Bab 5 Renal Replacement Therapy

Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009

BAB 5

5. RENAL REPLACEMENT THERAPY

When patients have reached and stage renal disease are gibe option

to decide or decided by the nephrologists based on patient conditions

for a renal replacement theraphy. The option that are available are :-

5.1 Continuous Ambulatory Peritoneal Dialysis

- A tenckoff catheter is inserted into the peritoneum cavity and after

10 – 14 days, a training is given by a nurse.

- It’s a dialysis process that dose non stop. It’s continuously cleans

the blood 24 hours a day.

- Patient is free between 2 exchanges.

- Peritoneal membrane works like a semi-permeable filter.

5.2 Haemodialysis

- Haemodialysis is a procedure for removing dissolved waste or

contaminants ( eg urea, creatinine uric acid) from the blood

mainly by diffusion through a semipermeable membrane (dialyser

membrane) by using dialysate as a buffer when the kidney

filtration function fail. Diffusion, ultrafiltration and osmosis will be

happen during haemodialysis.

- A permanent access is created either ateriovenous fistula or

Brachiocephalic fistula or a temporary acces is inserted to the

patient haemodialysis procedure done.

____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman


Process A Semipermeable Membrane

(Sumber: http//www.shodor.org/master/biomed/physio/haemodialysis/fig2.jpg)

5.3 Kidney Transplant

Is the transfer of a healthy from the donor to patient with end stage

kidney failure. Only kidney transplant can replace all of the functions

of the kidney.



Schedule : Anemia for year 1999

Date HB Sr IRON Sr Ferritin Sr IPTH TIBC(g/dL) (umol/L) (µg/L) (pg/ml) (µmmol/L)

25.05.99 9.4 14 - - 54

06.07.99 8.1 29 - 45

12.08.99 8.1 20 - - 42

07.10.99 11.3 10 - - 45

22.11.99 13.2 10 - - 48



07.03.00 8.5 - - - -

13.04.00 8.9 18 - - 46

08.08.00 9.2 23 - - 49

07.09.00 10.8 10 - - 49

Schedule : Hemoglobin 1999 & 2000



MINISTRY OF HEALTH, MALAYSIA

DIALYSIS LABORATORY RESULTS CHARTHospital Raja Puteri Bainun, Ipoh, PerakName: Koh Kam Wah I/C No. : 590530-08-6095

LAB Test Date25.05.99 06.07.99 12.08.99 07.10.99 22.11.99

BiochemistryUrea pre

1.7 – 8.3 mmol/L21 20.2 18.7

Urea postSodium pre

135-145 mmol/L147 147 145

Sodium postPotassium pre

3.5-5.0 mmol/L4.5 4.6 4.6

Potassium postCreatinine pre

64-122 mmol/L911 856 994

Creatinine postChloride pre/Co2 96-108 mmol/L 107 105 98Uric Acid 142-416 mmol/L 302 443 401Total Protein 66-87 g/L 61 72 71Albumin 35-50 g/L 37 42 43Total Bilirubin Up to 21 mmol/L 5 1 1Alk phosphatase 53-128 U/L 101 91 90SGOT/SGPT Up to 42 U/L 12/13 20/19Calcium 2.0-2.6 mmol/L 1.96 2.40 2.43Inorganic Phosphate 0.8-1.6 mmol/L 2.06 2.12 2.05Ca x Po4 1.0 1.1 1.4Total cholesterol < 5.7 mmol/L 5.2 6.6 5.6Triglyceride < 1.7 mmol/L 1.9 1.5LDL – Cholesterol < 3.9 mmol/L 1.7HDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS

HAEMATOLOGYHB g/dL 9.4 8.1 8.1 11.3 13.2TWDC 5300 5.5 4.6 4.5 4.8HCT 27.3 24.0 24.6 33.0 38.3Platelets THSD/mm³ 156,000 126,000 164,000 182,000 181,00MCV 91.7 93.3 98.3 96.0 90.5MCHC 34.4 33.8 33.0 34.2 34.5% Hypochromic RBCRetic/LymphoSr. IRON 10.6-28.3 µmol/L 14 29 20 10 10TIBC 44-75 µmmol/L 54 45 42 45 48Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml 522 665

