RENAL REPLACEMENT THERAPIES

The use of renal replacement therapies becomes necessary when the kidneys can no
longer remove wastes, maintain electrolytes, and regulate fluid balance. This can
occur rapidly or over a long period of time and the need for replacement therapy can
be acute (short term) or chronic (long term). The main renal replacement therapies
include the various types of dialysis and kidney transplantation.

Dialysis
Types of dialysis :
1-Hemodialysis
2-CRRT
3- PD.
Indications of Acute dialysis :
Increasing level of serum potassium, fluid overload, or impending pulmonary edema,
increasing acidosis, pericarditis, and severe confusion. It may also be used to remove
medicationsor toxins (poisoning or medication overdose) from the blood or for
edemathat does not respond to other treatment, hepatic coma, hyperkalemia,
hypercalcemia, hypertension, and uremia.
Indication of Chronic dialysis :
Chronic or maintenance dialysis is indicated in advanced CKD and ESRD in the
following instances: the presence of uremic signs and symptoms affecting all body
systems (nausea and vomiting, severe anorexia, increasing lethargy, mental
confusion), hyperkalemia, fluid overload not responsive to diuretics and fluid
restriction.

HEMODIALYSIS
Hemodialysis is used for patients who are acutely ill and require short-term dialysis
(days to weeks) and for patients with advanced CKD and ESRD who require longterm or permanent renal replacement therapy.
Hemodialysis prevents death but does not cure renal disease and does not compensate
for the loss of endocrine or metabolic activities of the kidneys.
The objectives of hemodialysis :
- to extract toxic nitrogenous substances from the blood.
- to remove excess water.
A dialyzer (also referred to as an artificial kidney) serves as a synthetic
semipermeable membrane, replacing the renal glomeruli and tubules as the filter for
the impaired kidneys.

In hemodialysis, the blood, laden with toxins and nitrogenous wastes, is diverted from
the patient to a machine, a dialyzer, where toxins are filtered out and removed and the
blood is returned to the patient.
The anticoagulant heparin is administered to keep blood from clotting in the dialysis
circuit.
Dialyzers
Dialyzers are hollow-fiber devices containing thousands of tiny strawlike tubes that
carry the blood through the dialyzer.
The tubes are porous and act as a semipermeable membrane allowing toxins, fluid,
and electrolytes to pass through.
The constant flow of the solution maintains the concentration gradient to facilitate the
exchange of wastes from the blood through the semipermeable membrane into the
dialysate solution, where they are removed and discarded

Vascular Access
Access to the patients vascular system must be established to allow blood to be
removed, cleansed, and returned to the patients vascular system at rates between 300
and 800 mL/min.
Several types of access are available.

1- Vascular Access Devices

Immediate access to the patients circulation for acute hemodialysis is achieved by
inserting a double-lumen, noncuffed, large-bore catheter into the subclavian, internal
jugular, or femoral vein by the physician (Fig. 44-4).

2- Arteriovenous Fistula
The preferred method of permanent access is an arteriovenous fistula (AVF) that is
created surgically (usually in the forearm) by joining (anastomosing) an artery to a
vein, either side to side or end to side (Fig. 44-5A). Needles are inserted into the
vessel to obtain blood flow adequate to pass through the dialyzer.
The arterial segment of the fistula is used for arterial flow to the dialyzer and the
venous segment for reinfusion of the dialyzed blood.
This access will need time, (2 to 3 months) to mature before it can be used. As the
AVF matures, the venous segment dilates due to the increased blood flow coming
directly from the artery.
Once sufficiently dilated it will then accommodate two large-bore (14-, 15-, or 16gauge) needles that are inserted for each dialysis treatment.
The patient is encouraged to perform hand exercises to increase the size of these
vessels (ie, squeezing a rubber ball for forearm fistulas) to accommodate the large
bore needles.

3- Arteriovenous Graft
An arteriovenous graft can be created by subcutaneously interposing a biologic,
semibiologic, or synthetic graft material between an artery and vein (Fig. 44-5B).
Usually a graft is created when the patients vessels are not suitable for creation of an
AV fistula.

Complications
-

Disturbances of lipid metabolism (hypertriglyceridemia) are accentuated and

contribute to cardiovascular complications. Heart failure, coronary heart
disease, angina, stroke, and peripheral vascular insufficiency may occur and
can incapacitatethe patient.

Anemia is compounded by blood lost during hemodialysis.

Gastric ulcers may result from the physiologic stress of chronic illness,
medication, and preexisting medical conditions (eg, diabetes).

Vomiting may occur during the hemodialysis treatment when rapid fluid shifts
and hypotension occur.
Malnutrition
Sleep disturbances
Episodes of shortness of breath often occur as fluid accumulates between
dialysis treatments.
Hypotension may occur during the treatment as fluid is removed.
Nausea and vomiting
Painful muscle cramping may occur.
Dysrhythmias may result from electrolyte and pHchanges or from removal
of antiarrhythmic medications during dialysis.
Air embolism is rare but can occur if air enters the vascular system.
Chest pain may occur in patients with anemia or arteriosclerotic heart disease.

Nursing Management
.
1- Promoting Pharmacologic Therapy
2- Promoting Nutritional and Fluid Therapy
With the initiation of hemodialysis, the patient usually requires some restriction of
dietary protein, sodium, potassium, and fluid intake. Protein intake is restricted to
about 1.2 to 1.3 g/kg ideal body weight per day; therefore, protein must be of high
biologic quality.
Sodium is usually restricted to 2 to 3 g/day; fluids are restricted to an amount equal to
the daily urine output plus 500 mL/day.

3- Meeting Psychosocial Needs.

4- Promoting Home and Community-Based Care.
5- Teaching Patients Self-Care.

SPECIAL CONSIDERATIONS: NURSING MANAGEMENT OF

THE HOSPITALIZED PATIENT ON DIALYSIS
1- Protecting Vascular Access
2- Taking Precautions During Intravenous Therapy
3- Monitoring Symptoms of Uremia
4- Detecting Cardiac and Respiratory Complications
5- Controlling Electrolyte Levels and Diet
6- Managing Discomfort and Pain
7- Monitoring Blood Pressure
8- Preventing Infection
9- Caring for the Catheter Site
10- Administering Medications
11- Providing Psychological Support