Chronic Kidney Disease

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Chronic Kidney Disease Treatment

• Vicky Jefferson, RN, CNN
• Satellite Dialysis
• (modified by Kelle Howard, MSN, RN, CNE)
• revised Fall 2012

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• Bones can break, muscles can atrophy, glands can
  loaf, even the brain can go to sleep without
  immediate danger to survival. But -- should
  kidneys fail.... neither bone, muscle, nor brain
  could carry on.
• Homer Smith, Ph.D.

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REVIEW

• What are nephrons?
• What are the functions of the kidneys?
• Normal creatinine BUN?
• Diagnostic tools

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Functions of the Kidneys

• Regulates ______ _________ of extracellular
  fluid
• Regulates fluid electrolyte balance thru
• processes of glomerular__________,
  tubular _________, and tubular _____________.
• Name some of the F Es regulated by kidneys
  __________________

10/16/2013
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Functions of the Kidneys (cont)

• Regulates acid-base balance through
• HCO3 and H
• Hormonal functions (BP control), multisystem
  effect.
• Renin Release

RAAS
10/16/2013
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Functions of the Kidneys (cont)

• Erythropoietin Release
• If a patient has chronic renal failure, what
  condition will occur?
• WHY???

10/16/2013
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Functions of the Kidneys (cont)

• Activate Vitamin D
• Necessary to absorb Calcium in the GI
• tract.
• If a patient has renal failure, what will happen
  to the patients serum calcium level?
  __________________

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Functions of the Kidneys

• _______________
• _______________
• _______________

• ______________
• ______________
• ______________
• ______________

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Diagnostic Tools for Assessing Kidney Failure

• Blood Tests
• BUN
• Creatinine
• K
• PO4
• Ca
• Urinalysis
• Specific gravity
• Protein
• Creatinine clearance

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BUN

• Normal 6-20 mg/dl
• Nitrogenous waste product of protein metabolism
• By itself Unreliable in measurement of renal
  function

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Creatinine

• A waste product of muscle metabolism
• Normal value 0.6 1.3 mg/dl
• 2 times normal 50 damage
• 8 times normal 75 damage
• 10 times normal 90 damage
• Exception -_______________________

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Diagnostic Tools

• Biopsy
• Ultrasound
• X-Rays
• Labs
• Anything else?

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Chronic Kidney Disease

• Slow progressive renal disorder related to
  nephron loss
• occurring over months to years
• Culminates in End Stage Renal Disease

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Chronic Kidney DiseaseCharacteristics

• Cause onset often unknown
• Loss of function _________ lab abnormalities
• Lab abnormalities ________ symptoms
• Symptoms (usually) evolve in orderly sequence
• Renal size is usually decreased

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Chronic Kidney DiseaseCauses

• ___________
• ___________
• ___________
• Cystic disorders
• Developmental/Congenital
• Infectious Disease

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Chronic Kidney DiseaseCauses (cont)

• Neoplasms
• Obstructive disorders
• Autoimmune diseases
• Hepatorenal failure
• Scleroderma
• Amyloidosis
• Drug toxicity

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Glomerular Filtration RateGFR

• 24 hour urine for creatinine clearance
• Most accurate indicator of Renal Function
• Reflects GFR
• Formula
• urine creatinine X urine volume
• serum creatinine
• Can estimate creatinine clearance by
• Men 140 age x IBW (kg)
• 72 x serum creatinine
• Women 140 age x IBW (kg)
• 85 x serum creatinine
• What is a normal GFR?

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Stages of Chronic Kidney DiseaseOld System

• Reduced Renal Reserve
• Renal Insufficiency
• End Stage Renal Disease (ESRD)

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Stages of Chronic Kidney DiseaseNKF
Classification System

• Stage 1
• GFR gt/ 90 ml/min despite kidney damage

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Stages of Chronic Kidney DiseaseNKF
Classification System

• Stage 2 Mild reduction
• (GFR 60 89 ml/min)
• 1. GFR of 60 may represent 50
  loss in function.
• 2. Parathyroid hormones starts to
  increase.

