CHRONIC KIDNEY DISEASE

Stage Description GFR*mL/min/1.73m2

1 Slight kidney damage with normal or increased filtration More than 90

2 Mild decrease in kidney function 60-893 Moderate decrease in kidney function 30-594 Severe decrease in kidney function 15-295 Kidney failure Less than 15 (or dialysis)

Stage 1 – no apparent clinical signs

Stage 2 – significant retention of urea and creatinine in the blood

Decreased tubule function failure to concentrate urine and control the secretion and exchange of acids and electrolytes Osmotic dieresis occurs as the remaining functional nephrons filter an increased solute load Excretion of large amounts of dilute urine (low fixed specific gravity) Decreased eryhtropoiesis Elevated BP

Stage 5 – also referred to as end-stage kidney disease, or end-stage renal disease, wherein there is total or near-total loss of kidney function

dangerous accumulation of water, waste, and toxic substances most individuals in this stage of kidney disease need dialysis or transplantation to stay alive.

Overview

occurs when one suffers from gradual and usually permanent loss of kidney function over time five stages of increasing severity (see table above) accumulation of water; waste; and toxic substances

Assessment:

1. Oliguric-anuric phase urine volume less than 400 ml per 24 hours increased in serum creatinine, urea, uric acid, organic acids, potassium, and magnesium

2. Diuretic phase urine output exceeds 500 ml per 24 hours, end when BUN and creatinine levels stop rising

3. Recovery phase asymptomatic

4. In prerenal disease decreased tissue turgor, dryness of mucous membranes, weight loss, flat neck veins, hypotension, tachycardia.

5. In postrenal disease difficulty in voiding, changes in urine flow.

6. In Intrarenal disease presentation varies; usually have edema, may have fever, skin rash Nausea, vomiting, diarrhea, and lethargy may also occur.

Causes

Type 1 and type 2 diabetes mellitus (causes diabetic nephropathy) Hypertension Glomerulonephritis Enlarged prostate Polycystic kidney disease Use of analgesics such as acetaminophen(Tylenol) and ibuprofen (Motrin, Advil) regularly over long durations of time Atherosclerosis Renal artery stenosis Obstruction of the flow of urine HIV infection sickle cell disease heroin abuse amyloidosis kidney stones chronic kidney infections

Risk Factors

Diabetes mellitus type 1 or 2 High blood pressure High cholesterol Obesity Heart disease Liver disease Amyloidosis Sickle cell disease Systemic Lupus erythematosus Vascular diseases such as arteritis, vasculitis, or fibromuscular dysplasia Vesicoureteral reflux (a urinary tract problem in which urine travels the wrong way back toward the kidney) Require regular use of anti-inflammatory medications A family history of kidney disease Smoking Age >65

Symptoms

Urinary frequency Nocturia swelling of the legs and puffiness around the eyes (fluid retention) high blood pressure fatigue and weakness (from anemia or accumulation of waste products in the body)

As the kidneys fail, they make less erythropoietin. With fewer red blood cells to carry oxygen, your muscles and brain become tired very quickly. -> ANEMIA

loss of appetite (may lead to weight loss), nausea and vomiting buildup of wastes in the blood

metallic taste in mouth/ammonia breath buildup of wastes in the blood (called uremia) can make food taste different and cause bad breath.

itching, easy bruising, and pale skin (from anemia)

buildup of wastes in the blood can cause severe itching shortness of breath from fluid accumulation in the lungs

extra fluid in the body can build up in the lungs. anemia (a shortage of oxygen-carrying red blood cells) can leave the body oxygen-starved and short of breath

headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep, altered mental status (encephalopathy from the accumulation of waste products or uremic poisons), and restless legs syndrome

Brain is not getting enough oxygen chest pain due to pericarditis (inflammation around the heart) bleeding (due to poor blood clotting) bone pain and fractures decreased sexual interest and erectile dysfunction feeling cold

due to anemia

Physical Examinations

Abdominal masses (PKD) Diminished pulses (atherosclerotic peripheral vascular diseases) Abnormal bruit ( renovascular disease) Pallor Excoriations (uremic pruritus) Muscle wasting Uremic breath hypertension

