Nephro Nursing:

Renal Replacement Therapies

Trisha Isabel F. Guioguio, RN, MAN
https://youtu.be/mi34xCfmLhw
Renal Replacement Therapies
A. Dialysis
B. Kidney Surgery
C. Kidney Transplantation
DIALYSIS
Dialysis
A. Hemodialysis
B. Continuous
Renal
Replacement
Therapies
(CRRT)
C. Peritoneal
Dialysis
 Hemodialysis
● The patient’s blood is pumped through
semi-permeable capillaries in a hemodialyzer.
● Dialysate fluid - a premixed concentrate of
electrolytes flows countercurrent to blood flow
through the intercapillary spaces of the dialyzer.
● Prevents death but does not cure renal disease
and does not compensate for the loss of
endocrine or metabolic activities of the kidneys.
 Hemodialysis
● Dialyzer (artificial kidneys)
● Principles: Diffusion, osmosis, and ultrafiltration
● In hemodialysis, the blood, laden with toxins and
nitrogenous wastes, is diverted from the patient
to a machine, a dialyzer, where toxins are filtered
out and removed and the blood is returned to
the patient.
 Hemodialysis
● Dialyzer
● Dialysate Bath
- composed of
water and major
electrolytes
 Hemodialysis
● Vascular Access
○ Vascular Access Devices
■ Immediate access for
acute hemodialysis
■ Insert catheter to
subclavian, internal
jugular/femoral vein.
 Hemodialysis
● Vascular Access
○ External Atriovenous Shunt
■ Two Silastic cannulas are surgically inserted
into an artery and vein in the forearm or leg
to form an external blood path
■ The cannulas are connected to form a U
shape; blood flows from the client’s artery
through the shunt into the vein.
 Hemodialysis
● Vascular Access
○ External
Arteriovenous
Shunt
 Hemodialysis
● Vascular Access
○ Arteriovenous Fistula
■ permanent access
■ surgically anastomosing an artery to a vein
■ The arterial segment of the fistula is used for
arterial flow to the dialyzer and the venous
segment for reinfusion of the dialyzed blood.
Hemodialysis
● Vascular Access
○ Arteriovenous
Fistula
 Hemodialysis
● Vascular Access
○ Arteriovenous Graft
■ Subcutaneously interposing a biologic,
semibiologic, or synthetic graft material
between an artery and vein
■ The patient is asked to identify which is the
current access in use and it is checked
carefully for the presence of a bruit and thrill.
 Hemodialysis
● Vascular Access
○ Arteriovenous Graft
 Hemodialysis
● Complications:
○ Episodes of shortness of breath
○ Hypotension
○ Painful Muscle cramping
○ Exsanguination
○ Dysrhythmias
○ Air embolism
○ Chest Pain
○ Dialysis disequilibrium
 Hemodialysis
● Nursing Management:
○ Promoting Pharmacologic Therapy
○ Promoting Nutritional and Fluid Therapy
○ Meeting Psychosocial Needs
○ Promoting Home and Community-Based Care
■ Teaching Patients Self-Care
■ Continuing Care
■ Home Hemodialysis
Continuous Renal Replacement Therapies
- Indicated for patients with:
- acute or chronic renal failure who are too
clinically unstable for traditional
hemodialysis,
- fluid overload secondary to oliguric renal
failure
- kidneys that cannot handle their acutely
high metabolic or nutritional needs.
Continuous Renal Replacement Therapies
Continuous Venovenous Hemofiltration (CVVH)

- Blood from a double-lumen venous catheter is

pumped through a hemofilter and then
returned to the patient through the same
catheter.
- CVVH provides continuous slow fluid removal
(ultrafiltration)
Continuous Renal Replacement Therapies
Continuous Venovenous Hemodialysis (CVVHD)

