Nutrition for People on In-center Hemodialysis

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• The main goal of the diet is to help the patient have good nutrition while keeping the build-up of wastes between treatments to a minimum.
• The in-center HD diet is based on the following food groups:
     • Meat and meat substitutes
       (beef, pork, chicken, eggs, fish, cheese, peanut butter, tofu, and vegetarian meat products)
    • Dairy (including milk, ice cream, yogurt, and pudding)
     • Bread and starches
     • Vegetables and fruits
     • Fats (includes butter and oils) ,„ Calorie boosters (hard candy or jelly beans)
     • Miscellaneous (spices and condiments)



Proteins
• All foods contain large or small amounts of protein.
• Types:
     • High biological value (HBV) or animal protein
       (meat, fish, poultry, eggs, tofu, soy milk, and dairy products)
     • Low biological value (LBV) or plant protein
       (breads, grains, vegetables, dried beans and peas, and fruits)

In the body, proteins:
• Aid growth and maintain body tissues
• Provide energy
• Keep fluid balance in the body
• Form parts of enzyme, hormones, and growth factor
• Form parts of antibodies
• People on Hemodialysis should eat 1.2 grams per kilogram (kg) of body weight per day; half of this should be animal protein.

• After protein is eaten, nitrogenous wastes, such as urea and creatinine, are left over.
• Creatinine is a normal by product of muscle metabolism that healthy kidneys remove.
• Like BUN, high creatinine levels may suggest poor dialysis, but low levels alone don't mean the patient is getting adequate dialysis. Low creatinine levels may occur in patients with poor muscle mass.

Calories
• Calories in food provide energy to run the body
• People on dialysis must eat enough calories to meet their energy needs - or they become malnourished; they will burn protein for fuel
• It is vital to note loss of lean body mass and not mistake it for fluid removal from treatment.
• Signs that a patient has lost body weight, even if postdialysis weight is unchanged, include: fluid buildup in the ankles and fingers, shortness of breath, or the patient saying he or she can't lay flat in bed.

Malnutrition
• Studies have found that many hemodialysis patients are malnourished
• Patients whose serum albumin (protein) levels are less than 4.0 g/dL are more likely to die
• The risk of death also rises as cholesterol levels fall, because low cholesterol also indicates poor nutrition.

Other factors that raise the chances of malnutrition in people on dialysis:
• Metabolic acidosis (a shift of the body's acid-base balance toward acid)
• Illnesses besides kidney failure
• Too many diet limits
• Loss of nutrients during dialysis
• Not enough dialysis
• Hospitalization and surgeries
• Chronic inflammation and infection

Treatment of malnutrition:
• The first step is to try to get the patient to eat more
• If this does not work, oral supplements (nutritional drinks, protein powders, and bars)
• If supplements don't work, tube feedings are a next step
• If tube feedings fails, intradialytic parenteral nutrition (IDPN) or total parenteral nutrition (TPN) - intravenous feeding of a special solution that may have carbohydrates, protein, fat, sugars, and amino acids - may be used.

How You Can help Your Patients Achieve Better Nutrition Status
• At each treatment, ask your patients how they are eating Tell the dietitian and nurse about any changes in appetite, taste, Gl problems (feeling full after very little food, constipation, diarrhea, bloating and heartburn, nausea or vomiting), or trouble keeping blood sugar levels in control.
• Tell the dietitian and social worker if a patient is missing meals due to dialysis treatment times or can't afford to buy food.
• Tell the dietitian and nurse when a patient consistently arrives below dry weight Any unplanned weight loss or low energy level may mean there are nutrition concerns
• For diabetic patients, tell the dietitian if a patient tells you that he/she is having trouble eating or keeping blood sugar under control.
• Encourage patients to follow their fluid and sodium limits. Tell the nurse or dietitian is a patient gains a lot of fluid between treatments.
• Encourage patients to eat as much as they can, but follow the prescribed meal plan.
• Remind patients to take their binders with meals and/or snacks and other drugs and nutritional supplements as prescribed.
• Encourage patients to come for their treatments and stay for the whole time. Tell the nurse and the dietitian if a patient is having problems with treatments that may affect adequacy, like not getting the prescribed blood flow or problems with needle sticks.
• Get involved with patient education.                      |



FLUIDS
• Once the kidneys fail, they make little or no urine. So almost all of the excess fluid patients eat or drink must be removed by dialysis.
• Less obvious forms of fluid loss: breathing, stool, perspiration, etc. use up about 600 mL of fluid each day.
• Fluid limit (most often for in-center HD patients) is the volume of the patient's urine output plus 1 liter (4 cups) per day.
•  Part of the predialysis assessment is figuring out how much water to remove at each treatment.
• Ideally, each treatment will remove the amount of fluid the patient gained between treatments.
• Dry weight is the postdialysis weight at which all or most excess fluid has been removed.
• People at their true dry weight should feel well, have no excess fluid or trouble breathing, and need few, if
any, blood pressure pills.
• If a treatment removes too much fluid, or removes it too quickly, the patient will have hypotension (low blood pressure) painful muscle cramps, dizziness, nausea and vomiting, and may pass out. The patient feel "washed out" and ill for a few hours after the treatment.
• If not enough fluid is removed by a treatment, the patient must try to be even stricter with fluid intake - a discouraging task!
• In the long term, fluid overload can cause congestive heart failure (CHF; the heart cannot pump out all the blood it receives).
• Signs include edema and shortness of breath.


Helpful Hints for Patients About Thirst and Fluid
• Avoid salty or sugary foods that make you thirsty.
• Ask your doctor or pharmacist if any of your drugs have thirst or dry mouth as a side effects. If so, ask your doctor if there is a substitute that doesn't have this problem.
• Know your fluids (all foods that are liquid at room temperature - like popsicles and ice cream - are fluids).
• Use small cups or glasses instead of large ones.
• Know how much fluid your favorite glass holds. Use small cup size, such as an S ounce cup.
•  Quench thirst with hard candies, (Use sugar-free candies if you have diabetes).
• Brush your teeth or rinse your mouth with mouthwash.
• Rinse your mouth with cold water or cold mouthwash, then spit it out.
•  Suck on frozen grapes or ice cubes.
• Use lemon wedges to help stimulate saliva.
• Make your own popsicles out of a low potassium juice (e.g., grape)
• Ask the wait staff not to refill your glass when you eat out. Ask for a cup of ice and a bit of fluid and take small sips (limit to 1 cup).
• Take pills with pudding or applesauce instead of fluid.
• Measure your fluids. Fill a quart jug of water each morning with your daily fluid limit. Use water from this jug all day. If you drink other fluid, pour that amount out of the jug.



