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Bonent Exam (2023 – 2024) With
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I n center hemo must be done - 3x a week for about 4 hours Cons of in center HD - Most limitation on Diet, fluid than other modalities Requires the most medication Most symptoms Patients who run 4 hours tx - Are 30% less likely to die than pts who run shorter times Each 30 mins extra of tx increase life by 7% Patients are 50% more likely to die after - 2 day no treatment weekend, the last 12 hours of the 2 days the risk of death triples diastolic blood pressure - When the heart is at rest. Benefits of nocturnal in center - You get 2x as many txs as standard because it is longer and gentler with fluid removal Rarely cramp Easy on heart Fewer limitations on food and drink Free days 72% better survival rate than standard in center You check blood pressure with - Stethoscope and sphygmomanometer Nocturnal in center hemo must be done - 3x a weeks about 8 hours per tx
If BP site is below the heart.... - The reading will be to high Benefits of nocturnal home hemo - Better protein level Don't need binders No fluid limits Fewer symptoms Less heart damage Live as long as people who get a deceased kidney transplant If BP site is above the heart.... - The reading will be to low Home hemo must be done - 3x a week 4-6 hours per tx Benefits of PD - Can do alone at home or work Only need 1-2weeks of training Allows for a more normal diet Allows pt to feel more normal peritonitis - inflammation of the peritoneum, this can scar the peritoneum and make PD no longer possible, can be avoided by doing a sterile exchange 2 types of PD - Continuous ambulatory peritoneal dialysis (CAPD) Automated peritoneal dialysis (APD)- uses cycled at night done 8-10 hours during sleep During in center HD how much blood is outside of body at a time - 1/2 cup Short Daily Home Hemodialysis must be done - 5 - 6days a week for the 2.5-4 hour per tx a bp cuff that is too small or to loose will cause a - Higher reading
Quality Incentive Program - Pay for performance, Cuts pay by 2% if measures aren't met. (Kt/v and hemoglobin) ESRD networks - Oversees quality of care, 18 mostly nonprofit organizations. Renal physicians association (RPA) - 1993 nephrologist made first clinical practice guidelines, including minimum dose of HD, when to start and stop HD and care for kidney disease for pt not on HD National Kidney Foundation (NKF) - 1995, experts set guidelines for anemia, adequacy, and vascular access KDOQI - Kidney Disease Outcomes Quality Initiative, improves care and outcomes of all people with kidney disease Dialysis Outcomes and Practice Pattern Study - DOPPS - Help pts love longer by finding patterns incenter that can be changed to improve outcome state survey - An inspection of the facility by state surveyors for compliance with rules and regulations of Medicare. If clinics don't follow, they must make a plan of correction. Continuous Quality Improvement (CQI) - Finding problems and fixing them. 4 step process 4 steps of continuous quality improvement - 1. identify the problem- collect data and figure out how to fix 2.analyze problem-see if there is a standard or guideline to fix it, look at patterns or trends 3.cause of problem? 4.Plan, do, check, act- make a plan to fix, try plan, check results and make changes if needed Professionalism - The quality of performing at a high level and conducting oneself with purpose and pride
Boundaries - Never share personal life or concerns with patients, never date pts, never borrow money, never invite to home or events, never except tips or money, do not sexually harass How big are the kidneys? - size of fist, 5oz a piece What protect the kidneys - Pads of fat and the bones of the rib cage What makes up the outside of the kidney - Tough fibrous capsule, inside the capsule is the cortex which is made of layers of cells Medulla - Inner part of kidney which is made up of pie shaped wedges called pyramids In the medulla the points of the pyramid are called - Papillae calyx - Cup shaped opening at the end of the papillae, which sends drops of Urine to the renal pelvis. The renal pelvis links to ureters (tube to bladder) nephron - filtering unit of the kidney, In the renal cortex and ends into medulla, gets rid of excess water and waster keeps what the body needs. Made up of glomeruli and tubules glomeruli - Ball of capillaries in a sac called Bowman's capsule. Filtration system Capillary wall are semipermeable Blood enters the glomeruli through an afferent (towards organ) arteriole, with each heart beat blood pressure forces water out of blood through tiny slits and into Bowman's capsule. Small waste that passes through the pores is called glomerular filtrate Glomerular filtrate - Substances that filter out of the blood through the thin walls of the glomeruli, adults make 125ml each minute. And 180 liters a day. Nearly all filtrate is reabsorbed in the tubules Healthy glomeruli walls keep - large cells like blood cells and protein
