Chronic Kidney Disease

Prepared by D. ChaplinPrepared by D. Chaplin

Chronic Kidney Disease




Progressive, irreversible damage to the nephrons and glomeruli

Progressive, irreversible damage to the nephrons and glomeruli


Major causes are

Diabetes and high blood pressure Type 1 and type 2 diabetes mellitus High blood pressure (hypertension) Glomerulonephritis Polycystic kidney disease Use of analgesics - acetaminophen(Tylenol) and ibuprofen (Motrin,

Advil Clogging and hardening of the arteries(atherosclerosis) Obstruction of the flow of urine by stones, an enlarged prostate,

strictures (narrowings), or cancers. HIV infection, sickle cell disease, heroin abuse, amyloidosis, kidney

stones, chronic kidney infections, and certain cancers.


Kidney functions - monitored regularly

Diabetes mellitus type 1 or 2 High blood pressure High cholesterol 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


Chronic Renal FailureEnd Stage Renal Disease (ESRD)

Protein and waste metabolism accumulates in the blood (azotemia)

90% of kidney function is lost (kidney cannot adequately function)

Hypothesis: Nephrons remains intact, others progressively destroyed.

Adaptive response maintains function until ¾ are destroyed

Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately

Protein and waste metabolism accumulates in the blood (azotemia)

90% of kidney function is lost (kidney cannot adequately function)

Hypothesis: Nephrons remains intact, others progressively destroyed.

Adaptive response maintains function until ¾ are destroyed

Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately


Stage DescriptionGFR*

mL/min/1.73m2

1Slight kidney damage with normal or increased filtration

More than 90

2 Mild decrease in kidney function 60-89

3Moderate decrease in kidney function

30-59

4Severe decrease in kidney function

15-29

5 Kidney failureLess than 15 (or dialysis)

Table 1. Stages of Chronic Kidney Disease*GFR is glomerular filtration rate, a measure of the kidney's function.


Modifiable Factors

-Diabetic Mellitus-Hypertension-Increase Protein and Cholesterol Intake-Smoking-Use of analgesics

Non-Modifiable Factors-Hereditary-Age greater than 60 years old-Gender-Race

Decreased renal blood flowPrimary kidney disease

Damage from other diseases

Urine outflow obstruction

Decreased glomerular

filtration

Serum Creatinine

BUN

Hypertrophy of remaining nephrons

Inability to concentrate urine

Dilute Polyuria

Dehydration

Further loss of nephron function

Loss of nonexcretory renal

function

Failure to convert inactive forms of

calcium

Calcium absorption

1

Failure to produce

eryhtropoietin

AnemiaPallor

Impaired insulin action

Erratic blood glucose levels

Production of lipids

Advanced atherosclerosis

Immune disturbance

s

Delayed wound healing

Infection

Disturbances in reproduction

Libido Infertility

2a

Loss of Sodium in Urine

Hyponatremia

Chro

nic

Kid

ney

Dis

ease

-

Pat

hop

hys

iolo

gy


Hypocalcemia Osteodystrophy

Excretion of nitrogenous

waste

Uremia

BUN,CreatinineUric Acid

Proteniuria

Peripheral nerve

changes

Pericarditis

CNS changes

Altered Taste

Bleeding Tendencies

Decreased sodium

reabsorption in tubule

Water Retention

HypertensionHeart Failure

Edema

Decreased potassium excretion

Hyperkalemia

Decreased phosphateexcretion

Hyperphosphatemia

Decreased calcium

absorption

Hypocalcemia

Hyperparathyroidism

Decreased potassium excretion

Increased potassium

Decreased hydrogen excretion

Metabolic acidosis

12a

Loss of excretory renal function

Pruritus


Weakness and tiredness/ fatigue.