Sodium
• Is found naturally in foods and is the major part of table salt.
• 1/2 teaspoon of salt == has more than 1 gram or 1000 mg of sodium.
• Dialysis patients should not use table salt or most salt substitutes (which have potassium), or eat most foods that are processed with added salt.
• Sodium causes thirst and plays a role in high blood pressure and fluid weight gain.
• Sodium that is retained in the body attracts fluid, which causes swelling.
• Unhealthy kidneys cannot remove excess sodium. Patients must reduce their intake of both sodium and fluids if they develop edema in the face, hands, or feet; if their blood pressure rises; or if they gain weight rapidly.
• Patients who limit sodium in their diet are usually less thirsty - this makes it easier to control their fluid intake.
•  Recommended sodium limit for in-center Hemodialysis is most often 2-4 grams (87-174mEq) per day.
•  This level can be reached by avoiding table and cooking salt, canned foods, packaged "helper" foods,
pickled foods, and preserved meats, such as cold cuts, sausages, and hot dogs.
• Encourage patients to read labels and try no-salt-added herbs and spices (e.g.' basil, lemon pepper, and Mrs.Dash),



Potassium
• A well dialyzed patient should be able maintain a normal range of serum potassium (3.5 - 5.5 mEq) with a diet that includes 2-3 grams (51-77 mEq) of potassium or 1 mEq/gm of protein.
• Patients can leam to limit the obvious high-potassium foods - espresso/cappuccino, avocados, mangos, bananas, orange juice, dried fruit, cantaloupe, dried peas and beans, tomato sauce, and potatoes.
• Patients should also leam proper portion sizes.

Facts About Potassium that Patients Need to Know
• Potassium overload can cause sudden death.
• Symptoms ofhyperkalemia include muscle weakness,
abnormal heart rhythms, and cardiac arrest.
• Most salt substitutes have potassium-it Hyperkalemia may occur most often after a weekend -
the longest period between in-center HD treatments.


Calcium & Phosphorus
•KDOQl Clinical Practice guidelines recommend keeping the serum calcium levels of people with stage 5 CKD at the lower end of the normal range (8.4 - 9.5 mg/dL).
• Total intake of elemental calcium (diet and binders) should not exceed 2,000 mg per day.
• Serum Phosphorus level should be maintained between 3.5-5.5 mg/dL.
• Symptoms of high phosphorus include itching, bone and joint pain, muscle weakness, and bone fractures.
• Dialysis removes some phosphorus.
• For some dialysis patients, phosphorus must also be controlled with phosphate binders and diet, and by avoiding some foods like dairy products,
• Hyperphosphatemia or high serum phosphorus is related to secondary hyperparathyroidism and bone damage - which may have no symptoms until significant damage has been done. And is linked with an increased risk of death.
• A typical phosphorus diet limit is 800-1,000 mg/day adjusted for dietary protein needs.
• Foods high in phosphorus: dairy, meats, nuts, peanuts and other dried beans and peas, whole grains, chocolate, and colas.
• Many foods high in phosphorus are also good sources of protein.


Phosphate Binders
• Are a group of medications used to control the amount of phosphorus absorbed from food.
• They should be taken with meals and snacks.
• Patients who take binders often complain of constipation. In these cases, the doctor may prescribe a stool softener, since most patients on hemodialysis have limited fluid and fiber intake.

Suggestions for Patients on Managing Phosphorus Levels


• Do not skip or shorten treatment time - dialysis removes some phosphorus, so it helps to get every minute of treatment the doctor prescribes.
• Follow a low phosphorus diet.
• Take phosphate binders with meals and snacks


 
Vitamins

• Dialysis removes some water-soluble vitamins, so patients need supplements.
• Megadoses of water-soluble vitamins (biotin, folacin, niacin, pantothenic acid, riboflavin, thiamin, and vitamins B12, B6,and c) or any fat-soluble vitamins (vitamins A, D, E and K) are not recommended for them.
• Patients should take 60-100 mg of vitamin C, 0-8-1.0 mg (800-1000 rocg) offolic acid, and the recommended Dietary References Intakes (DRI) for the B-complex vitamins

Hemodialysis Care Team

Hemodialysis Care Team

PATIENT:
• Leam about kidney failure and its treatment
• Have input into the care plan, then follow it (diet and fluid limits, drugs, dialysis)
• Tell the care team about symptoms or problems.
• Know his or her rights and responsibilities.

NEPHROLOGIST:
• Licensed physician who specializes in kidney disease
• He/she establishes the plan of care with the other care team members, prescribes the patient's treatment and medications, orders blood tests, and makes changes as needed based on a patient assessment

NURSE:
• Works to coordinate each patient's care with the other members of the care team
• Responsible for implementing the plan of care, designing and implementing the patient education plan, assessing each patient before and after dialysis treatment, providing direct patient care during a treatment, and training other staff.
• A nurse may also be the manager of the center

SOCIAL WORKER:
• Help patients and family members adjust to dialysis and rebuild their lives.
• Counsels patient and family members to help with the emotional and financial issues that are part of dialysis
• Addresses healthcare coverage, rehabilitation, patient resources, and community services.

DIALYSIS TECHNICIAN:
• Patient care technicians - provide care for patient on dialysis, working under a registered nurse
• Biomedieal equipment technicians — maintain and repair the equipment
• Reuse technicians — reprocess dialyzers

RENAL DIETIAN:
• Incorporate patient's nutritional needs, dietary restrictions, and food preferences into a meal plan that will maintain health and that the person can follow and enjoy.
• Teaches the patient, family members, and other caregivers how to best meet nutrition needs.

No Treatment: Treatment Options of End Stage Renal Disease

• Without dialysis or transplant, people with kidney failure will die.
• The care team uses all resources to make sure the patient and family have reached a comfortable decision, and to support them as the patient passes away

Dialysis: Treatment Options of End Stage Renal Disease

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• Is the process of cleaning the blood by removing wastes and fluid that build up when the kidneys fail.
• Is a way to replace some, but not all, kidney functions.
• The goal of dialysis is to help keep people with kidney failure as healthy as possible.
• Dialysis can't fully clean the blood.


