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HEMODIALYSIS

• Shunting of blood the dialyzer in osmosis, and processes occurs and particles from from the body to which diffusion, ultrafiltration separating fluid the blood.

• Uses of hemodialysis
– Cleanses the blood of accumulated waste products – Removes the by-products of protein metabolism, such as urea, creatinine, and uric acid – Removes excessive fluids – Maintains or restores the body’s buffer system – Maintains or restores electrolyte levels

• Principles of hemodialysis – The semipermeable membrane is made of a thin. and blood cells are too large to pass through the membrane – The client’s blood flows into dialyzer. and water molecules – Proteins. such as urea. uric acid. the movement of substances occurs from the blood to the dialysate – Diffusion: The movement of particles from an area of greater concentration to one of a lesser concentration – Osmosis: The movement of fluids across a semipermeable membrane from an area of lesser concentration of particles to an area of greater concentration of particles – Ultrafiltration: The movement of fluid across a semipermeable membrane as a result of an artificially created pressure gradient . creatinine. bacteria. porous cellophane – The pore size of the membrane allows small particles to pass through.

during.• Implementation – vital signs – laboratory values before. such as water-soluble vitamins and certain antibiotics – Monitor for shock and hypovolemia during the procedure – Provide adequate nutrition (client may eat prior to the procedure) . and after dialysis – Assess the client for fluid overload prior to the procedure – Assess patency of the blood access device – Weigh the client before and after the procedure to determine fluid loss – Hold antihypertensives and other medications that can affect the BP prior to the procedure. as prescribed – Hold medications that could be dialyzed off.

causing cerebral edema . fluid is pulled into the brain.COMPLICATIONS OF HEMODIALYSIS: Disequilibrium in the composition of – A rapid change syndrome the extracellular fluid (ECF) occurs during hemodialysis – Solutes are removed from the blood faster than from the cerebrospinal fluid (CSF) and brain.

• Assessment – – – – – – – Nausea Vomiting Headache Hypertension Restlessness and agitation Confusion Seizures Reduce environmental stimuli Prepare to dialyze the client for a shorter period at reduced blood flow rates to prevent occurrence • Implementation – – .

aluminum in the H2O sources used in the dialysate. and the ingestion of aluminum-containing antacids (phosphate binders) .Dialysis encephalopathy • aluminum toxicity .

• Assessment – – – – – – – Progressive neurological impairment Mental cloudiness Speech disturbances Dementia Muscle incoordination Bone pain Seizures • Implementation – – – Monitor for signs of disequilibrium syndrome Notify the physician if signs of disequilibrium syndrome occur Administer aluminum-chelating agents as prescribed so that the aluminum is freed up and dialyzed from the body .

dislodging. bleeding. and infection Do not use these catheters for any reason other than dialysis Maintain an occlusive dressing • Implementation – – – .• Subclavian vein catheter – – – Is usually filled with heparin and capped to maintain patency between dialysis treatments The catheter should not be uncapped The catheter may be left in place for up to 6 weeks if complications do not occur Assess insertion site for hematoma.

and pulses – Prevent pulling or disconnecting of the catheter when giving care – Use an IV control pump with microdrip tubing if a heparin infusion is prescribed . temperature.• Femoral vein catheter – The client should not sit up more than 45 degrees or lean forward. or the catheter may kink and occlude – Assess extremity for circulation.

to form an external blood path U shape. blood flows artery  shunt  vein A tube leading to the membrane compartment of the dialyzer is connected to the arterial cannula Blood fills the membrane compartment and flows back to the client by way of a tube connected to the venous cannula When dialysis is complete.External arteriovenous shunt (AV shunt) – – – – – surgical insertion of two Silastic cannulas into an artery and a vein in the forearm or leg. the cannulas are clamped and reattached to form their U shape .

or clotting – Skin erosion around the catheter site can occur • . infection.• Advantages – Can be used immediately following creation – No venipuncture is necessary for dialysis Disadvantages – External danger of disconnecting or dislodging – Risk of hemorrhage.

place an IV. or infection occur .• Implementation – Avoid wetting the shunt – A dressing is completely wrapped around the shunt and kept dry and intact – Cannula clamps need to be available at the client’s bedside – Do not take a blood pressure. or administer injections in the shunt extremity – patent if it is warm to touch – Auscultate and palpate for a bruit. hemorrhage. draw blood. although a bruit may not be heard and is not always felt with the shunt – Notify the physician immediately if signs of clotting.

check for Fibrin-white flecks noted in the tubing – The absence of a previously heard bruit – Coolness of the tubing or extremity – Client complaints of a tingling sensation .• Signs of clotting – Fold back the dressing.

