Chronic Kidney Disease Flashcards
Primary Kidney Functions (3)
Filtration
Regulation
Excretion
Secondary Kidney Functions : to Regulate
- regulate blood pressure. RAA system
- regulation of bone density
- regulation of erythropoiesis (the process that produces red blood cells)
Chronic Kidney Disease (CKD)
- involves progressive, irreversible loss of kidney function
Definition of CKD
- the presence of either kidney damage or glomerular filtration rate (eGFR) <60 mL/min for 3 months or longer
- classified as 1 or 5 stages, depending on disease severity (measured by GFR)
Disease staging based on decreases in GFR
- normal GFR - 125 mL/min, which is reflected by urine creatinine clearance
- up to 80% of GFR may be lost with a few changes in functioning of body
- remaining nephrons hypertrophy to compensate
- end result is systemic disease in every organ
- its presentation can be highly varied
Leading cause of ESRD
- diabetes
- renal vascular disease
Stage 5 (end stage renal disease - ESRD)
occurs when GFR < 15 mL/min
ESRD treatment options
- renal replacement therapy (RRT)
Hemodialysis
Peritoneal Dialysis - transplant
Clinical Manifestations of CKD
- result of these retained substances (6)
- urea
- creatinine
- phenols
- hormones
- electrolytes
- water
Uremia
syndrome that incorporates all S&S seen in various systems throughout the body due to the build-up of waste products and excess fluid associated with kidney failure
Clinical Manifestations: Urinary system - polyuria
- polyuria (early stages) results from inability of kidneys to concentrate urine, occurs most often at night (nocturia) specific gravity fixed around 1.010
oliguria
A urinary clinical manifestation of CDK
decreased urine output < 400mL/day
occurs as CDK worsens
Anuria
- a urinary clinical manifestation of CKD
- urine output < 40 ml/24 hours
Metabolic Disturbances
- waste product accumulation
decreased GFR = increased BUN and Creatinine
Altered carbohydrate metabolism
- metabolic disturbance of CKD
- caused by impaired glucose use0 fro cellular insensitivity to normal action of insulin
- because Type 2 diabetes and CDK often go together
Defective carbohydrate metabolism
- clients with diabetes who become uremic may require less insulin than before the onset of CKD
- insulin is dependent on kidneys for excretion - so the patient will need less of it when they cant get rid of it
Elevated triglycerides
- metabolic disturbance
- hyperinsulinemia (because the body is not excreting the insulin) stimulates hepatic production of triglycerides
- altered lipid metabolism - due to decreased levels of enzyme lipoprotein lipase
what kind of drug will clients in stages 1-3 be on?
- some kind of statin drug to lower cholesterol and decreases chances of hyperlipidemia that are so common with CKD because of increased triglycerides
Electrolyte/Acid-Base Imbalances: Potassium
- hyperkalemia (most serious electrolyte disorder in kidney disease. Can cause fatal dysrhythmias when serum K levels 7-8 mmol/L)
- Decreased excretion by the kidneys in CKD
Sodium
- may be normal or low
- because of impaired excretion, sodium is retained along with water
- if water is retained (edema, hypertension, CHF, dilution hyponatremia)
Other Electrolyte/Acid-Base Imbalances
- calcium and phosphate alterations (musculoskeletal implications)
- magnesium alterations
- metabolic acidosis
Metabolic acidosis
inability of kidneys to excrete acid load (primarily ammonia)
- defective reabsorption/regeneration of becarbonate
Anemia - very common in CKD
- due to decreased production of erythropoietin, which is the hormone that stimulates RBC production in the bone marrow
- other factors: nutritional deficiencies, increased hemolysis or RBC’s, frequent blood sampling, GI bleed
- elevated PTH (control calcium levels in blood) levels (due to low serum calcium) can inhibit erythropoiesis (destroying bone for calcium)
- Iron deficiencies
- folic acid deficiencies
Bleeding Tendencies
- defect in platelet function
- usually correctable with regular RRT