Normal Kidney Function Compared to Dialysis

Kidney	Dialysis
Removes all excess fluid each day	Removes some fluid on treatment days
Removes waste product each day	Removes some wastes on treatment days
Control electrolyte and acid/base	Helps restore electrolyte and acid/base balance
Controls blood pressure by fluid removal, sodium balance, and hormonal action	Helps control blood pressure by removing fluid and balancing sodium on treatment days
Makes erythropoetin, a hormone that triggers the bone marrow to make red blood cells	Can't make erythropoetin, but recombinant or genetically engineered erythropoetin is given
Controls calcium / phosphorus balance each day	Can change serum calcium levels somewhat by adjusting calcium in dialysate, can remove some phosphorus, but not as well as healthy kidney
Plays a role in hormonal balance	Has little, if any, effect on hormones
Activates vitamin D	Cannot activate vitamin D, vitamin D sterols can be given.

• Blood is pumped out of the patient's body, through an artificial kidney, or dialyzer, then back into the patient.
• Both blood and dialysate fluids are pumped through different parts of the dialyzer at the same time.
• A semi permeable membrane keeps the blood and the dialysate from mixing.
• Excess water and wastes pass out of the blood through pores in the membrane, into the dialysate.
• The used dialysate is sent down a drain.
• Only a small amount of blood is out of the body at one time.

In-center Hemodialysis
• Some patients feel safer getting treatment in a center with nurses and technicians there to help.
• They like the chance to meet other people who need dialysis and may make friends at the center
• Patient has days off between treatments not to think about dialysis.

Conventional Hemodialysis
• Patients and their partners are trained for a few weeks in how to put in needles, order supplies, run the machine, take blood samples, report problems, and respond to emergencies.

Nocturnal Hemodialysis
• Patients are trained to do their treatments from 3-7 nights each week, for about 8 hours, while they sleep
• Special connectors keep the needles from coming out in case patients toss or turn.
• Bedwetting alarms, placed beneath the needle insertion area, may be used to detect moisture and wake the patient up if even a drop of blood is lost.
• In some programs, the machine is linked by a modem to the hospital so a nurse or technician can follow each treatment.
• Patients who receive 48 hours of treatment each week ate a normal diet and had normal blood pressure without drugs.
• They did not need phosphate binders.
• Most had no fluid limits.
• They also had fewer symptoms - including less fatigue, cramping, dizziness, shortness of breath, or feeling cold.
• They felt more in control, and had better physical functioning.
• They have less heart damage than patients on conventional in-center hemodialysis                   .
• Longer treatments also remove much more b2m, the protein that causes amyloidosis

In-center nocturnal Hemodialysis
• Patient sleep in the center while getting their treatment.
• They get about 24 hours of treatment a week instead of the 9-12 they would normally get in-center

Short Daily Hemodialysis
• 2-3 hours treatment done 5-7 days per week

Newest type of home Hemodialysis

Kidney Transplantation: Treatment Options of End Stage Renal Disease

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Living transplantation
     • First successful kidney transplantation between twin brothers in Boston on December 23, 1954
     • Human beings can live well with only one kidney
     • Many Benefits; better survival and good planification » Risks: emotional if the kidney does not work
     • Role of transplant coordinator
• A kidney transplant gives a patient one healthy kidney from a donor and a lifestyle that is closest to normal.
• Options for a kidney transplant:
     • A kidney from a blood relative (living related donor)
     • A kidney from a non-blood relative, spouse, or friend (living nonrelated donor)
     • A deceased donor kidney (from someone who has died)
• A transplant is not a cure for kidney disease, it is another form of treatment.
• A transplant may last 5,10,20, or more years - or it may not work at all.
• On average, between 89 and 95% of transplanted kidneys work for one year after surgery.
• The most common problem after surgery is rejection - the body's immune system see the transplant as "foreign" and attacks it
• A severe shortage of deceased donor organs for transplant means that people who want one may have to wait a long time.

Who can have a transplant?
• Up to 40% of ESRD patients are suitable (not if serious heart or lung disease or cancer)
• Usually no age limit but.
• Not suitable if proven non-compliance


Who can donate a kidney?
• Almost anyone can donate a kidney to a loved one
• Best donors: identical twin, non-identical twin, first degree (but also more distant) relative, spouse, close friend, or partner between 18 and 70 years old who is healthy and willing

Who can not donate a kidney?
• HIV or AIDS-related infection
• Hepatitis B or C infection
• Major heart or breathing problems
• Diabetes
• Extreme obesity
• Significant kidney disease
• Most cancers
• IV drug abuse
• Pregnancy
• High BP
• Having only one kidney
• Evidence of financial or non-financial coercion
• Inability to give informed consent/psychiatric disorders

Removing the kidney from the donor
• Open nephrectomy : usual technique; much larger scar; longer recovery; reduced risk of complications during the operation; return to work after about 3 months
• Laparoscopic nephrectomy: smaller sear and shorter recovery; longer operation; potential damage to the donated kidney; return to work within 1 month

• General anaesthesia and lasts about 2-3 hours
• Incision into the abdomen, right or left, below the navel
• Patient's own kidneys are usually left in place 
• Transplant kidney is placed lower in theabdomen, just above the groin

Do you have to be on dialysis first?
• Depends on unit and national policy
• Patient can be put on a waiting list when GFR is < 20 ml/rnin/1.73m (true for new pts or those with a failing transplant)
• Sense of fairness would not allow that given the shortage of kidneys for transplantation
• Best chance to escape dialysis if living donor

Post-operative monitoring of recipient
• Very close monitoring in the first few days (serum creatinine, fluid intake and urine output, blood pressure)
• Usually two weeks stay in hospital
• Afterwards, visits at the clinic at a slowly decreasing frequency
• Return to normal activities after 3-6 months      

Immuno-suppression
• A difficult balance : to dampen down the immune system enough to stop it rejecting the grafted kidney, while keeping it active enough to fight infection.
• Various combinations of drugs (steroid, cyclosporin/tacrolimus, azathioprine/MMF) that MUST be taken continuously
• Danger : many interactions with other medications causing either of the IS drugs (mostly cyclosporin and tacrolimus) to work too well (toxicity) or less well (risk of rejection)

