Module 1: Chronic Kidney Disease

Question 1

Chronic Kidney Disease (CKD)

Answer 1

Progressive, irreversible loss of kidney function

Characterized by:

1. Kidney damage — pathologic abnormalities; and markers of damage (elevated BUN and Cr)
2. Low GFR (<60) for more than 3 mos.

Epidemiology:

1. AA and NA > Whites — indicative of racism and SDOH
2. Men > Women
3. There are no strong racial or genetic tendencies

Common co-morbidities that lead to CKD:

1. HTN (leading cause)
2. DM (especially with HTN)
3. Lupus
4. Polycystic kidney disease
5. Pyelonephritis
6. AKI

Etiology:

1. Leading causes: DM (50%) and HTN (25%)
2. Individuals with CKD are frequently asymptomatic until the disease is advanced
3. Often under diagnosed and untreated

Question 2

CKD: Staging

Answer 2

Disease staging is based on decreasing kidney function (measured with GFR); GFR is calculated from serum Cr, age, body size, and gender

Normal GFR = 125 ml/min/1.73

Staging:
Stage 1: Kidney damage (i.e. protein in urine) with normal kidney function (GFR >90)

Stage 2: Kidney damage with mild loss of function (GFR 89-60)

Stage 3a: Mild to moderate loss of kidney function (GFR 59-45)

Stage 3b: Moderate to severe loss of kidney function (GFR 44-30)

Stage 4: Severe loss of kidney function (GFR 29-15)

Stage 5: Kidney failure; ESRD (GFR <15)

Question 3

CKD: Clinical Manifestations

Answer 3

With low GFR, the body is unable to excrete toxic substances (i.e. urea, Cr, phenols, hormones, electrolytes, and water)

CMs:

1. HTN
2. Uremia
3. Anemia (decreased EPO production)
4. Metabolic acidosis (late)
5. Hypocalcemia (unable to produce quantities of vitamin D sufficient for calcium absorption from the GI tract)
6. Hyperphosphatemia
7. Hyperkalemia
8. Bone loss

Question 4

CKD: Progression of Clinical Manifestations

Answer 4

Early stages of CKD:

1. No change in urine output
2. Polyuria may be present (related to DM)

As CKD progresses, patients experience increasing fluid retention; this manifests as LE edema before resulting in decreased urinary output

ESRD patients may experience anuria (produce <100 ml urine in 24 hours); anuric patients experience uremia (buildup of toxins in the blood) which affects multiple body systems

Question 5

Normal Laboratory References

Answer 5

Sodium: 135-145 mg/dl

Potassium: 3.5-5.0 mEq/dl

Creatine: 0.2-1.0 mg/dl

Phosphorus: 2.4-4.4 mg/dl

GFR: 90-125 ml/min

BUN: 8-20 mg/dl

Hemoglobin: 13.9-16.3 (males); 12.0-15.0 (females)

Question 6

CKD: Patient Assessment

Answer 6

Assessment of patients with CKD:
1. Complete history of existing kidney diseases and family history — i.e. Long-term health problems, drugs and herbal preparations (especially NSAIDs and nephrotoxic agents), dietary habits, and support systems

2. Measure height and weight (evaluate any recent weight changes)
3. Monitor and evaluate I&Os
4. Systemic effects — i.e. Fatigue, anorexia, N/V, depression
5. Monitor for changes in vitals, respirations, cardiac rhythm, SpO2
6. Monitor labs

Question 7

CKD: Diagnostic Studies

Answer 7

Diagnostic studies of patients with CKD:
1. Urinalysis — dipstick evaluation of protein in urine

2. Renal ultrasound/biopsy — measures size and appearance
3. Renal CT — locate tumors, lesions, cysts, and blockages
4. Albumin to Cr ratio (first morning void)
5. GFR

Question 8

CKD: Treatment

Answer 8

Treatment goals of CKD:
1. Retain kidney function

2. Treat symptoms
3. Prevent complications

Question 9

Interprofessional Care of CKD #1: Measures to lower potassium

Answer 9

Measures to lower potassium:
1. Restriction of high potassium foods (i.e. potatoes, bananas) and drugs

2. Laxative admin. — excretion of excess potassium and toxins (can cause further kidney damage)
3. Dialysis
4. IV Insulin and glucose admin. — insulin shifts potassium into cells
5. IV 10% Calcium gluconate admin. — prevents cardiac arrhythmia due to severe hyperkalemia

Question 10

Interprofessional Care of CKD #2: Antihypertensive therapy

Answer 10

Antihypertensive therapy (with BP goal <130/80):
1. Weight loss (if indicated)

2. Therapeutic lifestyle changes
3. Diet recommendations (i.e. DASH diet)
4. Antihypertensive drug admin. (monitor elevations in potassium) — i.e. ACE inhibitors (assess for cough) and ARB agents

Question 11

Interprofessional Care of CKD #3: Mineral deregulation and bone disease management

Answer 11

Serum calcium and phosphate have an inverse relationship (phosphorus binds to calcium, reducing the available free calcium in blood); PTH stimulates the release of calcium from large calcium stores in the bones into the bloodstream

