Chronic Kidney Disease
CKD
Dialysis
Renal Transplant

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.
Functions of the Kidney

Primary function
◦ _________________________
◦ _________________________

Other functions
◦ ______________________
◦ ______________________
◦ ______________________
◦ ______________________
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?
Biopsy
 Ultrasound
 X-Rays
 Labs
 Anything else?

Diagnostic studies


Blood Tests
◦ BUN
◦ Creatinine
◦ K+
◦ PO4
◦ Ca
Urinalysis
◦ Specific gravity
◦ Protein
◦ Creatinine clearance
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 -_______________________

Glomerular Filtration Rate
GFR- Cannot be directly measured
 Uses

◦
◦
◦
◦
◦
Serum creatinine
Gender
Ethnicity
Age
Weight
◦ Why would you need to estimate GFR?
Glomerular Filtration Rate
Creatinine Clearance
 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?
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
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

Chronic Kidney Disease
Causes
_________________
 _________________
 _________________
 Cystic disorders
 Developmental /Congenital
 Infectious Disease

Chronic Kidney Disease
Causes
Neoplasms
 Obstructive disorders
 Autoimmune diseases
 Hepatorenal failure
 Scleroderma
 Amyloidosis
 Drug toxicity

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
CKD
During Stage 1& 2

No symptoms

Serum creatinine doubles

Up to 50% nephron loss

Why does PTH increase? (2 reasons)
Stages of CKD
Stage 3:
Moderate reduction -GFR 30-59 ml/min
1.
2.
3.
4.
Why?
Calcium absorption decreases
Malnutrition onset
Anemia
Left ventricular hypertrophy
Stages of CKD
Stage 4:
Severe reduction -GFR 15-29 ml/min
1. Serum triglycerides increase
2. Hyperphosphatemia
3. Metabolic acidosis
4. Hyperkalemia
Why?
Stages of CKD
During Stage 3-4

Signs and symptoms worsen if kidneys are
stressed

Decreased ability to maintain homeostasis

75% nephron loss
Stages of CKD
During Stage 3 &4

Decreased:
◦
◦
◦
◦

__________
__________
__________
__________
Symptoms:
◦ elevated BUN & Creatinine
◦ mild azotemia
◦ anemia
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
•
Marked increase in:
• ___________
• ___________
• ___________
•
Marked decrease in:
• ___________
• ___________
• ___________
•
Fluid overload
CKD
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

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
CKD Manifestations

Metabolic
◦ Waste Products Accumulate
◦ Altered carbohydrate Metabolism
 Insulin resistance
◦ Elevated triglycerides
CKD Manifestations

Electrolyte and acid Base
◦ Potassium
◦ Sodium
◦ Calcium and Phosphorus
◦ Magnesium
◦ Metabolic Acidosis
◦ Volume expansion and fluid overload
◦ Change in urine specific gravity
CKD Manifestations


Endocrine
◦ Hyperparathyroidism
◦ Hypothyroidism
◦ Erythropoietin production decreased
◦ Parathyroid hormone and Vitamin D3
Reproductive
◦ Amennorrhea
◦ Erectile dysfunction
◦ Gonadal dysfunction
CKD Manifestations
Hematologic
 Anemia
 Bleeding tendencies
◦ Platelet dysfunction
 Infection

CKD Manifestations

Cardiovascular
◦ Hypertension
◦ Congestive heart failure
◦ Pericarditis
◦ Atherosclerotic vascular disease
◦ Cardiac dysrhythmias

Respiratory
◦ Pulmonary edema
◦ Pleural effusions
CKD Manifestations

GI tract
◦ Uremic fetor
◦ Anorexia, nausea, vomiting
◦ GI bleeding

Musculoskeletal
◦ Muscle cramps
◦ Soft tissue calcifications
◦ Weakness
◦ Renal Osteodystrophy
CKD Manifestations

