Continuous renal replacement therapy (CRRT) represents a family of modalities that provide continuous support of severely ill patients in ARF. It is used when hemodialysis is not feasible. CRRT works more slowly than hemodialysis and requires continuous monitoring. It is indicated for patients who are no longer responding to diuretic therapy, are in fluid overload, and/or are hemodynamically unstable.
Procedure
CRRT requires placement of a continuous arteriovenous hemofiltration (CAVH) catheter or continuous venovenous hemofiltration (CVVH) catheter and a mean arterial pressure of 60 mm Hg.
Other types of CRRT include:
■ Continuous arteriovenous hemodialysis (CAVHD)
■ Continuous venovenous hemodialysis (CVVHD)
■ Slow continuous ultrafiltration (SCUF)
■ Continuous arteriovenous hemodiafiltration (CAVHDF)
■ Continuous venovenous hemodiafiltration (CVVHDF)
Because it is difficult to obtain and maintain arterial access, CVVH or venous access is preferred.
CRRT provides for the removal of fluid, electrolytes, and solutes. CRRT differs from hemodialysis in the following ways:
■ It is continuous rather than intermittent, and large fluid volumes can be removed over days instead of hours.
■ Solute removal can occur by convection (no dialysate required) in addition to osmosis and diffusion.
■ It causes less hemodynamic instability.
→
■ It requires a trained ICU RN to care for patient but does not require constant monitoring by a specialized hemodialysis nurse.
■ It does not require hemodialysis equipment, but a modified blood pump is required.
■ It is the ideal treatment for someone who needs fluid and solute con- trol but cannot tolerate rapid fluid removal.
■ It can be administered continuously, for as long as 30–40 days. The hemofilter is changed every 24–48 hours.
Nursing Care
■ Monitor fluid and electrolyte balance.
■ Monitor intake and output every hour.
■ Weigh daily.
■ Monitor vital signs every hour.
■ Assess and provide care of vascular access site every shift.
Renal Transplant
A renal transplant is the surgical placement of a cadaveric kidney or live donor kidney (including all arterial and venous vessels and long piece of ureter) into a patient with end-stage renal disease (ESRD).
Operative Procedure
The surgery takes 4–5 hours. The transplanted kidney is usually placed in the right iliac fossa to allow for easier access to the renal artery, vein, and ureter attachment. The patient’s nonfunctioning kidney usually stays in place unless there is a concern about chronic infection in one or both kidneys.
Postoperative Care
■ Admit to ICU.
■ Monitor vital signs frequently as per ICU policy.
■ Monitor hourly urine output for first 48 hours.
■ Assess urine color.
■ Obtain daily urinalysis, urine electrolytes, urine for acetones, and urine culture and sensitivity.
■ Administer immunosuppressive drug therapy ( risk of infection).
■ Provide Foley catheter care.
■ Maintain continuous bladder irrigation as needed.
■ Strict intake and output.
■ Monitor daily weight.
■ Administer diuretics.
■ Obtain daily basic metabolic panel (BMP).
Complications
■ Rejection (most common and serious complication): A reaction between the antigens in the transplanted kidney and the antibodies in the recipient’s blood → tissue destruction → kidney necrosis.
■ Thrombosis to the major renal artery, may occur up to 2–3 days postop → may be indicated by sudden ↓ in urine output → emergent surgery is required to prevent ischemia to the kidney.
■ Renal artery stenosis → HTN is the manifestation of this complication → a bruit over the graft site or ↓ in renal function may be other indi- cators → may be repaired surgically or by balloon angioplasty.
■ Vascular leakage or thrombosis → requires emergent nephrectomy surgery.
■ Wound complications: Hematomas, abscesses → risk of infection → exertion on new kidney. Infection is major cause of death in trans- plant recipient. These patients are on immunosuppressive therapy → signs and symptoms of infection may not manifest in its usual way. Watch for low-grade fevers, mental status changes, and vague com- plaints of discomfort.
