The of

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The of

ABCs
Chronic Kidney Disease

• Mary T. Sinnen APRN BC ANP

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YOU CAN HELP SAVE KIDNEYS!

• Review basic anatomy and physiology
• Update chronic kidney disease (KDOQI evidenced
  based practice)
• Understand how to save nephron mass
• Describe the ABCs which need to be addressed in
  stages 3 5 of CKD

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Kidney Disease in the United States

• A SILENT epidemic
• ESRD ONLY chronic condition financially covered
• growing numbers
• growing costs
• WE can make changes

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Growing numbers and costs.
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New starts on dialysis

• Over one-half of patients initiating dialysis are
  65 years and older
• Over 40 of patients initiating dialysis have
  diabetes mellitus

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New starts on dialysis

• Over one-half of patients initiating dialysis are
  65 years and older
• Over 40 of patients initiating dialysis have
  diabetes mellitus

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Mortality with ARF

• International study of 29,269 patients of these
  1,738 (5.7) had ARF / ICU stay. (1,260 on RRT)
• Overall hospital death rate 60.3
• Dialysis dependence 13.8 for survivors
• Septic shock, vasopressors, intubation

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Renal Anatomy

• Kidney 10 x 5 x 2.5 (size of fist)
• weight 125 to 170 gms, adrenal glands on top
• ureters 2 to 8 mm in diameter 25 to 35 cm long
  innervated
• bladder collecting reservoir, inner mucous wall
  has phagocytic ability, capacity 1000 to 1800 ml.

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Healthy Kidneys homeostasis

• Eliminate wastes
• Fluid balance
• Electrolyte balance
• Acid base balance
• Blood pressure control renin
• Red blood cell production erythropoetin
• Healthy bones calcium, phosphorus, PTH

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Physiological processes

• REMEMBER the NEPHRONS !
• Filtration
• Reabsorption
• Secretion

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The aging process

• As we ageso do our bodily organs, this includes
  the kidneys
• People are living longer
• People are living longer with chronic diseases
• We are using more nephrotoxic drugs.

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Age related kidney changes

• Ages 40 to 80 years we loose 20 of kidney mass
• Vascular changes include a decrease in renal
  blood flow rate of 10 per each decade of life
  after age 30.
• GFR decrease 1 ml/min/year beginning at age 40.
  This is accompanied by a decrease in muscle
  massso the serum creatinine level does NOT
  increase.

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Age related kidney changes..

• adaptive mechanisms become impaired
• Kidneys loose ability to dilute and concentrate
  urine
• Elderly have alteration in thirst
• Elderly have alteration in sodium balance

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Chronic Kidney Disease

• One of every Nine adults in the state
• Silent in nature until 80 to 85 loss
• RISKS African Americans, Native Americans,
  Hispanics, Older adults
• Family history of kidney disease

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Who is at risk?

• Those with Diabetes (Primary cause of end stage
  renal disease) 43.4 of new dialysis cases are
  diabetic.
• Black Americans are twice as likely to have
  diabetes as whites Americans of same age.
• Prediction new end stage renal disease cases
  will continue rises if diabetes remains unchecked
  in our society.

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Who is at Risk?

• those with High Blood pressure
• In addition to strokes and heart disease, high
  blood pressure causes kidneys to fail

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Who is at Risk?

• Those who smoke an independent risk factor
  leading to kidney failure.

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Who is at risk?

• Obese people.with body mass index in obese
  parameters. are three times more likely to have
  kidney disease

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EVIDENCED BASED PRACTICE..

• What does the research tell us about kidney
  disease??

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Kidney Disease Outcomes Quality Initiatives
(KDOQI)

• Highly structured process
• Multidisciplinary work groups
• Review of published evidence
• Open review process
• Published guidelines based on evidence and
  opinion
• Existing guidelines dialysis adequacy, vascular
  access, anemia, nutrition, CKD, bone metabolism,
  dyslipidemia

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Estimates of GFR

• Are the best overall indices of the level of
  kidney function
• Serum creatinine alone should not be used to
  assess the level of kidney function
• In adults MDRD (Modification of Diet in Renal
  Disease study) and COCKCROFT-GAULT equations

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CKD stages
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GFR SLIDE RULE EXERCISE

• 70 year old Caucasian
• Serum creatinine of 1.0 ml/min
• What is her GFR?
• What is her stage of CKD?

• 24 year old African American male
• Serum creatinine of 7.0 ml/min
• What is his GFR?
• What is his stage of CKD?

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The ABCs of CKD..

• A anemia management
• B bone health
• C cardiovascular health
• D disease management
• E elimination of nephrotoxins
• F fistula first for those going to
  Hemodialysis

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The ABCs of CKD.

