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Chronic Kidney Disease

Chronic Kidney Disease

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Chronic Kidney Disease

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  1. Chronic Kidney Disease CKD Dialysis Renal Transplant

  2. 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.

  3. Functions of the Kidney • Primary function • _________________________ • _________________________ • Other functions • ______________________ • ______________________ • ______________________ • ______________________

  4. Review • What are nephrons? • Why would a person with kidney disease have anemia? • What happens to the serum calcium? Why? • How does the kidney control blood pressure?

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

  6. Diagnostic studies • Blood Tests • BUN • Creatinine • K+ • PO4 • Ca • Urinalysis • Specific gravity • Protein • Creatinine clearance

  7. BUN and Creatinine • BUN- Normal 6-20 mg/dl • Nitrogenous waste product of protein metabolism • By itself: Unreliable in measurement of renal function • Creatinine- Normal 0.6 - 1.3 mg/dl • A waste product of muscle metabolism • 2 times normal = 50% damage • 8 times normal = 75% damage • 10 times normal = 90% damage • Exception -_______________________

  8. Glomerular Filtration Rate • GFR- Cannot be directly measured • Uses • Serum creatinine • Gender • Ethnicity • Age • Weight • Why would you need to estimate GFR?

  9. Glomerular Filtration Rate CreatinineClearance • 24 hour urine for creatinine clearance • Most accurate indicator of Renal Function • Reflects GFR • Formula: • urine creatinine X urine volume serum creatinine What is a normal GFR?

  10. Chronic Kidney Disease (CKD) • Slow and progressive, irreversible loss of kidney function occurring over months to years • National Kidney Foundation- • Presence of kidney damage or decreased GFR < 60 mL/min for longer than 3 months • End Stage Renal Disease -GFR<15 mL/min • Renal transplant/dialysis

  11. Chronic Kidney Disease (CKD) • Cause & onset often unknown • Loss of function _________ lab abnormalities • Lab abnormalities ________ symptoms • Symptoms (usually) evolve in orderly sequence • Renal size is usually decreased

  12. Chronic Kidney DiseaseCauses • _________________ • _________________ • _________________ • Cystic disorders • Developmental /Congenital • Infectious Disease

  13. Chronic Kidney DiseaseCauses • Neoplasms • Obstructive disorders • Autoimmune diseases • Hepatorenalfailure • Scleroderma • Amyloidosis • Drug toxicity

  14. Stages of CKD Stage 1: GFR >/= 90 ml/min despite kidney damage 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

  15. CKDDuring Stage 1& 2 • No symptoms • Serum creatininedoubles • Up to 50% nephron loss • Why does PTH increase? (2 reasons)

  16. Stages of CKD Stage 3: Moderate reduction -GFR 30-59 ml/min 1. Calcium absorption decreases 2. Malnutrition onset 3. Anemia 4. Left ventricular hypertrophy Why?

  17. Stages of CKD Stage 4: Severe reduction -GFR 15-29 ml/min 1. Serum triglycerides increase 2. Hyperphosphatemia 3. Metabolic acidosis 4. Hyperkalemia Why?

  18. Stages of CKDDuring Stage 3-4 • Signs and symptoms worsen if kidneys are stressed • Decreased ability to maintain homeostasis • 75% nephron loss

  19. Stages of CKDDuring Stage 3 &4 • Decreased: • __________ • __________ • __________ • __________ • Symptoms: • elevated BUN & Creatinine • mild azotemia • anemia

  20. Stages of CKD Stage 5: Kidney failure -GFR < 15 ml/min Azotemia • Residual function < 15% of normal • Excretory, regulatory and hormonal functions severely impaired. • Metabolic acidosis

  21. Marked increase in: • ___________ • ___________ • ___________ • Marked decrease in: • ___________ • ___________ • ___________ • Fluid overload

  22. CKDStage 5 • Uremic syndrome develops affecting all body systems • can be diminished with early diagnosis & treatment • Last stage of progressive CKD • Fatal if no treatment

  23. CKD Manifestations • Urinary • Early • may be no change in urine output • May see polyuria (not related to kidney disease) why? • Later- • Fluid retention, edema • Dialysis- may develop anuria

  24. CKD Manifestations • Metabolic • Waste Products Accumulate • Altered carbohydrate Metabolism • Insulin resistance • Elevated triglycerides

  25. CKD Manifestations • Electrolyte and acid Base • Potassium • Sodium • Calcium and Phosphorus • Magnesium • Metabolic Acidosis • Volume expansion and fluid overload • Change in urine specific gravity

