Chronic kidney disease (CKD) - Also known as chronic renal disease - A progressive loss in renal function over a period

of months or years. - The symptoms of worsening kidney function are non-specific, and might include feeling generally unwell and experiencing a reduced appetite. - Chronic kidney disease is identified by a blood test for creatinine. - Higher levels of creatinine indicate a lower glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products. - Creatinine levels may be normal in the early stages of CKD, and the condition is discovered if urinalysis (testing of a urine sample) shows that the kidney is allowing the loss of protein or red blood cells into the urine. Peritoneal Dialysis - A tube is inserted into the peritoneal cavity. - A sterile solution containing glucose is passed through this tube. - The peritoneal membrane acts as a semi-permeable membrane and the dialysate is allowed to remain there for some time. - This helps it absorb the waste products from the body that is drained out through the tube, called the drain process. Hemodialysis - The process where the blood is pumped into the blood compartment of the dialyzer - a special machine that helps filter the blood. Diagnosis Serum creatinine, found in higher levels in the blood if kidneys fail. Urinary creatinine, lower in kidney failure. Urinary output, measuring both fluid intake and all urine produced. Urinary osmolality, measuring the concentration of the urine, an indicator of kidney filtering ability. Blood urea nitrogen (BUN), harmful nitrogen waste that increases in the blood as kidney function decreases. Electrolytes in blood and urine, minerals that result from the breakdown of salts (sodium, potassium, magnesium, and chloride), often out of balance when kidneys fail. Potassium, for example, increases in the blood during kidney failure and can cause heart irregularities.

ARTERIOVENOUS FISTULA
Arteriovenous fistula - an abnormal connection or passageway between an artery and a vein. - may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm. - the connection of a vein and an artery, usually in the forearm, to allow access to the vascular system for hemodialysis, Vascular access - An access or entry to the vascular system is needed to perform the bloodcleansing role of the kidneys through hemodialysis.

There are three types of vascular access: arteriovenous fistula, grafts, and catheters. ARTERIOVENOUS FISTULA. - Best kind of vascular access for people whose veins are large enough. - Less likely than other types of access to form clots or become infected - Lower risk of infection than grafts or catheters - Allows for greater blood flow - Increases the effectiveness of hemodialysis as well as reducing treatment time - Stays functional for longer than other access types. - In some cases a well-formed fistula can last for decades - Usually less expensive to maintain than synthetic accesses * If the veins are not large enough, or there is no time to wait for a fistula to develop, a graft or a catheter must be used. GRAFT. - Preferred when a hemodialysis patient has small veins that will not likely develop properly into a fistula. - Uses a synthetic tube implanted under the skin of the arm that can be used repeatedly for needle placement. - Unlike a fistula, which requires time to develop, a graft can be used as soon as two to three weeks after placement. - Known to have more problems than fistulas, such as clots and infection, and will likely need replacement sooner. CATHETER. - Used to provide temporary vascular access. - It is a tube that is inserted into a vein in the neck, chest, or in the leg near the groin. - Two chambers in the tube allow blood to flow in and out. - Effective for dialysis for several weeks or months while surgery is performed and an AV fistula develops. - Not used for permanent access because they can clog, become infected, or can cause the veins to narrow. - Long-term catheter access must be used in patients for whom fistula or graft surgery has not been successful. Additional information: Bovine graft transplanted vein from a cow. Also used for vascular access. Causes of having AV Fistula Congenital (developmental defect) Rupture of arterial aneurysm in adjacent vein Penetrating injuries Inflammatory necrosis of adjacent vessels Intentionally created (for example, Cimino fistula as vascular access for hemodialysis) Patophysiology AV Fistula can lead to a large decrease in peripheral resistance. Lowered peripheral resistance causes the heart to increase cardiac output to maintain proper blood flow to all tissues.

Manifestation: normal systolic blood pressure with a decreased diastolic blood pressure resulting in a wide pulse pressure. Normal blood flow in the brachial artery: 85 to 110 milliliters per minute (mL/min). With Fistula: 400500 mL/min immediately, and 7001,000 mL/min within 1 month. Bracheocephalic fistula above the elbow has a greater flow rate than a radiocephalic fistula at the wrist. Cephalic vein increased from 2.3 mm to 6.3 mm diameter after 2 months.

Complications Berry Aneurysm, an intracerebral arteriovenous fistula can rupture causing subarachnoid hemorrhage. * Aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. * Subarachnoid hemorrhage is bleeding into the subarachnoid spacethe area between the arachnoid membrane and the pia mater surrounding the brain Nursing Responsibilities: Making sure the access is checked before each treatment. Not allowing blood pressure to be taken on the access arm. Checking the pulse in the access every day. Keeping the access clean at all times. Using the access site only for dialysis. Being careful not to bump or cut the access. Not wearing tight jewelry or clothing near or over the access site. Not lifting heavy objects or putting pressure on the access arm. Sleeping with the access arm free, not under the head or body. Request that blood being drawn is taken from your non-access arm The vibration of blood going through your arm is called the thrill. You should check this several times a day. If the thrill changes or stops a blood clot may have formed. Using a stethoscope, or even putting your ear to the access, you can hear the sound of blood flowing through your access. This sound is called the bruit. If the sound gains in pitch and sounds like a whistle, your blood vessels could be tightening (called stenosis). If the tightening becomes too severe, blood flow could be cut off completely. Assess for infections o If there is pain, tenderness, swelling or redness around the access area and fever. Problems that may occur during or after hemodialysis: Low blood pressure, if fluid and wastes are removed from the blood too quickly. Nausea, because of changes in blood pressure. Muscle cramps from the removal of too much fluid from the blood. Headaches near the end of a dialysis session, due to changes in the concentration of fluid and waste in the blood. Fatigue after treatment, lasting sometimes into the next day.

Notes to remember: Must be prepared by a surgeon weeks or months before dialysis is started. When the vein and artery are joined, the vein gradually becomes larger and stronger Hemodialysis is usually done three times a week, taking between three and five hours each time. The hemodialysis patient should expect needle insertion in the AV fistula at every dialysis session When the vein is large enough to allow cannulation, the fistula is defined as "mature."