Psychologic
◦ Anxiety
◦ Depression

Neurologic
◦ Mood swings
◦ Impaired judgment
◦ Inability to concentrate and perform simple
math functions
◦ Tremors, twitching, convulsions
◦ Peripheral Neuropathy
CKD Manifestations

Skin
◦ Pale, grayish-bronze color
◦ Dry scaly
◦ Severe itching
◦ Bruise easily
◦ Uremic frost
◦ Calcium/Phos deposits

Eyes
◦ Visual blurring
◦ Blindness
Treatment Options
Conservative Therapy
 Hemodialysis
 Peritoneal Dialysis
 Transplant
 Nothing

Conservative Treatment
GOALS:





Detect & treat potentially reversible causes of
renal failure
Preserve existing renal function
Treat manifestations
Prevent complications
Provide for comfort
Conservative Treatment

Control
◦
◦
◦
◦
◦
◦
◦
◦
◦
Hyperkalemia
Hypertension
Hyperphosphatemia
Hyperparthryoidism
Anemia
Hyperglycemia
Dyslipidemia
Hypothyroidism
Nutrition : Describe a renal diet

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?
Renal Diet
Fluids ?
 Avoid high protein
diet
 Restrict:

◦ sodium
◦ potassium
◦ phosphorous

Consume enough
calories, to maintain
weight
◦ esp. if losing weight
Patient Teaching
Dialysis

Removal of soluble
substances and water
from the blood by
diffusion through a
semi-permeable
membrane.
Peritoneal Dialysis
 Hemodyalisis

Dialysis
Osmosis
 Diffusion
 Ultrafiltration


What GFR value indicates need for
hemodialysis?
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

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

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

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
PD Teaching
Asepsis
 Empty bladder first
 Monitor urine output
 Monitor s/s of infection
 Monitor s/s of FVO

Complications of Peritoneal
Dialysis
Exit site infection
 Peritonitis
 Hernias
 Low Back problems
 Bleeding
 Pulmonary Complications
 Protein Loss

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
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.

Reinforce exit 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.
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
Hemodialysis (HD)

Dialysis
 Survival Rates (probability of survival)
approx:
 1 year
80%
 2 years
68%
 5 years
35.8%
 10 years
11%
 5 year survival rate for transplant: 85.5%
History of HD
Early animal experiments began 1913
 1st human dialysis 1940’s by Dutch physician Willem
Kolff
 Considered experimental through 1950’s, No
intermittent blood access; for acute renal kidney injury
only.
 1940’s -1960’s
◦ Dr. Scribner developed Scribner Shunt
 1960’s
◦ machines expensive, scarce, no funding
 “Death Panels” panels within community decided now
who got to dialyze

Hemodialysis Process
Blood removed from
patient into the
extracorporeal
circuit.
 Diffusion and
ultrafiltration take
place in the dialyzer.
 Cleaned blood
returned to patient

Vascular Access
Arterio-Venous shunt
 Arterio-venous fistula (AVF)
 Arterio-venous Graft (AVG)
 Temporary Catheters

Arterio-Venous (AV) Fistula
Primary Fistula



Patients 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
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

Scribner Shunt

External
◦ One end into artery
◦ One end into vein

Advantage
◦ Place at bedside
◦ Use immediately

Disadvantages
◦
◦
◦
◦
Infection
Skin erosion
Accidental separation
Limits use of extremity
Vascular Access Complications

AV fistula with
aneursym

Steal syndrome
Temporary Catheters
•
•
•
Dual lumen catheter placed
into a central veinsubclavian, jugular or
femoral.
Advantages
– immediate use
– no needle sticks
Disadvantages
– high incidence of infection
– subclavian vein stenosis
– poor flow-inadequate
dialysis
– clotting
– restricts movement
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

Care of Vascular Access
(PTFE Graft or AV Fistula)
NO BP’s, 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.

