1. MOKGWANE EUTLWETSE SPARKS
5TH YEAR MED STUDENT
UWI,,NASSAU CAMPUS

2.  DEFINITION
 CLASSIFICATION
 INCIDENCE
 AETIOLOGGY
 CLINICAL PRESENTATION
 INVESTIGATION
 SURGICAL MANAGEMENT
 COMPLICATIONS
 SUMMARY
 REFERENCES

3.  Chronic renal failure (CRF) is a progressive
decrease in renal function (CFR <60 ml/min
for ≥3 mo) with subsequent accumulation of
waste products in the blood, electrolyte
abnormalities, and anemia.
Ferri: Ferri's Clinical Advisor 2008, 10th ed.

5.  Number of patients with ESRD is increasing at
the rate of 7% to 9%/yr in the U.S.
 Each year 2/10,000 persons develop end-stage
CRF.
 In the U.S., >250,000/yr receive dialysis
treatment for ESRD.

6.  15 million dollars annually to provide free dialysis
treatment to 330 persons with kidney disease.
 costs a whopping $45,000 per patient per year.
 Recent data confirms that there are more than 330
persons in The Bahamas receiving free dialysis
treatment as a result of kidney disease.
 The total cost to treat those persons: $14,850,000.

7.  Estimated figures will increase by some 60 % to 80
% above current levels in all countries by the year
2020.
 Diabetes is by far the single largest contributor to
causes of kidney failure, accounting for some 47%
of diagnoses in the United States as reflected in the
USRDS statistics for 2011.
 Hypertension (high blood pressure) is
second, accounting for some 25-30%.

8. MONTH NEW
PTS
ACUTE
PTS
TRANSIE
NT PTS
TOT
PTS
TOT
Rx
DEAT
HS
JAN 11 1 3 139 1569 2
FEB 3 5 5 139 1628 5
MARCH 4 0 1 142 1722 3
APRIL 3 3 7 142 1527 3
MAY 6 2 3 150 1698 2
JUNE 2 0 5 157 1754 0
JULY 3 2 4 159 1750 2
AUG 7 0 7 163 1902 3
SEP 9 0 10 153 1624 0
OCT 3 2 6 156 1814 0
NOV 1 0 8 157 1611 0
DEC 3 0 2 155 1503 6

9.  Diabetes (37%)
 Hypertension (30%)
 Chronic glomerulonephritis (12%)
 Polycystic kidney disease
 Tubular interstitial nephritis (e.g., drug hypersensitivity, analgesic
nephropathy)
 Obstructive nephropathies (e.g., nephrolithiasis, prostatic disease)
 Vascular diseases (renal artery stenosis, hypertensive
nephrosclerosis)

10.  The clinical presentation varies with the degree of renal
failure and its underlying etiology.
 Skin pallor,
 Ecchymoses
 Edema
 Hypertension
 Emotional lability
 depression
 Common symptoms are generalized fatigue, nausea,
anorexia, pruritus, insomnia, taste disturbances

11.  LABORATORY EVALUATION
 IMAGING STUDIES
 KIDNEY BIOPSY

12.  LABORATORY EVALUATION
 Urinalysis: may reveal proteinuria, RBC casts
 Serum chemistry: elevated BUN and
creatinine, hyperkalemia, hyperuricemia, hypocalcemia, hyperpho
sphatemia, hyperglycemia, decreased bicarbonate
 Urinary protein excretion. Ratio of protein to creatinine of >1000
mg/g suggests the presence of glomerular disease
 Cystatin C is a cysteine proteinase inhibitor produced by all
nucleated cells, freely filtered at the glomerulus but not secreted
by tubular cells. Given these characteristics, it may be superior to
creatinine concentration both in kidney disease and as a marker of
acute kidney injury.

