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© Ausmed Publications March 2002
First Published March 2002
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National Library of Australia Cataloguing-in-Publication data:
Terrill, Bobbee, 1948–.
Renal nursing—a practical approach.
Includes index.
ISBN 09577988–8 1.
1.Urological nursing. 2. Kidneys—diseases. I. Dunning Trisha, 1946–. II. Title.
610.7369.
Cover, design, typesetting and printing by Hyde Park Press, 4 Deacon Avenue, Richmond,
South Australia 5033, telephone (08) 8234 2044, fax, (08) 82
Table of Contents
Overview of the book xxiii
SECTION 1
Chapter 1: Chronic renal failure 3
Introduction 3
1.1 Pathophysiology of renal impairment 3
Terminology 3
Disease progression 4
Causes of end stage renal disease 5
Clinical presentation and treatment options 6
1.2 Pathophysiology: a systems review 7
Where problems start 7
What happens to the systems involved? 8
1.3 Slowing the progress to end stage renal disease 15
Factors that accelerate nephron loss 15
1.4 Nutrition 17
History 17
Assessment 18
Diet in chronic renal failure 18
1.5 Indigenous issues 20
A worldview 20
The Australian perspective 20
Chapter 2: Acute renal failure 23
Introduction 23
2.1. The development of acute renal failure 23
Definitions 23
Causes of acute renal failure 23
2.2. Management of established renal failure 27
Basic nursing care 27
Hyperkalaemia 27
Volume expansion 27
Metabolic acidosis 28
Renal replacement therapy 28
Pharmacological treatment of acute renal failure 29
Nutrition 31
2.3. The changing clinical course 32
Progress from insult to recovery 32Chapter 3: Renal osteodystrophy 37
Introduction 37
3.1. The minerals and hormones involved 37
When the balance is disturbed 39
3.2. Classification and management of bone disease 39
Osteitis fibrosa 39
Osteomalacia 40
Adynamic bone disease 41
Aluminium bone disease 41
3.3. Complications 42
The dangers of poor control 42
3.4. Associated disorders 44
Amyloidosis 44
Upper extremity problems 44
Chapter 4: Selected disease processes 47
Introduction 47
4.1. Glomerular disease 47
Pathogenesis of glomerular disease 47
Classification of glomerulonephritis 49
Syndromes associated with glomerulonephritis 50
Evaluation and management 52
4.2. Interstitial and tubular disease 53
Interstitial nephritis 53
Diabetic nephropathy 55
Cystic kidney disease 56
Reflux nephropathy 58
Hypertension 58
Analgesic nephropathy 59
Renal tubular disease 60
4.3. Pregnancy and renal disease 64
Alterations to structure and function 64
Complications 65
Chapter 5: Pharmacology 69
Introduction 69
5.1. Why are alterations in drug dosage necessary? 69
Pharmacokinetics 69
Volume of distribution 71
Metabolism 72
Clearance 725.2. Drug administration in end stage renal failure 73
Assessment of renal function 73
Calculating dose adjustments 73
5.3. Drug removal during dialysis 74
Factors affecting removal 74
Supplementary dosages 75
Pharmacological problems specific to renal failure 75
5.4. Drugs in the treatment of renal failure 77
Commonly used drugs 77
Chapter 6: Investigation of structure and function 81
Introduction 81
6.1. Urinary examination 81
Overview 81
Physical and chemical properties 82
Tests of glomerular function 84
6.2. Haematological/serological examination 85
Serum biochemistry 85
Red blood cells and the importance of iron 85
6.3. Imaging techniques 88
Radiological imaging 88
Intravenous urography 88
Renal angiography 89
Renal venography 89
Computerised tomography 89
Ultrasonography 90
Radionuclide studies 90
6.4. Renal biopsy 91
Role of renal biopsy 91
Evaluation of biopsy findings 91
Indications for biopsy 92
The biopsy procedure 93
6.5. Summary 94
An approach to diagnosis 94
SECTION 2
Chapter 1: An overview of treatment 99
Introduction 99
1.1. A brief history of haemodialysis 99
Development 99
