RCS 6080 Medical and Psychosocial Aspects of

Rehabilitation Counseling

Renal FailureRenal Failure

Function of Kidneys

Remove toxic waste productsRemove toxic waste products Remove excess water and saltsRemove excess water and salts Play a part in controlling blood pressurePlay a part in controlling blood pressure Produce erythropoetin (epo) which Produce erythropoetin (epo) which

stimulates red cell productionstimulates red cell production Helps to keep calcium and phosphate in Helps to keep calcium and phosphate in

balance for healthy bonesbalance for healthy bones Maintains proper pH for the bloodMaintains proper pH for the blood

Definitions Azotemia: Elevated blood urea nitrogenAzotemia: Elevated blood urea nitrogen

(BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL)(BUN>28mg/dL) & Creatinine (Cr>1.5mg/dL) Uremia: azotemia with symptoms or signs of renal failureUremia: azotemia with symptoms or signs of renal failure End Stage Renal Disease (ESRD): uremia requiring End Stage Renal Disease (ESRD): uremia requiring

transplantation or dialysistransplantation or dialysis Chronic Renal Failure (CRF): irreversible kidney Chronic Renal Failure (CRF): irreversible kidney

dysfunction with azotemia >3 mos.dysfunction with azotemia >3 mos. Creatinine Clearance (CCr): rate of filtration of creatinine Creatinine Clearance (CCr): rate of filtration of creatinine

by the kidney (marker for GFR)by the kidney (marker for GFR) Glomerular Filtration Rate (GFR): the total rate of Glomerular Filtration Rate (GFR): the total rate of

filtration of blood by the kidney.filtration of blood by the kidney.

Nephrons Nephrons are the units in the kidney that transfer Nephrons are the units in the kidney that transfer

waste products from the blood to urine.waste products from the blood to urine. A human kidney has approximately one million A human kidney has approximately one million

nephrons.nephrons. Glomeruli are the filtration units of the nephron. Glomeruli are the filtration units of the nephron.

The Glomerulus (first structure of the nephron) is a tuft of capillaries. Blood enters the glomerulus by the afferent arteriole and exits by the efferent arteriole

Bowman’s capsule is a tough layer of epithelial Bowman’s capsule is a tough layer of epithelial cells that surrounds the glomerulus ;there is a cells that surrounds the glomerulus ;there is a small holding area for the initial filtrate in small holding area for the initial filtrate in between the capillary walls of the glomerulus between the capillary walls of the glomerulus and the inner layer of Bowman’s capsule; this and the inner layer of Bowman’s capsule; this area is called Bowman’s space. Fluid and solutes area is called Bowman’s space. Fluid and solutes filtered by the glomerulus collect in this space. filtered by the glomerulus collect in this space. The space connects to the proximal convoluted The space connects to the proximal convoluted tubule, which is the first section of the nephron’s tubule, which is the first section of the nephron’s tube system tube system

a network of tubules extends from Bowman’s a network of tubules extends from Bowman’s capsule: capsule:

proximal convoluted tubule (PCT)proximal convoluted tubule (PCT) Loop of Henle—has a descending and Loop of Henle—has a descending and

ascending limb ascending limb distal convoluted tubuledistal convoluted tubule Collecting ductCollecting duct

Renal Failure Acute Renal FailureAcute Renal Failure

Prerenal azotemiaPrerenal azotemia An abnormally high level of An abnormally high level of

nitrogen-type wastes in the nitrogen-type wastes in the bloodstream. It is caused by bloodstream. It is caused by conditions that reduce blood conditions that reduce blood flow to the kidneys.flow to the kidneys.

Postrenal azotemiaPostrenal azotemia An obstruction of some kind An obstruction of some kind

(i.e., bladder cancer, uric acid (i.e., bladder cancer, uric acid crystals, urethral stricture etc)crystals, urethral stricture etc)

Intrinsic Renal DiseaseIntrinsic Renal Disease Usually glomerular diseaseUsually glomerular disease Usually leads to End Stage Usually leads to End Stage

Renal DiseaseRenal Disease

Chronic Renal Failure Diabetic NephropathyDiabetic Nephropathy

50K cases of DN ESRD annually50K cases of DN ESRD annually Diabetes most common contributor to ESRDDiabetes most common contributor to ESRD >30% of ESRD cases attributed to Diabetes>30% of ESRD cases attributed to Diabetes

HypertensionHypertension CFR with Hypertension causes 23% of ESRD annuallyCFR with Hypertension causes 23% of ESRD annually

Glomerulonephretis: 10%Glomerulonephretis: 10% Polycystic Kidney Disease: 5%Polycystic Kidney Disease: 5% Rapidly progressive glomerulonephrities (vasculitis): 2%Rapidly progressive glomerulonephrities (vasculitis): 2% Renal Vascular Disease (i.e., renal artery stenosis)Renal Vascular Disease (i.e., renal artery stenosis) MedicationsMedications Analgesic Nephropathy (progression after many years)Analgesic Nephropathy (progression after many years) Pregnancy: high incidence of increased creatitine and HTN during pregnancy Pregnancy: high incidence of increased creatitine and HTN during pregnancy

associated with CRFassociated with CRF

Chronic Renal Failure

CRF is defined as a permanent reduction in glomerular filtration rate (GFR) sufficient to produce detectable alterations in well-being and organ function. This usually occurs at GFR below 25 ml/min.