13.  IMAGING STUDIES- ULTRA SOUND

14. People with chronic kidney failure have three
treatment choices.
 DIALYSIS
 RENAL TRANSPLANT
 CONSERVATIVE TREATMENT

15.  a method of removing toxic substances (impurities
or wastes) from the blood when the kidneys are
unable to do so.
 most frequently used for patients who have
kidney failure, but may also be used to quickly
remove drugs or poisons in acute situations.
 This technique can be life saving in people with
acute or chronic kidney failure.
 2 methods: hemodialysis and peritoneal dialysis

16. Hemodialysis
 Peritoneal Dialysis

17.  A dialysis process
which requires a
machine to transport
the blood and
dialysing fluid on
either side of a semi-
permeable membrane
to effect the removal
of toxic metabolites
and excess water

18. Hemodialysis Treatment with the new
dialysis machine

19. 1. blood
6. dialysate
7. body
2. access
3. tx w/ heparin
4. dialyser
5. solute exchange
4-6 hours

20.  may be inserted for
short term or temporary
use in acute renal
failure
 usually filled w/
heparin & capped to
maintain patency
between dialysis
treatments
 may be left in place for
up to 6 wks if
complications do not
occur

21.  may be inserted for short
term or temporary use in
acute renal failure
 client should not sit up
more than 45 or lean
forward, or the catheter
may kink & occlude.
 an IV infusion pump w/
microdrip tubing should
be used if a heparin
infusion through the
catheter is prescribed

22.  Assess insertion site for
hematoma, bleeding, dislodging, and infection.
 Do not use these catheters for any reason other
than dialysis.
 Maintain an occlusive dressing.

23.  Access is formed by
the surgical insertion
of 2 silastic cannulas
into an artery or vein
in the forearm or leg
to form an external
blood path.

24. ADVANTAGES DISADVANTAGES
 Can be used immediately
after insertion
 No venipuncture
necessary for dialysis
 External danger of
disconnecting or dislodging
the shunt
 Risk of hemorrhage,
infection or clotting
 Skin erosion around the
catheter site

25.  Avoid wetting the shunt.
 A dressing is wrapped completely around the shunt & kept
dry & intact.
 Cannula clamps need to be available at the client’s bedside.
 Do not take BP, draw blood, place an IV line, or administer
injections in the shunt extremity.
 Monitor for hemorrhage, infection and clotting.
 Monitor skin integrity around the insertion site.
 Note that the shunt is patent if it is warm to touch.
 Auscultate & palpate for a bruit, although a bruit may not
be heard & is not always with the shunt.
 Notify the physician immediately if signs of
clotting, hemorrhage, or infection occur.

26.  for chronic dialysis
clients
 created surgically by
anastomosis of a large
artery & a large vein
in the arm
 Maturity: veins
become engorged due
to the flow of arterial
blood into the venous
system; takes 1-2 wks.
 Maturity is required
before the fistula can
be used

27.  Preferred form of dialysis access
 Types
 Radiocephalic (first choice)
 Brachiocephalic (second choice)
 Brachiobasilic (third choice, requires
superficialization of basilic vein, i.e. transposition)
 Lower extremity fistulae are rare

28. ADVANTAGES DISADVANTAGES
 Less danger of clotting
and bleeding
 Can be used indefinitely
 Decreased incidence of
infection
 No external dressing
required
 Freedom of movement
 Cannot be used
immediately after insertion
 Venipuncture is required
for dialysis
 Infiltration of needles →
hematoma
 Aneurysm in the fistula
 Arterial steal syndrome
 Congestive heart failure

29.  for chronic dialysis clients
who do not have adequate
blood vessels for the
creation of a fistula
 Gore-Tex or a bovine
(cow) carotid artery as
artificial vein for blood
flow
 Procedure involves the
anastomosis of the graft to
the artery, a tunneling
under the skin, and
anastomosis to a vein.
 can be used 2 wks after
insertion
 Complications: clotting,
aneurysms and infection

30.  Synthetic conduit, usually polytetrafluoroethylene
(PTFE, aka Gortex), between an artery and a vein
 Either straight or looped
 Common sites
 Straight forearm : Radial artery to cephalic vein
 Looped forearm : brachial artery to cephalic vein
 Straight upper arm : brachial artery to axillary vein
 Looped upper arm : axillary artery to axillary vein

