DIALYSIS. Ellie Stanger, Tessie Atwater, Summer White, McKenzie Driscoll

Transcription

1 DIALYSIS Ellie Stanger, Tessie Atwater, Summer White, McKenzie Driscoll

2 PATHOPHYSIOLOGY Chronic Kidney Disease A wide range of kidney lesions characterized by a slow, steady decline in renal function A number of other kidney diseases can lead to renal failure Some patients with CKD can be stable for months or years, while others progress to renal failure and dialysis CKD is defined as GFR<60 ml/min/1.73 m2 for 3 months OR individuals with kidney damage, regardless of GFR

3 HOW IT STARTS In response to a decreasing GFR, the kidneys adapt to prevent it from decreasing further Short-term improvement in filtration rate but long-term loss of nephrons and progressive renal insufficiency Once patient has lost ½ to 2/3 kidney function, progressive loss of function continues, regardless of underlying disease National Kidney Foundation s GFR calculator

4 KIDNEY DISEASE CLASSIFICATION Vascular includes large vessel disease such as bilateral renal artery stenosis and small vessel disease such as ischemic nephropathy, hemolytic-uremic syndrome and vasculitis Glomerular includes primary glomerular disease such as IgA nephritis and secondary glomerular disease such as diabetic nephropathy and lupus nephritis Tubulointerstitial including polycystic kidney disease, drug and toxin-induced chronic tubulointerstitial nephritis and reflux nephropathy Obstructive such as with bilateral kidney stones and diseases of the prostate In rare cases, pin worms infecting the kidney can also cause nephropathy

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6 ETIOLOGY DM HTN Autoimmune diseases (like lupus, HIV and IgA nephropathy) Genetic diseases (like polycystic kidney disease) Injuries Some medicines or other drugs The three most common causes (DM, HTN & glomerulonephritis) account for 75% of adult cases

7 Risk Factors DM HTN CV disease Family history of kidney disease African American, Hispanic, Native American or Asian Over 60 years old

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9 END-STAGE RENAL DISEASE (ESRD) During Stage 4, a fistula or peritoneal catheter is typically placed so it has several weeks to heal before patient needs to start dialysis

10 END-STAGE RENAL DISEASE (ESRD) 90% of ESRD patients have diabetes mellitus, HTN or glomerulonephritis No lab values correspond directly with beginning of symptoms, but BUN >100 mg/dl and Cr mg/dl are usually close Normal BUN = 6-21 mg/dl and Cr = mg/dl

11 END-STAGE RENAL DISEASE (ESRD) Kidneys cannot sufficiently excrete waste products, maintain fluid and electrolyte balance and produce hormones As renal failure progresses, uremia develops syndrome of malaise, weakness, N/V, muscle cramps, itching, metallic taste in mouth, neurologic impairment

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13 DIAGNOSIS When a patient progresses to Stage 5 CKD, it s considered renal failure/esrd Options are dialysis, kidney transplant or medical management progressing to death

14 KIDNEY FAILURE SYMPTOMS Most people don t exhibit symptoms in early stages Symptoms begin to appear during later stages as damage worsens Fluid retention Dehydration urination Fatigue Confusion N/V Loss of appetite Pale skin Kidney failure has usually progressed significantly by the time symptoms appear ESRD is not reversible

15 BIOCHEMICAL DATA BUN Creatinine Albumin Na/K P/Ca PTH Hct/Hgb Urinalysis Volume, urea, protein, Na Normal Levels for Dialysis BUN: mg/dL Creatinine: <15mg/dL

16 Normal for Dialysis High Serum Levels Low Serum Levels Sodium mEq/L Check fluid status Check fluid status Potassium mEq/L Avoid foods with more than 250mg/serving (<2000 mg/day) Add one high K food per day Calcium mg/dL Temporarily stop Ca supplements May need Ca supp and active vit D Phosphorus 3-6mg/dL Limit dairy Add 1 serving/day of dairy or high P food BUN mg/dL Underdialysis Inadequate oral intake; loss of muscle Creatinine <15mg/dL Dialysis normally controls creatinine; Low creatinine may indicate low body muscle PTH pg/mL Indicates bone loss; active vit D No treatment available

17 United States Renal Data System s 2010 Annual Data Report and 2011 Annual Data Report MORBIDITY Affects more than 20 million Americans (1 in 9) 398,861 ESRD pts were being treated with some form of dialysis in ,533 had kidney transplants Cost for treating ESRD patients cost over $40 billion in % pts starting dialysis have diabetes

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22 WHEN IS DIALYSIS NEEDED? Stage 5 chronic kidney disease 85-90% loss of kidney function Kidneys no longer remove waste and fluids