Current applications 1001.2. Overview of treatment 101
A brief review 101
The aims of treatment 102
1.3. Achieving the treatment aims 103
The physiology of solute removal 103
The physiology of water removal 104
1.4. Isolated ultrafiltration 107
An alternative approach 107
1.5. Patient education 108
The importance of nurse involvement 108
Chapter 2: Vascular access 111
Introduction 111
2.1. The development of vascular access for haemodialysis 111
Significant history of vascular access 111
Types of vascular access 112
2.2. Vascular access creation and revision 114
Internal devices 114
Percutaneously inserted central venous catheters 114
2.3. Nursing management of vascular access 115
Peripheral vascular access 115
Central vascular access 115
2.4. Cannulation of vascular access 116
Cannulation techniques 116
2.5. Complications 117
Summation 117
2.6. Patient education 118
The role of the nurse 118
Chapter 3: The extracorporeal circuit 121
Introduction 121
3.1. A historical review 121
3.2. Dialyser design 123
Hollow fibre dialysers 123
Parallel plate dialysers 124
3.3. Membranes 124
3.4. Sterilisation methods 125
From old to new 125
Personal safety 1273.5. Membrane reactions 127
Complement reactions 127
Hypersensitivity 128
The AN69 membranes 129
The interleukin hypothesis 129
3.6. Circuit reuse 130
Reuse of dialysers and blood lines 130
3.7. Bloodlines 131
Chapter 4: Anticoagulation 131
Introduction 131
4.1. The coagulation cascade 131
Activation of the coagulation cascade 131
4.2. Anticoagulation 134
Anticoagulant drugs 134
Anticoagulation during haemodialysis 135
Low molecular weight heparin 136
4.3. Complications associated with anticoagulation therapy 137
Bleeding tendencies 137
Vascular access clotting 138
Chapter 5: Dialysate preparation 141
Introduction 141
5.1. History 141
Early experiences 141
Composition 142
5.2. Dialysate manipulation 143
Sodium 143
Potassium 143
Calcium 144
Chlorine and magnesium 144
Glucose 144
5.3. Buffering agents 145
Acetate 145
Bicarbonate 146
5.4. Water treatment 147
Why all the fuss? 147
Chapter 6: Impact of chronic illness 149
Introduction 149
6.1. Effects of chronic illness 149
Acute versus chronic illness 149
xivPsychological and social issues 150
Adaptability and uncertainty 151
Nurse’s role in alleviating uncertainty 151
Coping strategies 152
6.2. Spirituality 153
Spiritual needs of the sick 153
6.3. Death in the dialysis unit 154
Withdrawal of treatment 155
Chapter 7: Dialysing the acutely ill patient 159
ntroduction 159
7.1. Indications for treatment 159
Aim of treatment 160
7.2. The haemodialysis prescription 161
Initial considerations 161
Important considerations 161
Dialysate composition 162
Post dialysis assessment 165
7.3. The use of profiling techniques 165
Sodium profiles 166
Ultrafiltration profiles 167
Bicarbonate profiles 167
Chapter 8: Acute complications of haemodialysis 171
ntroduction 171
8.1. Hypotension 171
Occurrence 171
Pathophysiology of hypotension 172
Management of hypotension 174
8.2. Dialysis disequilibrium 175
Development and clinical manifestations 175
Management 176
8.3. Haemolysis 177
Definition and occurrence 177
Signs, symptoms and management 178
8.4. Membrane reactions 178
Blood gas abnormalities 178
8.5. Air embolism 179
Causes and frequency 179
Management 180
xv8.6. Seizures 180
Predisposing haemodialysis factors 180
Predisposing patient factors 181
Therapeutic considerations 183
8.7. Cardiac arrhythmias 183
Diabetes and cardiac dysfunction 184
Chapter 9: Assessment of therapy 187
Introduction 187
9.1. Historical perspective 187
9.2. The kinetics of urea generation and removal 189
Why measure urea? 189
9.3. Determining the dialysis prescription 192
Factors to consider 192
Deciding on the amount 193
9.4. Problems and pitfalls 194
Traps for new players 194
SECTION 3
