THE RENAL UNIT k or w g n di r a w e ut r b g n di n a m e D THE RENAL UNIT A. J. Wing, MA, DM, MRCP, Physician, St. Thomas's Hospital Mary Magowan, SRN, Nursing Officer, St. Thomas's Hospital M ISBN 978-1-349-02529-9 ISBN 978-1-349-02527-5 (eBook) DOI 10.1007/978-1-349-02527-5 ©A. J. Wing and Mary Magowan 1975 @Appendix B: M. Vennegoor 1975 Softcover reprint of the hardcover 1st edition 1975 978-0-333-18014-3 All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission First published in 1975 by THE MACMILLAN PRESS LTD London and Basingstoke Associated companies in New York Dublin Melbourne Johannesburg and Madras SBN 333 18014 3 Preface 'Watch me-one day you'll be doing this for yourself'-so the nurse initiates a patient to his first haemodialysis. The specialist nurse in a renal unit must be competent, knowledgeable and understanding. This book is an introductioo to what she will need to know and what she will be teaching her -patients. There is a brief summary of normal renal structure and function and brief allusion to the investigation and treatment of renal disease, but the book really begins when the patient's renal function requires replacement. We describe the history and prin ciples of dialysis, which have determined why techniques and ap paratus are the way they are, and which will determine future de velopments. The technology of peritoneal dialysis, vascular access and haemodialysis makes up the central section of the book. Nurses will want to know something of the medical problems and complications of home dialysis and transplantation, for on all these things their patients are always likely to ask penetrating questions. Throughout the book an attitude to the patient emerges making a contrast with nursing in other fields. The degree to which patients are involved in their own care is extraordinary and at first the nurse will find it surprising. Doctors and nurses in this new field have learned that self-dialysis makes sense. Home dialysis has been particularly developed in the UK. We hope that the nurse who reads this book will be better able to participate in the brave experiment in long-term treatment which this specialist work represents. Miss Yvonne Banks has made a fine job of converting our sketches into pleasing drawings. We are grateful to the following colleagues for reading and commenting on various parts of the manuscript: J. V. Banatvala, Miss G. Boase, N. F. Jones, W. Lloyd-Davies and A. E. Thompson. Mary Magowan St. Thomas's Hospital A. J. Wing January, 1975. Contents PREFACE 1 RENAL FUNCTION AND ITS REPLACEMENT 1 The kidneys 1 Renal function 3 Renal failure 10 2 HISTORY OF DIALYSIS AND TRANSPLANTATION 18 Development of the artificial kidney 18 Development of peritoneal dialysis 23 Other techniques 25 Dialysis in terminal renal failure 25 Home dialysis 28 Transplantation 29 Hepatitis in renal units 32 3 PRINCIPLES OF DIALYSIS 33 The purpose of dialysis 33 Diffusion 34 Osmosis and ultrafiltration 39 The membranes 41 Dialysis fluid 41 4 PERITONEAL DIALYSIS 51 The role of peritoneal dialysis: when and where 51 Technique for insertion of the peritoneal dialysis catheter 52 Complications associated with the peritoneal catheter 56 Carrying out a peritoneal dialysis 57 Problems encountered in running a peritoneal dialysis 62 Care of the patient 63 Biochemical complications 64 Contents Vll Medical complications 66 Nutritional disturbances 69 Automatic cycling machines 70 5 SHUNTS AND FISTULAE 71 The external shunt (Quinton-Scribner) 71 Nursing care of the shunt 76 General shunt care 78 Declotting a shunt 80 Prevention of infection in the shunt 85 The internal fistula 92 The surgery of fistulae 94 Catheters for ~enovenous dialysis (Shaldon) 101 6 HAEMODIALYSIS PRINCIPLES AND EQUIPMENT 103 Illustrated principles of haemodialysis 103 Anticoagulation 105 The dialyser: factors influencing choice 108 The production and delivery of dialysis fluid 113 Monitoring the dialysis 122 7 HAEMODIALY SIS TECHNIQUE 135 Preparing the equipment 135 Preparing the patient 143 The dialysis 143 Major complications during dialysis 151 8 MEDICAL ASPECTS OF REGULAR DIALYSIS TREATMENT 161 Dietary restriction and supplements 161 Blood pressure control 168 Anaemia 173 Bone disease 177 Neurological complications 182 Growth and development of children on RDT 184 9 HEPATITIS IN DIALYSIS UNITS 185 Epidemiology 185 Hepatitis prevention 189 Vlll Contents 10 DIALYSIS IN THE HOME 195 The advantages 195 Training the patient 196 Preparing the home 198 Supporting the home patient 206 The cost of home dialysis 208 11 DIALYSIS AND TRANSPLANTATION 211 Selection 212 Inter-relationship of hospital and home dialysis and transplantation 215 Survivals compared 217 Transplantation-pre-operative care 219 Grafting 224 Nursing the transplant patient 227 Diagnosing and treating rejection 230 Abandoning the graft 236 12 WORKING IN A DIALYSIS UNIT 238 Understanding the patient's problems 238 Understanding the family's problems 243 Understanding our own problems 247 Conclusion 248 APPENDIX A: NURSING RESPONSIBILITIES IN SETTING UP A NEW UNIT FOR REGULAR DIALYSIS TREATMENT 252 Treatment to be carried out in the unit 252 The situation of the unit in relation to the rest of the hospital and other facilities 252 The construction of the unit 254 Allocation of responsibilities 256 APPENDIX B: DIALYSIS, DIET AND DISCRETION: INSTRUCTIONS FOR PATIENTS 258 by Miss M. Vennegoor, SRD, Dietician, St. Thomas's Hospital Contents IX GLOSSARY 262 BIBLIOGRAPHY 268 NOTE ON UNITS OF MEASUREMENT 269 INDEX 271