23 PRINCIPLES OF DIALYSIS Solute (pink circles) moves from blood to dialysate (dashed arrows) in response to a concentration gradient (diffusion) There s a forced movement of water (blue circles) to try to maintain osmolarity This flux of solute and water (ultrafiltration) may be enhanced by 1. increased osmotic pressure (i.e. glucose in peritoneal dialysis fluid) or 2. increased hydrostatic pressure (created mechanically as transmembrane pressure in hemodialysis)

24 MECHANISMS CONT.

25 TYPES OF DIALYSIS 1. Hemodialysis (HD) In-center At home 2. Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycling Peritoneal Dialysis (CCPD)

26 Dialysis machine Dialyzer artificial kidney removes wastes and extra fluids from blood Most common form of dialysis Requires a permanent access to bloodstream 1. Arteriovenous fistula 2. Artificial loop graft 3. Central venous catheter (temporary) HEMODIALYSIS

27 HEMODIALYSIS

28 Gold Standard for long-term vascular access Low rates of complications, clotting, and infection Connects artery directly to vein Increased pressure inside vein makes it stronger and larger over time Easier for repeated dialysis needle insertions and allows increased blood flow ~3 months before starting dialysis so fistula can heal Can last for several years Approximately 500 ml s are outside the body at a time Blood leaves the fistula at a rate of 400 ml/mi FISTULA

29 HEMODIALYSIS PROCESS During each treatment two needles, that are attached to plastic tubes, are inserted into access Needle sticks are one of the hardest parts of hemodialysis treatment for some people Blood pumped from body to the dialysis machine through one of the plastic tubes After blood is cleaned, it is carried back to body through a second tube Blood is cleaned by the dialyzer

30 DIALYZER Artificial kidney ; plastic tube containing thousands of small fibers through which blood is passed 2 sections, one for blood and one for dialysate, separated by a semipermeable membrane thin surface with tiny holes that allows small particles (waste products & excess fluid) pass through, but keeps large particles (blood cells) back Dialysate Solution of water, electrolytes, and salts Pumped around fibers Pulls waste products from blood into dialysate via diffusion Extra fluid is removed via filtration Dialyzer can be reused more than once if it is cleaned before each use and tested each time to make sure it still works

31 DIALYZER

32 EFFECTIVENESS OF HEMODIALYSIS Blood is tested 1x/month to see if dialysis is removing enough wastes 2 formulas: 1. Kt/V a measure of the dialyzer size, time, and the amount of fluid in your body; should always be at least 1.2 {K= how much urea is removed; T= amount of time on dialysis; V- volume of urea in your body (blood, urine, body fluid)} 2. Urea reduction ratio (URR) test that shows how much urea is removed during dialysis treatment; URR should always be at least 65%. You may get less hemodialysis than you need if: The dialyzer is too small for you Your fluid goal is figured or set wrong Your access isn t working well You shorten or skip a treatment

33 HD: LOCATION OF TREATMENT In-Center 3x/week 3-5 hours/session Strict schedule Home Flexible schedule Daily for hours Or nocturnally 3x/week for 8 hours

34 HD: IN-CENTER PROS & CONS PROS Trained professionals Medical help is readily available in case of emergency 3x/week, 4 days off CONS Must travel to dialysis center Fixed diet and fluid restrictions Treatment times scheduled by dialysis center 2 needle insertions every visit

35 HD: HOME PROS AND CONS PROS Same person always helps you More control over dialysis times and treatments (within the doctors orders) No travel to dialysis clinic Comfort and privacy of own home Being able to eat and drink when you choose CONS You and care partner need several weeks of training Training for home HD is not offered by all dialysis centers Care partner generally needs to be present during all treatments Need room for storage and supplies Need to call paramedic for help in an emergency Some plumbing and wiring changes may be necessary in home to accommodate machine

36 TYPES OF DIALYSIS 1. Hemodialysis (HD) In-center At home 2. Peritoneal Dialysis Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycling Peritoneal Dialysis (CCPD)

37 Uses peritoneum as filter Peritoneum: A natural membrane that covers the abdominal organs and lines the abdominal wall Peritoneum is a porous membrane that allows wastes and fluid to be filtered from the blood Permanent access to peritoneal cavity required (catheter) Surgical procedure to insert a small, soft tube through the abdominal wall and into peritoneal cavity Catheter carries the dialysis solution into and out of abdomen Healing takes about 3 weeks 2 types of peritoneal dialysis (PD): Continuous ambulatory peritoneal dialysis (CAPD) Continuous cycling peritoneal dialysis (CCPD) PERITONEAL DIALYSIS