• A is for anemia management

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Signs and symptoms of anemia

• Pallor of skin and mucous membranes
• Loss of libido
• Menstrual problems
• Impaired T-cell macrophage function

• Fatigue
• Depression
• Impaired cognitive function
• Anorexia
• Nausea
• Exertional dyspnea
• Cardiac enlargement
• Left Ventricular Hypertrophy
• Systolic ejection murmur

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Anemia and the elderly

• Anemia associated morbidity
• Cardiovascular disease
• Falls
• Functional impairment
• Cognitive and mood
• dysfunction
• Age 65 are 3 times more likely to have CKD

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Treatment for anemia related to CKD

• Subcutaneous Injections with erythropoetin
  stimulating agents
• Target hemoglobin 11 to 12 g/dL
• MUST HAVE IRON AVAILABLE!!!
• Iron studies and replacement of iron orally and
  IV when TSAT and ferritin warrant.

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ANEMIA MANAGEMENT CLINICS

• Clinics designed to better manage the treatment
  of anemia
• Point of care testing with HEMOCUE
• Adjusting medications
• Attention to reimbursement and regulations

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The ABCs of CKD

• B is for bone health

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TRUE OR FALSE

• The use of sun block still allows us to get
  sufficient vitamin D?
• Do we live in a vitamin D deficient society?

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Bone health.

• Weaker bone structure
• Aches and pains in bones and joints
• Fractures
• Ligament and tendon tears
• Itching of the skin
• Calcium deposits

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Calciphylaxis
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Treatment for Bone health..

• Monitor serum calcium phosphorus and intact PTH
  levels
• Treat metabolic acidosis
• Vitamin D evaluation and replacement
• Low phosphorus diet
• PHOSPHATE BINDERS WITH FOOD!

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The ABCs of CKD

• C is for cardiovascular health

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Renal blood flow

• Kidney gets 20 to 25 of cardiac output
• auto regulation maintains consistency in GFR.
  Mean arterial pressure between 80 and 180
  prevents large changes in GFR because of ability
  of the afferent arteriole to constrict and
  dilate.
• Autoregulation fails at MAP of 70 mm Hg or less

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Terms you need to know

• Proteinuria spilling protein into the urine
• The kidneys should NOT leak protein
• Protein should go back into the blood stream
• This is one of the EARLIEST signs of kidney
  damage
• This can be detected with a simple urine test

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Cardiac remodeling
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Cardiovascular treatments

• Lipid monitoring and medications
• Smoking cessation
• Weight management
• Routine exercise
• Cardiac evaluations

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The ABCs of CKD

• D is for disease management

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Help control chronic illnesses which cause
kidney damage

• Diabetic management
• Blood sugar control
• Monitor proteinuria
• Use ACE inhibitors or Angiotensen receptor
  blockers (ARBs) for renal protection. These
  medications are renal-protective and can slow
  losses by 50.

• Hypertensive management
• Blood pressure control
• Newest guidelines those with CKD / proteinuria
  goal BP is 120/70
• Use of ACE or ARB for renal protection

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The ABCs of CKD

• E is for eliminating nephrotoxins

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Protecting further nephron loss

• CAUTION!!!!
• Hydration before contrast
• Use of mucomyst
• NSAID use prescription and non-prescription.
  Prostaglandin INHIBITORS!
• Calculated antibiotic doses

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The ABCs of CKD.

• F is for fistula First for those choosing
  hemodialysis

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CKD IV access????

• THINK VESSEL PRESERVATION
• Need for AV fistula creation
• Native vessels are the BEST

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Vessel preservation

• No blood pressures, IV or blood draws in
  designated arm.
• When hospitalized and GFR is below 30 protect
  one arm.
• Teach patients and phlebotomists to use the hand
  veins whenever possible in those with known
  Chronic kidney disease.

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Stage 4.

• Learn about options
• See nephrologist
• Make decision
• ACCESS placement!!!!!

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End Stage Renal Disease

• Options
• Hemodialysis
• Three times per week
• Home everyday
• Peritoneal dialysis
• Manual exchanges
• Cycler (automated exchanges)
• Transplant
• Cadaver or living related
• death

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Hemodialysis

• Usually three times every week
• Nocturnal
• Daily (home)
• Access
• Restrictions
• Anemia
• Bone health
• Cardiovascular health

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Care of the hemodialysis patient..

• Know their Outpatient unit and usual schedule.
  Check inpatient KD.
• Green arm band on access extremity
• Hold meds Blood pressure related
• Give pain medication prior to dialysis
• Diet and educational reinforcement

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Peritoneal Dialysis

• Performed daily by patient at home
• Maybe manual or automated
• Less restrictions
• Use in end stage heart pts.

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Transplant Option

• Living related
• Cadaver
• Not a cure, but another
• form of renal
• replacement
• therapy

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Living with ESRD

• Dietary restrictions Fluid restrictions
• Medications
• Anemia management
• Bone health
• Management of existing chronic conditions
• Hypertension
• Diabetes Mellitus
• Cardiac health

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We all pay in the end!