overload...

RENAL REPLACEMENT THERAPIES Mario R. Marasigan, RN, MAN, PhD Alexis Luigi Lorenzo C. Cresencia, RN, MD  D I A LY S I S A. Hemodialysis B. Peritoneal Dialysis C. Continuous Renal Replacement Therapy Acute/Urgent  High & Increasing K  Fluid Overload  Impending Pulmonary Edema  Increasing acidosis  Pericarditis (uremic)  Advanced Uremia Chronic/Maintenance  Advanced CKD & ESKD  Uremic Signs & Symptoms  Hyperkalemia  Fluid Overload not responsive to Diuretics & Fluid Restriction  General lack of well-being D I A LY Z E R S Hollow-fiber devices containing tiny capillary tubes Tubes – porous; act as semipermeable membrane Constant flow of the solution maintains the concentration gradient to facilitate the exchange of wastes from the blood across the semipermeable membrane into the dialysate solution, where they are removed and discarded. High-flux dialysis – highly permeable membranes to increase the clearance of low- and mid-molecular-weight molecules  HEMODIALYSIS PERITONEAL DIALYSIS Access Arteriovenous Peritoneum Fistula Internal Jugular/ Subclavian/ Femoral Vein Catheterization Arteriovenous Graft Duration 3 to 4 hours 36 hours Complications Disequilibrium Exit Site Infection Syndrome Peritonitis Hypotension Hernia Bleeding Pulmonary  HEMODIALYSIS PERITONEAL DIALYSIS Nursing Check BP and pulse rate every Monitor vital signs and Interventions 30-60 minutes to monitor for observe for changes in hypotension behavior. Weigh patient before and after Make sure that dialysis catheter is patent. Monitor intake and output May add procaine HCl Monitor for signs of in the dialysate to disequilibrium syndrome minimize discomfort. (headache, hypertension, Observe for signs of restlessness, mental confusion peritonitis. and nausea) Maintain aseptic Watch out for signs of bleeding. technique during Avoid taking BP on site of AV insertion of catheter fistula. and throughout the Avoid blood extraction on site procedure. of AV fistula. Provide diversion activities throughout the duration of dialysis.  CONTINUOUS RENAL REPLACEMENT THERAPIES Hemofilter Indications:  Acute or Chronic Kidney (too clinically unstable)  Fluid Overload secondary to Oliguric Kidney Disease  High Metabolic/Nutritional Needs Continuous Venovenous Hemofiltration (CVVH) Continuous Venovenous Hemodialysis (CVVHD)  K I D N E Y T R A N S P L A N TAT I O N Kidney from a living donor or human cadaver Donors who are related to the patient are slightly more successful than those from cadaver donors Transplanted kidney is placed in the iliac fossa anterior to the iliac crest Ureters of the newly transplanted kidney is transplanted into the bladder or anastomosed to the ureter of the recipient P R E O P E R AT I V E M A N A G E M E N T Bring the patient’s metabolic state to a level as close to normal as possible. Complete physical examination Tissue typing, blood typing, and antibody screening The lower urinary tract is studied to assess bladder neck function and to detect ureteral reflux. Patient must be free of infection at the time of transplantation Psychological evaluation is also done before the surgery because corticosteroid may aggravate psychiatric conditions. Hemodialysis is done before the day of the scheduled transplantation to optimize the patient’s physical status.  P R E O P E R AT I V E N U R S I N G INTERVENTION Management is like that of a patient undergoing an elective abdominal surgery Preoperative teaching on: Postoperative pulmonary hygiene Pain management options Dietary restrictions Intravenous and arterial lines Tubes (indwelling catheter and possibly a nasogastric tube) Early ambulation P O S T- O P E R AT I V E M A N A G E M E N T The goal is to maintain homeostasis until the transplanted kidney is functioning well Immunosuppressive therapy:  Azathioprine (Imuran)  Corticosteroid (Prednisone)  Cyclosporine (Neoral)  OKT-3 (a monoclonal antibody)  Prograf (formerly FK-506)  Mycophenolate (RS-61433) Doses of immunosuppressive agents are gradually tapered off over several weeks The patient will take an anti-rejection medication as long as he has the transplanted kidney  R E J E C T I O N & FA I L U R E HYPERACUTE ACUTE CHRONIC Within 24 hours Within 3 to 14 days After Immediate antibody- Tenderness at transplant Fatigue mediated reaction -> site Anuria or Decreased UO Decrease in serum generalized glomerular creatinine Generalized Edema capillary thrombosis & Fever Tenderness at transplant necrosis Malaise site Oliguria Immediate removal of Early recognition & Immunosuppressant transplanted organ immunosuppressant Therapy Diagnostics on rejection therapy Ultrasound - to detect kidney enlargement Percutaneous renal biopsy – most reliable test in evaluating rejection X-ray  P O S T- O P E R A T I V E N U R S I N G INTERVENTIONS Assess for signs and symptoms of rejection  Oliguria  Edema  Fever  Increasing blood pressure  Weight gain  Swelling or tenderness over the transplanted kidney or graft Assess for rise in the serum creatinine level and BUN Monitor leukocytes and platelets A distinction should be made between infection and rejection  M O N I T O R C L O S E LY F O R INFECTION 1. Protect the client from hospital staff, visitors and other patients who have active infections 2. Careful hand washing is imperative; face mask may be worn by hospital staff and visitors. Clinical manifestations of infection include:  Shaking chills  Fever  Tachycardia & tachypnea  Either an increase or a decrease in WBCs (leukocytosis or leukopenia) Practice strict aseptic technique  U P D AT E New research from Stanford University Medical Center New approach: preventing rejection WITHOUT the use of immunosuppressive drugs Transplantation begins with the usual process – surgery, immunosuppressive drugs (until the completion of the next step) Given multiple small doses of radiation targeting the immune system in combination of a drug reducing the number of cells capable of an immune attack. Blood stem cells from the kidney donor is injected to the patient The newly injected stem cells find their way into the patient’s bone marrow where they reproduce new cells and immune cells that mix with those of the patient. After this procedure, the patient’s immune cells recognize the donor’s organ as friend rather than foe. The Stanford team monitored the recipient’s new hybrid immune system looking for a mixture of cells from both the recipient and the donor. These cells were tested in the laboratory and did not attack cells taken from the donor. This told the team that the new hybrid immune system would not mount an attack against the transplanted organ. At this time, the team slowly weaned the patient away from the immunosuppressive drugs KIDNEY TRANSPLANT VIDEO https://youtu.be/SKsrj-76n30