Helping Patients Cope with Dialysis

Financial Concerns:
• Hospital bills
• Disability or retirement pays them less than work did
• Buy special foods
• Costly drugs
• Transportation

Travel:
• Dialysis away from home
• Not all centers have room or staff to care for visiting patients
Some insurer wont pay for out-of-network

Body Image / Sexuality:

• Patients feel their vascular access or PD catheters are ugly, or may worry about loss of muscle mass, scars, and hair loss (usually temporary if caused by dialysis)
• Patients may report problems with sexual function due to their illness or drugs they take, and this is a vital issue for them.
• About half of babies born to women on dialysis survive.
• Baby survival is better with more intensive dialysis (e.g., daily or nocturnal treatment.

Pain:
• Pain can result from surgeries, cramping, needle sticks, neuropathy and bone disease.
• 60% of dialysis patients had chronic pain; 66% take pain pills

Life Changes:
• Having to limit food and fluids and learn new ways to eat and cook is a huge day-to-day-burden.
• Patients may react to the changes in their lives by withdrawing; missing treatments; leaving early; or acting hostile, very dependent, or demanding.
• Beneath these behaviors is a grieving process for the loss of the way things used to be. Keep this in mind when you work with patients who may be rude or mean to you.

• Members of the care team must understand that anger, depression, and/or denial are normal reactions to a chronic illness such as CKD.
• You can play a pivotal role in helping patients adjust by talking to them and referring them to the social worker, who is specially trained to help people cope with their feelings and behaviors, and to help ease grief.

Communication:

• The way you interact with your patients is very important in their care.
• Everything you do and say, along with your body language, are part of the care you provide and the messages you give patients.
• Keep good communication in mind at all times.

Patient Confidentiality

• Patients need to feel safe in the center, and this extends to keeping their confidences in the team and in the treatment setting.
• Patients need to feel that all their information is taken seriously and not shared inappropriately with others.
• You should never discuss a patient's condition when anyone can overhear.
• THE MAIN RULE OF PATlENT/CAREGiVER INTERACTION IS CONFIDENTIALITY.
• HIPAA or Health Insurance Portability and Accountability Act

• Became law in 1996
• Created national rules about the security and privacy of health data, that took effect in 2003.

Active Listening

• Active listening is a skill used to give patients undivided attention and to be sure you understand them.
• Some things you can do to be a good, active listener are:
     • Talk very little
     • Use short, open-ended questions to draw out what the patient means
     • Make eye contact
     • Focus on the words and the non-verbal clues, asking questions like:
          • Can you describe the pain in your feet?
          • Do I understand you to mean that you..?
          • Can you tell me more about what you ate yesterday
• Watch body language, facial expressions, and tone of voice. Caregivers use these clues to help patients share their feelings and to find more information.

• Open ended questions followed by silence can help patients tell you what is really going o
• Don't ask "yes-no" questions.
• Is a skill that takes time to learn.

• One sign that you are not doing active listening is that you find yourself preoccupied with what you want to tell the patient, rather than listening to what he or she is telling you.
• You can be a good listener by paying close attention and learning to draw patients put.

Boundaries

• Psychological boundaries are the rules people use to create appropriate relationship with each other.
• In the healthcare setting, good boundaries are vital to good communication.
• It is also not appropriate to see your patients on a social basis outside the center.
• It is not appropriate to give gifts to or accept gifts from patients, or to buy things for or sell things (e.g., candy) to patients.
• Focus all talks on the patient, not your own life. This is one way to keep talks professional.
• Keep in mind that anger - though it seems to be aimed at you - is most often about other things in their lives.

• Don't show anger yourself.
• As a caregiver, always act in a calm, professional, accepting way.
• Don't argue with a patient.
• Treat your patients and fellow staff as you would like to be treated.
• You must have a thorough knowledge of CKD and its treatments.
• Patients will ask you questions.
• Be sure not to give answers or advice that are beyond your scope of practice.
• If you don't know the answer, refer the patient to the right member of the care team.


Patient Education
Key points about how adults learn;

READINESS
     • Adult learn only when they are ready.
     • Pain and fear can make it impossible to learn.
     • Wait for sign of readiness, such as when a patient asks questions or shows less fear,
     • It is vita) to repeat information as patients become more ready to learn over time.

NEED
     • Adults learn only what they feel they need to know -what is relevant to their lives

APPROPRIATE LEVEL
• All learning must be tailored to the learner.
• The only way for staff to know patient's educational background is to ask them - never assume.
• It includes the patient's ability to see, read, hear, and understand the language.