Nocturia is often an early symptom

Itchiness of the skin which can progressively worsen

Pale skin which is easily bruised

Muscular twitches, cramps and pain

Pins and needles in the hands and feet

Nausea


As the condition worsens the symptoms progress to:

Oedema (swelling of the face, limbs and abdomen) Oliguria (greatly reduced volume of urine) Dyspnoea (breathlessness) Vomiting Confusion Seizures Severe lethargy Very itchy skin Breath that smells of ammonia


Associated complications of chronic Kidney Disease would be:

Anaemia, mostly due to deficiency of

erythropoietin

Bleeding which is caused by impairment of platelet

function

Metabolic Bone Disease (known as Renal

Osteodystrophy)


Cardiovascular Disease

- hypertension, (which may further exacerbate

the renal failure)

-accelerated atherosclerosis

-pericarditis. 80% of those with chronic renal

failure develop hypertension which must be

treated



Nervous system – neuropathy caused by the loss of myelin from nerve fibres – may improve when dialysis is established

Gastrointestinal complications - anorexia, nausea and vomiting, and a higher incidence of peptic ulcer disease



Skin disease – itching, which is attributed to the retention of metabolic waste products. It often improves with dialysis. Dry skin can also occur

Muscle dysfunction - myopathy leading to muscle cramps and the “restless leg” syndrome



Metabolic dysfunction - involving lipids, insulin and uric acid (gout). Metabolic acidosis is also associated



Diagnosis

Urine Tests Urinalysis Twenty-four hour urine

tests Glomerular filtration

rate (GFR) Blood Tests Creatinine and urea

(BUN) in the blood

Estimated GFR (eGFR) Electrolyte levels and

acid-base balance Blood cell counts Other tests Ultrasound: Biopsy


Treatment Modalities

Decrease fluid 1000ml/day

Decrease protein (.5-1kg body weight)

Decrease sodium (1-4gm variable)

Decrease potassium

Decrease phosphorous (<1000mg/day)

Dialysis (periotoneal, hemodialysis)

RBC, Vitamin D (calcitrol replacement) etc.

Decrease fluid 1000ml/day

Decrease protein (.5-1kg body weight)

Decrease sodium (1-4gm variable)

Decrease potassium

Decrease phosphorous (<1000mg/day)

Dialysis (periotoneal, hemodialysis)

RBC, Vitamin D (calcitrol replacement) etc.


Dialysis Hemodialyis(Hemo)Peritoneal (PD)

General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another

Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)

Peritoneal – Peritoneal membrane is the semi permeable membrane

General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another

Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)

Peritoneal – Peritoneal membrane is the semi permeable membrane


Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through

Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment

Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through

Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment

Osmosis - movement fluid from an area of < to > concentration of solutes (particles)

Osmosis - movement fluid from an area of < to > concentration of solutes (particles)

Osmosis-Diffusion-Ultrafiltration


Peritoneal Dialysis

Catheter placement – anterior abdominal wallTenckoff (25cm length with cuff anchor and

migration)Dialysis solution (1-2 liters sometimes smaller)Three phases of PD

Inflow (fill) approximately 10 minutes, could be in cycles)

Dwell (equilibration) (approximately 20-30 min or 8 hours+)

Drain (approximately 15 minutes) These 3 phases are called Exchanges

Catheter placement – anterior abdominal wallTenckoff (25cm length with cuff anchor and

migration)Dialysis solution (1-2 liters sometimes smaller)Three phases of PD

Inflow (fill) approximately 10 minutes, could be in cycles)

Dwell (equilibration) (approximately 20-30 min or 8 hours+)

Drain (approximately 15 minutes) These 3 phases are called Exchanges


Peritoneal Dialysis


Hemodialysis

Vascular access for high blood flow

Shunts, (teflon, external)

Arteriovenous fistulas and grafts (AV)

Anastomosis between an artery and vein

Fistulas are native vessels (4-6 wks maturity)

Grafts are artificial/synthetic material

Vascular access for high blood flow

Shunts, (teflon, external)

Arteriovenous fistulas and grafts (AV)

Anastomosis between an artery and vein

Fistulas are native vessels (4-6 wks maturity)