Increases susceptibility to infection
- change in leukocyte function
- altered immune response and function
- diminished inflammatory response
Cardiovascular System (7)
- hypertension
- heart failure
- left ventricular hypertrophy
- peripheral edema
- dysrhythmias
- uremic pericarditis
- Diabetes
Respiratory System (7)
- Kussmaul’s respirations
- Dyspnea
- Pulmonary edema
- Uremic pleuritis
- Uremic pneumonitis
- Pleural effusion
- Predisposition to respiratory infection
GI system
every part of the GI is affected due to inflammation of the mucosa related to excessive urea
Common GI symptoms of CKD and elevated urea
- stomatitis with exudates and ulcerations
- uremic factor
- GI bleeding
Diabetic gastroparesis can compound the above in diabetics
Constipation common related to supplements and limited fluid intake
Neurological System
- changes are expected as renal failure progresses
- generally speaking the CNS becomes depressed
Neurological Changes are attributed to:
- increased nitrogenous waste products
- electrolyte imbalance
- metabolic acidosis
- axonal atrophy
- demyelination of nerve fibers
Neurological symptoms (6)
- restless leg syndrome
- muscle twitching
- fatigue irritability
- apathy
- decreased ability to concentrate
- peripheral neuropathy
Musculo-skeletal system
- CKD mineral and bone disorder - missing activated vitamin D that is needed to absorb calcium. without calcium they will break down and demineralize to release calcium into the blood stream
Systemic sydrome that includes:
- bone abnormalities
- changes in mineral balance
- vascular and other soft tissue calcification
results in skeletal complications, renal osteodystrophy and extraskeletal (vascular and soft tissue complications) calcfications
Integumentary System
pruritus - very common
uremic frost - very uncommon
Reproductive System
- both men and women can experience infertility, decreased libido, low sperm counts, sexual dysfunction
Psychological Changes
- personality and behavioral changes
- emotional lability
- withdrawal
- depression
Diagnostic Studies
- history and physical examination
- urinalysis dipstick evaluation - common
- albumin - creatinine ration - preferred screening for proteinuria
Labs: BUN
measures urea levels in the blood it is elevated if excretion is insufficient
Labs: Creatinine
nitrogenous waste produce from muscle metabolism elevated if excretion is insufficient
- creatinine clearance - commonly used to assess GFR, determines how efficiently kidneys clear creatinine from the blood. GFR determines how fast the blood is filtered through the glomerulus
Labs: other
- renal ultrasound
- Xray KUB (kidneys, ureters, bladder)
- CT KUB
- Renal biopsy’s
Collaborative Care: common management measure in CKD (7) (MAACCEN)
- correction of extracellular fluid volume overload or deficit
- nutritional therapy
- erythropoietin therapy
- calcium supplementation, phosphate binders (reduce the amount of phosphate absorbed from your food and since it in inversely related to calcium this will increase calcium - since phosphate binds to calcium normally and keeps it from being available in the blood)
- antihypertensive therapy
- measures to lower potassium
- adjustment of drug dosages to degree of renal function
Hyperkalemia (C BIG K+ D (rop))
C - calcium gluconate - stabalize myocarium
B - B2 adrenergic agonists such as salbutamol to shift potassium into the cells
I - IV insulin (shift K+ into cells)
G - IV glucose to manage hypoglycemia
K - kayexalate - increases fecal loss of potassium
D - diuretics or dialysis
Hypertension
- lifestyle changes: (weight loss, diet recommendations, sodium and fluid restrictions)
- antihypertensive drugs (thiazide or loop diuretics, calcium channel blockers, ACE inhibitors, ARB agents)
CKD- MBD
- phosphate intake restricted to < 1000mg/24 hr
- phosphate binders (calcium carbonate = binds to phosphate in bowel and excretes in stool - sevelamer hydrocholoride = lowers cholesterol and LDLs -
Phosphate binders