- Similar to CVVH.
- In addition to the benefits of ultrafiltration,
CVVHD uses a concentration gradient to
facilitate the removal of uremic toxins and
fluid.
Peritoneal Dialysis
Goals:
● To remove toxic
substances &
metabolic wastes
● To reestablish
normal fluid and
electrolyte
balance.
● Treatment of choice for patients with renal failure
who are unable or unwilling to undergo
hemodialysis or renal transplantation.
 Peritoneal Dialysis
Dietary Management:
● Protein intake: HD, 1.2 g/kg/day with 50% of high
biological value; PD, 1.2 to 1.3 g/kg/day with 50%
biological value and increases to 1.5 g/kg/day
with malnutrition or peritonitis (Krause, 2010).
● Sodium is restricted in ESRD to minimize thirst.
Daily recommendations are: HD, 1000 to 3000
mg/day; PD, 2000 to 4000 mg/day.
● Potassium: HD, 40 to 70 mEq/day; PD, 75 to 100
mEq/day.
 Peritoneal Dialysis
Dietary Management:
● Phosphate: HD and PD, less than 17 mg/kg/day.
● Fluid intake: HD, 1000 mL/day plus volume to
replace any urinary output. PD: may not have a
fluid restriction or may be individualized based
on current clinical presentation.
○ The goal is to limit weight gain between
dialysis treatments to 2 to 5 percent of the
established dry weight
Peritoneal Dialysis
● Preparing the Patient
- Obtain consent, explain the procedure
- Obtain baseline Vital Signs, weight, serum
electrolyte
- Evaluate abdomen for catheter placement
Peritoneal Dialysis
● Preparing the Equipment
- consults with the physician to determine the
concentration of dialysate
- Before medications are added, the dialysate
is warmed to body temperature to prevent
patient discomfort and abdominal pain and
to dilate the vessels of the peritoneum to
increase urea clearance.
- Do not soak the bag into a solution of warm
water or use microwave oven to heat the fluid
Peritoneal Dialysis
● Preparing the Equipment
- Immediately before initiating dialysis,
assemble the administration set and tubing:
- tubing is filled with the prepared dialysate
to reduce the amount of air entering the
catheter and peritoneal cavity

● Inserting the Catheter (assist the doctors)

Peritoneal Dialysis
● Complications:
○ Acute Complications
■ Peritonitis
■ Leakage
■ Bleeding
○ Long-Term:
■ Hypertriglyceridemia
■ Abdominal hernias, hemorrhoids
■ Low back pain, anorexia
Peritoneal Dialysis
● Performing the Exchange
○ Series of exchanges or cycles
■ Infusion - The dialysate is infused by
gravity into the peritoneal cavity. Takes
about 5-10 minutes to infuse 2-3L of fluid
■ Dwell (equilibrations) - diffusion and
osmosis occurs.
■ Drainage - 10-20 minutes to drain fluid.
Peritoneal Dialysis
● Nursing Responsibilities before Treatment:
○ Monitor vital signs.
○ Monitor daily weight on the same scale.
○ Have the client void, if possible.
○ Assess electrolyte and glucose levels.
○ Assess the peritoneal catheter dressing and
site
 Peritoneal Dialysis
● Nursing Responsibilities during Treatment:
○ Monitor vital signs (respiratory distress, pain, or
discomfort, blood pressure)
○ Monitor for signs of pulmonary edema.
○ Monitor for malaise, nausea, and vomiting.
○ Assess the catheter site dressing for wetness
bleeding.
○ Monitor dwell time as prescribed by the HCP.
■ Do not allow dwell time to extend because this
increases the risk for hyperglycemia.
 Peritoneal Dialysis
● Nursing Responsibilities during Treatment:
○ Initiate outflow; 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 and clarity.
○ Monitor intake and output accurately; if outflow is
less than inflow, the difference is equal to the
amount absorbed or retained by the client during
dialysis and should be counted as intake.
Care of the Hospitalized Dialysis Patient
A. Protecting Vascular Access
B. Precautions During Intravenous Therapy
C. Monitoring Symptoms of Uremia
D. Detecting Cardiac and Respiratory Complications
E. Controlling Electrolyte Levels and Diet
F. Managing Discomfort and Pain
G. Monitoring Blood Pressure
H. Caring for the Catheter Site
I. Administering Medications
J. Providing Psychological Support
 Peritoneal Dialysis
● Other Nursing Responsibilities:
○ Teaching Patients Self-Care
■ Training usually takes 5 days to 2 weeks
■ Discuss: basic information about kidney
function, disease process, peritoneal dialysis,
VS monitoring, Fluid balance management,
aseptic technique and care of the catheter site,
prevention of complications, dietary
restrictions, follow up care, danger signs, etc
KIDNEY SURGERY
 Kidney Surgery
Nursing Management:
● Pre-Operative
○ Encourage fluid, Administer antibiotic (if
Prescribed), Monitor Coagulation studies
● Intra-Operative
○ Common approaches: flank, lumbar, and
thoracoabdominal
● Post-Operative
○ Monitor for signs and symptoms of bleeding
 Kidney Surgery
Nursing Management:
● Providing Immediate Postoperative Care
○ Respiratory Status
○ Circulatory Status and Blood Loss
○ Pain
○ Urinary Drainage
● Monitoring and Managing Potential
Complications
○ Bleeding, Pneumonia, Infection, Fluid
imbalance
 KIDNEY
TRANSPLANTATION
 Kidney Transplant
● A human kidney from a compatible donor is
implanted into a recipient.
● Kidney transplantation is performed for
irreversible kidney failure; specific criteria are
established for eligibility for a transplant
● Kidney transplantation is performed for
irreversible kidney failure; specific criteria are
established for eligibility for a transplant
Kidney Transplant
 Kidney Transplant
DONORS
- may be living donors (related or unrelated to the
client), non-heart-beating donors (NHBDs), or
cadaver donors
- Physical criteria:
- excellent health, with 2 functioning kidneys.
- absence of systemic disease and infection
- no history of cancer
- no kidney disease or hypertension, and adequate
kidney function
 Kidney Transplant
DONORS
- Donors are screened