Grafts are artificial/synthetic material


Hemodialysis

AV Fistula CommunicationAV Fistula Communication

AV Graph AccessAV Graph Access


Hemodialysis

Hemodialysis MachineHemodialysis MachineHemodialysis CircuitHemodialysis Circuit


PD Advantages and Disadvantages

Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Bacterial/chemical peritonitis

Protein lossExit site of catheterSelf imageHyperglycemiaSurgical placement of

catheterMultiple abdominal

surgery

Bacterial/chemical peritonitis

Protein lossExit site of catheterSelf imageHyperglycemiaSurgical placement of

catheterMultiple abdominal

surgery

AdvantagesAdvantages DisadvantagesDisadvantages


Hemo Advantages & Disadvantages

Rapid fluid removalRapid removal of urea

& creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at

the bedside

Rapid fluid removalRapid removal of urea

& creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at

the bedside

Vascular access problems

Dietary & fluid restrictions

HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist

Vascular access problems

Dietary & fluid restrictions

HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist

AdvantagesAdvantages DisadvantagesDisadvantages


Disequalibrium SyndromeFluid removal and decrease in BUN during

hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures

Treatment: Hypertonic saline, Normal saline

Fluid removal and decrease in BUN during hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures

Treatment: Hypertonic saline, Normal saline


The following are general dietary guidelines:

Protein restriction: Salt restriction Fluid intake: Potassium restriction: Phosphorus restriction: Control blood pressure and/or diabetes; Stop smoking; and Lose Excess Weight


Avoided or used with caution:

Certain analgesics: Aspirin; ibuprofen Fleets or phosphosoda enemas because of their high

content of phosphorus Laxatives and antacids containing magnesium and

aluminum such as magnesium hydroxide Ulcer medication H2-receptor

antagonists: cimetidine, ranitidine Decongestants such as pseudoephedrine especially if

they have high blood pressure Herbal medications


Nursing Care Pre, Post Dialysis

Weigh before & after

Assess site before & after (bruit, thrill, infection, bleeding etc.)

Medications (precautions before & after)

Vital signs before and after etc.

Weigh before & after

Assess site before & after (bruit, thrill, infection, bleeding etc.)

Medications (precautions before & after)

Vital signs before and after etc.


Renal Transplant

Living and Cadaveric donors

Predialysis: obtain a dry weight free of excess fluids and toxins

More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement

Delay may increase ATN

Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)

Living and Cadaveric donors

Predialysis: obtain a dry weight free of excess fluids and toxins

More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement

Delay may increase ATN

Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)


Complications Post Transplant

Rejection is a major problem

Hyperacute rejection: occurs within minutes to hours after transplantation

Renal vessels thrombosis occurs and the kidney dies

There is no treatment and the transplanted kidney is removed

Rejection is a major problem

Hyperacute rejection: occurs within minutes to hours after transplantation

Renal vessels thrombosis occurs and the kidney dies

There is no treatment and the transplanted kidney is removed


Immunological Compatibility of Donor and Recipient

Done to minimize the destruction (rejection) of the transplanted kidney

HUMAN LEUKOCYTE ANTIGEN (HLA)

This gives you your genetic identity (twins share identical HLA)

HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.

Done to minimize the destruction (rejection) of the transplanted kidney

HUMAN LEUKOCYTE ANTIGEN (HLA)

This gives you your genetic identity (twins share identical HLA)

HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.


Immunological Analysis

WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney

A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation

WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney

A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation


Immulogical AnalysisMIXED LYMPHOCYTE CULTURE

The donor and recipient lymphocytes are mixed. Result = HIGH SENTIVITY, this is

contraindicated for renal transplantation.

ABO BLOOD GROUPING

ABO blood group must be compatible

MIXED LYMPHOCYTE CULTURE

The donor and recipient lymphocytes are mixed. Result = HIGH SENTIVITY, this is

contraindicated for renal transplantation.

ABO BLOOD GROUPING

ABO blood group must be compatible


Surgery

LLQ of the abdomen outside of the peritoneal cavity

Renal artery and vein anastomosed to the corresponding iliac vessels

Donor ureters are tunneled into the recipients’ bladder.