Possible problems after transplantation
• Rejection -acute -chronic
• Drug side effects
• Infection
• Card io-vascular disease
• Cancer
• l.ymphoma

Acute rejection of transplanted Kidney
• Very common (in about 40% of patients in the first year post-transplant and mostly in the first few weeks) 
• May also happen at any time if IS drugs are stopped!
• Can cause pain and fever but mostly, increase in serum creat. [one must first rule out other causes (urologic, vascular) before biopsy!
• If biopsy confirms rejection : treatment with steroid 'pulses' or stronger IS drugs : this usually works

Chronic rejection of transplanted Kidney
• More appropriately named 'transplant nephropathy'
• Usually starts after the first year
• Usually slowly progressive
• Diagnostic: transplant biopsy
• Confusion possible with cyclosporin toxicity

Drug side effects
1. Cyclosporin and tacrolimus: most important drugs for rejection prevention; work in a similar way;
if doses too high, induces renal toxicity (decrease' renal function and increase blood pressure); but if too low, risk of rejection is high; cyclosporin can also cause gum hypertrophy and excessive growth of hair; tacrolimus can cause hair loss and trembling; mostly tacrolimus can induce diabetes (in up to 10% of patients) -> lifelong need of insulin; both can damage the liver and nervous system.

2. Sirolimus; also a calcineurin inhibitor but no renal toxicity; major side effect: very high serum cholesterol levels

3 Azathioprine and mycophenolate mofetil: effective drugs but can suppress activity in the bone marrow —> anemia, neutropenia(4-ability to fight infection) and thrombocytopenia (—> bleeding tendency): stopping or decreasing the dose puts matters right; azathioprine can cause damage to the liver; MMF can cause abdominal pain and diarrhea

4. Prednisolone: a steroid and as such many problems; thinning of the skin, facial swelling, acne, diabetes, high BP, osteonecrosis (mostly in the hips —> prosthesis may become needed), osteoporosis (prevention by calcium and Vit.D)


Infection
• Immunosuppression but not as in AIDS
• Particular problem :CMV (for cytomegalovirus) infection that can be a severe illness contrary to a 'flu-like mild disease in the general population (Risk increased if donor + and patient -) but can be treated (ganciclovir injections)

Cardiovascular problems
• Continuation of the previous effects of CKD : increased risk of MI, stroke and peripheral arteritis
• Importance of controlling blood pressure (< 120/70) with low salt diet and antihypertensive drugs, diabetes (de novo) with oral or insulin treatment, cholesterol levels with statins (<180 mg/dl or 5 mmol/1) and weight (+ no smoking and exercise)
• Also interest of low doses of aspirin

Lymphoma
• 2-5% of transplant patients develop lymphoma
• 60% of cases occur in the first year post-transplant
• Average time about 9 months after transplantation
• More common after stronger immune-suppression
• Treatment with high doses of chemotherapy and often with stopping immune-suppressants—>loss of kidney • Mortality rate: 30-50% within 2 years

Cancer
• Due to immune-suppression
• Higher frequency of some types (not breast or lung), especially skin (3 times more likely) —> strong "sun block' cream to avoid sunburn
• Exposure to the sun greatly increases the risk (in Australia, the risk is increased 40 times!)
• Not a major problem if diagnosed and removed in good time

Conclusion
• A successful kidney transplant is a more effective treatment for kidney failure than either PD or HD
• Not all patients are suitable for kidney transplant Transplant doesn't always last for ever.
• Transplants from living donors last longest
• If transplant fails, patients can go back to dialysis. Most can have another transplant.
• Tranplantation is an integrated part of the 'integrated care' concept.

Treatment Options of End Stage Renal Disease

• Conservative Management
• Hemodialysis, hemodiafiltration, hemofiltration
          • In-center, Low care and Home hemodialysis
• Peritoneal Dialysis
          • CAPD, APD (or CCPD), NIPD, OCPD
• Transplantation
• No Treatment

Electrolyte Imbalance - Conditions Caused by Chronic Kidney Failure

• Electrolytes are compounds that break apart into ions - electrically charged particles - when they dissolve in a fluid.
• Electrolytes are found in body fluids and cells, and play a role in many basic cell functions, like sending
nerve signals to muscles.

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Sodium (Na+)
• Helps maintain the body's water content and fluid balance
• Plays an important role in keeping acids and alkaline substances in balance in the body and helps transmit nerve signals.

• Hypernatremlia is too much sodium in the blood. Symptoms can include intense thirst, flushed skin, fever, seizures, and death.
• Hyponatremia or low blood sodium levels can occur in CKD, most often if the dialysate does not have enough sodium. Signs and symptoms can include low blood pressure, muscle cramping, restlessness, anxiety, pain in the access site, headache, and nausea


Potassium (K+)
• Helps control the nerves and muscles - including the heart.
• It helps keep the body's water balance and aids glucose metabolism

• Hyperkalemia - higher-than-normal level of potassium in the blood.
     • Causes:
          • Eating too many high-potassium foods (dialysis patients)
          • Bleeding
          • Trauma
          • Hemolysis (breakdown of Red Blood Cells)
          • Missed treatments

• Symptoms of hyperkalemia:
     • Muscle weakness
     • Abdominal cramps
     • Abnormal heart rhythyms
     • May be sudden cardiac arrest with no early warning symptoms.

• Hypokalemia- lower-than-normal blood potassium level.
• Not common in people on dialysis
• Can occur if the patient is vomiting and has diarrhea, has a diet that does not include enough potassium, or has too much potassium removed by dialysis.
• Can be very dangerous, causing fatigue, muscle weakness, and abnormal heart rhythms.



Calcium (Ca++)
• Mainly found in bones and teeth              :
• The body needs small, constant levels of calcium in the blood and fluids at all times to control blood clotting, enzyme regulation, hormone action, and nerve and muscle function.