peritoneal dialysis. this creates an opening or fistula between a large artery and a large vein The flow of arterial blood into the venous system causes the veins to become engorged (matured or developed) Maturity takes about 1 to 2 weeks and is required before the fistula can be used. so that the engorged vein can be punctured with a large-bore needle for the dialysis procedure Subclavian or femoral catheters. or an external AV shunt can be used for dialysis while the fistula is maturing or developing – – – .Internal arteriovenous fistula (AV fistula) – – chronic dialysis clients Created surgically by anastomosis of an artery in the arm to a vein.

less danger of clotting and bleeding – used indefinitely – Decreased incidence of infection – No external dressing is required – freedom of movement Disadvantages – Cannot be used immediately after insertion – Needle insertions are required for dialysis – Infiltration of the needles during dialysis can occur and cause hematomas – An aneurysm can form in the fistula – Arterial steal syndrome can develop (too much blood is diverted to the vein. and arterial perfusion to the hand is compromised) .• • Advantages – Since the fistula is internal.

Internal arteriovenous graft (AV graft) – – – – – chronic dialysis clients who do not have adequate blood vessels for the creation of a fistula Gore-Tex or a bovine (cow) carotid artery is used to create an artificial vein for blood flow The procedure involves the anastomosis of the graft of the artery. aneurysms. a tunneling under the skin. and anastomosis to a vein The graft can be used 2 weeks after insertion Complications of the graft include clotting. and infection .

and arterial perfusion to the hand is compromised) – CHF can occur from the increased blood flow in the venous system . there is less danger of clotting and bleeding – The graft can be used indefinitely – Decreased incidence of infection – No external dressing is required – Allows freedom of movement Disadvantages – Cannot be used immediately after insertion – Needle insertions are required for dialysis – Infiltration of the needles during dialysis can occur and cause hematomas – An aneurysm can form in the graft – Arterial steal syndrome can develop (too much blood is diverted to the vein.• • Advantages – Since the graft is internal.

place an IV.• Implementation for AV fistula and AV graft – Do not measure a blood pressure. 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 sounds for signs of CHF – Notify the physician immediately if signs of clotting. . draw blood. or administer injections in the fistula or graft extremity – Monitor for clotting • Complaints of tingling or discomfort in the extremity • Inability to palpate a thrill or auscultate a bruit over the fistula or graft – Monitor for arterial steal syndrome • Palpate pulses below the fistula or graft.

and the dialysis occurs via the transfer of fluid and solute from the bloodstream through the peritoneum large and porous. allowing solutes and fluid to move via an osmotic gradient from an area of higher concentration in the body at an area of lower concentration in the dialyzing fluid The peritoneal cavity is rich in capillaries. therefore.PERITONEAL DIALYSIS • • The peritoneum is the dialyzing membrane (semipermeable membrane) and substitutes for kidney function during kidney failure Works on the principles of diffusion and osmosis. it provides a ready access to blood supply • • .

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prevent peritonitis – Insulin: .to control blood sugar most esp for pt with DM .• Contraindications to peritoneal dialysis – Peritonitis – Recent abdominal surgery – Abdominal adhesions – Impending renal transplant • Dialysate-sterile – The higher the glucose concentration.prevent clotting of the catheter – Antibiotics: Prophylactic . the greater the amount of fluid removed during an exchange – Heparin.

ingrowth of fibroblasts and blood vessels into the cuffs of the catheter. which fix the catheter in place and provide an extra barrier against dialysate leakage and bacterial invasion .ACCESS FOR PERITONEAL DIALYSIS • • • • siliconized rubber catheter 3 to 5 cm below the umbilicus avascular and has less fascial resistance The catheters are tunneled under the skin to stabilize the catheter and reduce the risk of infection 1 to 2 weeks .

dwell. prescribed by the physician usually about 20-30 mins Outflow: Fluid drains out of body by gravity into the drainage bag .and outflow =one exchange open system .Peritoneal dialysis infusion – – – – – One infusion (inflow).risk of infection Inflow: 1 to 2 liters of dialysate 10 to 20 minutes Dwell time: The amount of time in the cavity.

if possible – Assess electrolyte and glucose levels .• Implementation before treatment – Monitor vital signs – Obtain weight – Have the client void.

pain. vomiting – Assess the catheter site dressing for wetness or bleeding – Do not allow dwell time to extend  hyperglycemia – Turn the client from side to side or have the client sit upright if the flow is slow to start – Monitor outflow. which should be a continuous stream after the clamp is opened – Monitor outflow for color and clarity. – Monitor for respiratory distress. the difference is equal to the amount absorbed or retained by . I & O accurately – If outflow is less than inflow. or discomfort – Monitor for signs of pulmonary edema – Monitor for hypotension and hypertension – Monitor for malaise. nausea.• Implementation during treatment – Monitor for signs of infection.