Chapter 1: Haemofiltration 201
Introduction 201
1.1. Overview of haemofiltration 201
Historical perspective 201
Transport principles 202
Fluid replacement 203
Circuit maintanence 204
Patient or machine-generated circuitry 204
Terminology 205
1.2. Continuous therapies 206
Ultrafiltration 206
1.3. Renal replacement therapies 206
Intermittent therapies 207
The future for patients with end stage renal failure 207
Health care ethics and distributive justice 208
Chapter 2: Plasma exchange and haemoperfusion 211
Introduction 211
2.1. Apheresis 211
Treatment methodology 212
Therapeutic application 214
xviReplacement fluids 216
Alternative techniques 216
Risks of apheresis 218
2.2. Haemoperfusion 218
Overview of poisoning 218
Choice of therapy 219
Principles of haemoperfusion 220
Toxins removed by haemoperfusion 221
Complications 221
SECTION 4
Chapter 1: Anatomy and physiology 227
Introduction 227
1.1. Brief history 227
How it all started 227
Early peritoneal dialysis 229
1.2. Anatomy and physiology 230
Anatomy 230
Physiology of solute movement 232
Physiology of water movement 234
Chapter 2: Initiation and maintenance of therapy 237
Introduction 237
2.1. Peritoneal access 237
Beginning principles 237
Catheter design 239
2.2. Initiation of therapy 240
Preoperative care 240
Intraoperative care 241
Postoperative care 241
Observation and protection of the exit site 242
2.3. Patient selection 244
Cognition and learning 244
The impact on carers and society 246
Chapter 3: Treatment: modalities modifications and measurement 249
Introduction 249
3.1. Choice of therapy 249
General principles 249
The peritoneal equilibration test 251
xviiTreatment options 252
Continuous ambulatory peritoneal dialysis 252
Continuous cyclic peritoneal dialysis 252
Intermittent peritoneal dialysis 253
Tidal peritoneal dialysis 253
3.2. Choice of dialysate and delivery apparatus 253
Conventional dialysate solutions 253
Recent introductions 255
Addition to the dialysate fluids 257
3.3. Assessment of therapy 258
What is adequate therapy? 258
How should ‘adequate therapy’ be achieved? 259
What other factors are important? 260
3.4. Limitations of treatment 261
Considerations 261
Chapter 4: Complications of therapy 263
4.1. Infective complications 263
Peritonitis 263
Exit site and tunnel infection 267
4.2. Noninfective complications 267
Short term 267
Long term 269
4.3. Contraindications to commencing or continuing therapy 271
Overview 271
Relative contraindications 272
SECTION 5
Chapter 1: The history of transplantation 277
Introduction 277
1.1. Overview of development 277
The first attempts 277
Immunosuppression 278
Related milestones 279
1.2. Terminology 280
Common terms and their meaning 280
Chapter 2: Recipient selection and preparation 283
Introduction 283
2.1. General issues 283Education 283
General medical and physical examination 284
Psychiatric evaluation 285
Recipient perceptions and expectations 288
2.2. Contraindications 288
Relative contraindications 288
Absolute contraindications 289
2.3. Matching the donor and recipient 290
Preamble 290
Histocompatibility complex 290
Cross match 291
Cytotoxic antibodies 292
Highly sensitised patients 292
The role of blood transfusion 293
Chapter 3: Donor selection and preparation 295
Introduction 295
3.1. Cadaveric (beating heart) donation 295
Criteria for brain death 296
Donor criteria 297
Organ preservation 299
Organ allocation 301
3.2. Living donors 302
The related donor 302
The unrelated donor 302
2.3. Other options 304
The cadaveric (nonbeating heart) donor 304
Chapter 4: The perioperative period 307
Introduction 307
4.1. The immediate preoperative period 308
The intraoperative period 309
Transplantation technique 309
Drug and fluid management 310
4.3. The immediate postoperative period 311
Intensive Care Unit 311
Renal Ward 311