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During Stage 1 - 2

• No symptoms
• Serum creatinine doubles
• Up to 50 nephron loss

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Stages of Chronic Kidney DiseaseNKF
Classification System

• Stage 3 Moderate reduction
• (GFR 30 59 ml/min)
• 1. Calcium absorption decreases
• 2. Malnutrition onset
• 3. Anemia
• 4. Left ventricular hypertrophy

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Stages of Chronic Kidney DiseaseNKF
Classification System

• Stage 4 Severe reduction
• (GFR 15 29 ml/min)
• 1. Serum triglycerides increase
• 2. Hyperphosphatemia
• 3. Metabolic acidosis
• 4. Hyperkalemia

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During Stage 3 - 4

• Signs and symptoms worsen if kidneys are stressed
• Decreased ability to maintain homeostasis

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During stages 3 - 4

• 75 nephron loss
• Decreased
• __________
• __________
• __________
• __________
• Symptoms
• elevated BUN Creatinine, mild azotemia, anemia

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Stages of Chronic Kidney DiseaseNKF
Classification System

• Stage 5 Kidney failure (GFR lt 15 ml/min)
• 1. Azotemia

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During Stage 5End Stage Renal Disease

• Residual function lt 15 of normal
• Excretory, regulatory and hormonal functions
  severely impaired.
• Metabolic acidosis
• Marked increase in
• ___________
• ___________
• ___________
• Marked decrease in
• ___________
• ___________
• ___________
• Fluid overload

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During Stage 5

• Uremic syndrome develops affecting all body
  systems
• can be diminished with early diagnosis
  treatment
• Last stage of progressive CKD
• Fatal if no treatment

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Manifestations of Chronic Uremia
Fig. 47-5
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What happens when the kidneys dont function
correctly?
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Manifestations of CKD Nervous System

• Mood swings
• Impaired judgment
• Inability to concentrate and perform simple math
  functions
• Tremors, twitching, convulsions
• Peripheral Neuropathy

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Manifestations of CKDSkin

• Pale, grayish-bronze color
• Dry scaly
• Severe itching
• Bruise easily
• Uremic frost
• Calcium/Phos deposits

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Manifestations of CKDEyes

• Visual blurring
• Blindness

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Manifestations of CKD Fluid - Electrolyte - pH

• Volume expansion and fluid overload
• Metabolic Acidosis
• Change in urine specific gravity
• Electrolyte Imbalances
• Potassium
• Magnesium
• Sodium

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Manifestations of CKDGI Tract

• Uremic fetor
• Anorexia, nausea, vomiting
• GI bleeding

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Manifestations of CKD Hematologic

• Anemia
• Platelet dysfunction

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Manifestations of CKD Musculoskeletal

• Muscle cramps
• Soft tissue calcifications
• Weakness
• RENAL OSTEODYSTROPHY

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Calcium-Phosphorous Balance
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Manifestations of CKDHeart - Lungs

• Hypertension
• Congestive heart failure
• Pericarditis
• Pulmonary edema
• Pleural effusions
• Atherosclerotic vascular disease
• Cardiac dysrhythmias

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Manifestations of CKD Endocrine - Metabolic

• Erythropoietin production decreased
• Hypothyroidism
• Insulin resistance
• Growth hormone decreased
• Gonadal dysfunction
• Parathyroid hormone and Vitamin D3
• Hyperlipidemia

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Treatment Options

• Conservative Therapy
• Hemodialysis
• Peritoneal Dialysis
• Transplant
• Nothing

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Conservative Treatment

• GOALS
• Detect treat potentially reversible causes of
  renal failure
• Preserve existing renal function
• Treat manifestations
• Prevent complications
• Provide for comfort

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Conservative Treatment

• Control
• Hyperkalemia
• Hypertension
• Hyperphosphatemia
• Hyperparthryoidism
• Hyperglycemia
• Anemia
• Dyslipidemia
• Hypothyroidism
• Nutrition
• Describe a renal diet while on conservative
  treatment?

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Hemodialysis

• Removal of soluble substances and water from
  the blood by diffusion through a semi-permeable
  membrane.

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History

• Early animal experiments began 1913
• 1st human dialysis 1940s by Dutch physician
  Willem Kolff
• Considered experimental through 1950s, No
  intermittent blood access for acute renal kidney
  injury only.