• Implementation after the treatment – Clean the port and insertion site with antiseptic solution and sterile cap is applied. – Pt should WOF s/sx of peritonitis (most common complication which includes • Fever and chills • Diffuse abdominal pain • Board like abdomen • Cloudy dialysate .

• Continuous Ambulatory Peritoneal Dialysis (CAPD) – Same principle with regular PD but the dwell time is approximately longer (4-6hrs) with 4-5 exchanges/day in a week.• Continous Cyclic Peritoneal Dialysis (CCPD) Other approaches to Peritoneal Dialysis – Use of a special machine called cycler used to instil and drain the dialysate from the pt. – Does not require special machine . – Therefore it allows pt to maintain sound sleep at night. – The machine has a series of automatic on/off switches that regulate the instillation and draining of the dialysate in and out of the pt’s abdomen.

– Must be of legal age. perfusing a heparinised electrolyte solution at 2OC-4OC. use of pulsatile flow pump and oxygenator.twins less possibility of rejection – Non-living donor or cadaveric donors – Histocomaptibility by blood (ABO and Rh) and human leukocyte antigen (HLA) profile. mentally healthy and free from systemic diseases – Harvested kidneys is viable for transplantation within 72 hrs. • Donor Selection – Living donor. – Methods of preservation includes washing off formed blood elements.• Permanently solves the problem of ESRD pt. The earlier the transplantation the better the outcomes. RENAL TRANSPLANTATION .

renal vein. and ureter. renal artery.• The transplant surgeon will harvest the kidney. • Recipient selection – Age – Must have an advanced and irreversible renal damage – Must be free from systemic illness – Compatible profile with the donor .

Urine may begin to flow from the ureter immediately. . surgery begins an hour or two before the recipient’s surgery is started. The kidney should become firm and pink. The donor vein is anastomosed to the recipient’s external iliac vein. The donor artery is anastomosed to the recipient’s internal iliac or external iliac artery.donor nephrectomy is performed. the clamps are released. When the anastomoses are complete. Mannitol or furosemide may be administered to promote diuresis. and the donors ureter is implanted directly to the bladder. and blood flow to the kidney is reestablished.

discharged in 4 to 7 days and can usually return to work in 6 to 8 weeks. • The creatinine should be less than 1.4 mg/dl • hematocrit should not fall more than 3 to 6 points from pre-op value • Pain alleviating measures must be implemented to maintain comfort. – Laparoscopic nephrectomy. – Conventional nephrectomy.discharged in 2 to 4 days and can return to work in 4 to 6 weeks. .Post Op Care.Donor • Postoperative care is similar to that following conventional or laparoscopic nephrectomy • Close monitoring of renal function to assess for impairment and of the hematocrit to assess for bleeding is essential.

which inhibits the kidney from concentrating urine normally.Recipient 1. Priority is maintenance of fluid and electrolyte balance. Initial renal tubular dysfunction. Very large volumes (UO=1L/hr) of urine may be produced soon after the blood supply to the transplanted kidney is reestablished. . which acts as an osmotic diuretic.Post Op Care. This diuresis is due to a. b. The new kidney’s ability to filter BUN. c. The abundance of fluids administered during the operation.

Organ Rejection • Hyperacute (antibody-mediated. The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing low-grade immune-mediated injury. humoral) rejection occurs minutes to hours after transplantation. This type of rejection is mediated by the recipient’s T cytotoxic lymphocytes. . Condition is reversible with additional immunosuppressive therapy • Chronic rejection occurs over months or years and is irreversible. • Acute rejection occurs days to months after transplantation.2.

• Signs of acute rejection –  creatinine and BUN – Chills and fever – Weight gain (2-3 lbs in 24 hrs) – urine output –  BP – Pain and tenderness over the transplanted kidney – General malaise – Edema .

same as Azathioiprine plus destroys circulating lymphocytes.• Immunosuppressant Therapy – Azathioiprine (Imuran).inhibits antibody production that leads to graft rejection. – Cyclosporine (Sandimmune). – Cyclophosphamide (Cytoxan). Major SE is nephrotoxicity. – Steroids (Prednisone) suppresses phagocytic activity of macrophage.inhits DNA/RNA synthesis thereby suppressing antibody formation. .

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