LLQ of the abdomen outside of the peritoneal cavity

Renal artery and vein anastomosed to the corresponding iliac vessels

Donor ureters are tunneled into the recipients’ bladder.



Acute Rejection: occurs 4 days to 4 months after transplantation

It is not uncommon to have at least one rejection episode

Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)

Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys

Acute Rejection: occurs 4 days to 4 months after transplantation

It is not uncommon to have at least one rejection episode

Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)

Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys



Chronic Rejection: occurs over months or years and is irreversible.

The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury

Gradual occlusion renal blood vessels

Signs: proteinuria, HTN, increase serum creatinine levels

Supportive treatment, difficult to manage

Replace on transplant list

Chronic Rejection: occurs over months or years and is irreversible.

The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury

Gradual occlusion renal blood vessels

Signs: proteinuria, HTN, increase serum creatinine levels

Supportive treatment, difficult to manage

Replace on transplant list


Complications Post TransplantInfectionHypertensionMalignancies (lip, skin,

lymphomas, cervical)Recurrence of renal diseaseRetroperiotneal bleedArterial stenosisUrine leakage

InfectionHypertensionMalignancies (lip, skin,

lymphomas, cervical)Recurrence of renal diseaseRetroperiotneal bleedArterial stenosisUrine leakage


100 patients with eGFR < 60

(Tuesday morning in Outpatients)


Tuesday morning 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)


Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD


The majority of patients with CKD 1-3 do not progress to ESRF.

Their risk of cardiovascular death is higher than their risk of progression.


Optimise risk factors

Cardiovascular disease Proteinuria Hypertension Diabetes Smoking Obesity Exercise tolerance

TAKE HOME MESSAGE


Nursing Care Plan of a Patient With ESRD

• Nursing diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water.• Goal: Maintenance of ideal body weight without excess fluid.

46


Assess fluid status (Daily weight, intake and output balance, skin turgor and presence of edema, distention of neck veins, blood pressure, pulse rate, and rhythm, respiratory rate and effort).

Limit fluid intake to prescribed volume. Identify potential sources of fluid (medications and fluids

used to take medications; oral and intravenous, foods).

Explain to patient and family rationale for restriction.


Nursing Care Plan of a Patient With ESRD (Cont…)

Nursing diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea, vomiting, and dietary restrictions.

• Goal: Maintenance of adequate nutritional intake.

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• Interventions: The nurse should: Assess nutritional status (weight changes, serum electrolyte,

BUN, creatinine, protein, transferrin, and iron levels). Assess patient’s nutritional dietary patterns (diet history, food

preferences, calorie counts). Assess for factors contributing to altered nutritional intake

(Anorexia, nausea, or vomiting, diet unpalatable to patient, depression, lack of understanding of dietary restrictions, stomatitis).

Provide patient’s food preferences within dietary restrictions. Promote intake of high biologic value protein foods



Nursing diagnosis: Deficient knowledge regarding condition and treatment.• Goal: Increased knowledge about condition and related treatment.

50


• Interventions: The nurse should: Assess understanding of cause of renal failure, its meaning

and consequences, and its treatment. Provide explanation of renal function and consequences of

renal failure at patient’s level of understanding and guided by patient’s readiness to learn.

Provide oral and written information as appropriate about renal function and failure, fluid and dietary restrictions, medications, reportable problems, signs, and symptoms, follow-up schedule, community resources, and treatment options.



Nursing diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure.• Goal: Participation in activity within tolerance.• Interventions: The nurse should: Assess factors contributing to fatigue (anemia, fluid and electrolyte imbalances, retention of waste products, depression) Promote independence in self-care activities as tolerated; assist if fatigued. Encourage alternating activity with rest. Encourage patient to rest after dialysis treatments.

52TAKE HOME MESSAGE


THANK YOU

Have a check on your blood pressureSugar & Salt / year

Chronic Kidney Disease

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