Mineral deregulation and bone disease management:
1. Monitor bone loss (if indicative) — XRAY, bone scans, biopsy, and densitometry

2. Check labs regularly
3. Nutritional phosphate intake not restricted (<1 g/day) until ESRD
4. Phosphate binders admin. (i.e. Calcium acetate, calcium carbonate, and sevelamer hydrochloride) with each meal (monitor for constipation)
5. Avoid aluminum/magnesium preparations (depend on kidneys for excretion) — aluminum is associated with dementia and bone loss
6. Vitamin D supplement admin. (i.e. calcitriol) promotes GI calcium absorption — lower serum phosphate prior to vitamin D or calcium admin. (to prevent binding)
7. Control secondary hyperparathyroidism — Tx: Calcimimemtic agents (i.e. cinacalcet) suppress PTH levels; Subtotal/total parathyroidectomy (if severe)

Question 12

Interprofessional Care of CKD #4: Management of anemia

Answer 12

Management of anemia:
1. Iron supplements admin. (common) if plasma ferritin level <100 ng/ml — Side effects (due to difficulty absorbing iron): Gastric irritation, major constipation, dark/green stool

2. Folic acid supplement admin. promote RBC formation (admin. after dialysis)
3. Avoid blood transfusions — prevents increased antibody development, iron overload, and fluid imbalance
4. IV or SQ Erythropoietin (EPO) admin. in advanced CKD — increases H&H in 2-3 weeks; Side effects: Thromboembolism and HTN

Question 13

Interprofessional Care of CKD #5: Dyslipidemia management

Answer 13

Dyslipidemia management:
1. Statins admin. to lower LDL levels (i.e. Atorvastatin)

2. Fibrates (fibric acid derivatives) admin. to lower triglyceride levels (i.e. Gemifibrozil)

Question 14

Interprofessional Care of CKD #6: Management of complications

Answer 14

Management of complications:
1. Monitor and admin. drug treatments — Risk for drug toxicity due to poor excretion of drug substrates

2. Fluid overload
3. HTN crisis
4. HF

Question 15

Interprofessional Care of CKD #7: Nutritional therapy

Answer 15

Nutritional therapy:
1. Manage electrolyte and fluid imbalances — General recommendation: Low protein and low phosphorus

2. Normal protein intake for patients on hemodialysis; increased protein intake for patients on peritoneal dialysis
3. Monitor I&Os — Fluid intake/restriction depends on daily urine output
4. Sodium restriction (2-4 g/day limit) — avoid foods high in salt (i.e. cured meats, canned foods, soy sauce), and salt substitutes containing potassium chloride
5. Potassium restriction (2-3 g/day limit) — avoid foods high in potassium (i.e. tomatoes, bananas, melons, raisins, beans)
6. Phosphate restriction in ESRD (1 g/day limit) — avoid foods high in phosphate (i.e. meat, dairy products); most foods high in phosphate are also high in protein and calcium (phosphate binders are essential)

Question 16

Interprofessional Care of ESRD (CKD Stage 5)

Answer 16

ESRD management:
1. Dialysis options: Hemodialysis, continuous veno-venous hemodialysis, and peritoneal dialysis

2. Kidney transplant
3. Palliative care
4. Active case management (highly beneficial)

Question 17

Dialysis

Answer 17

Line management of:

1. Hickman/central line (short-term solution)
2. AV fistula & AV graft (long-term solutions)

Pre-dialysis assessment:

1. Vitals
2. Med. admin.
3. Access

During dialysis:

1. Dialysis procedure
2. Maintain BP

Post-dialysis assessment:

1. Vitals
2. Med. admin.

Dialysis complications:

1. Hypotension
2. Electrolyte imbalance — S/S: Cramps, HA, N/, dizziness
3. Bleeding
4. CLABSI
5. Dialysis-related dementia
6. Disequilibrium syndrome (usually if HD is performed too quickly)
7. Access complications

Question 18

Nursing Management of ESRD

Answer 18

Nursing diagnoses of patients with ESRD:

1. Excess fluid volume
2. Risk for electrolyte imbalance
3. Disturbed thought process
4. Fatigue (related to anemia)
5. Risk for injury
6. Imbalanced nutrition (less than body requirements)

Health promotion of patients with ESRD:

1. Identify individuals at risk for CKD — patients with a history of DM, HTN, FHX of kidney disease, repeated UTIs
2. Regular checkups
3. Monitor changes in urine and labs

Acute care of ESRD:

1. Inpatient care is required for management of complications — i.e. Sudden change in urine output, fluid overload, co-morbid HF, changes in MS
2. Kidney transplant

ESRD ambulatory care (Education):

1. Most care for CKD occurs on an outpatient basis
2. Diet — limit protein, phosphorous, and sodium
3. Drugs — address common side effects, suggest pill organizer, and discuss all OTC drugs with provider (especially NSAIDs)
4. Take daily BP and weight (after first morning void)
5. Identify S/S of fluid overload and electrolyte imbalances
6. Report weight gain >4 lbs. in a week
7. As disease progresses, help patients and family through options: PD and home dialysis modalities, HD, transplantation, and palliative care