Chapter 5: Complications of transplantation 315
Introduction 3155.1. Primary lack of function 315
Hyperacute rejection 315
Acute tubular necrosis 316
Vascular complications 317
5.2. Early dysfunction 317
Acute rejection 317
Urinary complications 317
Acute renal failure 318
5.3. Late dysfunction 318
Chronic rejection 318
5.4. Infection 319
5.5. Long term complications 321
SECTION 6
Chapter 1: Renal function in the child 327
Introduction 327
1.1. The development of renal function 327
Metabolic and fluid balance 328
1.2. Causes of renal failure 328
Acute renal failure 328
Chronic renal failure 329
1.3. Facts and figures for Australian children 330
Chapter 2: Extracorporeal management 333
Introduction 333
2.1. Haemodialysis 333
Beginning principles 333
The dialysis prescription 334
2.2. Vascular access 336
Some differences between children and adults 336
2.3. Anticoagulation 338
For haemodialysis 338
For haemofiltration 339
2.4. Complications 339
Physiological complications of haemodialysis 339
2.5. Haemofiltration 340
Slow continuous therapies 340
Chapter 3: Paediatric peritoneal dialysis 343
Introduction 343
3.1. The paediatric peritoneal membrane 343A brief history of paediatric peritoneal dialysis 343
Anatomy and physiology 344
3.2. Peritoneal access 345
Why peritoneal dialysis? 345
Catheters for acute renal failure 345
Catheters for end stage renal failure 345
3.3. Treatment modalities 347
Which therapy is best suited to the child? 347
The dialysis prescription 347
Assessment of adequacy 348
3.4. Complications 348
Problems related to peritoneal dialysis in children 348
Chapter 4: Paediatric renal transplantation 351
Introduction 351
4.1. Donor selection 351
The choice between living and cadaveric donors 351
Transplantation before or after dialysis 352
4.2. Surgical technique 352
Practical considerations 352
Anaesthetic considerations 353
Surgical considerations 353
Physiological considerations 354
4.3. Nursing management 354
Chapter 5: Physical and psychological consequences of renal disease in children 357
Introduction 357
5.1. Physical complications of end stage renal disease 358
Anaemia 358
Growth 358
Renal osteodystrophy 359
Acid base regulation 359
Nutrition 360
5.2. Psychological complications of chronic illness 361
SECTION 7
Chapter 1 367
Use of complementary therapies and alternative medicine in renal disease 367
Introduction 367LIST OF TABLES AND FIGURES
Tables
Table 1.4.1: Clinical evaluation and treatment of glomerulonephritis 52
Table 4.3.1: Solute values commonly available in dialysate solutions 254
Table 4.2.1: Infective organisms and the percentage of infections they cause
(Zamaloukas & Fox 1999)
Table 5.3.1: Causes of brain death in Australia and New Zealand for 1998
from ANZDATA 1999 298
Table 7.1.1: Commonly used herbal preparations and the adverse events
relevant to renal disease associated with their use 368
Figures
Figure 1.4.1: The changes observed in glomerulonephritis 49
Figure 1.4.2: Angiotensin cascade 59
Figure 2.1.1: Contribution of venous positive pressure resistance to
water removal 104
Figure 2.1.2: Contribution of negative dialysate pressure to water removal 105
Figure 2.1.3: Contribution of positive dialysate pressure to water removal 106
Figure 2.5.1: Provision of buffer via the addition of bicarbonate. 141
This was an early method of preparing the dialysate using
lactate and CO
2 to prevent bicarbonate precipitations
(Terrill 1999)
Figure 2.5.2: Metabolism of acetate as it enters the Krebs cycle 146
Figure 2.9.1: The formula used to determine dialyser clearance rates 191
Appendices
Appendix A: Classification of normal and diseased exit sites, Peritoneal 372
Dialysis International vol 16, supplement 3 1996 modified,
with permission, by Baxter Corporation 1996.
Index 373
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