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History contd

• 1960 Dr. Scribner developed Scribner Shunt
• 1960s Machines expensive, scarce, no funding.
• Death Panels panels within community decided
  who got to dialyze.

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Hemodialysis Process

• Blood removed from patient into the
  extracorporeal circuit.
• Diffusion and ultrafiltration take place in the
  dialyzer.
• Cleaned blood returned to patient.

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Extracorporeal Circuit
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How Hemodialysis Works
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Vascular Access

• Arterio-Venous shunt
• (Scribner External Shunt)
• Arterio-Venous
• (AV) Fistula
• PTFE Graft
• Temporary catheters
• Permanent catheters

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Scribner Shunt

• External
• one end into artery
• one into vein
• Advantages
• place at bedside
• use immediately
• Disadvantages
• infection
• skin erosion
• accidental separation
• limits use of extremity

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Arterio-Venous (AV) FistulaPrimary Fistula

• Patients own artery and vein surgically
  anastomosed.
• Advantages
• patients own vein
• longevity
• low infection and thrombosis rates
• Disadvantages
• long time to mature, 1- 6 months
• steal syndrome
  
• requires needle sticks
  devita.com

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PTFE (Polytetrafluoroethylene) Graft

• Synthetic vessel anastomosed into an artery and
  vein.
• Advantages
• for people with inadequate vessels
• can be used in 1-4 weeks
• prominent vessels
• Disadvantages
• clots easily
• steal syndrome more frequent
• requires needle sticks
• infection may necessitate removal of graft

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Temporary Catheters

• Dual lumen catheter placed into a central
  vein-subclavian, jugular or femoral.
• Advantages
• immediate use
• no needle sticks
• Disadvantages
• high incidence of infection
• subclavian vein stenosis
• poor flow-inadequate dialysis
• clotting
• restricts movement

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Cuffed Tunneled Catheters

• Dual lumen catheter with Dacron cuff surgically
  tunneled into subclavian, jugular or femoral
  vein.
• Advantages
• immediate use
• can be used for patients that can have no other
  permanent access
• no needle sticks
• Disadvantages
• high incidence of infection
• poor flows result in inadequate dialysis
• clotting

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Care of Vascular Access

• NO BPs, needle sticks to arm with vascular
  access. This includes finger sticks.
• Place ID bands on other arm whenever possible.
• Palpate thrill and listen for bruit.
• Teach patient nothing constrictive.

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Potential Complications of Hemodialysis

• During dialysis
• Fluid and electrolyte related
• hypotension
• Cardiovascular
• arrythmias
• Associated with the extracorporeal circuit
• exsanguination
• Neurologic
• Disequilibrium Syndrome seizures
• Musculoskeletal
• cramping
• Other
• fever sepsis
• blood born diseases

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Potential Complications of Hemodialysis

• Between treatments
• Hypertension/Hypotension
• Edema
• Pulmonary edema
• Hyperkalemia
• Bleeding
• Clotting of access

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Complications of Hemodialysis contd

• Long term
• Metabolic
• hyperparathyroidism
• diabetic complications
• Cardiovascular
• CHF
• AV access failure
• cardiovascular disease
• Respiratory
• pulmonary edema
• Neuromuscular
• neuropathy

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Complications of Hemodialysiscontd

• Long term contd
• Hematologic
• anemia
• GI
• bleeding
• Dermatologic
• calcium phosphorous deposits
• Rheumatologic
• amyloid deposits

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Complications of Hemodialysis contd

• Long term contd
• Genitourinary
• infection
• sexual dysfunction
• Psychiatric
• depression
• Infection
• blood borne pathogens

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Dietary Restrictions on Hemodialysis

• Fluid restrictions
• Phosphorous restrictions
• Potassium restrictions
• Sodium restrictions
• Protein to maintain nitrogen balance
• too high - waste products
• too low - decreased albumin, increased mortality
• Calories to maintain or reach ideal weight

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Peritoneal Dialysis

• Removal of soluble substances and water from the
  blood by diffusion through a semi-permeable
  membrane that is intracorporeal (inside the body).