Nephrectomy
Radical nephrectomy is the removal of the kidney, the ipsilateral adrenal gland, surrounding tissue, and, at times, surrounding lymph nodes. Due to the increased risk of reoccurrence in the ureteral stump, a ureterecto- my may be performed as well.
Pathophysiology
Primary indication is for treatment of renal cell carcinoma (adenocarcino- ma of the kidney), in which the healthy tissue of the kidney is destroyed and replaced by cancer cells.
Secondary indication is for treatment of renal trauma → penetrating wounds or blunt injuries to back, flank, or abdomen injuring the kidney; injury or laceration to the renal artery → hemorrhage.
Clinical Presentation
■ Flank pain (dull, aching)
■ Gross hematuria
→
■ Palpable renal mass
■ Abdominal discomfort (present in 5%–10% of cases)
■ Hematuria (late sign)
■ Muscle wasting, weakness, poor nutritional status, weight loss (late signs)
Diagnostic Tests
■ Urinalysis (may show RBCs)
■ Complete blood count
■ Complete metabolic panel (CMP)
■ Erythrocyte sedimentation rate (ESR or sed rate)
■ Human chorionic gonadotropin (hCG) level
■ Cortisol level
■ Adrenocorticotropic hormone level
■ Renin level
■ Parathyroid hormone level
■ Surgical exploration
■ IV urogram
■ Nephrogram
■ Sonogram
■ CT of abdomen/pelvis with contrast
■ MRI
Postop Management
■ Monitor vital signs frequently.
■ Provide pain management.
■ Encourage patient to cough and deep breathe, and to use incentive spirometer every hour.
■ Encourage early mobilization.
■ Monitor intake and output strictly.
■ Assess for bleeding.
■ Administer IV fluids.
■ May require blood transfusion.
■ Obtain CBC every 6 hours x 24 hours, then every 12 hours for 24 hours early postop.
■ Monitor daily weight.
■ Monitor for adrenal insufficiency.
Cystectomy
A radical cystectomy is the removal of the bladder, prostate, and seminal vesicles in men; and the bladder, ureters, cervix, urethra, and ovaries in women. The ureters are diverted into collection reservoirs → urinary diver- sion (ileal conduit, continent pouch, bladder reconstruction [neobladder], ureterosigmoidostomy).
Pathophysiology
Primary indication is for treatment of carcinoma of the bladder (transition- al cell, squamous cell, or adenocarcinoma). Once the cancer spreads beyond the transitional cell layer, the risk of metastasis greatly.
Secondary indication is as part of pelvic exoneration for sarcomas or tumors of the GI tract or GYN system.
Clinical Presentation
■ Gross painless hematuria (chronic or intermittent)
■ Bladder irritability with dysuria, urgency, and frequency
■ Urine cytology positive for neoplastic or atypical cells
■ Urine tests positive for bladder tumor antigens
Diagnostic Tests
■ Urine cytology
■ Urine for bladder tumor antigens
■ IV pyelogram
■ Ultrasound of bladder, kidneys, and ureters
■ CT of abdomen and pelvis
■ MRI of abdomen and pelvis
■ Cystoscopy and biopsy (confirmation of bladder carcinoma)
Postop Management
■ Monitor vital signs frequently, as per hospital policy immediately postoperatively.
■ Encourage patient to cough and deep breathe, and to use incentive spirometer every hour.
■ Monitor and record amount of bleeding from incision and in urine.
■ Monitor and record intake and output.
■ If patient has a cutaneous urinary diversion, assess stoma for warmth and color every 8 hours in early postop period (ostomy appliance will collect urine).
→
■ Collaborate with enteral stoma nurse regarding stoma, skin, and urinary drainage.
■ If Penrose drain or plastic catheters in place, monitor and record drainage.
■ Monitor hemoglobin and hematocrit levels.
■ Provide pain management.
■ Encourage early ambulation.