31. ADVANTAGES DISADVANTAGES
 Less danger of clotting
and bleeding
 Can be used indefinitely
 Decreased incidence of
infection
 No external dressing
required
 Freedom of movement
 Cannot be used
immediately after insertion
 Venipuncture is required
for dialysis
 Infiltration of needles →
hematoma
 Aneurysm in the fistula
 Arterial steal syndrome
 Congestive heart failure

32.  Do not measure BP, draw blood, place an IV line, or
administer injections in the fistula or graft extremity.
 Monitor for clotting.
 Monitor for arterial steal syndrome.
 Palpate or auscultate for bruit or thrill over the fistula
or graft.
 Palpate pulses below the fistula or graft, and monitor
for hand swelling as an indication of ischemia.
 Note temperature and capillary refill of the extremity.
 Monitor for infection.
 Monitor lung and heart sound for signs of CHF.
 Notify the physician immediately if sings of clotting,
infection, or arterial steal syndrome occur.

33. Hemodialysis
 Peritoneal Dialysis

34.  A dialysis process which requires the
introduction of peritoneal dialysis solution
(dialysate) into the peritoneal cavity via gravity
or a cycler.
 A soft, elastic tube (catheter) inside the
abdomen is inserted through a minor surgical
operation.

35.  Peritoneum – semi-permeable; rich blood
supply
 When a dialysate is put into the peritoneal
cavity, the dialysate gently pulls the small
pieces of waste products & water from the
blood into the dialysate via the semi-permeable
membrane. (diffusion & osmosis)

36. 1. Urea &
other toxic wastes
6. Drained out
2. Capillary blood
3. Peritoneal
membrane
4. dialysate
5. “effluent”

37.  Continuous Ambulatory Peritoneal Dialysis
(CAPD)
 Automated Peritoneal Dialysis (APD)

38.  A dialysis treatment
carried out
continuously 24/7
without the use of a
dialysis machine

39. CAPD Solution Bag
has 2 short tubes at the bottom end:
Shorter tube w/ aluminum cap: for adding medication
Longer tube w/ connector: for connection w/ the Y-Set
Always check the ff before use:
Strength: 1.5 GLU to 4.25 GLU
Clarity: clear & w/o particles
Amount: 1L to 2L
Leakage: no leaking bags
Expiry Date: do not use after expiry date

40.  CAPD Y-Set
 Connection for the patient line, new solution bag and empty bag
 Patient Line
 Attached to the catheter
 Reduces exit site infection
 White Caps
 Used to cover the end of the patient line after an exchange
 Braunoderm (Skin disinfectant)
 For disinfection
 Masks
 Protection for both the nurse and equipment

42. 1. The dialysate is instilled
into the peritoneal cavity
through an implant catheter
attached to a
transferline, which is
attached to a bag of
dialysate.
2. Once the fluid has been instilled
completely into the peritoneal cavity, the
empty bag and transferline are folded up
and worn in a cloth pouch beneath the
clothing. Thus, the patient is free to
ambulate and resume his normal daily
activities.

43. 3.When it is time to drain off the effluent, the bag is
unfolded, placed on the floor and drainage is achieved by
gravity. A new bag of dialysate is then attached to the
transferline and the process is repeated. Usually the
solution exchange procedure takes about 15 minutes.

44.  Continuous Ambulatory Peritoneal Dialysis
(CAPD)
 Automated Peritoneal Dialysis (APD)

45.  Similar to CAPD
 Requires a peritoneal
cycling machine
called a cycler
 Can be done as
intermittent
peritoneal dialysis,
continuous cycling
peritoneal dialysis, or
nightly peritoneal
dialysis