Serum Aluminium

Pre DFOPost DFODelta

VIROLOGY / SEROLOGYHBs Ag -ve -veAnti HBsHBc AgAnti HCV -ve -veAnti HIV -ve -veCMVBlood group ‘o’



MINISTRY OF HEALTH, MALAYSIA DIALYSIS LABORATORY RESULTS CHART Hospital Raja Puteri Bainun, Ipoh, PerakName: Koh Kam Wah I/C No. : 590530-08-6095

LAB Test Date07.03.00 13.04.00 08.08.00 07.09.00

BiochemistryUrea pre

1.7 – 8.3 mmol/L20.2 22.2

Urea postSodium pre

135-145 mmol/L140 143


3.5-5.0 mmol/L4.5 4.6

Potassium postCreatinine pre

64-122 mmol/L1150

Creatinine postChloride pre/Co2 96-108 mmol/L 97 106Uric Acid 142-416 mmol/L 453 591Total Protein 66-87 g/L 70 71Albumin 35-50 g/L 41 39Total Bilirubin Up to 21 mmol/L 9 1Alk phosphatase 53-128 U/L 129 104SGOT/SGPT Up to 42 U/L 14/15Calcium 2.0-2.6 mmol/L 2,37 2.29Inorganic Phosphate 0.8-1.6 mmol/L 2.14 1.22Ca x Po4 0.9 1,1Total cholesterol < 5.7 mmol/L 6.0 5.9Triglyceride < 1.7 mmol/L 1.4 1.5LDL – Cholesterol < 3.9 mmol/LHDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS

HAEMATOLOGYHB g/dL 8.5 8.9 9.2 10.8TWDC 4.1 5.4 4.3 5.7HCT 24.2 23,7 26.0 30Platelets THSD/mm³ 148,000 168,000 162,000 225,000MCV 86.7 89.4 90.6 89.6MCHC 3.51 37.6 35.4 36% Hypochromic RBCRetic/Lympho 2.87 3.35Sr. IRON 10.6-28.3 µmol/L 18 23 10TIBC 44-75 µmmol/L 46 49 49Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml 456

Serum Aluminium


VIROLOGY / SEROLOGYHBs Ag -ve -veAnti HBsHBc AgAnti HCV -ve -veAnti HIV -ve -veCMV -ve -veVDRLBlood group





I LAB Test Date

03.01.08 03.04.08 10.08.08 16.10.08Biochemistry

Urea pre1.7 – 8.3 mmol/L

15.9 22.90 25.2 23.5Urea post 3.8 5.0 6.8 5.9Sodium pre

135-145 mmol/L3.8 5.0 6.8 5.9


3.5-5.0 mmol/L142 139 140 144

Potassium post 3.10 2.6 4.8 2.8Creatinine pre

64-122 mmol/L1014.0 1187.0 1227.0 1290

Creatinine postChloride pre/Co2 96-108 mmol/L 99 94 92 92Uric Acid 142-416 mmol/L 435 512 500 570Total Protein 66-87 g/L 75 73 79 79Albumin 35-50 g/L 46 46 40 47Total Bilirubin Up to 21 mmol/L 15.6 14.0 10.4 11.8Alk phosphatase 53-128 U/L 83 100 74 69Alanine Transminase Up to 42 U/L 21 16 20 28Calcium 2.0-2.6 mmol/L 2.32 2.28 2.45 2.82Inorganic Phosphate 0.8-1.6 mmol/L 1.60 1.53 2.37 1.75Magnesium 0.7-1.10mmol/L 1.09 1.04 1.12 .135Total cholesterol < 5.7 mmol/L 3.20 3.40 4.0 3.7Triglyceride < 1.7 mmol/L 1.40 1.60 4.4 2.7LDL – Cholesterol < 3.9 mmol/L 1.46 1.47 0.90 1.4HDL – Cholesterol > 1.4 mmol/L 1.10 1.20 1..10 1.10% of HDL > 25 mmol/L 2.91 2.83 3.64 3.36FBS 3.9 5.0 4.2 4.6SGOT 12.0 14.0 10 16