38 Catheter fills abdomen with high dextrose dialysate Walls of abdominal cavity, lined with peritoneal membrane, allows waste products and extra fluid to pass from blood into dialysis solution After the completed dwell time (time solution is in abdomen) the solution is drained and thrown away Process of draining and filling abdominal cavity is called an exchange and takes minutes A typical PD schedule calls for 4 exchanges/day, each with a dwell time of 4-6 hours Different types of PD have different schedules of exchanges PD: HOW IT WORKS

39 TYPES OF PD 1. Continuous Ambulatory Peritoneal Dialysis (CAPD) No machine reqiured 4-5 times/day every 4-6 hours drain solution, containing the wastes, then repeat cycle with fresh bag of solution One evening exchange with long overnight dwell time while asleep 24 hour/day treatment Free to do normal activities while the dialysis solution dwells in the abdomen inbetween exchanges 2. Continuous Cyclic Peritoneal Dialysis (CCPD) Machine called a cycler fills and drains dialysate while asleep In the morning, begin 1 exchange with a dwell time that lasts the entire day More flexibility for during the day May preform an exchange during the day if needed

40 EFFECTIVENESS OF PD Peritoneal Equilibration Test (PET) Important in determining correct prescription for PD Takes samples of dialysis fluid and blood Measures how much glucose and waste products (urea and creatinine) are drawn into the dialysate solution over a 4-hour dwell time Measures amount of glucose remaining in dialysate; if glucose levels are low, body may be absorbing too much glucose during dwell time Kt/V Clearance test Takes samples of used dialysate over 24-hours and a blood sample; compare the amount of waste in the used solution to the waste in blood Using this data it measures the amount of waste (urea) from the bloodstream

41 PD: PROS & CONS PROS Relatively independent Control over schedule No needles required Less restricted diet Simple to learn and preform CONS Permanent external catheter (body image) Dialysis fluid in abdomen may be uncomfortable Risk of peritonitis (infection), caused by bacteria entering catheter Some people get tired of daily dialysis schedules Possible weight gain (glucose content of dialysate results in higher intake of kcals) Storage space needed for supplies

42 COSTS OF DIALYSIS Dialysis is very expensive Medicare and Medicaid will pay 80% of the cost Private health insurance or state medical aid also help with costs

43 QUALITY OF LIFE Many dialysis patients live normal lives apart from the time needed for treatment Maintaining an active lifestyle is important to health and well-being Studies have suggested that more frequent dialysis treatments have improved quality of life, compared to those on conventional dialysis Take all medications, follow diet carefully, do all dialysis treatments (do not skip treatments)

44 MEDICATIONS Calcitriol Ca regulator Treatment for hypocalcemia in dialysis patients Treatment for secondary hyperparathyroidism in predialysis patients Active vit D3 PTH Ca and P With dialysis consume P diet and adequate Ca ( Ca absorption) Zemplar IV form of Calcitriol Hectorol

45 MEDICATIONS Sensipar Hyperparathyroidism treatment ( PTH) Calcium imitator drug EPO Anti-anemic; stimulates RBC production May need Fe, vit B 12, or folate supplements BP, RBC, Hgb, and Hct

46 MEDICATIONS Phosphate binders Renegel, Fosrenal, Renvela, Tums Taken with meals to P absorption Consume low P diet

47 KIDNEY TRANSPLANT Most common transplant in the U.S. Kidneys can be donated by the living or deceased Dysfunctional kidney is not typically removed 3-4 hr procedure

48 PROGNOSIS AFTER TRANSPLANT Better quality of life Living donor kidneys usually do better than a kidney from the deceased

49 MNT

50 HEMODIALYSIS & PERITONEAL DIALYSIS

51 MNT GOALS - DIALYSIS Prevent deficiency and maintain good nutrition status Control edema and electrolyte imbalance Prevent or retard the development of renal osteodystrophy Enable the patient to eat a palatable, attractive diet Coordinate patient care Provide nutrition education

52 PROTEIN - DIALYSIS Dialysis drains some body protein Protein intake must be increased accordingly Hemodialysis - 1.2g/kg Peritoneal Dialysis g/kg At least 50% should be HBV protein Monitor serum BUN, Cr levels, uremic symptoms, and weight Prealbumin (metabolized by the kidney) not a good nutritional marker Challenging to consume adequate protein due to uremia Phosphorus restriction may be lifted to meet protein needs

53 ENERGY - DIALYSIS Should be adequate to spare protein for tissue protein synthesis and to prevent its metabolism for energy Needs: varies between 25-40kcal/kg Lower end for PD & transplant Higher range for nutritionally depleted

54 FLUID - DIALYSIS Must be assessed frequently Hemodialysis: Level of fluid intake is prescribed based on urine output plus 500 to 1000 ml per day Allows for weight gain of 4 5lb between dialyses Goal for fluid gain : <4% of Body weight 2-3g Na restriction will usually meet these guidelines Only liquids at room temperature qualify as fluids

