Chronic Kidney Disease Prepared by D Chaplin Chronic

Chronic Kidney Disease Prepared by D. Chaplin

Chronic Kidney Disease Progressive, irreversible damage to the nephrons and glomeruli Prepared by D. Chaplin

Major causes are n n n n n 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. Prepared by D. Chaplin

Kidney functions - monitored regularly n n n 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 Prepared by D. Chaplin

Chronic Renal Failure End 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 Prepared by D. Chaplin

Table 1. Stages of Chronic Kidney Disease *GFR is glomerular filtration rate, a measure of the kidney's function. Stage Description GFR* m. L/min/1. 73 m 2 1 Slight kidney damage with normal More than 90 or increased filtration 2 Mild decrease in kidney function 60 -89 3 Moderate decrease in kidney function 30 -59 4 Severe decrease in kidney function 15 -29 Kidney failure Less than 15 (or dialysis) 5 Prepared by D. Chaplin

Non-Modifiable Factors -Hereditary -Age greater than 60 years old -Gender -Race Pa ey. D ise as BU dn e N Dilute Polyuria nic Ki -Diabetic Mellitus -Hypertension -Increase Protein and Cholesterol Intake -Smoking -Use of analgesics Decreased renal blood flow Primary kidney disease Damage from other diseases Urine outflow obstruction th op hy sio log y Modifiable Factors Serum Creatinine Decreased glomerular filtration Hypertrophy of remaining nephrons Loss of Sodium in Urine ro Inability to concentrate urine Hyponatremia Ch Dehydration Further loss of nephron function Loss of nonexcretory renal function Failure to convert inactive forms of calcium Calcium absorption Failure to produce eryhtropoietin Anemia Pallor Prepared 1 by D. Chaplin 2 a Impaired insulin action Erratic blood glucose levels Production of lipids Advanced atherosclerosis Immune disturbance s Delayed wound healing Disturbances in reproduction Infection Libido Infertility

Hypocalcemia 1 Excretion of nitrogenous waste Uremia BUN, Creatinine Uric Acid Proteniuria Peripheral nerve changes Pericarditis CNS changes Pruritus Altered Taste Bleeding Prepared by Tendencie D. Chaplin Osteodystrophy Decreased sodium reabsorption in tubule Water Retention Hypertension Heart Failure Edema 2 a Loss of excretory renal function Decreased potassium excretion Hyperkalemia Decreased phosphate excretion Decreased hydrogen excretion Hyperphosphatem ia Metabolic acidosis Decreased calcium absorption Hypocalcemia Hyperparathyroidis m Decreased potassium excretion Increased potassium

üWeakness and tiredness/ fatigue. üNocturia is often an early symptom üItchiness of the skin which can progressively worsen üPale skin which is easily bruised üMuscular twitches, cramps and pain üPins and needles in the hands and feet üNausea Prepared by D. Chaplin

As the condition worsens the symptoms progress to: n n n n n 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 Prepared by D. Chaplin

Associated complications of chronic Kidney Disease would be: n Anaemia, mostly due to deficiency of erythropoietin n Bleeding which is caused by impairment of platelet function n Metabolic Bone Disease (known as Renal Osteodystrophy) Prepared by D. Chaplin

Associated complications of chronic Kidney Disease would be: n 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 Prepared by D. Chaplin

Associated complications of chronic Kidney Disease would be: n Nervous system – neuropathy caused by the loss of myelin from nerve fibres – may improve when dialysis is established n Gastrointestinal complications - anorexia, nausea and vomiting, and a higher incidence of peptic ulcer disease Prepared by D. Chaplin

Associated complications of chronic Kidney Disease would be: n Skin disease – itching, which is attributed to the retention of metabolic waste products. It often improves with dialysis. Dry skin can also occur n Muscle dysfunction - myopathy leading to muscle cramps and the “restless leg” syndrome Prepared by D. Chaplin

Associated complications of chronic Kidney Disease would be: n Metabolic dysfunction - involving lipids, insulin and uric acid (gout). Metabolic acidosis is also associated Prepared by D. Chaplin

Prepared by D. Chaplin

Diagnosis n n n Urine Tests Urinalysis Twenty-four hour urine tests Glomerular filtration rate (GFR) Blood Tests Creatinine and urea (BUN) in the blood Prepared by D. Chaplin n n n Estimated GFR (e. GFR) Electrolyte levels and acid-base balance Blood cell counts Other tests Ultrasound: Biopsy