chronic kidney failure - A long-standing disease resulting in scarring in the kidney, permanently altering function. Nephron function is lost uremia - Toxins in the blood Symptoms of uremia - Edema Trouble breathing Making more or less urine or nocturia Foamy/bubbly urine Severe itching from calcium phosphate Ammonia breath, metal taste, nausea Avoidance of protein food Jaundice Pain around kidneys In center HD replaces what percent of kidney function - 10 - 15% People can stay healthy with fewer than ______ nephrons working - Half Good screening tools for CKD include - Urine tests and blood pressure checks Creatine - waste product of muscle metabolism healthy kidneys remove Creatine test - Done to determine how well the kidney is working Most people with CKD also have - Heart problems People with CKD can slow the process by - Keeping blood sugar in range, blood pressure within target, avoid said, quit smoking
Stages of CKD - 1 GFR > 2 GFR 60- 89 3 GFR 30- 59 4 GFR 15- 29 5 GFR < Causes of kidney failure - Diabetes, hypertension, glomerular disease Type 1 diabetes - Immune system kills cells in the pancreas that creates insulin type 2 diabetes - the pancreas doesn't produce enough insulin, cells are resistant to insulin, or both. #1 cause of kidney failure Leading cause of blindness and limb loss Native Americans, African Americans and Hispanics are at higher risk. How to prevent diabetes type 2 - Losing 5% of body weight, exercising 30 mins a days 5 days a week can decrease risk by 34% Why does high BP cause CKD - It can damage the blood vessels and the tiny glomeruli that lead to the kidneys Primary (essential) hypertension - No identifiable cause, develops over years secondary hypertension - high blood pressure caused by the effects of another disease glomerular disease - Make up 9% of people with kidney failure glomerulonephritis - inflammation of the glomeruli of the kidney
Gland eventually grows so large it's unable to shut off Symptoms of Secondary hyperparathyroidism - Joint and bone pain Muscle pain Weakness that causes trouble walking Can cause calcium deposits in heart and blood vessels Technician role in secondary hyperparathyroidism - Listen to symptoms and report to nurse Reinforce teachings from nurse de dieticians Urge pts to take meds and follow diet plan (symptoms) pruritus - Itching. Disrupts sleep Can reduce quality of life Raise risk of hospitalization neuropathy - Nerve damage, peripheral neuropathy is in hands and feet Symptoms of neuropathy - Burning of hands and feet Pins and needle feeling Muscle weakness Erectile dysfunction Walking problems Vitamin b6 helps ease pain sleeping problems - Common in CKD along with sleep apnea, unclear why. Nocturnal HD is known to help with these problems because it can help bring back the normal rhythm of melatonin
Electrolyte - Carry electrical current like a nerve signal Sodium - Is an electrolyte that helps help water balanced Hypernatremia - to much sodium, increase thirst, flushed skin, fever, seizures and death Hyponatremia - low sodium in the blood, low BP cramps, restlessness, anxiety, access pain, headaches and nausea Potassium - Controls nerves and muscles, also can help with water balance and the bodies use of glucose Lab value for Potassium - 3.5-5.5 mEq/L Foods high in potassium - • Avocado
- Bananas
- Cantaloupe
- Carrots
- Fish
- Mushrooms
- Oranges
- Potatoes
- Pork, Beef, Veal
- Raisins
- Spinach
- Strawberries
- Tomatoes Chewing tobacco is high in potassium Patients should avoid using salt substitutes because - It has high levels of potassium
Patient should limit phosphorous levels to - 800 - 1000mg a day Lab values for phosphorous - 3.5-5. Hyperphosphatemia - excessive phosphate in the blood, failed kidneys can't remove and neither can tx. Can cause servers itching and bone disease. Tell patients to take binders with meals Binders - Bind with the gut so it absorbs less phosphorus. Extra skeletal calcification - If calcium and phosphorous are both high at the same time they bond together creating sharp crystals which can form in eyes, lungs, heart, joints and can block BV. Patients can lose limbs if this occurs Hypothermia - Low phosphorous in blood, rare in HD due to poor diet or eating to many binders. Weakness paralysis and RBC function problems Dialysis blood test include - Kt/v Hematocrit Albumin Calcium Phosphorus PTH HD pts are 89% more likely to live if they - Hit targets for all blood tests at the same time 91.7% of HD patients are doing - In center HD transplant - Get 1 healthy kidney from a donor Go through a large number of test to make sure you are healthy enough Transplant doesn't cure kidney failure