About 100 to 150 per million persons in the U.S. About 100 to 150 per million persons in the U.S. develop CRF annually develop CRF annually

Average annual cost is $25,000 – 35,000 per Average annual cost is $25,000 – 35,000 per patient per year patient per year

Stages of Chronic Renal Failure

1.1. Silent – GFR up to 50 ml/min.Silent – GFR up to 50 ml/min.

2.2. Renal insufficiency – GFR 25 to 50 Renal insufficiency – GFR 25 to 50 ml/min.ml/min.

3.3. Renal failure – GFR 5 to 25 ml/minRenal failure – GFR 5 to 25 ml/min

4.4. End-stage renal failure – GFR less than 5 End-stage renal failure – GFR less than 5 ml/min.ml/min.

Diabetic Nephropathy

What can be done to reduce the risk of problems? Blood glucose control Blood pressure control Using ACE inhibitors and AT II antagonists Diet Controlling blood lipids and cholesterol Smoking

Treatment for Diabetic NephropathyStageStage AssessmentAssessment TreatmentTreatment

No ProteinuriaNo Proteinuria Monitor BP & GlucoseMonitor BP & Glucose

Screen for Screen for micoalbumininuriamicoalbumininuria

Hypertension drugs if Hypertension drugs if needed (BP should be needed (BP should be 130/85 or lower). Dietary 130/85 or lower). Dietary advice for sugar and fat, advice for sugar and fat, stop smokingstop smoking

MicroalbuminuriaMicroalbuminuria Close monitoring of BP, Close monitoring of BP, Glucose and blood lipids, Glucose and blood lipids, monitor urinary proteins monitor urinary proteins & CCr& CCr

Add more Hypertension Add more Hypertension drugs if needed needed. drugs if needed needed. Monitor cholesterol and Monitor cholesterol and add ACE inhibitor if add ACE inhibitor if neededneeded

ProteinuriaProteinuria Close monitoring of BP, Close monitoring of BP, glucose and blood lipids, glucose and blood lipids, monitor urinary protein monitor urinary protein and 24 CCrand 24 CCr

BP should be lower than BP should be lower than 125/75, low protein diet125/75, low protein diet

Declining kidney functionDeclining kidney function Prepare for dialysis &/or Prepare for dialysis &/or transplanttransplant

Metabolic changes

Na+ excretion initially increasedNa+ excretion initially increased Edema occurs when GFR continues to diminish.Edema occurs when GFR continues to diminish. NH4+ excretion declines adding to metabolic NH4+ excretion declines adding to metabolic

acidosis.acidosis. Bone CaCO3 begins to act as a buffer for the Bone CaCO3 begins to act as a buffer for the

acidosis and leading to chronic bone loss and bone acidosis and leading to chronic bone loss and bone lesions develop (renal osteodystrophy).lesions develop (renal osteodystrophy).

Accumulations of normally secreted uremic toxinsAccumulations of normally secreted uremic toxins

Uremic Syndrome

Uremia occurs in stage 3 & 4 of CRF. It Uremia occurs in stage 3 & 4 of CRF. It means literally “urine in the blood”means literally “urine in the blood” Symptomatic azotemiaSymptomatic azotemia Fever, MalaiseFever, Malaise Anorexia, NauseaAnorexia, Nausea Mild neural dysfunctionMild neural dysfunction Uremic pruritus (itching)Uremic pruritus (itching)

Associated problems with CFR ImmunosuppressionImmunosuppression

Increased risk of infectionIncreased risk of infection People with CFR should be vaccinated regularlyPeople with CFR should be vaccinated regularly

AnemiaAnemia Due to reduced erythropoietin production by kidney. Usually doesn’t occur until Due to reduced erythropoietin production by kidney. Usually doesn’t occur until

6-12 mos prior to dialysis6-12 mos prior to dialysis Hyperuricemia (Gout)Hyperuricemia (Gout)

Increased uric acid in systemIncreased uric acid in system Pain in joints, may contribute to renal dysfunctionPain in joints, may contribute to renal dysfunction