HAEMATOLOGYHB g/dL 12.1 11.7 12.2 11.7TWDC 5.1 8.1 7.6 6.5HCT 36.7 34.1 37.5 35.7Platelets THSD/mm³ 173 188 191 198MCV 99.6 95.9 101.0 102.6MCHC 33.0 34.4 32.6 32.8% Hypochromic RBCRetic/Lympho 13.4 12.7 3.71 3.47Sr. IRON 10.6-28.3 µmol/L 19.10 13.40 14 21TIBC 44-75 µmmol/L 39.40 44.40 44.0 50Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/L 644.7 705.0 743.7 641.9E.S.R mm/hrSerum intact PTH 13-54 pg/ml 407 637.60 242.8 104.70

Serum Aluminium


VIROLOGY / SEROLOGYHBs Ag -ve -ve -ve -veAnti HBsHBc AgAnti HCV -ve -ve -ve -veAnti HIV -ve -ve -ve -veCMVVDRL -ve -ve -ve -veBlood group





LAB Test Date

05.02.09 07.05.09 13.08.09Biochemistry


26.0 26.7 23.3Urea post 6.2 6.6 5.1Sodium pre

135-145 mmol/L139 138 139

Sodium post 143 141 143Potassium pre

3.5-5.0 mmol/L4.0 4.3 4.4

Potassium post 2.8 2.9 3.1Creatinine pre

64-122 mmol/L1250 1275 1266

Creatinine post 364 380 355Chloride pre/Co2 96-108 mmol/L 90/91 90/95 95/98Uric Acid 142-416 mmol/L 598 611 503Total Protein 66-87 g/L 75 74 70Albumin 35-50 g/L 45 44 47Total Bilirubin Up to 21 mmol/L - 13.9 14.5Alk phosphatase 53-128 U/L - 66 64Alanine Transminase Up to 42 U/L 31 39 20Calcium 2.0-2.6 mmol/L 2.12 2.45 2.55Inorganic Phosphate 0.8-1.6 mmol/L 2.18 1.49 1.37Magnesium 0.7-1.10mmol/L 1.17 1.27 1.49Total cholesterol < 5.7 mmol/L 4.5 4.5 3.4Triglyceride < 1.7 mmol/L 9.52 2.86 2.30LDL – Cholesterol < 3.9 mmol/L 0.5 2.4 1.5HDL – Cholesterol > 1.4 mmol/L 0.70 0.80 0.70% of HDL > 25 mmol/L 6.43 5.63 3.78FBS 4.8 4.1 4.4SGOT 16 15 11

HAEMATOLOGYHB g/dL 12.5 13.2 12.2TWDC 5.6HCT 36.9 40.0 35.7Platelets THSD/mm³ 193 169 183MCV 103.8 104.0 104.5MCHC 33.8 33.0 34.2% Hypochromic RBCRetic/Lympho 3.56 3.04 3.41Sr. IRON 10.6-28.3 µmol/L 13 26 14TIBC 44-75 µmmol/L 50 46 33Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/L 2542.0 1504.0E.S.R mm/hrSerum intact PTH 13-54 pg/ml 440.80 453.90

Serum Aluminium


VIROLOGY / SEROLOGYHBs Ag -ve -ve -veAnti HBsHBc AgAnti HCV -ve -ve -veAnti HIV -ve -ve -veCMVVDRL -ve -ve -veBlood group




