Chronic Kidney Disease

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Chronic Kidney Disease
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Chronic Kidney Disease

• Progressive, irreversible damage to the nephrons
  and glomeruli

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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(atheroscler
  osis) 
• 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.

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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

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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

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Table 1. Stages of Chronic Kidney Disease GFR is
glomerular filtration rate, a measure of the
kidney's function.
Stage Description GFRmL/min/1.73m2
1 Slight kidney damage with normal or increased filtration More than 90
2 Mild decrease in kidney function 60-89
3 Moderate decrease in kidney function 30-59
4 Severe decrease in kidney function 15-29
5 Kidney failure Less than 15 (or dialysis)
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Modifiable Factors -Diabetic Mellitus -Hypertensio
n -Increase Protein and Cholesterol
Intake -Smoking -Use of analgesics
Non-Modifiable Factors -Hereditary -Age greater
than 60 years old -Gender -Race
Decreased renal blood flow Primary kidney
disease Damage from other diseases Urine outflow
obstruction
Chronic Kidney Disease - Pathophysiology
Serum Creatinine
BUN
Decreased glomerular filtration
Hypertrophy of remaining nephrons
Dilute Polyuria
Inability to concentrate urine
Loss of Sodium in Urine
Hyponatremia
Dehydration
Further loss of nephron function
Loss of nonexcretory renal function
2a
Failure to convert inactive forms of calcium
Failure to produce eryhtropoietin
Impaired insulin action
Production of lipids
Immune disturbances
Disturbances in reproduction
Erratic blood glucose levels
Advanced atherosclerosis
Calcium absorption
Anemia Pallor
Delayed wound healing
Infection
Libido
Infertility
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2a
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Hypocalcemia
Osteodystrophy
Loss of excretory renal function
Excretion of nitrogenous waste
Decreased sodium reabsorption in tubule
Decreased potassium excretion
Decreased phosphate excretion
Decreased hydrogen excretion
Uremia
Hyperkalemia
Hyperphosphatemia
Metabolic acidosis
Water Retention
BUN, Creatinine Uric Acid
Decreased calcium absorption
Hypertension Heart Failure Edema
Proteniuria
Hypocalcemia
Peripheral nerve changes
Hyperparathyroidism
Decreased potassium excretion
Pericarditis
Increased potassium
CNS changes
Pruritus
Altered Taste
Bleeding Tendencies
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• 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

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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

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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)

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Associated complications of chronic Kidney
Disease would be

• 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

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Associated complications of chronic Kidney
Disease would be

• 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

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Associated complications of chronic Kidney
Disease would be

• 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

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Associated complications of chronic Kidney
Disease would be

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

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Diagnosis

• Estimated GFR (eGFR)
• Electrolyte levels and acid-base balance  
• Blood cell counts 
• Other tests
• Ultrasound
• Biopsy

• Urine Tests
• Urinalysis
• Twenty-four hour urine tests 
• Glomerular filtration rate (GFR)
• Blood Tests
• Creatinine and urea (BUN) in the blood

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Treatment Modalities

• Decrease fluid 1000ml/day
• Decrease protein (.5-1kg body weight)
• Decrease sodium (1-4gm variable)
• Decrease potassium
• Decrease phosphorous (lt1000mg/day)
• Dialysis (periotoneal, hemodialysis)
• RBC, Vitamin D (calcitrol replacement) etc.

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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

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Osmosis-Diffusion-Ultrafiltration
Osmosis - movement fluid from an area of lt to gt
concentration of solutes (particles)

• Diffusion - movement of solutes (particles)
  from an area of gt concentration to area of lt
  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

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Peritoneal Dialysis

• Catheter placement anterior abdominal wall
• Tenckoff (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

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Peritoneal Dialysis
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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

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Hemodialysis
AV Fistula Communication
AV Graph Access
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Hemodialysis
Hemodialysis Machine
Hemodialysis Circuit
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PD Advantages and Disadvantages
Advantages
Disadvantages

• Bacterial/chemical peritonitis
• Protein loss
• Exit site of catheter
• Self image
• Hyperglycemia
• Surgical placement of catheter
• Multiple abdominal surgery

• Immediate initiation
• Less complicated
• Portable (CAPD)
• Fewer dietary restrictions
• Short training time
• Less cardio stress
• Choice for diabetics

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Hemo Advantages Disadvantages
Advantages
Disadvantages

• Rapid fluid removal
• Rapid removal of urea creatinine
• Effective K removal
• Less protein loss
• Lower triglycerides
• Home dialysis possible
• Temporary access at the bedside

• Vascular access problems
• Dietary fluid restrictions
• Heparinization
• Extensive equipment
• Hypotension
• Added blood lost
• Trained specialist

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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

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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

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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 cimetidi
  ne, ranitidine
• Decongestants such as pseudoephedrine  especially
  if they have high blood pressure 
• Herbal medications

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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.

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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)

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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

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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.

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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

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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

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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.

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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-CD3, ALG, or ATG)
• Signs increasing serum creatinine, elevated BUN,
  fever, wt. gain, decrease output, increasing BP,
  tenderness over the transplanted kidneys

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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

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Complications Post Transplant

• Infection
• Hypertension
• Malignancies (lip, skin, lymphomas, cervical)
• Recurrence of renal disease
• Retroperiotneal bleed
• Arterial stenosis
• Urine leakage

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100 patients with eGFR lt 60 (Tuesday morning in
Outpatients)
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Tuesday morning 1 year later 1 patient needs
RRT, 10 patients have died (gt 50 CV death)
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Tuesday morning 10 years later 8 patients need
RRT, 65 patients have died, 27 have ongoing CKD
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• 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.

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Optimise risk factors

• Cardiovascular disease
• Proteinuria
• Hypertension
• Diabetes
• Smoking
• Obesity
• Exercise tolerance

TAKE HOME MESSAGE
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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.

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• 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.

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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 patients 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 patients food preferences within
  dietary restrictions.
• Promote intake of high biologic value protein
  foods

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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.

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• 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 patients level
  of understanding and guided by patients
  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.

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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
• 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.

TAKE HOME MESSAGE
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THANK YOU