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Types of Peritoneal Dialysis

• CAPD Continuous ambulatory peritoneal dialysis
• CCPD Continuous cycling peritoneal dialysis
• Aka. APD Automated Peritoneal Dialysis
• IPD Intermittent peritoneal dialysis

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Peritoneal Dialysis

• Warm sterile dialysate ? into peritoneal cavity
  from previously placed catheter ? wastes lytes
  diffuse into dialysate until equilibrium achieved
  ? diffuse controlled by dextrose concentration
• Concentrations available 1.5, 2.5, 4.25
• Usually about 2L -----(can be 1.5L-3L)
• What does this do to blood sugar calorie count?

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Peritoneal Catheter Exit Site
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Phases of A Peritoneal Dialysis Exchange

• Fill fluid infused into peritoneal cavity
• Dwell time fluid remains in peritoneal cavity
• Drain time fluid drains from peritoneal cavity

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CAPD

• Catheter into peritoneal cavity
• Exchanges 4 - 5 times per day
• Treatment 24 hours 7 days a week
• Solution remains in peritoneal cavity except
  during drain time
• Independent treatment

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Complications of Peritoneal Dialysis

• Infection
• peritonitis
• tunnel infections
• catheter exit site
• Hypervolemia
• hypertension
• pulmonary edema
• Hypovolemia
• hypotension
• Hyperglycemia
• Malnutrition

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Complications of Peritoneal Dialysis contd

• Obesity
• Hypokalemia
• Hernia
• Cuff erosion
• Low back pain
• Hyperlipidemia

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Advantages of CAPD

• Independence for patient
• No needle sticks
• Better blood pressure control
• Some diabetics add insulin to solution
• Fewer dietary restrictions
• protein loses in dialysate
• generally need increased potassium
• less fluid restrictions

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Lets Talk About

• Medications

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Medications Common to Dialysis Patients

• Vitamins - water soluble
• Phosphate binder ---- GIVE WITH _____
• Phoslo (calcium acetate)
• Renagel (sevelamere hydrochloride)
• Caltrate (calcium cabonate)
• Amphojel (aluminum hydroxide)
• Iron Supplements
• dont give with phosphate binder or calcium
• Antihypertensives
• When do we give these?

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Medications Common to Dialysis Patients contd

• Erythropoietin
• Calcium Supplements
• Between meals, not with ______
• Activated Vitamin D3
• Antibiotics
• hold dose prior to dialysis
• Why?

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Medications

• Many drugs or their metabolites are excreted by
  the kidney
• Dosages
• many change when used in kidney failure patients
• Why?
• Dialyzability
• many removed by dialysis varies between HD and PD

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Patient Education

• Alleviate fear
• Dialysis process
• Fistula/catheter care
• Diet and fluid restrictions
• Medication
• Diabetic teaching

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Transplantation

• Treatment not cure

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Transplanted Kidney
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Advantages

• Restoration of normal renal function
• Freedom from dialysis
• Return to normal life
• Reverses pathophysiological changes related to
  Renal Failure
• Less expensive than dialysis after 1st year

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Disadvantages

• Life long medications
• Multiple side effects from medication
• Increased risk of tumor
• Increased risk of infection
• Major surgery

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Care of the Recipient

• Major surgery with general anesthesia
• Assessment of renal function
• Assessment of fluid and electrolyte balance
• Prevention of infection
• Prevention and management of rejection

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Monitoring Transplant Function

• ATN? (acute tubular necrosis)
• Urine output gt100 lt500 cc/hr (initially)
• Labs
• Fluid Balance
• Ultrasound
• Renal scans
• Renal biopsy

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Fluid Electrolyte Balance

• Accurate I O
• CRITICAL TO AVOID DEHYDRATION
• Output normal - gt100 lt500 cc/hr, could be 1-2
  L/hr
• Potential for volume overload/deficit
• FLUID RESCUITATION 24HR URINE OUPUT
• Daily weights
• Postassium (K)___________
• Sodium (Na) _____________
• Blood sugar _____________

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Prevention of Infection

• Major complication of transplantation due to
  immunosuppression
• What do you teach?