DIALYSIS LABORATORY RESULTS CHART

Hospital Umum Sarawak

Name: Jachin ak. Kirat I/C No. : 800107-13-5235 LAB Test Date

23.08.04 02.09.04 06.10.04Biochemistry


Urea postSodium pre

135-145 mmol/LSodium postPotassium pre

3.5-5.0 mmol/LPotassium postCreatinine pre

64-122 mmol/LCreatinine postChloride pre/Co2 96-108 mmol/LUric Acid 142-416 mmol/LTotal Protein 66-87 g/LAlbumin 35-50 g/LTotal Bilirubin Up to 21 mmol/LAlk phosphatase 53-128 U/LAlanine Transminase Up to 42 U/LCalcium 2.0-2.6 mmol/LInorganic Phosphate 0.8-1.6 mmol/LCa x Po4Total cholesterol < 5.7 mmol/LTriglyceride < 1.7 mmol/LLDL – Cholesterol < 3.9 mmol/LHDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS

HAEMATOLOGYHB g/dLTWDCHCTPlatelets THSD/mm³ MCVMCHC% Hypochromic RBCRetic/LymphoSr. IRON 10.6-28.3 µmol/LTIBC 44-75 µmmol/LTransferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml

Serum Aluminium


VIROLOGY / SEROLOGYHBs AgAnti HBsHBc AgAnti HCVAnti HIVCMV

Blood group




DIALYSIS LABORATORY RESULTS CHART

Hospital Umum Sarawak

Name: Jachin ak. Kirat I/C No. : 800107-13-5235 LAB Test Date

25.02.04 26.07.04 07.06.04 10.06.04 15.08.04Biochemistry


Urea postSodium pre

135-145 mmol/LSodium postPotassium pre

3.5-5.0 mmol/LPotassium postCreatinine pre

64-122 mmol/LCreatinine postChloride pre/Co2 96-108 mmol/LUric Acid 142-416 mmol/LTotal Protein 66-87 g/LAlbumin 35-50 g/LTotal Bilirubin Up to 21 mmol/LAlk phosphatase 53-128 U/LAlanine Transminase Up to 42 U/LCalcium 2.0-2.6 mmol/LInorganic Phosphate 0.8-1.6 mmol/LCa x Po4Total cholesterol < 5.7 mmol/LTriglyceride < 1.7 mmol/LLDL – Cholesterol < 3.9 mmol/LHDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS

HAEMATOLOGYHB g/dLTWDCHCTPlatelets THSD/mm³ MCVMCHC% Hypochromic RBCRetic/LymphoSr. IRON 10.6-28.3 µmol/LTIBC 44-75 µmmol/LTransferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml

Serum Aluminium


VIROLOGY / SEROLOGYHBs AgAnti HBsHBc AgAnti HCVAnti HIVCMV

Blood group





25.05.99 9.4 14 - - 54

06.07.99 8.1 29 - 45

12.08.99 8.1 20 - - 42

07.10.99 11.3 10 - - 45

22.11.99 13.2 10 - - 48



07.03.00 8.5 - - - -

13.04.00 8.9 18 - - 46

08.08.00 9.2 23 - - 49

07.09.00 10.8 10 - - 49

Schedule : Hemoglobin 1999 & 2000



5.4 KT / V

Regular measurement of the delivered dose of haemodialysis. The

dialysis care team should routinely measure and monitor the delivered

dose of haemodialysis at last 3 monthly. The single pool Kt/V is a

dimensionless ratio representing fractional urea clearance.

a) “K” is the dialysis blood water urea clearance by using the

diayzer and speed the blood pump and dialysate flow for

clearance the urea from the patient blood to dialysate.by using

principle “diffusion”, “ultrafiltration”, “convection” and osmosis.

b) “T” is dialysis session length (hours).The longer hours (4

hours) patient diaysis, patient will better urea clearance.

c) “V” is the total volume of blood cleared during the dialysis

session. ( the urea distribution volume )

Schedule : Haemodialysis urea modeling

Date Dialyzer Blood flow Dialysate flow Urea Kt/v (ml/min) (ml/min) clearance

(ml/min)



21.11.03 F8 350 500 238 1.45

07.01.04 F8 350 500 241 1.65

05.04.04 F8 350 500 239 1.54

12.08.04 F8 350 500 237 1.44

Schedule : Haemodilysis urea modeling

Date BUN (mg/dl) Berat badan (kg)

Pre dialysis Post dialysis Pre dialysis Post dialysis

21.11.03 37 10 50.0 49.0

07.01.04 53 14 52.5 49.0

05.04.04 61 16 52.0 50.6

12.08.04 47 13 53.0 52.6

Graf : Kt/v Level



5.5 Nursing intervention for anaemia

a) Monitor blood status for maintain adequate iron store in blood.