Rejection is possible Types of transplants - Blood relative Non blood relative Deceased kidney donor You can shorten the transplant wait by - Receiving incompatible blood type kidney (ABO) transplant Receive from older pts (expanded criteria donor) Donor exchange- family member or friend gives kidney to someone else compatible while you receive a compatible kidney palliative care - Hospice care advance directives - a living will; a document, written in advance, that states the patient's wishes regarding end-of-life care. Protein - Need both plant and animal protein Helps maintain body muscle and tissue Dialysis pts need 50% more protein Protein leaves a waste like urea or BUN or creatine Protein lab values - High bun-poor dialysis or too much protein Low bun-good dialysis or poor muscle mass High creatinine- poor dialysis Low creatinine- good dialysis or low muscle mass Pts who ate uremic often - Lose appetites, food taste strange or metallic, or may feel sick and vomit s Signs patient is having real weight loss - Sob, not able to lay flat, edema,
Riboflavin (B2) Thiamin Vitamins b6, b12, c Transient Patient - Traveling patient Patients can lose hair due to - Lack of protein during CKD Starting of dialysis Babies born to women on dialysis have - 50% survival rate Patient education steps include - Readiness, need, language, repeat, belief Solution - mixture of solvent and solute Solvent - Fluid Solute - A substance that is dissolved in a solution. What is the solution, solvent, and solute in dialysis? - Solution-dialysate Solvent-treated water Solute-electrolytes and glucose Why do we match the electrolytes in dialysate closely to patients’ blood? - To avoid loss of electrolytes during tx Solubility - How well a solute fully dissolved in a solvent concentration - Only so much solute can be dissolved before a solvent become saturated (full)
Why do we use 2 concentrates to make dialysate - To avoid the formation of solids acid concentrate - Has calcium and magnesium bicarbonate concentrate - Has bicarb and carbonate When water has bicarb and carbonate.... - We can't add calcium and magnesium without forming solids so we dilute with water Precipitate - Solids that can form when some solutes mix , we make dialysate out of 2 solutions to avoid this Diffusion - Solutes move across membrane till both sides are equal when to solutions come in contact with a semipermeable membrane. In dialysis waste diffuses across membrane to dialysate Gradient - The difference between the 2 concentrations in both sides of the semipermeable membrane. We use in dialysis to force waste out of blood, and to balance electrolytes Hypotonic - Lower solutes than blood Isotonic - Same solutes as blood Hypertonic - More solute than blood Factors that affect diffusion - Size of solute-smaller move more quickly and easily Temperature-Warmer moves faster and fluids diffuse faster and size of dialyzer pores= larger pores faster diffusion Surface area-larger more diffusion The direction of flow- of blood and dialysate are flowing in opposite direction, diffusion is higher
Biocompatibility of dialyzer - How much it's like the human body, how well a membrane adsorbs protein is key to whether it's biocompatible (the protein coats the inside of the fiber so the blood doesn't detect a foreign substance and cause an immune response. Characteristics of a dialyzer - Biocompatibility How much surface area Molecular weight cutoff (largest molecule to pass through) UF coefficient (how much water it can remove) Mass transfer coefficient (how well a solute will pass through membrane) Clearance (how well solutes are removed from blood Membrane materials - Cellulose-plant fiber not biocompatible Modified cellulose-chemically changed to be biocompatible Synthetic- biocompatible very good and highly absorptive Dialyzer clearance - The amount of blood cleared from solute within a minute of tx at any given BFR and DFR Diffusion, convection and adsorption can affect clearance What's in dialysate - Acid Bicarb Sodium Magnesium Potassium Calcium Chloride Glucose Acetate Citrate
Osmolarity (total solute level) must closely match - Blood to keep to much water from diffusing across membrane. What does potassium in dialysate do - Helps bring patient to normal plasma levels What does magnesium do in dialysate - Triggers enzymes that are key to carb use What does glucose do in dialysate - Prevent loss of blood glucose Can help diabetic and malnourished pts Normal sodium range in the blood - 135 - 147 Dialysate is kept between 139and 144 Sodium Modeling - Sodium level is changed during tx Starts out high and is lower throughout tx When sodium level of dialysate is high more water is removed from blood Can cause thirst, weight gain and high BP Capillary refill rate - Time taken for water to move back into blood stream In sodium modeling if the UFR is higher than the cap refill rate what can happen? - Drop blood pressure Bicarbonate - Neutralizes acid that forms when cells use protein for fuel It's considered a buffer (helps keep a constant ph) Pts can't get rid of enough acid in their urine so they are at a constant metabolic acidosis Bicarb is added to maintain pts PH Ranges from 33- 38 Helps with cramping, low bP, nausea and fatigue after tx