- phosphate binders (calcium carbonate = binds to phosphate in bowel and excretes in stool - sevelamer hydrocholoride = lowers cholesterol and LDLs
- administered with each meal
- adverse effect - constipation
Supplementing vitamin D
- calcitriol
- serum phosphate level must be lowered before calcium or vitamin D is administered
Controlling secondary hyperparathyroidism
- calcimimetic agents - to reduce PTH
- cinacelcet - increases sensitivity to calcium receptor glands
subtotal parathyroidectomy
Anemia: erythropoietin
- erythropoiesis - stimulating agents
- administered IV or subcut
- increase hemoglobin and hematocrit in 2-3 weeks
- adverse effect: hypertension
Amenia: Iron Supplements
- if plasma ferritin < 100 mg/ml
- adverse effects: gastric irritation, constipation
- may make stool darker in colour
Anemia: Folic acid supplement
needed for RBC formation
removed by dialysis
avoid blood transfusions
Dsylipidemia
Statins in clients with stages 1-3 CKD
Drug Toxicity
- digoxin
- oral glycemic agents
- antibiotics
- opioids (hydromorphone, morhphine)
- also avoid NSAIDS and use acetaminophen
Protein restriction
- benefits are being studied
- guided by stage of CKD
Water Restriction
- intake depends on daily urine output and overall fluid balance
- for patients not on dialysis, fluids not generally restricted
- fluids should be spaced throughout the day
Sodium Restriction
- diets vary from 2 to 4 g depending on degree of edema and hypertension
- sodium and salt should not be equated
- salt substitutes should not be used, they contain potassium chloride
Potassium restriction
- 2-4 g
- avoid foods high in potassium
Nursing Assessment
- complete health history or any existing renal disease, family history - complete med history (Rx, OTC)
- long-term health problems
- dietary habits
- clinical manifestations of CKD
- patients goals of care
Nursing Diagnosis
- excess fluid volume
- risk for electrolyte imbalance
- imbalanced nutrition: less than body requirements
Nursing Planning - overall goals for the patient
- to demonstrate knowledge and ability to comply with therapeutic regimen
- to participate in decision making
- to demonstrate effective coping strategies
- to continue with activities of daily living within physiological limitations
Health promotion: nursing implementation
- identify individuals at risk for CKD (history of renal disease, hypertension, diabetes mellitus, repeated UTI)
- regular checkups and changes in urinary appearance, frequency, and volume should be reported
Care considerations for chronic kidney disease in stages 4-5
- daily weight, BP
- identify S&S of fluid overload, hyperkalemia, and electrolyte imbalances
- strict dietary adherence
- medication education
- motivate clients in management of their disease
- ambulatory and home care
Treatment
when conservative therapy is no longer effective, HD, PD, and transplantation are treatment options
- client/family need clear explanation of dialysis and transplantation
Evaluation
- maintenance of ideal body weight
- acceptance of chronic disease
- no infection
- no edema
- hematocrit, hemoglobin, and serum albumin levels in acceptable range
Hypervolemia
- too much blood volume
- too much/too fast IV fluid
- organ issues (heart failure, kidney dysfunction, cirrhosis)
- increase Na+ intake
- hypertonic solution
Hypervolemia manifestations
CNS: lethargy, seizure, coma CVS: increased HR (bounding pulse), increase BP, JVD Resp: pulmonary edema GU: increase U/O (dilute) Skin: edema
Hypovolemia
- decreased BV
- vomiting/diarrhea
- severe dehydration
- trauma, burn
- medications (diuretics)
- third spacing
Hypovolemia manifestations
CNS: thirst, confusion, lethargy, seizure, coma
CVS: increased HR (thready pulse), decreased BP, orthostatic hypotension
Resp: RR increased
Sodium function
- generation and transmission of nerve impulses and muscle contractions
- maintains fluid balance
- regulates blood pressure
Filtration
to remove waste products from the bloodstream
Regulation
fluid and electrolyte and acid base balance
Excretion
of metabolic waste products