• Hypercalcemia - high blood calcium level.
     • Most often due to high doses of Vitamin D or calcium
     • Symptoms: Vomiting, weakness, confusion, coma

• Hypocalcemia - low calcium level.
     • Most often due to problems with the metabolism and absorption of calcium
     • Occurs with hyperphosphatemia
     • Symptoms: numbness, seizures, tetany (tremors, muscle spasms, and muscle pain)


Phosphorus (P)
• Like calcium, phosphorus is mainly found in the bones and teeth
• Plays a vital role in the body's use of energy

• Hyperphosphatemia - high phosphorus level
     • People whose kidneys don't work can't excrete phosphorus, so it builds up in their blood
     • Short term: Can cause severe itching
     •Long term: Contributes to bone disease
     • Most important problems related to hyperphosphatemia is hypocalcemia and metastatic calcification (calcium phosphate deposits that are found in the skin, eyes, lungs, heart, joint, and blood vessels)

• Hypophosphatemia- low phosphorus level
     • In CKD patients, this is most often due to a poor diet or taking too many phosphate binders.
     • Mild or moderate hypophosphatemia usually does not have symptoms.
     • Symptoms are usually not seen until phosphorus is < l mg/dl and include muscle weakness, paralysis, and problems with the function of red blood cells
.



Nurse's Role in Electrolyte Management
• Water system checks are critical. Patients should not start dialysis each day until the water system QA/QC has been completed.
• Double check that the correct dialysate is delivered.
• If you mix dialysate, double check, with other staff person, that you have mixed the solution correctly.
• Encourage patients to follow their prescribed diet and fluid limits. Reinforce what patients are told about diet
and fluids.
• Report all symptoms to the nurse.

Bleeding Problems - Conditions Caused by Chronic Kidney Failure

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Causes:
• Complex blood factor changes
Signs:
• Easy bruising
• GI bleeding
• Blood in the stool
• Nosebleeds

Your Role in Bleeding Problem Management
• Question patients about any bleeding between dialysis treatments.
• Report excessive postdialysis bleeding to the nurse.
• If you are allowed to give heparin, be sure that the dose is correct
• If bleeding occurs, get advice from the nurse about how the heparin dose should be changed.
• Report excessive dialyzer clotting to the nurse

Sleep Problems - Conditions Caused by Chronic Kidney Failure

• Common in people with kidney fai1ure
• Causes are unclear
• Improved with more intensive dialysis (e.g., nocturnal dialysis)
• Further research is needed

Neuropathy (Nerve Damage) - Conditions Caused by Chronic Kidney Failure

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Symptoms;
     • Burning of the hands and feet,
     • "Pins and needles" feeling
     • Restlessness in the legs ("restless leg syndrome")
• Cause is unknown but secondary hyperparathyroidism, sodium imbalance, and high serum calcium levels have
been considered.
• Retention of some other toxin, which are not efficiently removed by dialysis can also be responsible usfor neuropathy.

Amyloidosis - Conditions Caused by Chronic Kidney Failure

Micrograph showing amyloid deposition (red fluffy material) Image Source: Wikipedia.com

• Is a condition where a waxy protein is deposited in the soft tissues, bones and joints.
• This protein, beta-2-microglobulin (B2m) is normally found on the surfaces of cells and in body fluids.
• When the kidneys fail, B2m serum levels increase, it enters the tissues, and is converted to amyloid.
• Deposits of amyloid can cause carpal tunnel syndrome (painful compression of a key nerve in the wrist.

• On x-ray, amyloid is found in about:
     • 20% of patients after 10 years of hemodialysis
     • 30-50% after 15 years
     • 80-100% after 20 years or more
• Synthetic dialyzer membranes remove more B2m than membranes made of cellulose.
• Longer and/or more frequent treatments also remove more B2m.

Pericarditis - Conditions Caused by Chronic Kidney Failure

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Inflammation of the membrane or sac around the heart.
Causes:
     • Poor dialysis
     • Infection
     • Surgery
     • Acute illness
Symptoms
     • Constant pain in the center of the chest
    • Fever
     • Low blood pressure
     • Irregular heart beat - typical heart sound: 'pericardial friction rub'

Treatment:
• Good dialysis
• Getting enough fluids
• Anti-inflammatory drugs
• Anti-biotics
• Maybe surgery to relieve pressure in the sac that surrounds the heart


Your Role In Pericarditis Management
• Report any and all complaints of chest pain to the nurse right away.
• If a patient has chest pain before dialysis, do not start the treatment until the nurse has seen the patient.
• If a patient develops chest pain during a treatment, tell the nurse right away.
• Be sure that patients receive their full dialysis prescription.

Pruritus - Conditions Caused by Chronic Kidney Failure

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Common in CKD
Causes:
• High phosphorus and calcium levels
• Secondary parathyroidism
• Changes in calcium metabolism
• Dry skin
• Uremic Toxins
• Drug allergies (pork or beefheparin)
• Reactions to chemicals used to sterilize a new dialyzer

Your Role In Pruritus Management
• Work with the nurse to find out if oatmeal baths (Aveeno® soap) can be advised.
• Work with the nurse and dietitian to sec if advising the patient to be sure they take their phosphate binders is
appropriate.
• Encourage patients to come for each treatment and stay the whole time.

Secondary Hyperparathyroidism - Conditions Caused by Chronic Kidney Failure

Image Source: ADAM

• Overproduction of parathyroid hormone (PTH) by the parathyroid gland in the neck
• Calcitrol - active form of Vitamin D. A hormone produced by healthy kidneys.
• Having less calcium triggers the parathyroid gland to release PTH. PTH controls calcium and phosphorus levels in the blood.
• In time the parathyroid glands grow so large they can't shut off. - secondary parathyroidism

Treatment
• Phosphate binders to remove excess phosphorus
     • PhosLo® - calcium acetate
     • Renagel® - sevelarner HC1
• To increase serum calcium and decrease PTH
     • Zemplar® (paracalcitol)
     • Hectorol® (doxercaleiferol)
     • Calcijex® (calcitriol)
• To reduce PTH, serum calcium, and phosphorus
     • Sensipar®(cinacalcetHCI


Your Role In Secondary Hyperparathyroidism Management
• Listen well and report symptoms that patients tell you they have
• Reinforce what the doctor, nurses, and dietitian teach patients.
• Tell the nurse if patients report problems with the drugs they take to treat the disease.
• Urge patients to take medications as prescribed and to follow their diets.