Diagnosis

urinalysis proteinuria hematuria cast

24 hour urine collection - presence of protein in the urine indicates kidney damage Glomerular Filtration Rate (GFR) Creatinine and urea in blood - the level of these substances rises in the blood as kidney function worsens Electrolyte levels and acid-base balance - Kidney dysfunction causes imbalances in electrolytes, especially potassium,

phosphorus, and calcium CBC - kidney disease disrupts blood cell production and shortens the survival of red cells, the red blood cell count

and hemoglobin may be low (anemia) Ultrasound - kidneys are shrunken in size Biopsy

Complications

Fluid retentiono Nursing Intervention: accurate I&O, weigh daily

Hyperkalemia Cardiovascular disease Anemia high blood pressure

acidosis (excessive acidity of body fluids) disorders of cholesterol and fatty acids bone disease (weak bones) impotence decreased immune response

Prognosis

CKD patients have a higher risk of developing strokes and heart attacks People underging dialysis has a survival rate of 32 percent Recipients of a kidney transplant from a living related donor have a two year survival rate greater than 90% Recipients of a kidney from a donor who has died have a two year survival rate of 88%.

Treatment

Protein restriction - Decreasing protein intake may slow the progression of chronic kidney disease. Protein makes the kidneys work a little harder

Salt restriction - Limit to 4-6 grams a day to avoid fluid retention and help control high blood pressure. Fluid intake - Excessive water intake does not help prevent kidney disease Potassium restriction - kidneys are unable to remove potassium. High levels of potassium can cause abnormal heart

rhythms. Phosphorus restriction - Decreasing phosphorus intake is recommended to protect bones Stop smoking Lose excess weight

Nursing Interventions1. Monitor 24-hour urine volume to follow clinical course of the disease.2. Monitor BUN, creatinine, and electrolyte.3. Monitor ABG levels as necessary to evaluate acid-base balance.4. Weigh the patient to provide an index of fluid balance.5. Measure blood pressure at various times during the day with patients in supine, sitting, and standing positions.6. Adjust fluid intake to avoid volume overload and dehydration.7. Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. Have

resuscitation equipment available in case of cardiac arrest.8. Watch for urinary tract infection, and remove bladder catheter as soon as possible.9. Employ intensive pulmonary hygiene because incidence of pulmonary edema and infection is high.10.Provide meticulous wound care.11. Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional

calories.12. Institute seizure precautions. Provide padded side rails and have airway and suction equipment at the bedside.13. Encourage and assist the patient to turn and move because drowsiness and lethargy may reduce activity.14. Explain that the patient may experience residual defects in kidney function for a long time after acute illness.15. Encourage the patient to report routine urinalysis and follow-up examinations.16. Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism.

Four goals of Therapy (since there is no treatment0

slow the progression of disease Control of blood glucose Control of high blood pressure - ACE inhibitors and ARBS Lower cholesterol - statins Diet

treat underlying causes and contributing factors treat complications of disease

Diuretics – fluid retention Eryhtropoietin – anemia Vitamin D – bone disease Sodium bicarbonate – acidosis

replace lost kidney function dialysis kidney transplant

Drugs to avoid

Aspirin NSAIDs Fleets or phosphoda enemas – high phosphorus content Magnesium and aluminum containing laxatives and antacids H2 receptor antagonists Decongestants Alka Seltzer – contains high amount of salt

Prevention

Avoid exposure to drugs and toxic substances

*Dialysis

There are two types of dialysis 1) hemodialysis (in-center or home) and 2) peritoneal dialysis. Before dialysis can be initiated, a dialysis access has to be created.

Dialysis Access

A vascular access is required for hemodialysis so that blood can be moved though the dialysis filter at rapid speeds to allow clearing of the wastes, toxins, and excess fluid. There are three different types of vascular accesses: arteriovenous fistula (AVF), arteriovenous graft, and central venous catheters.

1. Arteriovenous fistula (AVF): The preferred access for hemodialysis is an AVF, wherein an artery is directly joined to a vein. The vein takes two to four months to enlarge and mature before it can be used for dialysis. Once matured, two needles are placed into the vein for dialysis. One needle is used to draw blood and run through the dialysis machine. The second needle is to return the cleansed blood. AVFs are less likely to get infected or develop clots than any other types of dialysis access.

2. Arteriovenous graft: An arteriovenous graft is placed in those who have small veins or in whom a fistula has failed to develop. The graft is made of artificial material and the dialysis needles are inserted into the graft directly.

3. Central venous catheter: A catheter may be either temporary or permanent. These catheters are either placed in the neck or the groin into a large blood vessel. While these catheters provide an immediate access for dialysis, they are prone to infection and may also cause blood vessels to clot or narrow.

