CHRONIC KIDNEY DISEASE (CKD)/END STAGE KIDNEY DISEASE (ESKD) Flashcards
GFR (kidney function) is used to stage
chronic kidney disease
eGFR considers creatinine levels, gender, race, and body size but it only used for screening & antibiotic/med dosing.
True or False
True
GFR > 90mL/min
At risk, normal kidney function but urine findings, structural abnormalities, or genetic trait points to kidney disease
Stage 1
GFR 60-89mL/min
Mild CKD; reduced kidney function; lab values and other findings point to kidney disease
Focus on reduction of risk factors
Stage 2
GFR 30-59mL/min
Moderate CKD
Implement strategies to slow disease progression
Stage 3
GFR 15-29mL/min
Severe CKD
Manage complications; Education on renal replacement therapy
Stage 4
GFR < 15mL/min
End stage kidney disease (ESKD)
Implement renal replacement therapy or kidney transplant
Stage 5
What is the leading cause of death in patients with ESKD?
CVD
Is CKD/ESKD reversible?
No. It is progressive, irreversible, w/no recovery.
S/Sx
- Uremia
- Azotemia
- Anuria
- Uremic fetor
- Stomatitis
- Halitosis
- Metallic taste in mouth/anorexia/nausea
- Polyuria
- Pruritis
- HTN
- Hyperlipidemia
- Anemia
- Increased risk of infection
Erythropoietin injections for
anemia
Manifestations of ESKD
Neuro: HA, weakness & fatigue, sleep disturbances
Cardio: ^BP, Pitting edema, HF, PAD
Pulm: pulmonary edema, pneumonia
GI: ammonia odor breath, metallic taste, anorexia, NV, GI bleeding
Psych: withdrawn, depressed, behavioral changes
Hematologic: anemia, infection, bleeding tendencies
Fluid and electrolytes: ^Pot, metabolic acidosis
Skin: dry & flaky, pruritis, ecchymosis, yellow-grey color
Musculoskeletal: cramps, bone pain, renal osteodystrophy
- Decrease calcium (Trousseau’s Sign, Chvostek’s Sign, Fractures)
- Increased clotting time
- Anxiety and irritability
- Heart arrhythmias
- Increased serum calcium and serum phosphorus
- Vascular and soft tissue calcifications - > calcium is deposited in atherosclerotic plaques in the lining of blood vessels - > increased CVD
CKD-MBD (Mineral and Bone Disorder)/Renal Osteodystrophy
Risk factors for CKD
diabetes, hypertension, age>60, cardiovascular disease, family hx of CKD, exposure to nephrotoxic drugs, ethnic minority (African American, Native American)
Nephrotoxic drugs
antibiotics/antimicrobials, aminoglycoside antibiotics, chemotherapy agents, NSAIDs
Others- acetaminophen, metformin, pesticides, radiographic contrast medium, fungicides, arsenic, lead, copper sulfate, bismuth
Labs
Increased serum creatinine
Increased BUN
Decreased Na (hyponatremia)
Increased K (hyperkalemia)
Diagnostics
ABG - metabolic acidosis
H&H
UA - +protein, glucose, WBC, decreased urine osmolarity. Late
CKD – osmolarity increases.
Blood osmolarity / osmolality – decreased early and increased late
GFR
Renal US - atrophy, fibrosis
Biopsy
Xray - hand bones may show CKD- mineral bone disease (MBD)
Meds
loop diuretics, thiazide diuretics, vitamins & minerals, erythropoietin stimulating agents, parathyroid hormone modulator, antihypertensive therapy (ACEi, ARBs, CCBs), statins to lower lipids, insulin may be decreased
Why would insulin needs be decreased?
Kidneys excrete insulin and if they are not working, insulin sits in the body longer –> risk for hypoglycemia
Dietary restrictions needed for severe kidney disease
Protein: 0.55-0.60g/kg/day
Fluid: depends on urine output but may be as high as 1500-3000mL/day
Potassium: 60-70mEq or mmol daily
Sodium: 1-3g/day
Phosphorus: 700mg/day
Why is protein restriction necessary in CKD?
Increased protein leads to increased protein breakdown and waste in the body. Kidneys are unable to remove the waste. Protein intake can’t go too low or other issues will occur.
High protein foods- red meats, poultry, fish/seafood, eggs, milk & cheese, beans, legumes, nuts, and soy
Low protein foods- fruits, veggies, grains (not whole grains), cereals
Healthy kidneys control how much sodium is in your body. If your kidneys do not work well, too much sodium can cause fluid buildup, swelling, high BP, and strain the heart.
CKD patients should avoid foods high in sodium to prevent water retention and HTN.
What foods should be avoided?
No processed food, fast food, chips, pretzels, pickles, ham, bacon, sausage, and no salt substitutes.
Potassium works with the muscles, including the heart. Too much or too little potassium in the blood can be dangerous. How much potassium you need is based on how well your kidneys are working and the meds you are taking.
High vs low potassium food examples
High- bananas, melons, oranges, kiwi, mango, dates, avocados, broccoli, brussels sprouts, sweet potatoes, pumpkin, spinach, black beans, lentils, legumes, milk, yogurt, nuts & seeds, chocolate, peanut butter
Low- apples, blueberries, grapes, peaches, raspberries, pineapple, asparagus, carrots, celery, cucumber, corn, green beans, lettuce, onions, rice, pasta, yellow cake, angel cake
As kidney function gets lower, extra phosphorus can start building up in the blood. High phosphorus levels can cause bones to get weaker.
High vs low phosphorus food examples
High- dairy products, nuts, seeds, black beans, kidney beans, bran cereals, whole grain products, ale, beer, dark cola drinks
Low- fresh fruits and veggies, popcorn, crackers, rice cereal, sherbert/sorbet, coffee or tea, light colored sodas fruit juices
Managing fluid volume in CKD/ESKD
Monitor for fluid overload (pulmonary edema), crackles in lungs, weight gain, balanced I&O
Loop diuretic reminders
Furosemide
Bumetanide
Dose varies w/ severity of kidney damage, not effective in ESKD
Expected outcome is for output to be greater than intake by 500-1000 mL/24hr
Vitamin B reminders
Folic acid/folate & cyanocobalamin
Take the drugs after dialysis
& w/ meals to reduce nausea and abd discomfort
Oral iron salts reminders
Ferrous sulfate
Take stool softeners daily
Remind pts that they will change the color of stool
Parenteral iron salts reminders
Iron dextran
test dose is recommended because the incidence of allergic reaction is high
Vitamin D reminders
Calcitriol
Can lead to hypocalcemia
Vitamin D is lipid soluble and can be over ingested –> toxicity
Erythropoietin stim agents reminders
Epoetin alfa
Should not be given when hemoglobin is greater than 13g/dL and pt is hypertensive
