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By guzilla Oct 20, 2013 1190 Words
Percutaneous Nephrostomy
Percutaneous nephrostomy, or nephropyelostomy, is an interventional procedure that is used mainly in the decompression of the renal collecting system. percutaneous nephrostomy catheter placement has been the primary option for the temporary drainage of an obstructed collecting system. With proper training, technical success is achieved in more than 95% of cases. Diagnostic imaging often demonstrates the level and cause of obstruction; however, at the time of tube placement, the cause of obstruction may not be known. Indications

Temporary urinary diversion associated with urinary obstruction secondary to calculi Diversion of urine from the renal collecting system in an attempt to heal fistulas or leaks resulting from traumatic or iatrogenic injury, malignant or inflammatory fistulas, or hemorrhagic cystitis Treatment of nondilated obstructive uropathy

Treatment of urinary tract obstruction related to pregnancy
Treatment of complications related to renal transplants
Access for interventions such as direct infusion of substances for dissolving stones, chemotherapy, and antibiotic or antifungal therapy Access for other procedures (eg, benign stricture dilatation, antegrade ureteral stent placement, stone retrieval, pyeloureteroscopy, or endopyelotomy) Decompression of nephric or perinephric fluid collections (eg, abscesses or urinomas)

Contraindications

Bleeding diathesis (most commonly, uncontrollable coagulopathy) Uncooperative patient
Severe hyperkalemia (>7 mEq/L); this should be corrected with hemodialysis before the procedure

Patient Preparation
The patient is commonly placed in a prone or prone-oblique position, with elevation of the side to be punctured. The region of the projected percutaneous nephrostomy should be evaluated by means of ultrasonography, CT, or fluoroscopy, and the puncture site should be marked. This region should then be prepared (eg, cleansed with povidone-iodine solution) and draped in the usual manner. After proper positioning, the patient is given an appropriate medication for conscious sedation (eg, fentanyl and midazolam), along with a local anesthetic (usually 1% lidocaine) to anesthetize the skin. Procedure

Informed consent is obtained from the patient, next of kin, or healthcare proxy Appropriate laboratory studies are ordered, including prothrombin time, activated partial thromboplastin time, platelet count, blood urea nitrogen and creatinine levels, hematocrit and hemoglobin levels, white blood cell count, and urinalysis and urine culture Pertinent images (eg, sonograms, computed tomography (CT) scans, intravenous (IV) urograms, or radionuclide scintigrams) are reviewed to assess the location of the colon, liver, and spleen and help determine the optimal approach IV access is established, and the patient is adequately hydrated Prophylactic antibiotics are administered 60 minutes before the procedure, especially if pyonephrosis is suspected or if the obstruction is caused by a renal calculus The patient receives nothing by mouth for 4-8 hours before the procedure

Complications
Bleeding
Sepsis
Injury to an adjacent organ

Urinary diversion
Urinary diversion is indicated when the bladder can no longer safely function as a reservoir for urine storage. Indications
Bladder cancer requiring cystectomy
Neurogenic bladder conditions that threaten renal function
Severe radiation injury to the bladder
Intractable incontinence in females
Chronic pelvic pain syndromes

Contraindications
Elderly age and spinal cord injuries associated with poor hand coordination are absolute contraindications for continent urinary diversion (including neobladder) because of the need for intermittent catheterization and the potential for catastrophic complications should these individuals fail to do so. Bowel abnormalities such as Crohn disease, severe irritable bowel syndrome, fat malabsorption, and, potentially, ulcerative colitis preclude the surgeon from taking long segments of bowel. Patients with a preoperative creatinine clearance of less than 60 mL/min should not undergo continent urinary diversion. Those with a prior history of high-dose radiotherapy to the abdomen and/or pelvis should not have long lengths of small bowel used.

Patient Preparation
Preoperatively, ensure that the patient has undergone a full mechanical and antibiotic bowel preparation. If large-bowel segments are to be used, an air-contrast barium enema is recommended to rule out significant diverticulosis or other conditions that may exclude large bowel for use in urinary diversion. Complications

Secretory and/or osmotic diarrhea
Stomal stenosis, dermatitis, prolapse, retraction, and parastomal hernias (incidence, 15-40%) Poor drainage of conduit or reservoir
Retention in the continent reservoir
Volvulus and retention in conduit (rare)
Urinary lithiasis (especially in patients with secretory diarrhea and chronic dehydration) Recurrent symptomatic infections
Ureterosigmoidostomy - Adenocarcinoma, urosepsis, ureteral stenosis, and/or hydronephrosis

Renal Transplant
Renal transplantation has become the treatment of choice for most patients with end-stage renal disease (ESRD) Indications
Indications for renal transplantation include chronic renal failure (CRF) and renal tumors. Contraindications
Metastatic cancer
Ongoing or recurring infections that are not effectively treated Serious cardiac or peripheral vascular disease
Hepatic insufficiency
Serious conditions that are unlikely to improve after renal transplantation (ie, the patient’s life expectancy can be finitely measured) Demonstrated and repeated episodes of medical noncompliance

Inability to perform rehabilitation adequately after transplantation AIDS

Patient Preparation
The pretransplant evaluation must address potential contraindications, should include baseline immunologic studies, and should assess the patient’s likelihood of success with transplantation. Either a need for dialysis or a creatinine clearance below 20 mL/min is generally an accepted definition of chronic renal failure (CRF). A documented creatinine clearance of 20 mL/min or less is necessary to qualify for listing for transplantation.

Complications
Delayed graft function
Vascular thrombosis and stenosis
Ureteral obstruction
Urinary leakage
Lymphocele
Infection
Rejection

Dialysis
Dialysis treatment replaces the function of the kidneys, which normally serve as the body's natural filtration system. Through the use of a blood filter and a chemical solution known as dialysate, the treatment removes waste products and excess fluids from the bloodstream, while maintaining the proper chemical balance of the blood. There are two types of dialysis treatment: hemodialysis and peritoneal dialysis. Indications

Dialysis is most commonly prescribed for patients with temporary or permanent kidney failure. People with end-stage renal disease (ESRD) have kidneys that are no longer capable of adequately removing fluids and wastes from their body or of maintaining the proper level of certain kidney-regulated chemicals in the bloodstream. For these individuals, dialysis is the only treatment option available outside of kidney transplantation. Dialysis may also be used to simulate kidney function in patients awaiting a transplant until a donor kidney becomes available. Also, dialysis may be used in the treatment of patients suffering from poisoning or overdose in order to quickly remove drugs from the bloodstream.

Contraindications
Patients are weighed immediately before and after each hemodialysis treatment to evaluate their fluid retention. Blood pressure and temperature are taken and the patient is assessed for physical changes since their last dialysis run. Regular blood tests monitor chemical and waste levels in the blood. Prior to treatment, patients are typically administered a dose of heparin, an anticoagulant that prevents blood clotting, to ensure the free flow of blood through the dialyzer and an uninterrupted dialysis run for the patient. Patient Preparation

-Obtain accurate weight measurement
-Check Vital signs
-Review last ordered lab results
-Give scheduled medications
Procedure
The dialysis treatment prescription and regimen is usually overseen by a nephrologist. The hemodialysis treatment itself is typically administered by a nurse or patient care technician in outpatient clinics known as dialysis centers, or in hospital-based dialysis units. In-home hemodialysis treatment is also an option for some patients, although access to this type of treatment may be limited by financial and lifestyle factors. Complications

Anemia

Cramps, nausea, vomiting, and headaches

Hypotension

Infection

Infectious diseases

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