Serum ferritin – Iron store in the body

Serum Iron - To maintain target hemoglobin and iron

levels in haemodialysis patients. Oral iron given (100mg

– 200mg ) or intravenous (IV Dextran 100 mg every week

for 10 doses)

Transferrin Saturation ( TSAT) - Reflects availability of

iron. Minimum target TSAT is >20%.

b) Give epoetin eg injection eprex after iron difficiency treated .

Maximum dose 1200ii/week or 4000ii/day for maintain

hemoglobin.

c) Adequate haemodialysis - Time dialysis should be 4 hours for

every treatment, 3 times per week, blood pump high (300 –

400cc/min), diaylsate flow 500 – 800 cc/min and using high flux

diayser for good clearance.



d) Prevent blood loss - Minimize the volume of blood samplings

taken. Return blood after complete haemodialysis as

completely and as soon as possible. Monitor heparin dose

during haemodialysis to prevent clotting during dialysis. Pre test

the diayser to prevent leakage.

e) Health Education - Take food contain high in iron eg internal

organ, egg ect. Iron tablet should not taken with phostphate

binder ( Calcium carbonate ) because calcium carbonate can

bind iron together. Iron tablet take with citrus fruit and avoid

drink with caffeine eg coffee and tea.

f) Monitor FBC and Serum Iron, TIBC and Serum Ferrittin every 3

monthly – To know status of hemoglobin patient.

5.6 Nursing Intervention For Reduce Phosphate In Patient Diet.

Limit intake of phosphate to less then 1000 mg/day. This will

also help phosphate binders to work more efficiently.

Avoid eating very large servings of meat, if possible, unless

advised otherwise by dietitian or doctor.

Eat your phosphate binders with meals which contain high

protein foods such as fish, chicken, meat or with complet meals

such as nasi lemak.

Avoid eating the cartilage and soft bones of fish, shellfish and

meat.

Reduce intake of cocoa, chocolate-based beverages and cola

drinks.



Limit dairy food products such as milk, curd/yogurt and cheese.

Use non-dairy creamer to replace milk in your beverages.

Always choose foods with low or moderate content of

phosphate.

If your blood phosphate level is high, avoid foods that have high

phosphate content.

Increasing the portion size of the food will increase the amount

of phosphate you are eating. While 1 piece of kuih may have

low phosphate content, taking many pieces will increase your

phosphate intake.

Controlling PTH levels prevents calcium from being withdrawn from the

bones. Usually, overactive parathyroid glands are controllable with a change

in diet, dialysis treatment or medication. If PTH levels cannot be controlled,

the parathyroid glands may need to be removed surgically. If your kidneys

are not making adequate amounts of active vitamin D, you can take synthetic

vitamin D (eg alfacalcidol) as a pill or in an injectable form. Renal

osteodystrophy can also be treated with changes in diet. Reducing dietary

intake of phosphorus is on of the most important steps in preventing bone

disease.

5.7 Health Education

How to care of his AVF..



Exercise

Advice patient to exercise his AVF hand regularly with a

rubber ball to stimulate the development of his AVF

Do Not Wear Tight long sleeves shirt with tight button.

Not to sleep with the AVF hand under the pillow.

No BP or blood taking on the AVF hand.

Avoid heavy lifting - Never use the AVF hand to carry

heavy things, it can spoilt the AVF.

Monitor for Thrill - Advice patient to feel for the thrill all

the time especially in the earlier part. If no more thrill

felt, ask the patient to come quickly to hospital and refer

him to the surgeon. The surgeon will remove any blood

clot and the AVF might works again after that.

Cleanliness - Advise patient to keep his AVF hand

clean at all times to prevent infection.


Bab 5 Renal Replacement Therapy

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