Priority:
- Donors must have complete understanding of
the donation process and outcome by the donor
is necessary; usually kidney removal from the
donor is done using a laparoscopic procedure.
 Kidney Transplant
Preoperative Interventions:
- Verify histocompatibility tests of donor, which will
be done by organ bank personnel
- Administer immunosuppressive medications to
the recipient as prescribed.
- Maintain strict aseptic technique.
- Verify that hemodialysis of the recipient was
completed 24 hours before transplantation.
- Ensure that the recipient is free of any infections.
 Kidney Transplant
Preoperative Interventions:
- Assess renal function studies.
- Encourage discussion of feelings of the live
donor and the recipient.
- Provide psychological support to the live donor,
NHBD, or cadaver donor family and to the
recipient
 Kidney Transplant
Postoperative interventions for the recipient:
1. The transplanted kidney is placed in the anterior
iliac fossa; usually the recipient’s diseased
kidneys are left in place except for those with
polycystic kidney disease in which the kidneys
are often very enlarged and painful.
2. Urine output usually begins immediately if the
donor was a living donor; it may be delayed for a
few days or more with other donor types.
 Kidney Transplant
Postoperative interventions for the recipient:
3. Hemodialysis may be performed until adequate
kidney function is established.
4. Monitor vital signs and for signs of complications
such as rejection, thrombosis, renal artery
stenosis, or wound problems.
5. Monitor urine output hourly; immediately report
an abrupt decrease in output.
 Kidney Transplant
Postoperative interventions for the recipient:
6. Monitor IV fluids closely; for the first 12-24hrs., IV
fluid replacement is based on hourly urine output.
7. Administer prescribed diuretics & osmotic agents.
8. Monitor daily weight to evaluate fluid status.
9. Monitor daily laboratory results to evaluate renal
function, including hematocrit, BUN, and serum
creatinine levels, and monitor urine for blood and
specific gravity.
 Kidney Transplant
Postoperative interventions for the recipient:
10. Position the client in a semi-Fowler’s position to
promote gas exchange, turning from the back to
the non-operative side.
11. Monitor urinary catheter patency; the urinary
catheter usually remains in the bladder for 3 to 5
days to allow for anastomosis healing; it is
removed as soon as possible to prevent infection
 Kidney Transplant
Postoperative interventions for the recipient:
12. Note that urine is pink and may be bloody initially
but gradually returns to normal within several
days to weeks.
13. Notify the HCP if gross hematuria and clots are
noted in the urine.
14. Monitor the 3-waybladder irrigation, ifpresent, for
clots; irrigate only if an HCP’s prescription is
present.
 Kidney Transplant
Postoperative interventions for the recipient:
15. Maintain aseptic technique and monitor for
infection.
16. Maintain strict aseptic technique with wound
care.
17. Monitor for bowel sounds and for the passage of
flatus; initiate a specific diet and oral fluids as
prescribed when flatus and bowel sounds return
(usually, fluids, sodium, and potassium are
restricted if the client is oliguric).
 Kidney Transplant
Postoperative interventions for the recipient:
18. Maintain good oral hygiene, monitoring for
stomatitis and bacterial and fungal infections.
19. Encourage coughing and deep-breathing
exercises.
20. Administer immunosuppressive medications as
prescribed.
21. Assess for signs of organ rejection.
22. Promote relationship between the live donor and
recipient.
 Kidney Transplant
Postoperative interventions for the recipient:
23. Monitor both the donor and the recipient for
depression.
24. Provide the recipient with instructions following
the kidney transplantation (Box 58-10).
25. Assist the recipient to cope with the body image
disturbances that occur from long-term use of
immunosuppressants.
26. Advise the recipient of available support groups.
Kidney Transplant
Client Instructions Following Kidney
Transplantation:
● Avoid prolonged periods of sitting.
● Monitor intake and output.
● Recognize the signs and symptoms of
infection and rejection.
● Use medications as prescribed, and maintain
immunosuppressive therapy for life.
● Avoid contact sports.
Kidney Transplant
Client Instructions Following Kidney
Transplantation:
● Avoid exposure to persons with infections.
● Know the signs and symptoms that require
the need to contact the health care provider.
● Ensure follow-up care.