Potential Complications of HD
During dialysis
– Fluid and electrolyte related
• Hypotension
– Cardiovascular
• Arrythmias
– Associated with the extracorporeal circuit
• exsanguination
Potential Complications of HD
During dialysis
– Neurologic
• Disequilibrium Syndrome & seizures
– Musculoskeletal
• Cramping
– Other
• fever & sepsis
• blood born diseases
Potential Complications of HD
Between treatments
Hypertension/Hypotension
 Edema
 Pulmonary edema
 Hyperkalemia
 Bleeding
 Clotting of access

Potential Complications of HD
Long term
Metabolic
• Hyperparathyroidism
• Diabetic complications
• Cardiovascular
• CHF
• AV access failure
• Cardiovascular disease
• Respiratory
• Pulmonary edema
•
Potential Complications of HD
Long term
Neuromuscular
◦ neuropathy
 Hematologic
◦ Anemia
 GI
◦ Bleeding
 Dermatologic
◦ calcium phosphorous deposits

Potential Complications of HD
Long term
Rheumatologic
amyloid deposits
Genitourinary
 infection
 sexual dysfunction
◦ Psychiatric
 depression
◦ *Infection
 blood borne pathogens
Continuous Renal Replacement
Therapy (CRRT)



Used on hemodynamically unstable patients
Slower blood flow rates than HD
Uses double lumen catheter
CVVHD-Continuous venovenous hemodialysis
◦ Solute loss via convection/diffusion
 CVVH-Continuous venovenous hemofiltration
◦ Solute loss via convection (more like
mammalian filtration)
◦ Replacement fluid via hemodilution

CVVH/CVVHD

When is it indicated?
◦ AKI
◦ patient usually has low blood pressure or
other contraindications to hemodialysis
 Not a treatment for acute hyperkalemia
◦ slow continuous process
◦ sessions usually last between 12 to 24hrs
◦ usually performed daily in the ICU
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
Medications
Vitamins - water soluble
 Phosphate binder ---- Give with_____
◦ Phoslo (calcium acetate)
◦ Renagel (sevelamere hydrochloride)
◦ Caltrate (calcium carbonate)
◦ Amphojel (aluminum hydroxide)
 Iron Supplements –
◦ don’t give with phosphate binder or calcium
 Anti-hypertensives
◦ When do we give these?

Medications
Erythropoietin
 Calcium Supplements

◦ Between meals, not with ______
Activated Vitamin D3
 Antibiotics

◦ hold dose prior to dialysis
◦ Why?
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
Patient Education
Alleviate fear
 Dialysis process
 Fistula/catheter care
 Diet and fluid restrictions
 Medication
 Diabetic teaching


Ethics-time runs out
Transplantation

Treatment not cure
Transplantation
Only 4% ESRD get transplant
 75,000 on list in 2010
◦ 17,500 received kidney
 Most die while on wait list


1 year survival rate
◦ 90% for deceased donor
◦ 95% for live donor
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
Disadvantages





Life long medications
Multiple side effects
from medication
Increased risk of
tumor
Increased risk of
infection
Major surgery
Exclusion for Transplant


Morbidly obese or Current smoker
CV disease and DM considered high risk






Malignancies that have metastasized
untreated cardiac disease
chronic respiratory failure
extensive vascular disease
chronic infection
unresolved psych disorder (non-compliance
with prescribed medications, alcoholism,
drug addiction)
Criteria for Living Donors
Psychiatric evaluation
 Anesthesia evaluation
 Medical Evaluation
◦ Free from diseases listed under deceased
donor criteria
◦ Kidney function
◦ Cross-matches done at time of evaluation and
1 week prior to procedure
◦ Radiological evaluation


ethics and organ transplant
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 &
pronouncement of death made by MD
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
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

Monitoring Transplant Function
ATN? (acute tubular necrosis)
 Urine output >100 <500 ml/hr (initially)
 Labs
 Fluid Balance
 Ultrasound
 Renal scans
 Renal biopsy

