Chronic Kidney Disease

a) Irreversible loss of kidney function d) Renal Failure

b) Progressive Disease i. GFR 20% of normal
c) Renal Insufficiency e) End Stage Renal Disease (ESRD)/Uremia
i. GFR 25% of normal i. GFR 5-10% of normal
ii. Difficulty with ADLs

Functions of the kidney:

1. Maintain fluid, acid-base and electrolyte balance
2. Detoxify blood and eliminate wastes
3. Regulate blood pressure
4. Assist in red blood cell production
5. Regulate vitamin D and calcium formation

In chronic disease
a) Up to 80% of GFR may be lost with few changes in functioning of body
b) Remaining nephrons hypertrophy (get bigger) to compensate
c) End result is a systemic disease involving every organ
d) Leading causes of ESRD
a. Diabetes
b. Hypertension

Clinical Manifestations : Result of retained substances

1. Urea
2. Creatinine
3. Phenols
4. Hormones
5. Electrolytes
6. Water
7. Other substances

Urinary system
a) Polyuria
i. Results from inability of kidneys to concentrate urine
ii. Occurs most often at night
iii. Specific gravity fixed around 1.010…can’t adjust, can’t concentrate or dilate
iv. Inability to concentrate urine
v. Normal = 1.005 – 1.030

b) Oliguria: Occurs as CKD worsens

c) Anuria - NO urine output
i. Urine output <40 ml per 24 hours
ii. Normal minimum urine output per hour: 30 ml/hr

Metabolic disturbances
a) Waste product accumulation
b) As GFR ↓, BUN ↑ and serum Creatinine levels ↑
a. Serum Creatinine (end product of the breakdown of muscle) and creatinine clearance are more accurate
indicators of kidney function than BUN…Blood urea (end product of protein breakdown) nitrogen
c) Normal BUN: 5-20mg/dl

d) Normal Serum Creatinine: 0.5-1.5mg/dl

e) Defective carbohydrate metabolism
a. Caused by impaired glucose use
i. From cellular insensitivity to the normal action of insulin…some insulin resistance
ii. Results in hyperinsulinemia (high levels of insulin in the blood)  hepatic (liver) production of
triglycerides
iii. Triglyceride levels increase
iv. Risk for: stroke (CVA), Heart attack (MI)

Electrolyte/acid–base imbalances
a) Potassium
 a. Most serious
b. Normal: 3.5 – 5.0 mEq/L…when it reach 7-8 that’s a fatal level
c. Hyperkalemia
i. Most serious electrolyte disorder in kidney disease
ii. Fatal dysrhythmias
iii. Results from decreased excretion by kidneys

b) Sodium
a. Normal: 135-145 mEq/L
b. May be normal or low
c. Because of impaired excretion, sodium is retained
d. Water is retained
i. Edema
ii. Hypertension
iii. CHF
c) Calcium and phosphate alterations…work in opposite direction
a. Calcium deficit
i. R/T (related to) inability of GI tract to absorb calcium because of decrease in activated Vitamin D
b. Phosphate excess, kidneys can’t excrete
i. R/T (related to) excretion

d) Magnesium alterations – elevation…body can’t get rid of it, kidney can’t excrete it
e) Metabolic acidosis
a. Results from
i. Inability of kidneys to excrete acid load (primary ammonia)…retaining the acid
ii. Defective reabsorption of bicarbonate

Hematologic system
a) Anemia
a. Due to ↓ production of erythropoietin (help produce red blood cell, produces in bone marrow)
i. From ↓ of functioning renal tubular cells
b. These patient will have a decrease of hemoglobin (normal range 12-17 g/dl), and hematocrit

Cardiovascular system
a) Hypertension
b) Heart failure

c) Left ventricular hypertrophy

d) Peripheral edema…retention of Na and H 0 2

e) Dysrhythmias due to increased K levels

Respiratory system
a) Kussmaul respiration, deep, rapid breathing, trying to blow off C02 (metabolic acidosis)
b) Dyspnea
c) Pulmonary edema….CHF, SOB, fluid retention

Gastrointestinal system

Every part of GI is affected

a) Due to excessive urea
a. Mucosal ulcerations
b. Stomatitis
c. Uremic fetor (urinous odor of the breath)
d. Metallic taste in mouth
e. Anorexia
f. N/V

Neurologic system
a) Expected as renal failure progresses
 a.Attributed to
i. Increased nitrogenous waste products
ii. Electrolyte imbalances
iii. Metabolic acidosis
b) Altered mental ability
c) Decreased ability to concentrate
d) Lethargy
e) Fatigue
f) Seizures
g) Coma