Anemia - Conditions Caused by Chronic Kidney Failure

Image Source ADAM

Causes:
• decreased RBC (red blood cell) production
     • loss of functioning renal tissue (decreased EPO production)
     • vitamin deficiencies
     • iron deficiency
     • aluminum toxicity
• blood loss
     • abnormal bleeding
     • lab sampling
     • loss in dialyzer

• red blood cell (RBC) destruction
     • hemolysis during dialysis treatment
     • hemolytic anemia
     • Lupus, sickle cell
• bleeding abnormalities; prolonged bleeding
     • decreased number of platelets and platelet defects
     • severe anemia
     • Heparin therapy during hemodialysis
     • medications that decrease platelet adhesiveness



Symptoms:
• Severe fatigue
• Shortness of breath
• Weakness
• Dizziness
• Mental confusion
• Feeling cold all the time
• Pallor (pale skin, gums, and nail beds)

Anemia in CKD is associated with a heart problem called left Veniricular Hyperthrophy (LVH). which is one of the leading causes of death in people with kidney disease. 

• Recombinant human erythropoietin (Eprex, Neo-Recormon, Procrit, EPOGEN) or darbcpoietin (Aranesp) with increased half-life and activity.
• Given sub-cuteneous (pre-D and PD) or IV (HD)
• Stimulates RBC production by bone marrow
• Pt must be iron repleted for these drugs to work efficiently : major cause of resistance to EPO therapy
• Other causes of resistance :
     - inflammation (infection, cancer, ..)
     - Pure Red Cell Aplasia (antibodies against EPO seen with SC Eprex)


Hemoglobin
     • Chemical to which oxygen and carbon dioxide bind for transport
     • Carries oxygen and carbon dioxide between lungs and tissues
     • Normal hemoglobin
     • Men- 14.4-16.6 g/dL
     •Women 12.7- 14.7 g/dL
• NKF-KDOQ1™ Target hemoglobin for dialysis patients 11-12 g/dL for men and women.

Uremia - Conditions Caused by Chronic Kidney Failure

Image Source: wikipedia.org

A build-up of wastes in the blood 
Symptoms include:
• Fatigue, weakness; dizziness; feeling cold all the time; mental confusion; pale skin, gums, and fingernail beds (due to anemia, a shortage of red blood cells
• Edema (swelling) in the feet, hands, and face due to fluid retention
• More or less urine than usual, foamy or bubbly urine (due to protein), getting up at night to urinate (nocturia)
• Itching   
• Flu-like symptoms - muscle aches, nausea, and vomiting, poor appetite
• Ammonia breath, metallic taste in the mouth
• Pain in the back or flank
• Dyspnea (trouble breathing) due to fluid in the lungs
• Yellow skin complexion
• Sleep problems
• Joint swelling

Conditions Caused by Chronic Kidney Failure

Chronic Kidney Disease can affter every organ system in the body.

Image Source: infohaem.com

Conditions Caused by Chronic Kidney Failure
1. Uremia
2. Anemia
3. Secondary Hyperparathyroidism
4. Pruritus
5. Pericarditis
6. Amyloidosis
7. Neuropathy (Nerve Damage)
8. Sleep Problems
9. Bleeding Problems (Uremia)
10. Electrolyte Imbalance

Complications of Chronic Kidney Disease (CKD)

Patient may experience
• Loss of visual acuity
• Numbness, burning, or tingling in hands or feet
• Muscle weakness and pain
• Impotence
• Constipation or diarrhea
• fatigue

Medical Complications
• Atherosclerosis
• Skin changes
• Eye changes
• Kidney damage
• Peripheral vascular disease

Consequences of Chronic Kidney Disease (CKD)

• When 75 - 80% of renal function is lost, every organ system is affected
• End Stage Renal Disease (ESRD) is irreversible kidney disease
     • < 10 -15% of renal function remaining
• Patient must receive dialysis or transplant, or they will die!

Diseases Causing Chronic Kidney Disease (CKD)

Sections of Diseases Causing Chronic Kidney Disease (CKD)

• Diabetes
• Hypertension/Large Vessel Disease
• Glomerulonephritis
• Interstitial Nephritis/Pyelonephritis
• Congenital and Cystic Diseases
• Secondary Glomerulonephritis/Vasculitis
• Neoplasms/Tumor



Diseases Causing Chronic Kidney Disease (CKD)



Diabetes
• The number one cause of stage 5 CKD in the US
• Damages the small vessels in the glomeruli so they lose their selective permeability and become "leaky" (microalbuminuria)
• Proteinuria, low serum albumin, high cholesterol, and edema are some of the first symptoms of clear-cut diabetic nephropathy
• They are followed by the development of arterial hypertension and progressive chronic renal failure


Hypertension/Large Vessel Disease
• Renal arteries become thickened from the prolonged high pressures
• Renal arteries may narrow and cause further decrease of blood flow
• Renal arteries and glomerular capillaries become clogged and tubules atrophy

Glomerulonephritis
• inflammation that affects the glomerular capillaries, usually from an immunologic process
• antigen/antibody complexes are trapped in the glomeruli
• can occur after a beta-hemolytic streptococcal infection of throat or skin (acute)
• during childhood and adolescent years, more often in boys vs. girls
• treat the symptoms; usually given steroids and antibiotics
• generally good prognosis although patient can develop
• chronic glomerulonephritis and CKD

Interstitial Nephritis/Pyelonephritis
• inflammation usually caused by E. Coli
• may be asymptomatic to developing fever, chills, flank pain, bacteriuria, pyuria
• prognosis is good, however repeated recurrences may scar the kidney leading to CKD


Congenital and Cystic Diseases
• approx. 10% of newborns have significant malformations of the urinary tract "single kidney
     • fused kidney
     • displaced kidney
     • aplastic kidney

• Polycystic Kidney Disease
     • nephrons become cystic with outpouchings
     • onset usually at 30-50 years of age
     • inherited
• Medullary Cystic Disease
     • kidneys are small with medullary cysts
     • rare, sporadic occurring inherited disease

Secondary Glomerulonephritis/Vasculitis
• Scleroderma
     • vascular and collagen changes resulting in thickening and insufficiency
• Lupus Erythematosus
     • chronic systemic inflammatory disorder of the arterial vasculature from autoantibody formation
• Hemolytic Uremic Syndrome

Neoplasms/Tumor
• Neoplasm
     • usually is a metastasis from the lung
     • poor prognosis
     • radical nephrectomy is tx of choice
• Wilm's Tumor (children)
     • most common tumor of urinary tract in children

Stages of Chronic Kidney Disease CKD

Image Source: dwp.gov.uk

State	Description	GFR ml/min/1.73m2	Action
1	Kidney damage with normal or increase GFR. The patient usually has no symptons.	greater than 90 70% of normal function	Diagnose and treat cause. Try to slow progression Reduce CVD risk.
2	Kidney damage with mild decrease in GFR	70%	Estimate progression of disease
3	Modrate decrease in GFR.  Symptoms may become noticable. May have fatique, anemia disorder of calcium and phospoic balance, swelling, high blood pressure.	55%	- Assess anemia, nutrition and bone status. - Treat complications. - Stage 1 & 2
4	Severe decrease in GFR. Usually symptomatic.  Preparation for dialysis or transplant should begin.	25 %	-Referral to nephrologist. Prepare for RRT (Predialysis education) - Start RRT earlier if elderly, diabetes, CVD, other common complications
5	Kidney failure	less than 15 (dialysis)	- Uremic symptoms, marked increase in urea, creatinine, potassium, and fluids. - Start RRT.