Peritoneal access (for peritoneal dialysis): A catheter is implanted into the abdominal cavity (lined by the peritoneum) by a minor surgical procedure. This catheter is a thin tube made of a soft flexible material, usually silicone or polyurethane. The catheter usually has one or two cuffs that help hold it in place. The tip of the catheter may be straight or coiled and has multiple holes to allow egress and return of fluid. Though the catheter can be used immediately after implantation, it is usually recommended to delay peritoneal dialysis for at least 2 weeks so as to allow healing and decrease the risk of developing leaks.

Hemodialysis

Hemodialysis involves circulation of blood through a filter or dialyzer on a dialysis machine.

The dialyzer has two fluid compartments and is configured with bundles of hollow fiber capillary tubes.

Blood in the first compartment is pumped along one side of a semipermeable membrane, while dialysate (the fluid that is used to cleanse the blood) is pumped along the other side, in a separate compartment, in the opposite direction.

Concentration gradients of substances between blood and dialysate lead to desired changes in the blood composition, such as a reduction in waste products (urea nitrogen and creatinine); a correction of acid levels; and equilibration of various mineral levels.

Excess water is also removed.

The blood is then returned to the body.

Hemodialysis may be done in a dialysis center or at home. In-center hemodialysis typically takes three to five hours and is performed three times a week. You will need to travel to a dialysis center for in-center hemodialysis.

Some centers may offer the option of nocturnal (night-time) hemodialysis wherein the therapy is delivered while you sleep. Long nocturnal dialysis offers patients a better survival and an improvement in their quality of life.

Home hemodialysis is possible in some situations. A care partner is needed to assist you with the dialysis treatments. A family member or close friend are the usual options, though occasionally people may hire a professional to assist with dialysis. Home hemodialysis may be performed as traditional three times a week treatments, long nocturnal (overnight) hemodialysis, or short daily hemodialysis. Daily hemodialysis and long nocturnal hemodialysis offer advantages in quality of life and better control of high blood pressure, anemia, and bone disease.

Peritoneal dialysis

Peritoneal dialysis utilizes the lining membrane (peritoneum) of the abdomen as a filter to clean blood and remove excess fluid. Peritoneal dialysis may be performed manually (continuous ambulatory peritoneal dialysis) or by using a machine to perform the dialysis at night (automated peritoneal dialysis).

About 2 to 3 liters of dialysis fluid are infused into the abdominal cavity through the access catheter. This fluid contains substances that pull wastes and excess water out of neighboring tissues.

The fluid is allowed to dwell for two to several hours before being drained, taking the unwanted wastes and water with it.

The fluid typically needs to be exchanged four to five times a day.

Peritoneal dialysis offers much more freedom compared to hemodialysis since patients do not need to come to a dialysis center for their treatment. You can carry out many of your usual activities while undergoing this treatment. This may be the preferable therapy for children.

Most patients are candidates for both hemodialysis and peritoneal dialysis. There are little differences in outcomes between the two procedures. Your physician may recommend one kind of dialysis over the other based on your medical and surgical history. It is best to choose your modality of dialysis after understanding both procedures and matching them to your lifestyle, daily activities, schedule, distance from the dialysis unit, support system, and personal preference.

*Kidney Transplantation

Kidney transplantation offers the best outcomes and the best quality of life. Successful kidney transplants occur every day in the United States. Transplanted kidneys may come from living related donors, living unrelated donors, or people who have died of other causes (cadaveric donors). In people with type I diabetes, a combined kidney-pancreas transplant is often a better option.

However, not everyone is a candidate for a kidney transplant. People need to undergo extensive testing to ensure their suitability for transplantation. Also, there is a shortage of organs for transplantation, requiring waiting times of months to years before getting a transplant.

A person who needs a kidney transplant undergoes several tests to identify characteristics of his or her immune system. The recipient can accept only a kidney that comes from a donor who matches certain of his or her immunologic characteristics. The more similar the donor is in these characteristics, the greater the chance of long-term success of the transplant. Transplants from a living related donor generally have the best results.

Transplant surgery is a major procedure and generally requires four to seven days in the hospital. All transplant recipients require lifelong immunosuppressant medications to prevent their bodies from rejecting the new kidney. Immunosuppressant medications require careful monitoring of blood levels and increase the risk of infection as well as some types of cancer.