Transplantation & Renal Replacement Therapies Flashcards
- Life-sustaining treatment for ESRD
- Clients w/med problems that inc risks are disqualified
- Age <2, >70 (assessed case by case)
- Active, adv, metastatic or untreatable cancer
- Uncorrectable cardiac dz
- Severe psychosocial problems (chem depend)
- Chronic infections (HIV, hep C)
- Coagulopathies & some immune d/o’s
- Donors - may be living (related or unrelated)
- Non-heart beating
- Cadaver
- Improved immuno-suppressants have inc’d graft survival in the US to ~95%
! Organs from living RELATED donors have the highest rate of success; 90%
Preop/Postop Care
- Routine preop & postop care w/the add’n of mental & emotional needs, compliance, r/t lifelong immunosuppression therapies
- Postop rx’s incl immunosuppressant rx therapies
- Close attn to urine output, s/s infection
- Monitor for REJECTION
Rejection - Hyperacute
- Occurs within 48 hrs >surg with s/s of
> Fever, HTN
> Pain @ the transplant site
> Treatment is immediate removal of the donor kidney
Rejection - ?
- Occurs within 1 week to 2 years >surgery
! This is reversible !
S/S
> Oliguria, anuria, low-grade fever, HTN, tenderness over transplanted kidney, lethargy, azotemia, & fluid retention
Treatment: involves increased doses of immunosuppressive drugs
Acute
Rejection - ?
- Occurs gradually over months to yrs
S/S
> Gradual return of azotemia, fluid retention, electrolyte imbalances, & fatigue
Treatment: conservative until dialysis is required
Chronic
- This just bought the pt addl time for improved quality of life
Other complications
- Acute tubular necrosis (ATN)
- Renal artery stenosis
- Thrombosis
- Infection
Key Points
- Life-sustaining treatment for ESRD (NOT a cure)
- Candidate selection criteria
- Donors
- Preoperative care
- Immunologic studies
- Surgical team
- Operative procedure
- Postop care
?
Is the movement of fluid/molecules across a semipermeable membrane from 1 compartment to another
Used to correct fluid/electrolyte imbalances & to remove waste products in renal failure
Treat drug overdoses
Dialysis
2 methods of dialysis are available
- Peritoneal dialysis (PD)
- Hemodialysis (HD)
- Begun when pt’s uremia can no longer be adequately managed conservatively
- Initiated when GFR (or CC) is <15 mL/min
- ESKD treated w/dialysis b/c
> There is a lack of donated organs
> Some pts are physically or mentally unsuitable for transplantation
> Some pts do not want transplants
Diffusion
- Movement of solutes from an area of greater concentration to an area of lesser concentration
> Substances of low molecular weight can pass from the dialysate into a pt’s blood, & so the purity of the water used for dialysis is monitored & controlled
Osmosis
- Movement of fluid from an area of lesser concentration of solutes to an area of greater concentration
Ultrafiltration
- Water & fluid removal
- Results when there is an osmotic gradient across the membrane
Peritoneal Dialysis
- Peritoneal access is obtained by inserting a catheter through the anterior abdominal wall
- Technique for catheter placement varies
- Usually done via surgery
- After catheter inserted, skin is cleaned w/antiseptic solution & sterile dressing applied
- Connected to sterile tubing system
- Secured to abdomen w/tape
- Catheter irrigated immediately
- After initial insertion of PD catheter, ideally, there’s a 7-14 day waiting period for use
- 2-4 wks >implantation, exit site should be clean, dry, free of redness/tenderness
- Once site is healed, pt may shower & pat dry
Dialysis Solutions & Cycles
- Available in 1- or 2-L plastic bags w/glucose concentrations of 1.5%, 2.5%, & 4.25%
- Electrolyte composition similar to that of plasma
- Solution warmed to body temperature
3 phases of PD cycle
- Inflow
- Dwell
- Drain/Outflow
1 cycle is called an exchange
?