Causes of Acute Renal Failure

Causes of Acute Renal Failure

 "Pre-renal" - usually due to decreased blood flow to the kidneys
• hemorrhage, gastrointestinal bleeding leading to shock
• bums
• sepsis
• emboli, stenosis, occlusion, trauma to renal artery
• decreased cardiac output
     - congestive heart failure, myocardial infarction
• surgery


"Intra-renal" - injury to kidney tubules (most common form of acute renal failure) 
     - Prolonged "pre-renal" status
     - Drugs that are nephrotoxic
          • anti-neoplasties (chemotherapy)
          • x-ray dye
          • pesticides
          • heavy metals (lead, mercury)
          • plants, animals (mushrooms, snake bites)


"Intra-renal" (continued)
• Inflammation from bacteria/virus
• Trauma
• Immunological and vasculitic diseases
     - Auto-antibodie» (Goodpasture's, LED.Wegener’s,...)
•  Transfusion reactions
•  Vascular disorders
     - hypertension, diabetes
• Pregnancy disorders
     - pre-eclampsia, septic aboition
* Tissue or organ transplant rejection


"Post-renal" - the flow of urine from the kidneys to the exterior of the body is prevented, usually due to an obstruction (stones, tumors,...)

Acute Renal Failure

• Occurs over hours or few days
• Lasts hours to a few months, up to 1 year
• Can be reversible
• 50% mortality rate
     • major cause of death is infection

Acute Renal Failure

Stages of Acute Renal Failure
Initiating Stage - starts with injury of the kidney and lasts hours to days
• Oliguric Stage - lasts from 8-10 days, can persist for weeks
• Diuretic Stage - usually lasts 1-2 weeks, but can persist longer
• Recovery Stage - usually lasts several months to a year

Signs & Symptoms of Acute Renal Failure
• Decreased urine output (initiating stage)
• Elevated BUN, creatinine and/or potassium, fluid overload (oliguric stage)
• Large urine output, low BUN and creatinine level, hypokalemia (diuretic stage)

Classification of Renal Failure

Image Source: dwp.gov.uk

Acute Renal Failure
• Classified according to site of problem:
•  pre-renal
•  renal
•  post-renal

Chronic Renal Failure - Classified in 5 stages of increasing seriousness
1. mild damage
2. mild decrease of renal function
3. moderate renal insufficiency
4. severe damage
5. end stage renal disease (ESRD)

Renal Anatomy and Physiology

Sections of Renal Anatomy and Physiology

• Renal System
• Kidney
• The Basic Unit of the Kidney
• Functions of the Kidneys
• Kidney removes..
• Kidney regulates...

• Endocrine...

Renal System:

• Two kidneys

• Two ureters

• Bladder
• Urethra

Kidney
• Two Purplish lima bean - shaped organ
• Located in the lower flank
• Right kidney is lower than the left because the liver is above the right kidney
• Each kidney weighs approximately 1-1/2 pound
• Approximately the size of a fist
• The body's total blood supply circulates through the kidneys approximately 12 times per hour

The Basic Unit of the Kidney:

Nephron

• Each nephron is a tiny filter and purifier

• The body has about one million nephrons

• A nephron is made up ofaglomerulus and a tubule

Functions of the Kidneys



• R-Remove

• R-Regulate
• E-Endocrine


Removal of:
• waste products
• urea - breakdown of protein in the diet
• creatinine - end product of creatinine metabolism
• skeletal muscle breakdown
• uric acid - purine breakdown

Regulation of:
• fluid and electrolyte balance
• sodium, potassium, calcium phosphate, magnesium
• acid-base balance - prevents metabolic acidosis

Endocrine:
• production of Renin
          - an enzyme that controls blood pressure by affecting sodium and fluid volume.
• Erythropoietin formation
          - a hormone that controls red blood cell production in the bone marrow
•  stimulates conversion of Vitamin D to its active form -calcitrol
          - a hormone that enhances absorption of calcium from the intestines.

Image Source: medicalartlibrary.com

Person With A Kidney Failure: Objectives

After completing this module, the learner-will be able to:
1. Identify the structures and functions of" the normal kidney.
2. Describe acute renal failure vs chronic kidney disease.
3. List five symptoms of uremia.
4  Describe at least four conditions that often occur-due to kidney failure.
5  Discuss the treatment options for kidney failure
6  Identify members of the care team.
7. Discuss the communication skills dialysis staff use while working with patients.
8. Describe the goal of rehabilitation and the staffs role in it.



Person With A Kidney Failure



Objectives: Dialysis

Discuss how dialysis therapy is reimbursed in the United States.
• List two quality standards for dialysis treatment.
• List the steps of the continuous quality improvement (CQ1) process.
• Describe ways that dialysis staff can demonstrate professional behavior when working with patients.
• Explain the certification process for dialysis staff.

There are two types of dialysis:
• Hemodialysis (HD)
• Peritoneal Dialysis (HD)
• Hemodialysis is most common.

Image Source: kidney.niddk.nih.gov

Introduction

Main Goal in the treatment of CKD:
"To help each patient reach the highest level ofwellness possible".
Helping patients to reach this goal is one of the most rewarding parts of car ing for patients with CKD.



Image Source: kidney.niddk.nih.gov



Overview of Dialysis

Overview of Dialysis

• Dialysis is the main treatment for end-stage; renal disease (ESRD)
• It replaces three main kidney tasks:
     • Removing wastes from the blood
     • Removing excess fluid from the blood
     • Keeping electrolytes (electrically charged particles) in balance

There are two types of dialysis:
     • Hemodialysis (HD)
     • Peritoneal Dialysis (PD)

Hemodialysis is most common.

