Chronic Kidney Disease

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

24. 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

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

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

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

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

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

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

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

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

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

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

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

37. 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?

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

39. Patient Teaching

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

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

42. 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

43. 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

44. 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

45. 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

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

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

48. 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

49. 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.

50. 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