Treatment Modalities Decrease fluid 1000 ml/day Decrease protein (. 5 -1 kg body weight) Decrease sodium (1 -4 gm variable) Decrease potassium Decrease phosphorous (<1000 mg/day) Dialysis (periotoneal, hemodialysis) RBC, Vitamin D (calcitrol replacement) etc. Prepared by D. Chaplin

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 Prepared by D. Chaplin

Osmosis-Diffusion-Ultrafiltration Osmosis - movement fluid from an area of < to > concentration of solutes (particles) 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 Prepared by D. Chaplin

Peritoneal Dialysis Catheter placement – anterior abdominal wall Tenckoff (25 cm 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 Prepared by D. Chaplin

Peritoneal Dialysis Prepared by D. Chaplin

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 Prepared by D. Chaplin

Hemodialysis AV Fistula Communication Prepared by D. Chaplin AV Graph Access

Hemodialysis Circuit Prepared by D. Chaplin Hemodialysis Machine

PD Advantages and Disadvantages Advantages Immediate initiation Less complicated Portable (CAPD) Fewer dietary restrictions Short training time Less cardio stress Choice for diabetics Prepared by D. Chaplin Disadvantages Bacterial/chemical peritonitis Protein loss Exit site of catheter Self image Hyperglycemia Surgical placement of catheter Multiple abdominal surgery

Hemo Advantages & Disadvantages Advantages Rapid fluid removal Rapid removal of urea & creatinine Effective K+ removal Less protein loss Lower triglycerides Home dialysis possible Temporary access at the bedside Prepared by D. Chaplin Disadvantages Vascular access problems Dietary & fluid restrictions Heparinization Extensive equipment Hypotension Added blood lost Trained specialist

Disequalibrium Syndrome 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 Prepared by D. Chaplin

The following are general dietary guidelines: n n n n Protein restriction: Salt restriction Fluid intake: Potassium restriction: Phosphorus restriction: Control blood pressure and/or diabetes; Stop smoking; and Lose Excess Weight Prepared by D. Chaplin

Avoided or used with caution: n n n Certain analgesics: Aspirin; ibuprofen Fleets or phosoda enemas because of their high content of phosphorus Laxatives and antacids containing magnesium and aluminum such as magnesium hydroxide Ulcer medication H 2 -receptor antagonists: cimetidine, ranitidine Decongestants such as pseudoephedrine especially if they have high blood pressure Herbal medications Prepared by D. Chaplin

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. Prepared by D. Chaplin

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 –metha. Pred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran) Prepared by D. Chaplin

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 Prepared by D. Chaplin

Immunological Compatibility of Donor and Recipient Done to minimize the destruction (rejection) of the transplanted kidney HUMAN LEUKOCYTE ANTIGEN (HLA) This gives your genetic identity (twins share identical HLA) HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues. Prepared by D. Chaplin

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 Prepared by D. Chaplin

Immulogical Analysis 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 Prepared by D. Chaplin

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. Prepared by D. Chaplin

Complications Post Transplant 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-CD 3, ALG, or ATG) Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys Prepared by D. Chaplin

Complications Post Transplant 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 Prepared by D. Chaplin

Complications Post Transplant Infection Hypertension Malignancies (lip, skin, lymphomas, cervical) Recurrence of renal disease Retroperiotneal bleed Arterial stenosis Urine leakage Prepared by D. Chaplin

100 patients with e. GFR < 60 Prepared by D. Chaplin (Tuesday morning in Outpatients)

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

Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have Prepared by D. Chaplinongoing 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. Prepared by D. Chaplin

Optimise risk factors n n n n Cardiovascular disease Proteinuria Hypertension Diabetes Smoking Obesity Exercise tolerance Prepared by D. Chaplin 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. Prepared by D. Chaplin 46

Ø Ø 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. Prepared by D. Chaplin

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. Prepared by D. Chaplin 48

• Ø Ø Ø 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 Prepared by D. Chaplin

Nursing Care Plan of a Patient With ESRD (Cont…) Nursing diagnosis: Deficient knowledge regarding condition and treatment. • Goal: Increased knowledge about condition and related treatment. Prepared by D. Chaplin 50

• Ø Ø Ø 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. Prepared by D. Chaplin

Nursing Care Plan of a Patient With ESRD (Cont…) 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: Ø Assess factors contributing to fatigue (anemia, fluid and electrolyte imbalances, retention of waste products, depression) Ø Promote independence in self-care activities as tolerated; assist if fatigued. Ø Encourage alternating activity with rest. Ø Encourage patient to rest after dialysis treatments. Prepared by D. Chaplin TAKE HOME MESSAGE 52

THANK YOU Have a check on your blood pressure Sugar & Salt / year Prepared by D. Chaplin