Chronic Kidney Disease Chronic Kidney Disease CKD Involves

Chronic Kidney Disease

Chronic Kidney Disease (CKD) • Involves progressive, irreversible destruction of the nephrons in both kidneys • Can lose up to 80% of kidney function without overt body changes • Creatinine clearance: an indicator of GFR (amount of creatinine voided out in 24 hours) • Creatinine clearance falls below 1 m. L/sec

Chronic Kidney Disease (CKD) • Stages defined based on level of kidney function Ø Diminished renal reserve: normal BUN, creatinine, and creatinine clearance Ø Renal insufficiency: GFR 25% of normal; BUN and creatinine elevated Ø End-stage renal disease (ESRD) • Last stage • GFR <1 m. L/sec

Chronic Kidney Disease (CKD) • End result is a systemic disease involving every organ • Each year 70, 000 people die from causes related to renal failure

Chronic Kidney Disease (CKD) Leading causes of ESRD ØDiabetes ØHypertension

Clinical Manifestations Retained substances ØUrea ØCreatinine ØPhenols ØHormones ØElectrolytes ØWater

Manifestations of Chronic Uremia Fig. 45 -3

Clinical Manifestations Uremia ØIncorporates all the signs and symptoms seen in the various systems throughout the body

Clinical Manifestations Urinary System Polyuria ØResults from inability of the kidneys to concentrate urine ØOliguria and anuria develop ØCasts, protein, WBCs, RBCs in urine ØOccurs most often at night

Clinical Manifestations Urinary System Oliguria ØOccurs as CKD worsens Anuria <40 ml per 24 hours

Clinical Manifestations Urinary System • • Proteinuria Casts Pyuria Hematuria

Clinical Manifestations Metabolic Disturbances Waste product accumulation Ø BUN; creatinine ØNausea ØVomiting ØLethargy ØFatigue

Clinical Manifestations Metabolic Disturbances • Altered carbohydrate metabolism ØResults from cellular insensitivity to the normal action of insulin • Elevated triglycerides

Clinical Manifestations Electrolyte and Acid-Base Imbalances Potassium ØHyperkalemia • Most serious electrolyte disorder • Fatal arrhythmias • Results from excretion by kidneys

Clinical Manifestations Electrolyte and Acid-Base Imbalances Sodium ØMay be normal or low ØEdema ØHypertension ØCHF

Clinical Manifestations Electrolyte and Acid-Base Imbalances • Calcium and phosphate • Magnesium • Metabolic acidosis ØResults from inability of kidneys to excrete acid load (primarily ammonia)

Clinical Manifestations Hematologic System • Anemia Ø Due to production of erythropoietin • Bleeding tendencies Ø Defect in platelet function • Infection Ø Changes in leukocyte function Ø Altered immune response and function Ø Diminished inflammatory response

Clinical Manifestations Hematologic System Increased incidence of cancer ØLung ØBreast ØUterus ØColon ØProstate ØSkin

Clinical Manifestations Cardiovascular System • • Hypertension CHF Pulmonary edema Peripheral edema Arrhythmias Atherosclerosis Uremic pericarditis

Clinical Manifestations Respiratory System • Kussmaul respiration • Dyspnea • Pulmonary edema • Uremic pleuritis • Pleural effusion • Predisposition to respiratory infections • Depressed cough reflex

Clinical Manifestations Gastrointestinal System • Mucosal ulcerations: Anorexia, Nausea, Vomiting • Ulceration and bleeding • Uremic fetor (urinous odor of the breath)

Clinical Manifestations Neurologic System • • • Altered mental ability Seizures Coma Dialysis encephalopathy Peripheral neuropathy Lethargy Apathy Fatigue Irritability

Clinical Manifestations Musculoskeletal System Renal osteodystrophy ØSyndrome of skeletal changes ØResult of alterations in calcium and phosphate metabolism

Clinical Manifestations Musculoskeletal System Renal osteodystrophy ØTwo types associated with ESRD: • Osteomalacia • Osteitis fibrosa

Clinical Manifestations Integumentary System • • Yellow-gray discoloration of the skin Pruritus Uremic frost Dry, pale skin Dry, brittle hair Thin nails Petechiae

Clinical Manifestations Reproductive System • Infertility ØExperienced by both sexes • Decreased libido • Low sperm counts • Sexual dysfunction

Clinical Manifestations Endocrine System • Manifestations of hypothyroidism • Thyroid function may yield low to lownormal levels of T 3 and T 4 levels

Clinical Manifestations Psychologic Changes • • • Personality and behavioral changes Emotional lability Withdrawal Depression Life style changes

Collaborative Care Conservative Therapy Goals: ØPreserve existing renal function ØTreat clinical manifestations ØPrevent complications ØProvide for the patient’s comfort

Collaborative Care Drug Therapy Hyperkalemia ØIV glucose and insulin ØIV 10% calcium gluconate ØSodium polystyrene sulfonate (Kayexalate)

Collaborative Care Drug Therapy Hypertension ØSodium and fluid restriction ØAntihypertensive drugs

Collaborative Care Drug Therapy Renal osteodystrophy ØPhosphate intake restricted to <1000 mg/day ØCalcium-based phosphate binders

Collaborative Care Drug Therapy Anemia ØErythropoietin • Epogen • Procrit

Collaborative Care Drug Therapy Complications of drug therapy ØDrug toxicity • Digitalis • Antibiotics • Pain medication

Collaborative Care Nutritional Therapy • Protein restriction • Fluid restriction Ø Intake depends on daily output • Sodium and potassium restriction Ø Diets vary from 2 to 4 g depending on degree of edema and HTN • Phosphate restriction Ø 1000 mg/day Ø Foods high in phosphate • Dairy products

Nursing Management Nursing Assessment • Complete history of any existing renal disease • Long-term health problems • Dietary habits

Nursing Management Nursing Diagnoses • • • Excess fluid volume Impaired skin integrity Risk for injury Activity intolerance Imbalanced nutrition: less than body requirements • Anticipatory grieving • Risk for infection

Nursing Management Planning Overall goals: ØDemonstrate knowledge and ability to comply with therapeutic regimen ØParticipate in decision making ØDemonstrate effective coping strategies ØContinue with activities of daily living within psychologic limitations

Nursing Management Nursing Implementation Health Promotion ØIdentify individuals at risk for CKD • History of renal disease • Hypertension • Diabetes mellitus • Repeated urinary tract infection

Nursing Management Nursing Implementation Acute Intervention ØDaily weight ØDaily BPs ØIdentify signs and symptoms of fluid overload ØStrict dietary adherence

Nursing Management Nursing Implementation Ambulatory and Home Care ØWhen conservative therapy is no longer effective, HD, PD, and transplantation are treatment options

Nursing Management Evaluation • • Maintenance of ideal body weight Acceptance of chronic disease No infections No edema No itching or skin dryness Slowing of bone disease Hematocrit and hemoglobin levels in acceptable range