HyperphosphatemiaHyperphosphatemia Increased parathyroid hormone levelsIncreased parathyroid hormone levels Increased phosphate load from bone metabolismIncreased phosphate load from bone metabolism

HypertensionHypertension Poor coagulationPoor coagulation ProteinuriaProteinuria

Chronic Renal Failure Chronic Renal Failure and Its Chronic Renal Failure and Its

ProgressionProgression

Functional Adaptation to Functional Adaptation to Nephron LossNephron Loss Increased amount of sodium Increased amount of sodium

that escapes reabsorptionthat escapes reabsorption Excessive amount of Excessive amount of

potassium in bloodpotassium in blood Increased ammonia Increased ammonia

concentrationconcentration Calcium and phosphorus Calcium and phosphorus

metabolism are markedly metabolism are markedly alteredaltered

Treatment of Chronic Renal Failure

HypertensionHypertension Metabolic AcidosisMetabolic Acidosis AnemiaAnemia Renal OsteodystrophyRenal Osteodystrophy Uremic NeuropathyUremic Neuropathy Sexual DysfunctionSexual Dysfunction

Conservative Treatment

Dialysis Transplant

Hemodialysis Peritoneal Related Donor Cadaver Donor

Home Center

Treatment of End Stage Renal Failure HemodialysisHemodialysis

Uses a mechanized Uses a mechanized filter to remove filter to remove impurities from the impurities from the blood systemblood system

Essentially replaces Essentially replaces kidney with a machinekidney with a machine

Dialysis usually occurs Dialysis usually occurs a couple times per a couple times per week.week.

Hemodialysis

Vascular preparationVascular preparation Surgical procedures usually Surgical procedures usually

completed weeks before completed weeks before beginning hemodialysisbeginning hemodialysis

Treatment of End Stage Renal Failure

Peritoneal Peritoneal DialysisDialysis Uses the Uses the

abdominal abdominal cavity as a cavity as a filterfilter

Treatment of End Stage Renal Failure

TransplantationTransplantation

Treatment of End Stage Renal Disease

Survival of People with ESRDSurvival of People with ESRD Data show a mean expected remaining life span Data show a mean expected remaining life span

of just under 8 years for people 40-44 of just under 8 years for people 40-44 beginning dialysis and just over 4 years for beginning dialysis and just over 4 years for people 60-64people 60-64

Adequacy of DialysisAdequacy of Dialysis

NutritionNutrition

Chronic Renal Failure

Physical Rehabilitation – benefits of exercisePhysical Rehabilitation – benefits of exercise Vocational RehabilitationVocational Rehabilitation

The goal should be to help the person with chronic renal The goal should be to help the person with chronic renal failure to resume all the duties, responsibilities and failure to resume all the duties, responsibilities and benefits he or she enjoyed prior to the illnessbenefits he or she enjoyed prior to the illness

Gainful employment is extremely important for an adult Gainful employment is extremely important for an adult in the earning period of his or her life, to regain self-in the earning period of his or her life, to regain self-esteem and to interact with society confidentlyesteem and to interact with society confidently

Fear of losing financial benefits may deter some Fear of losing financial benefits may deter some people people

Some research has shown that multidisciplinary Some research has shown that multidisciplinary predialysis intervention leads to maintenance of jobpredialysis intervention leads to maintenance of job

Additional Resources and Information from the Web

Florida End Stage Renal Disease Network Florida End Stage Renal Disease Network (http://www.fmqai.com/ESRD/esrd.htm)(http://www.fmqai.com/ESRD/esrd.htm)

University Renal Research and Education Association University Renal Research and Education Association (www.urrea.org)(www.urrea.org)

National Institute of Diabetes & Digestive & Kidney Diseases National Institute of Diabetes & Digestive & Kidney Diseases (www.niddk.nih.gov)(www.niddk.nih.gov) National Kidney & Urologic Diseases Information National Kidney & Urologic Diseases Information

Clearinghouse (NKUDIC) (http://kidney.niddk.nih.gov/) Clearinghouse (NKUDIC) (http://kidney.niddk.nih.gov/) Life Options Rehabilitation Program (www.lifeoptions.org)Life Options Rehabilitation Program (www.lifeoptions.org) United Network for Organ Sharing (UNOS) United Network for Organ Sharing (UNOS)

(http://www.unos.org)(http://www.unos.org) American Society of Nephrology (www.asn-online.org)American Society of Nephrology (www.asn-online.org) National Kidney Foundation (www.kidney.org)National Kidney Foundation (www.kidney.org) JAN’s webpage (www.jan.wvu.edu/soar/other/renal.html)JAN’s webpage (www.jan.wvu.edu/soar/other/renal.html)