Musculoskeletal system
a) Renal osteodystrophy
a. Syndrome of skeletal changes
b. Result of alterations in calcium and phosphate metabolism
i. Weaken bones, increase fracture risk

Integumentary system
a) Most noticeable change
a. Yellow-gray discoloration of the skin
b. Due to absorption/retention of urinary pigments
b) Pruritus, itching, dry skin, decrease oil and sweat gland activity

c) Uremic frost (Happen when the BUN is very high, pt is refusing dialysis )
d) Dry, pale skin
e) Dry, brittle hair
f) Thin nails

Reproductive system
a) Infertility
b) Experienced by both sexes
c) Decreased libido
d) Low sperm counts
e) Sexual dysfunction

Psychologic changes
a) Personality and behavioral changes

b) Emotional liability…up and down emotion

c) Withdrawal
d) Depression

Diagnostic Studies
1. History and physical examination
2. Laboratory tests
a. BUN
b. Serum creatinine
c. Creatinine clearance…24 hr urine collection
d. Serum electrolytes
e. Urinalysis
f. Urine culture, bacteria growing in urine

g. Hematocrit and Hemoglobin

h. Renal ultrasound and renal scan

Collaborative Care : Conservative therapy
1. Correction of extracellular fluid volume overload or deficit
2. Nutritional therapy

3. Erythropoietin therapy…adequate RBC count

4. Calcium supplementation, phosphate binders
5. Antihypertensive therapy
6. Measures to lower potassium
 7. Adjustment of drug dosages based on degree of renal function…most drug are excrete from the kidney, if not will
build up

Drug therapy
Hyperkalemia…bring down the serum K+ level
1. IV insulin (regular)
a. Potassium moves from the extracellular (bloodstream) to intracellular space
b. IV glucose to manage hypoglycemia
2. Sodium polystyrene sulfonate (Kayexalate)
a. Cation-exchange resin
b. Resin in bowel exchanges potassium for sodium, gives body sodium for exchange of potassium
c. Evacuates potassium-rich stool from body
d. Educate patient that diarrhea may occur due to laxative in preparation
e. Given orally or rectally
Hypertension
1. Weight loss
2. Lifestyle changes
3. Diet recommendations
4. low Sodium and fluid restriction
5. Antihypertensive drugs
a) Diuretics
b) β-Adrenergic blockers
c) Calcium channel blockers
d) Angiotensin-converting enzyme (ACE) inhibitors
e) Angiotensin receptor blocker agents

Renal osteodystrophy
1. Phosphate Binders
a. Calcium Carbonate (Tums) and Calcium Acetate (Phos-Lo) ----- Bind phosphate in bowel and
excreted. Have to be taken within thirty minutes or so with meal…bind the phosphate that injested
with their food…30min-1hr when they eat
2. Sevelamer Hydrochloride (Renagel)
a. Lowers cholesterol and LDLs
b. Should be administered with each meal
c. Side effect: Constipation
3. Supplementing vitamin D
a. Calcitriol (Rocaltrol)
Anemia
1. Erythropoietin
a. Epoetin Alfa (Epogen, Procrit)
b. Administered IV or subcutaneously
c. Increased hemoglobin and hematocrit in 2 to 3 weeks
d. Side effect: Hypertension
2. Iron supplements
a. Side effect: Gastric irritation, constipation
b. May make stool dark in color
3. Folic acid supplements
a. Needed for RBC formation
b. Removed by dialysis

Dyslipidemia…high cholesterol levels

a. GOAL
i. Triglyceride level below 200 mg/dl
b. Statins
i. HMG-CoA reductase inhibitors
ii. Most effective for lowering LDL: Lipitor
Complications
Drug toxicity…retained in the kidney
a. Digitalis: increase contractility, decrease HR. Digoxin excreted in kidney. Decrease renal perfusion.
Decrease HR too much can cause cardiac arrest. If pulse <60, hold meds and count pulse for 1 min.
b. Antibiotics: aminoglycoside (nephritic toxic – worsen kidney damage)
 c. Pain medication (Demerol, NSAIDs): eliminated in kidney. Build up can cause respiratory depression

Nutritional therapy
Protein restriction
a. 0.6 to 0.8 g/kg body weight/day

Water restriction
a. Intake depends on daily urine output
b. Space fluid throughout the day
c. Fluids are liquid at room temperature…ice cream, sherbet, jello, Popsicle

Sodium restriction
a. Diets vary from 2 to 4 g / day depending on degree of edema and hypertension
b. Patient should be instructed to avoid high-sodium foods
c. Salt substitutes should not be used because they contain potassium chloride

Potassium restriction
a. 2 to 4 g / day
b. High-potassium foods should be avoided

Phosphate restriction
a. 1000 mg/day
b. Foods high in phosphate
c. Dairy products
d. Most foods high in phosphate are also high in calcium

Nursing Management: Nursing Diagnoses

a. Fatigue r/t anemia as AEB inability to perform ADLs

b. Fluid overload
c. Nutritional less than body require
d. Skin integrity
e. Knowledge deficit.