55 SODIUM - DIALYSIS 2-3 gram/day Avoid: salt in cooking salt at the table salted, smoked, or cured meat or fish salted snack foods, canned soups, or highsodium convenience foods Salt intake drives fluid consumption

56 DEALING WITH THIRST WITHOUT DRINKING Sucking on a few ice chips Chewing Gum Cold sliced fruit Frozen fruit Add lemon or lime juice to water Sour candies Take pills with soft foods instead of liquids Using artificial saliva

57 POTASSIUM - DIALYSIS Usually reduced to g Patients on high flux dialysis or with increased dialysis times or frequencies will be able to tolerate higher levels Some low-sodium foods contain potassium chloride If diet history does not reveal the reason for elevated serum potassium check non dietetic sources Poor dialysis adequacy Missed dialysis treatments Elevated sugar in patients with diabetes Acidosis Constipation Severe GI bleeding, blood transfusions Blood transfusions Chemotherapy/radiation

58 PHOSPHORUS - DIALYSIS Not easily removed by dialysis Usually restricted to <1200mg/day Difficult because of the necessity for high-protein diet Highly processed foods have commonly used additives containing phosphate Take phosphate binding medication with each meal or snack

59 CALCIUM AND PARATHYROID HORMONE Maintaining phosphorus-calcium balance is complicated GFR decreases, serum calcium levels decrease Decreased ability of the kidney to convert to inactive Vit D to its active form The need for serum Ca increases as serum phosphate levels increase Many patients on dialysis suffer from hypocalcemia regardless of calcium supplementation

60 VITAMINS - DIALYSIS Rapidly lost during dialysis Patients who still produce urine may be at increased risk of loss of water-soluble vitamins Folate is highly dialyzable Uremic toxins may interfere with the activity of some vitamins Water soluble vitamins usually abundant in high potassium foods Dialysis diets tend to be low in folate, niacin, riboflavin, and vitamin B6 Renal multivitamin

61 TRANSPLANTATION

62 TRANSPLANTATION MNT First 6 weeks after surgery High protein diet recommended g/kg IBW/day Energy 30-35kcal/kg IBW 2-3 g Na restriction After Recovery Protein 1 g/kg IBW/day Low fat diet Hypophosphatemia and mild hypercalcemia common Fluid- typically drink 2L a day, but overall needs depend on urine output Lipids- patients usually have elevated serum trigylcerides or cholesterol Calorie restriction for those who are overweight Cholesterol <300mg/day Limit total fat

63 Therapy Energy Protein Fluid Na+ K+ P Impaired renal function kcal/kg IBW g/kg IBW Ad libitum Variable 2-3 g/day Variable; usually ad libitum or increased to cover losses with diuretics g/day or 8-12 mg/kg IBW Hemodialy sis 35kcal/kg IBW 1.2 g/kg IBW mL/d ay urine output 2-3g/day 2-3 g/day or 40 mg/kg IBW g/day or < 17 mg/kg IBW Peritoneal Dialysis (CAPD) (CCPD) kcal/kg IBW g/kg BW Ad libitum ( minimum of 2000mL/d ay urine output) 2-4 g/day 3-4 g/day g/day Transplant (4-6 wks after) kcal/kg IBW g/day Ad libitum 2-3 g/day Varies May require restriction with cyclosporine-induced hyperkalemia Calcium 1.2 g/day No need to limit Phosphorus Transplant (6 wks or longer after) To achieve/maintain IBW: Limit simple CHO Fat < 35% kcals Cholesterol <400 mg/day PUFA/SFA ratio > 1 1g /kg BW Ad libitum 2-3 g/day Varies n/a

64 CASE STUDY

65 Patient: Enez Joaquin Ht: 5' wt: 170lb (with edema) Age: 26 Sex: Female

66 Dx: Renal insufficiency secondary to diabetes mellitus Complaints: anorexia, nausea, vomiting, SOB, pruritus, muscle cramps, inability to urinate Low - Na High- K+, P, Mg, Glucose, BUN, Cr, Cholesterol, Triglycerides 4 kg weight gain due to edema in the last weeks

67 Clinical symptoms: declining GFR, increasing creatinine and urea, elevated serum phosphate, normochromic normcytic anemia, will be receiving AV fistula to begin dialysis General appearance: overweight, lethargic, BP 220/80, HR 85, RR 25, mild asterixis

68 Dry weight 161 lbs Current weight 170 lbs (with edema) %IBW 153% (obese) IBW- 105 lbs (48) BMI 31.5 (obese) Calorie needs at 35 kcal/kg of IBW 1670kcals Protein needs.8g/kg 38g/day 8-12 g/kg Pho mg Phosphorus 2-3 g Na