  26. CKD Manifestations • Endocrine • Hyperparathyroidism • Hypothyroidism • Erythropoietin production decreased • Parathyroid hormone and Vitamin D3 • Reproductive • Amennorrhea • Erectile dysfunction • Gonadal dysfunction

  27. CKD Manifestations • Hematologic • Anemia • Bleeding tendencies • Platelet dysfunction • Infection

  28. CKD Manifestations • Cardiovascular • Hypertension • Congestive heart failure • Pericarditis • Atherosclerotic vascular disease • Cardiac dysrhythmias • Respiratory • Pulmonary edema • Pleural effusions

  29. CKD Manifestations • GI tract • Uremic fetor • Anorexia, nausea, vomiting • GI bleeding • Musculoskeletal • Muscle cramps • Soft tissue calcifications • Weakness • Renal Osteodystrophy

  30. CKD Manifestations • Psychologic • Anxiety • Depression • Neurologic • Mood swings • Impaired judgment • Inability to concentrate and perform simple math functions • Tremors, twitching, convulsions • Peripheral Neuropathy

  31. CKD Manifestations • Skin • Pale, grayish-bronze color • Dry scaly • Severe itching • Bruise easily • Uremic frost • Calcium/Phosdeposits • Eyes • Visual blurring • Blindness

  32. Treatment Options • Conservative Therapy • Hemodialysis • Peritoneal Dialysis • Transplant • Nothing

  33. Conservative Treatment GOALS: • Detect & treat potentially reversible causes of renal failure • Preserve existing renal function • Treat manifestations • Prevent complications • Provide for comfort

  34. Conservative Treatment • Control • Hyperkalemia • Hypertension • Hyperphosphatemia • Hyperparthryoidism • Anemia • Hyperglycemia • Dyslipidemia • Hypothyroidism • Nutrition : Describe a renal diet

  35. Control • Hyperkalemia – limit ex:citrus, meats, fish, avocado, beans, spinach • Hypertension -- weight loss, dec.etoh, smoking, DASH diet, meds, fluids • Hyperphosphatemia – meds, low phos diet – ex: milks & cheese • Hyperparthryoidism --deal with Calcium/Phos issue • Anemia – procrit/epogen (could take 2-3 weeks to see a change in HH) • Why don’t we transfuse these patients? • Hyperglycemia – oral anti-diabetic meds, insulin, diet • Dyslipidemia -- statins, keep LDL <100 & triglycerides <200 • Hypothyroidism – hormone replacement • Nutrition : NOW, describe a renal diet?

  36. Renal Diet • Fluids ? • Avoid high protein diet • Restrict: • sodium • potassium • phosphorous • Consume enough calories, to maintain weight • esp. if losing weight

  37. Patient Teaching

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

  39. Dialysis • Osmosis • Diffusion • Ultrafiltration • What GFR value indicates need for hemodialysis?

  40. Peritoneal Dialysis(PD) • 12% dialysis in US is PD • Types • APD: Automated Peritoneal Dialysis (CCPD: Continuous cycling peritoneal dialysis) • CAPD: Continuous ambulatory peritoneal dialysis • IPD: Intermittent peritoneal dialysis

  41. 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

  42. PD • Warm, sterile dialysate infused into peritoneal cavity through catheter. • 2000-2500ml • High concentration of glucose in dialysate • Wastes & lytes diffuse into dialysate until equilibrium achieved • Bag lowered, gravity drain • Solution should be clear/straw colored

  43. 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

  44. PD Teaching • Asepsis • Empty bladder first • Monitor urine output • Monitor s/s of infection • Monitor s/s of FVO

  45. Complications of Peritoneal Dialysis • Exit site infection • Peritonitis • Hernias • Low Back problems • Bleeding • Pulmonary Complications • Protein Loss

  46. Nursing considerations • Fluid & electrolyte balance must be maintained to prevent dehydration and/or fluid overload. • Assess: • Daily weights. • Lung sounds. • Presence of edema. • Total I & O (including + and – PD fluid balances). • Blood pressure. • Other S&S of dehydration or fluid overload

  47. Nursing considerations • Assess for alterations in blood glucose levels in diabetics from the use of dextrose-based dialysate. • Check visually for changes in the appearance of the effluent with each exchange. • Reinforceexit site dressing for newly inserted PD catheters. Do not remove original dressing unless trained to do so. • Be alert to tubing getting kinked or caught under patient, which will prevent infusion or draining of dialysate.

  48. 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