Fluid & Electrolyte Balance





Accurate I & O
◦ CRITICAL TO AVOID DEHYDRATION
◦ Output normal - >100 <500 ml/hr,
 could be 1-2 L/hr
◦ Potential for volume overload/deficit
Daily weights
Postassium (K+)___________
Sodium (Na) _____________
Blood sugar _____________
Prevention of Infection

Major complication of transplantation due
to immunosuppression

What do you teach?
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

Rejection
Acute –
 First 6 months

◦ 50% experience
◦ must differentiate between rejection and
cyclosporine toxicity
◦ Rx= Usually reversible with additional
immunosuppressants- put at higher risk for
infection
Rejection
Chronic
 gradual process over months or years
 Irreversible

◦ Repeated rejection episodes that have not
been completely resolved with treatment
◦ Rx = return to dialysis or re-transplantation
Immunosuppressant Drugs

Need to balance suppression with maintenance of
adequate defense

Side effects◦ Infection
◦ Malignancies
◦ Toxicity

Require frequent monitoring
Lowest dose to get response will least side effects

Immunosuppressant Drugs
2 categories:
 Induction agents
◦ Powerful antirejection medications used at
the time of transplant


Maintenance agents
◦ Antirejection medications used for the long
term.
Immunosuppressant Drugs
Maintenance agents -4 classes
1. Calcineurin Inhibitors: Tacrolimus,Cyclosporine
2. Antiproliferative agents:Mycophenolate Mofetil
3. mTOR inhibitor: Sirolimus
4. Steroids: Prednisone

Used in combination
◦ Triple therapy
◦ Wean off steroids or avoid use
Immunosuppressant Drugs



Cyclosporine
Azathioprine (Imuran)
Prednisone




OKT3
Atgam
Cytoxan - in place of Imuran less toxic
FK506 - 100 x more potent than
Cyclosporine
Prograf
CellCept


Immunosuppressant Drugs

many medications and food and
supplements can alter blood levels
◦
◦
◦
◦
◦
◦
Grapefruit juice
St. John's Wort
Erythromycin
anti TB medications
antiseizure medications
common blood pressure medications
(cardizem or diltiazem, and Verapamil
Patient Education
Signs of infection
 Prevention of infection
 Signs of rejection
◦ ____________
◦ ____________
◦ ____________
◦ ____________
 Medications

◦ _____________
The client with chronic renal failure
returns to the nursing unit following a
hemodialysis treatment. On assessment
the nurse notes that the client’s
temperature is 100.2. Which of the
following is the most appropriate nursing
action?
 Encourage fluids
 Notify the physician
 Monitor the site of the shunt for infection
 Continue to monitor vital signs

A client is diagnosed with chronic renal
failure and told she must start
hemodialysis. Client teaching would
include which of the following
instructions?
 Follow a high potassium diet
 Strictly follow the hemodialysis schedule
 There will be a few changes in your
lifestyle.
 Use alcohol on the skin and clean it due
to integumentary changes.






A client is undergoing peritoneal dialysis.
The dialysate dwell time is completed, and
the dwell clamp is opened to allow the
dialysate to drain. The nurse notes that the
drainage has stopped and only 500 ml has
drained; the amount the dialysate instilled
was 1,500 ml. Which of the following
interventions would be done first?
Change the client’s position.
Call the physician.
Check the catheter for kinks or obstruction.
Clamp the catheter and instill more dialysate
at the next exchange time.





A client receiving hemodialysis treatment
arrives at the hospital with a blood pressure
of 200/100, a heart rate of 110, and a
respiratory rate of 36. Oxygen saturation on
room air is 89%. He complains of shortness
of breath, and +2 pedal edema is noted. His
last hemodialysis treatment was yesterday.
Which of the following interventions should
be done first?
Administer oxygen
Elevate the foot of the bed
Restrict the client’s fluids
Prepare the client for hemodialysis.