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Rejection

• Hyperacute - preformed antibodies to donor
  antigen
• function ceases within 24 hours
• Rx removal
• Accelerated - same as hyperacute but slower, 1st
  week to month
• Rx removal

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Rejection contd

• Acute - generally after 1st 10 days to end of 2nd
  month
• 50 experience
• must differentiate between rejection and
  cyclosporine toxicity
• Rx steroids, monoclonal (OKT3), or polyclonal
  (HTG) antibodies

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Rejection contd

• Chronic - gradual process of graft dysfunction
• Repeated rejection episodes that have not been
  completely resolved with treatment
• 4 months to years after transplant
• Rx return to dialysis or re-transplantation

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Immunosuppressant Drugs

• Prednisone
• prevents infiltration of T lymphocytes
• Side effects
• cushingnoid changes
• avascular necrosis
• GI disturbances
• diabetes
• infection
• risk of tumor

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Immunosuppressant Drugs contd

• Azathioprine (Imuran)
• Prevents rapid growing lymphocytes
• Side Effects
• bone marrow toxicity
• hepatotoxicity
• hair loss
• infection
• risk of tumor

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Immunosuppressant Drugs contd

• Cyclosporine
• Interferes with production of interleukin 2 which
  is necessary for growth and activation of T
  lymphocytes.
• Side Effects
• Nephrotoxicity
• HTN
• Hepatotoxicity
• Gingival hyperplasia
• Infection

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Immunosuppressant Drugs contd

• Cytoxan - in place of Imuran less toxic
• FK506 - 100 x more potent than Cyclosporine
• Prograf
• CellCept

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Immunosuppressant Drugs contd

• OKT3 - monoclonal antibody used to treat
  rejection or induce immunosuppression
• decreases CD3 cells within 1 hour
• Side effects
• anaphylaxis
• fever/chills
• pulmonary edema
• risk of infection
• tumors
• 1st dose reaction expected wanted, pre-treat
  with Benadryl, Tylenol, Solumedrol

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Immunosuppressant Drugs contd

• Atgam - polyclonal antibody used to treat
  rejection or induce immunosuppression
• decreased number of T lymphocytes
• Side effects
• anaphylaxis
• fever chills
• leukopenia
• thrombocytopenia
• risk of infection
• tumor

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Patient Education

• Signs of infection
• Prevention of infection
• Signs of rejection
• ____________
• ____________
• ____________
• ____________
• Medications
• _____________

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Exclusion for Transplant

• Exclusion for Transplant not limited too
• Active vasculitis or
• Life threatening extrarenal congenital
  abnormalities or
• Untreated coagulation disorder or
• Ongoing alcohol or drug abuse or
• Age over 70 years with severe co-morbidities or
• Severe neurological or mental impairment, in
  persons without adequate social support, such
  that the person is unable to adhere to the
  regimen necessary to preserve the transplant.

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Exclusion for Transplant

• Exclusion for Transplant not limited too
• Active vasculitis or
• Life threatening extrarenal congenital
  abnormalities or
• Untreated coagulation disorder or
• Ongoing alcohol or drug abuse or
• Age over 70 years with severe co-morbidities or
• Severe neurological or mental impairment, in
  persons without adequate social support, such
  that the person is unable to adhere to the
  regimen necessary to preserve the transplant.

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Official Criteria for Deceased Donors

• Usually irreversible brain injury
• MVA, gunshot wounds, hemorrhage, anoxic brain
  injury from MI
• Must have effective cardiac function
• Must be supported by ventilator to preserve
  organs
• Age 2-70
• No IV drug use, HTN, DM, Malignancies, Sepsis,
  disease
• Permission from legal next of kin pronoucement
  of death made by MD

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Official Criteria for Living Donors

• Psychiatric evaluation
• Anesthesia evaluation
• Medical Evaluation
• Free from diseases listed under deceased donor
  criteria
• Kidney function evaluated
• Crossmatches done at time of evaluation and 1
  week prior to procedure
• Radiological evaluation

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Nurses Role in Event of Potential Donation

• Notify TOSA of possible organ donation
• Identify possible donors
• Make referral in timely manner
• Do not discuss organ donation with family
• Offer support to families after referral is made
  donation coordinator has met with family