RENAL REPLACEMENT
THERAPIES
Alexis Luigi Lorenzo C. Cresencia, RN, MD
D I A LY S I S
A. Hemodialysis
B. Continuous Renal Replacement Therapy
C. Peritoneal Dialysis
• Acute/Urgent
❖ High & Increasing K
❖ Fluid Overload
❖ Impending Pulmonary Edema
❖ Increasing acidosis
❖ Pericarditis (uremic)
❖ Advanced Uremia
• Chronic/Maintenance
❖ Advanced CKD & ESKD
❖ Uremic Signs & Symptoms
❖ Hyperkalemia
❖ Fluid Overload not responsive to Diuretics & Fluid Restriction
❖ General lack of well-being
HEMODIALYSIS PERITONEAL DIALYSIS
Access • Arteriovenous Fistula Peritoneum
• Internal Jugular/
Subclavian/ Femoral
Vein Catheterization
• Arteriovenous Graft
Duration 3 to 5 hours 36 hours
Complications • Disequilibrium • Exit Site Infection
Syndrome • Peritonitis
• Hypotension • Hernia
• Bleeding • Pulmonary
• Sepsis Complications
• Hepatitis • Protein Loss
HEMODIALYSIS PERITONEAL DIALYSIS
Nursing • Check BP and pulse rate every 30-60 • Monitor vital signs and
Interventions minutes to monitor for hypotension observe for changes in
• Weigh patient before and after behavior.
dialysis • Make sure that catheter is
• Monitor intake and output patent.
• Monitor for signs of disequilibrium • May add procaine HCl in
syndrome (headache, hypertension, the dialysate to minimize
restlessness, mental confusion and discomfort.
nausea) • Observe for signs of
• Watch out for signs of bleeding. peritonitis.
• Avoid taking BP on site of AV fistula. • Maintain aseptic technique
• Avoid blood extraction on site of AV during insertion of catheter
fistula. and throughout the
• Provide diversion activities procedure.
throughout the duration of dialysis.
CONTINUOUS RENAL REPLACEMENT THERAPIES
• Hemofilter
• Indications:
❖ Acute or Chronic Kidney (too clinically unstable)
❖ Fluid Overload secondary to Oliguric Kidney Disease
❖ High Metabolic/Nutritional Needs
• Continuous Venovenous Hemofiltration (CVVH)
• Continuous Venovenous Hemodialysis (CVVHD)
K I D N E Y T R A N S P L A N TAT I O N
• Kidney from a living donor or human
cadaver
• Donors who are related to the patient are
slightly more successful than those from
cadaver donors
• Transplanted kidney is placed in the iliac
fossa anterior to the iliac crest
• Ureters of the newly transplanted kidney is
transplanted into the bladder or
anastomosed to the ureter of the recipient
P R E O P E R AT I V E M A N A G E M E N T
• Bring the patient’s metabolic state to a level as close to normal as possible.
• Complete physical examination
• Tissue typing, blood typing, and antibody screening
• The lower urinary tract is studied to assess bladder neck function and to
detect ureteral reflux.
• Patient must be free of infection at the time of transplantation
• Psychological evaluation is also done before the surgery because
corticosteroid may aggravate psychiatric conditions.
• Hemodialysis is done before the day of the scheduled transplantation to
optimize the patient’s physical status.
P R E O P E R AT I V E N U R S I N G I N T E R V E N T I O N
• Management is like that of a patient undergoing an elective
abdominal surgery
• Preoperative teaching on:
❖Postoperative pulmonary hygiene
❖Pain management options
❖Dietary restrictions
❖Intravenous and arterial lines
❖Tubes (indwelling catheter and possibly a nasogastric tube)
❖Early ambulation
P O S T - O P E R AT I V E M A N A G E M E N T
• The goal is to maintain homeostasis until the transplanted kidney is functioning well
• Immunosuppressive therapy:
❖ Azathioprine (Imuran)
❖ Corticosteroid (Prednisone)
❖ Cyclosporine (Neoral)
❖ OKT-3 (a monoclonal antibody)
❖ Prograf (formerly FK-506)
❖ Mycophenolate (RS-61433)
• Doses of immunosuppressive agents are gradually tapered off over several weeks
• The patient will take an anti-rejection medication as long as he has the transplanted
kidney
R E J E C T I O N & FA I L U R E
HYPERACUTE ACUTE CHRONIC
Within 24 hours Within 3 to 14 days After
Immediate antibody-mediated • Tenderness at transplant site • Fatigue
reaction -> generalized • Decrease in serum creatinine • Anuria or Decreased UO
• Fever
glomerular capillary thrombosis • Malaise • Generalized Edema
& necrosis • Oliguria • Tenderness at transplant site
Immediate removal of Early recognition & Immunosuppressant Therapy
transplanted organ immunosuppressant therapy
Diagnostics on rejection
• Ultrasound - to detect kidney enlargement
• Percutaneous renal biopsy – most reliable test in evaluating rejection
• X-ray
P OST- O P E R AT I V E N U R S I N G I N T E R V E N T I O N S
• Assess for signs and symptoms of rejection
❖Oliguria
❖Edema
❖Fever
❖Increasing blood pressure
❖Weight gain
❖Swelling or tenderness over the transplanted kidney or graft
• Assess for rise in the serum creatinine level and BUN
• Monitor leukocytes and platelets
• A distinction should be made between infection and rejection
M O N I T O R C L O S E LY F O R I N F E C T I O N
1. Protect the client from hospital staff, visitors and other patients
who have active infections
2. Careful hand washing is imperative; face mask may be worn by
hospital staff and visitors.
• Clinical manifestations of infection include:
❖ Shaking chills
❖ Fever
❖ Tachycardia & tachypnea
❖ Either an increase or a decrease in WBCs (leukocytosis or leukopenia)
• Practice strict aseptic technique
U P D AT E
• New research from Stanford University Medical Center
• New approach: preventing rejection WITHOUT the use of immunosuppressive drugs
❖Transplantation begins with the usual process – surgery, immunosuppressive drugs (until
the completion of the next step)
❖Given multiple small doses of radiation targeting the immune system in combination of a
drug reducing the number of cells capable of an immune attack.
❖Blood stem cells from the kidney donor is injected to the patient
❖The newly injected stem cells find their way into the patient’s bone marrow where they
reproduce new cells and immune cells that mix with those of the patient.
❖After this procedure, the patient’s immune cells recognize the donor’s organ as friend
rather than foe.
• The Stanford team monitored the recipient’s new hybrid immune system looking for a
mixture of cells from both the recipient and the donor. These cells were tested in the
laboratory and did not attack cells taken from the donor. This told the team that the new
hybrid immune system would not mount an attack against the transplanted organ. At this
time, the team slowly weaned the patient away from the immunosuppressive drugs
KIDNEY TRANSPLANT VIDEO
https://youtu.be/SKsrj-76n30