REINFORCEMENT
• It is not enough to teach something once - teaching must be repeated many times to be learned.

BELIEF
• People must believe that the concept the staff is trying to teach them is true, that it will benefit them, and that learning will have the desired effect on their lives.


In CKD, the goal of treatment is not cure - it is rehabilitation: living as normal a life as possible.

The purpose of dialysis is to let patients feel their best so they can keep doing things that mean something to them, like caring for children or grandkids, staying active in their towns or churches, golfing, playing music, or keeping a job.

 
Improving Patient Outcome
• Is the end result of the care we give
• Some of the outcomes we look at are:

     • Morbidity - number and length of hospital stays
     • Mortality-death
     • Quality of life
     • A working vascular access

• Life Options Rehabilitation Program
     • Formed in 1993 with an unrestricted educational grant from Amgen Inc.
     • To look at how to improve outcomes in people with kidney disease.
     • In it you can see that the care you and your teammates deliver is vital.
     • The patient has a key role: Self-management
     • Self-management means that patients learn to become their own experts who can:
          • Follow their treatment plans - working with their care team
          • Keep themselves safe - by knowing how the treatment should be done
           • Recognize and report symptoms - to avoid serious problems
• It is self-management that makes rehabilitation possible.


Patient Self-Management
• In the center, it is vital to help patients become their own experts and feel more in control.
     • The center can urge patients to do as much as they can, for example:
           • Tracking their blood test results
           • Choosing the right foods
           • Learning to put in their own needles
           • Weighing themselves and writing down the number
           • Calculating how much fluid to remove al each treatment Checking their dialyzer with a staff member
           • Checking their machine settings and dialysate
           • Telling the staff about any symptoms they are having

Importance of Hope
For patients to self-manage:
     • They must first believe that they can have a good life on dialysis. Hope for a good life can motivate patients to learn.
     • Patients must know that they need to take an active role in their care. This idea is new to many patients (and staff, too).
     • All of these can be summed up in three words:
           • Attitude - looking on the bright side, being grateful to be alive.
           • Answers - learning what they need to know to care for themselves.
           •  Action ~ staying involved in the world and keeping physically fit.

Attitude
Several ways to give patients hope
     • Have a positive attitude yourself.
     • Expect patients to keep up with their favorite activities
     • Share success stories
     • Ask patients to help with their treatments
     • Talk to patients and find out what they value most
     • Act as a "holder of hope"

Answer
“Knowledge reduces fear and improves coping skills”

Several ways to help patient learn
     • Talk about what you're doing as you do it.
     • Be "askable"
     • Ask patient's simple "quiz" questions
     • Report patient questions or misconceptions

Action

• Staying alive in life includes things like keeping a job, volunteering, or exercise.
• Work is a source of income, health insurance, identity, and self esteem.

Keeping a job
• Helping patients keep their jobs is much easier than helping them find new ones.

Staying-fit
• Research shows that people on dialysis who say they have good physical functioning live longer than patients who don't.
• Exercise for people on dialysis may be, literally, a matter of life and death.
• The greatest barrier to exercise is a patient's lack of motivation.

Staying fit
You can help patient stay active in life by doing the following:
1. Suggest that patients with employment concerns talk with the social worker.
2. Work with the nurse and other team members to help patients understand their disease and its treatment
3. Talk to patients about what they enjoy doing.
4. Talk with retired patients to help them plan activities they will enjoy.
5. Share success stories.
6. Ask patients what they do for regular exercise.
7. Urge patients to take part in your center's exercise program, if you have one.
8. Allow patients to do as much as they can, physically.


Patient Resources
AAKP - American Association of Kidney Patients
ADA - American Diabetes Association
AKF - American Kidney Fund
DFC - Dialysis Facility Compare
End-Stage Renal disease networks
Home Dialysis Central™
Kidney School™
Life Options Rehabilitation Program
NKF - National Kidney Foundation
PKD Foundation
RSN - Renal Support Network


Conclusion
• A team approach to care that involves the patient, doctor, nurse, dietitian, social worker, and technician can give people with kidney failure the best possible care.
• With good care, patients can live long and live well on dialysis.
• You have chosen a demanding but rewarding career. Your contribution to the care of your patients can make a difference in their lives.

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

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

Image Source: health.allrefer.com

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

Image Source: tbeeb.com

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

Image Source: ADAM

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

Image Source: ADAM

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