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
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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(atherosclerosis)
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
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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 Failure
End 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
GFR*
mL/min/1.73m2
1
Slight kidney damage with normal
More than 90
or increased filtration
2
Mild decrease in kidney function 60-89
3
Moderate decrease in kidney
function
30-59
4
Severe decrease in kidney
function
15-29
Kidney failure
Less than 15 (or
dialysis)
5
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Modifiable Factors
Non-Modifiable Factors
-Hereditary
-Age greater than 60 years
old
-Gender
-Race
-Diabetic Mellitus
-Hypertension
-Increase Protein and
Cholesterol Intake
-Smoking
-Use of analgesics
Decreased renal blood flow
Primary kidney disease
Damage from other
diseases
Urine outflow obstruction
BUN
Dilute
Polyuria
Serum
Creatinine
Decreased
glomerular
filtration
Hypertrophy of
remaining
nephrons
Loss of Sodium
in Urine
Inability to
concentrate urine
Hyponatremia
Dehydration
Further loss of
nephron function
Loss of
nonexcretory renal
function
Failure to convert
inactive forms of
calcium
Calcium
absorption
Failure to
produce
eryhtropoietin
Anemia
Pallor
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2
a
Impaired
insulin action
Erratic blood
glucose
levels
Production of
lipids
Advanced
atherosclerosis
Immune
disturbance
s
Delayed
wound
healing
Disturbances in
reproduction
Infection
Libido
Infertility
Hypocalcemia
1
Excretion of
nitrogenous
waste
Uremia
BUN,
Creatinine
Uric Acid
Proteniuria
Peripheral
nerve
changes
Osteodystrophy
Decreased
sodium
reabsorption in
tubule
Water
Retention
Hypertension
Heart Failure
Edema
2
a
Loss of excretory
renal function
Decreased
potassium
excretion
Hyperkalemia
Decreased
phosphate
excretion
Decreased
hydrogen
excretion
Hyperphosphate
mia
Metabolic
acidosis
Decreased
calcium
absorption
Hypocalcemia
Hyperparathyroidis
m
Decreased
potassium
excretion
Pericarditis
Increased
potassium
CNS
changes
Pruritus
Altered
Taste
Prepared by
Bleeding
Tendencie
D. Chaplin
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:
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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:
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Anaemia, mostly due to deficiency of
erythropoietin
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Bleeding which is caused by impairment of platelet
function
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Metabolic Bone Disease (known as Renal
Osteodystrophy)
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Associated complications of chronic
Kidney Disease would be:
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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:
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Nervous system – neuropathy caused by the loss
of myelin from nerve fibres – may improve when
dialysis is established
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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:
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Skin disease – itching, which is attributed to the
retention of metabolic waste products. It often
improves with dialysis. Dry skin can also occur
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Muscle dysfunction - myopathy leading to
muscle cramps and the “restless leg” syndrome
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Associated complications of chronic
Kidney Disease would be:
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Metabolic dysfunction - involving lipids, insulin
and uric acid (gout). Metabolic acidosis is also
associated
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Diagnosis
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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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Estimated GFR (eGFR)
Electrolyte levels and
acid-base balance
Blood cell counts
Other tests
Ultrasound:
Biopsy
Treatment Modalities
Decrease fluid 1000ml/day
Decrease protein (.5-1kg body weight)
Decrease sodium (1-4gm variable)
Decrease potassium
Decrease phosphorous (<1000mg/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 < to >
concentration of solutes (particles)
Diffusion - movement of solutes (particles) from an
area of > concentration to area of < 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
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AV Graph Access
Hemodialysis
Hemodialysis Circuit
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Hemodialysis Machine
PD Advantages and Disadvantages
Advantages
Immediate initiation
Less complicated
Portable (CAPD)
Fewer dietary
restrictions
Short training time
Less cardio stress
Choice for diabetics
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Disadvantages
Bacterial/chemical
peritonitis
Protein loss
Exit site of catheter
Self image
Hyperglycemia
Surgical placement of
catheter
Multiple abdominal
surgery
Hemo Advantages & Disadvantages
Advantages
Rapid fluid removal
Rapid removal of urea
& creatinine
Effective K+ removal
Less protein loss
Lower triglycerides
Home dialysis possible
Temporary access at
the bedside
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Disadvantages
Vascular access
problems
Dietary & fluid
restrictions
Heparinization
Extensive equipment
Hypotension
Added blood lost
Trained specialist
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:
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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:
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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: cimetidine, 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 < 60
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(Tuesday morning in Outpatients)
Tuesday morning 1 year later: 1 patient needs RRT, 10
patients
have died (> 50% CV death)
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Tuesday morning 10 years later: 8 patients need RRT, 65 patients have
died,
have
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Chaplinongoing CKD
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
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Cardiovascular disease
Proteinuria
Hypertension
Diabetes
Smoking
Obesity
Exercise tolerance
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TAKE HOME MESSAGE
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 patient’s 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 patient’s 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 patient’s level of
understanding and guided by patient’s 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.
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TAKE HOME MESSAGE
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THANK YOU
Have a check on
your blood pressure
Sugar & Salt / year
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