Is the prescribed amt of sol’n infused through established catheter over ~10 min
After sol’n infused, inflow clamp closed to prevent air from entering tubing
Inflow
?
Also known as equilibration
Diffusion & osmosis occur between pt’s blood & peritoneal cavity
Duration of time varies, depending on method
Dwell
?
Lasts 15-30 minutes
May be facilitated by gently massaging abdomen or changing position
Drain
What is the most effective osmotic agent currently available?
Glucose
! Dextrose remains most commonly used osmotic agent avail in PD sol’ns
Automated Peritoneal Dialysis - APD
- Cycler delivers the dialysate
- Times & controls fill, dwell, & drain
> Most popular (lets pts accomplish dialysis while they sleep)
Continuous ambulatory peritoneal dialysis (CAPD)
- Manual exchange w/1.5-3L of peritoneal dialysate @ least 4x/day w/dwell times avg 4 hrs
PD - Complications
! Exit site infection (from S. aureus or S. epidermis)
! Peritonitis (d/t improper technique in making or breaking connections for exchanges)
! Hernias (b/c inc intraabdominal pressure 2nd to dialysate infusion)
! Aggravate lower back problems
! Bleeding [intraperitoneal]
! Pulmonary complications [atelectasis, pneumonia, bronchitis]
! Protein loss (~0.5 g/L of dialysate drainage but as high as 10-20 g/day)
Peritonitis - Manifestations
> Cloudy dialysate outflow (effluent) [is the earliest indication]
Fever, abd tenderness/pain
Gen malaise, N/V
- Send a specimen out for C&S, Gram stain, & cell count to ID
Pain during the inflow of dialysate is common when pts 1st started on PD therapy (warm bags)
PD - Effectiveness & Adaptation
- Short training program
- Independence
- Ease of traveling
- Fewer dietary restrictions
- Greater mobility than w/HD
Hemodialysis - Dialyzers
- Long plastic cartridges that contain thousands of parallel hollow tubes or fibers
- Fibers are semipermeable membranes
- 2 needles placed in fistula or graft
- 1 needle is placed to pull blood from the circulation to the HD machine
- The other needle is used to return the dialyzed blood to the pt
> Heparin is added to the blood as it flows into the dialyzer b/c any time blood contacts a foreign substance, it has a tendency to clot
HD - Procedure
- Dialyzer/blood lines primed w/saline sol’n to eliminate air
- Terminated by flushing dialyzer w/saline to remove all blood
- Needles removed & firm pressure applied
- Before treatment, RN should complete assessment of fluid status, cond of access, temp, & skin cond
- During treatment, RN should be alert to changes in cond & measure VS every 30-60 min
HD - Post Dialysis Care
- Hypotension (d/t hypovolemia, dec CO, & dec SVR)
- Muscle cramps
- N/V, HA, dizziness
- Loss of blood
- Hepatitis
- Dialysis Disequilibrium Syndrome (mild to moderate)
- Cardiac events > cardiac arrest
HD - Effectiveness & Adaptation
- Cannot fully replace normal functions of kidneys
- Can ease many of the symptoms
- Can prevent certain complications
Dialyzable Drugs
- Aminoglycosides, anti-TB, antiviral, antifungal, anticonvulsants, cephalosporins, penicillins, misc
HD - Vascular Access Sites
- Obtaining vascular access is 1 of the most difficult problems
- Arteriovenous (AV) fistulas & grafts
- Temporary vascular access
- Normally, a thrill can be felt by palpating the area of anastomosis, & a bruit (rushing sound) can be heard w/a stethoscope (bruit & thrill are created by arterial blood moving @ a high velocity through vein)
Vascular Access Catheter
Caring for the Pt w/an AV Fistula or AV Graft
Vascular Access Complications
- Thrombosis, stenosis
- Infection
- Aneurysm formation
- Ischemia
HF (b/c shunting of blood directly from arterial system to venous system through a fistula can cause HF in pts w/limited cardiac function)