Overview of Dialysis: Hemodialysis

Hemodialysis
• An entry into the system is needed - vascular access.
• During treatment, needles are placed into the access.
• Blood flows out of the patient, through an artificial kidney (dialyzer) where the blood is cleaned, and back to the patient.

• The dialyzer contains a semipermeable membrane which allows some substances such as wastes and excess water out, but keeps other, such as blood cells, in.
• Wastes and water pass through the membrane into a fluid called dialysate and some substances pass from dialysate into the blood.
• The dialysis machine, or delivery system, controls the flow of blood to the dialyzer, includes safety alarms to monitor the machine during a treatment, and mixes and delivers dialysate.
• HD is most often done in a center 3 times a week, for about 4 hours per treatment.
• Some patients do HD at home, and may do short treatments 5 or 6 days a week.
• Or they may do longer treatments at night while they sleep for 3 -7 nights per week.

Overview of Dialysis: Pertitoneal

Image Source: kidneyurology.org

Peritoneal Dialysis
• Access for Peritoneal Dialysis is through a catheter placed in the abdomen.
• The blood never leaves the body; instead, the lining of the abdomen, which has many tiny blood vessels, acts as a filter in the same as way a dialyzer.
• Most common - done at home, at night, while they sleep, with the use of a cycler machine.
• Can be done by hand, usually with four exchanges of fresh dialysate for used dialysate each day.
• Done 24 hours a day, 7 days a week.
• Can be done at home, at work, or while traveling.

History Of Dialysis

1943 - first hemodialysis treatment in a patient, using a cellulosic membrane, using a rotating drum artificial kidney. Developed by Dr. Willem Kolff (Dutch) - known today as "the Father of Dialysis''.

• KolflTs rotating drum device featured a large wooden
wheel dialyzer made of slats wrapped with 30-40 meters of
sausage casing (the cellophane membi we) u To gain access to the blood, a fresh artery and vein had to
be used for each treatment and tied off after.
• Because a patient had limited blood vessels, dialysis could only be used to treat patients whose kidneys were expected to recover.

1950-53: The science & technology of dialysis made great strides during the Korean War. Dialysis was used to treat soldiers with acute renal failure, improving their chances of survival.

SOURCE: http://en.wikipedia.org/wiki/Willem_Johan_Kolff

History Of Dialysis: Vascular Access

I960: The (Scribner) Shunt was developed by Dr. Belding Scribner and Dr. Wayne Quinton.
• This is the first vascular access. Made it possible to treat patients with chronic kidney failure, who would need dialysis for the rest of their lives
• A way to re-enter and use blood vessel multiple times for dialysis.
• A patient's artery and vein are linked using a plastic tube outside the skin. i But they become often infected or clotted.

1966: The arteriovenous (AV) fistula was develop by Dr. Jim Cimino and Dr. James Brescia.
• An artery and a vain are connected inside the arm.
• Cause fewer infections and blood clots than the shunt
• Even today, the AV fistula, or native fistula, lasts longest and is the best access for HD.

Source: Wikipedia.com

History Of Dialysis: Dialyzers

I960: Kiil dialyzer
• 70 pound flat plate. Their large surface areas were covered with by sheets of cellophane
• After each treatment, the membranes were cleaned and stored in a chemical bath (formaldehyde) or the plates were taken apart and the membranes replaced
• Rach comer of the dialyzer had to be uniform and "torqued down" - a lengthy task called "building a dialyzer". i Treatment took up to 14 hours, 3 times a week.

Coil dialyzer
• Also developed by Dr. Willem Kolff.
• First to be mass produced
• Cut treatment time to 8-10 hours
• A membrane supported by a mesh screen coiled around a central core
• Primed with a large amount of blood, set in a holding container called a canister, and bathed with dialysate
• Sterile and disposable - very costly.

Mid 1960s - Cuprophane - Gambro flat plate
• Small, 30 inches long, with many layers of membranes in pair. Each pair of membranes formed an envelope.
• During a treatment, blood flowed between the pairs of membranes, and dialysate flowed around the outside.

Late 1960s- small, lightweight, hollow fiber dialyzer
• Blood flowed through the insides of the fibers - thousands of tiny hollow tubes the size of hairs.
• Dialysate flowed around the outside of the fibers
• Much improved over the years- is the only type on the market today.


Advances that made dialysis more safe and reliable:
• Better membranes that are more compatible with the tissues of the human body (biocompatible) -increase treatment comfort for the patients
• Machine alarms and automated functions in the machine help protect patients from harm

Medicare Reimbursement for ESRD Patients



Image Source: goa-health-travel.co.in

 • Public Law 92-603
• Passed by the US Congress in 1972
• The Medicare End-Stage Renal Disease (ESRD) Program
• This gives Medicare to patients who are entitled to Social Security based on their work records (93%) of all patients.
• Covers both dialysis and kidney transplants
• Medicare pays 80% of allowable costs. Insurance, state programs or patients pays the other 20%.

• Today, kidney failure is still the only disease with its own Medicare program.
• More centers began to open.
• Most centers are free-standing
• 2/3 are part of a large dialysis organization (LDO), a company that owns many centers all over the country.
• Each year, there are fewer and larger LDOs as they buy more centers.


• Centers are paid a composite rate by Medicare for each treatment.
• Based on the patient's age, weight, and height. And is different for each patient.
• Covers overhead, staff wages and training, equipment, rehabilitation, and some drugs.
• The composite rate is not raised each year for inflation the way hospitals and nursing homes rates are. Instead, congress must pass a law to raise the rate.

Insurance
• Second source of income for centers
• During the first 30 months of treatment, if patients have an employer group health plan (EGHP) through a job or a spouse's job, that plan is primary - it pays first.
• 126,000 USD per patient, per year (Medicare pays 63,000 USD)


ESRD Networks
• Set in 1978 to oversee the quality of dialysis care across the country.
• 18 ESRD Networks, most are non-profit, all are under contract with Medicare to cover a region of 1 -6 states.
• Charged to promote rehabilitation, collect and report data, and do quality improvement projects.
• Also offer a patient grievance process and provides resources to staff and patients.