46.  Peritonitis
 Signs: cloudy bag, stomach pain, fever
 If suspected, obtain a culture of the outflow to determine the infective organism
 Abdominal Pain
 Pain during inflow is common during the 1st few exchanges & usually
disappears 1 to 2 wks of dialysis treatments
 Place heating pad
 Insufficient Outflow
 Check for kinks and placement; refer to physician
 Encourage high-fiber diet
 Leakage around the catheter site
 May take up to 2 wks for client to tolerate a full 2L exchange w/o leaking
around the catheter site
 Bladder or Bowel Perforation

47.  Monitor vital signs.
 Monitor for signs of infection.
 Monitor for respiratory distress, pain, or discomfort.
 Monitor signs of pulmonary edema.
 Monitor for hypotension & hypertension.
 Monitor for malaise, nausea, vomiting.
 Assess the catheter sit dressing for wetness or bleeding.
 Monitor dwell time as prescribed by the physician & initiate flow.
 Do not allow dwell time to extend beyond the physician’s order
because this increases the risk for hyperglycemia.
 Turn the client from side to side if the outflow is slow to start.
 Monitor outflow, which should be a continuous stream after the
clamp is opened.
 Monitor outflow for color & clarity.
 Monitor intake & output accurately.
 If outflow < inflow, inflow – outflow = amt absorbed/retained by
the client during dialysis and
should be counted as intake.

48.  Annual mortality rates for patients under dialysis
range from 21%-25%, but <8% with cadaveric and
<4% with living-related transplant recipients.
 Healthier patients generally are selected for
transplantation.
 The benefit of transplantation is most notable in
young people and in those with diabetes mellitus.
Projected years of life for patients 20-39 years old:
Dialysis Transplant
Non diabetic 20 31 years
Diabetic 8 25years

49. INDICATIONS CONTRAINDICATIONS
 All patients with ESRD
are candidates for KT
Absolute :
 Severe vascular
disease.
Relative :
 Recent malignancy.
 Coronary artery
disease.
 Active
bacterial, fungal, or
viral disease.
 HIV positivity.
 Social conditions.

50. - Blood relative.
- Highly motivated.
- ABO blood group-compatible.
- HLA-identical or haploidentical with negative
cross-match.
- Excellent medical condition with normal renal
function.

51. - Irreversible brain damage.
- Normal renal function appropriate for age.
- No evidence of preexisting renal disease.
- No evidence of transmissible diseases.
- ABO blood group-compatible.
- Negative cross-match.
- Best HLA match possible, particularly at the DR
and B loci.

52.  Wet ischemia time (time from cessation of
circulation to removal of organ and its
placement in cold storage) should not exceed
30 mins.
 Living donor transplants function immediately
after transplant, +/- 30% of cadaveric
transplants have delayed graft function
because of more prolonged ischemic cold
preservation. These pts need continued
dialysis support until the kidney starts to
function.

54.  Directly related to source of donor kidney.
 Recipients of cadaveric kidneys have more
episodes of rejection and lower graft survival
rates.
 Graft survival rates for kidneys from living
donor is 95% @ 1 yr and 76% @ 5 yrs vs graft
survival from a cadaveric kidney donor is 89%
@ 1 yr and 61% @ 5 yrs.

55.  Usual postop generic complications:
 Atelectasis
 Pneumonia
 Haemorrhage
 Venous thromboembolism
 Transplant rejection (hyeracute,acute,chronic)
 Wound infection
 Fever

56. I. Acute occlusion of transplant renal a or v.
II. Electrolyte imbalance
III. Peritransplant haematoma
IV. Urinary Leak
V. Obstructive uropathy
VI. Renal artery stenosis

57.  Chronic renal failure is a debilitating
condition.
 Urgent appropriate intervention tends to
prolong life and prevent a sequel of
complications
 Renal transplantation is superior compared to
dialysis
 Transplant tends to prolong life more
compared to dialysis

58.  Ferri: Ferri's Clinical Advisor 2008, 10th ed.
 Principles of Surgical Patient Care, 2nd edition,
CJ Mieny + V Mennen, 2003.
 Emedicine, Transplant, Renal, Richard Sinert +
Mert Erogul.
 Special thanks to Dialysis Unit PMH
 Special thanks to Dr McPhee