Nursing Management: Planning

Overall goals
a. Demonstrate knowledge and ability to comply with therapeutic regimen
b. Participate in decision making
c. Demonstrate effective coping strategies
d. Continue with activities of daily living within psychologic limitations

Nursing Management: Nursing Implementation: Acute intervention

a. Daily weight…best noninvasive way to determine pt. fluid volume states
i. Monitor I and O
b. Daily BPs
c. Identify signs and symptoms of fluid overload
d. Identify signs and symptoms of hyperkalemia
e. Strict dietary adherence
f. Medication education
g. Motivate patients in management of their disease

Ambulatory and home care

a. When conservative therapy is no longer effective, HD, PD, and transplantation are treatment options
b. Patient/family need clear explanation of dialysis and transplantation

This is how you evaluation to see if plan is effective

1. Maintenance of ideal body weight
2. Acceptance of chronic disease
3. No infections
4. No edema
 5. Hematocrit and hemoglobin levels in acceptable range

Focus on Dialysis
1. Movement of fluid/molecules across a semipermeable membrane from one compartment to another
2. Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure
3. Two methods of dialysis available
a. Peritoneal dialysis (PD)
b. Hemodialysis (HD)
4. Begun when patient’s uremia can no longer be adequately managed conservatively
5. Initiated when GFR (or creatinine clearance) <15 ml/min

General Principles of Dialysis

1. Diffusion: Movement of solutes from an area of greater concentration to an area of lesser

2. Osmosis: Movement of fluid from an area of lesser to area of greater concentration of solutes
3. Ultrafiltration
a. Water and fluid removal
b. Results when there is an osmotic gradient across the membrane…when you have an imbalance in the concentration
Osmosis and Diffusion Across Semipermeable Membrane
Peritoneal Dialysis
1. Peritoneal access is obtained by inserting a catheter through the anterior wall
2. Technique for catheter placement varies
3. Usually done via surgery
4. After catheter inserted, skin is cleaned with antiseptic solution and sterile dressing applied
5. Connected to sterile tubing system
6. Secured to abdomen with tape
7. Catheter irrigated immediately
8. Waiting period of 7 to 14 days preferable
9. 2 to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness
10. Once site healed patient may shower and pat dry

Peritoneal Dialysis : Dialysis Solutions and Cycles

1. Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%
2. Electrolyte composition similar to plasma

3. Solution warmed to body temperature

a. Prevent abdominal cramping
b. Promote the dialysis procedure/process movement of the fluid or waste product from the blood into the dialysate
solution. It helps dilate the blood vessels to cause by products or fluids to move from the vascular system into the
peritoneal dialysis.
4. Three phases of PD cycle
a. Called an exchange
i. Inflow (fill)
ii. Dwell (equilibration)
iii. Drain

Peritoneal Dialysis: Dialysis Solutions and Cycles

1. Inflow
a. Prescribed amount of solution infused through established catheter over about 10 minutes
b. After solution infused, inflow clamp closed to prevent air from entering tubing
c. If the patient c/o of cramping, slow the infusion
2. Dwell
a. Diffusion and osmosis occur between patient’s blood and peritoneal cavity
b. Duration of time varies depending on method
c. If the patient is complaining of abdominal discomfort radiating to shoulder, give patient Tylenol
3. Drain
a. 15 to 30 minutes
b. May be facilitated changing position
c. Put the bag below the patient – under the ground.

Peritoneal Dialysis: Systems

1. Automated peritoneal dialysis (APD)
a. Machine does everything; hooked up to the patient at night. Exchange done at night while patient’s asleep
b. Cycler delivers the dialysate
c. Times and controls fill, dwell, and drain
2. Continuous ambulatory peritoneal dialysis (CAPD)
 a. Patient must understand procedure and sequence
b. Learns sterile technique
c. Change 4x a day
d. Manual exchange

Peritoneal Dialysis: Complications

1. Exit site infection
2. Peritonitis
a. Cloudy peritoneal fluid.
b. Abdomen is hard.
c. Patient c/o of abdominal pain
d. If cured, scare tissue is formed and may not be an effective semipermeable membrane
3. Abdominal pain
a. Due to rapid infusion
4. Outflow problems
a. Change the patient’s position
b. Expect more fluid out during dialysis.
c. If it has outflow problems, reduced fluid
5. Loss of ultrafiltration
a. If there’s a problem with peritoneal lining (not acting effectively due to scar tissue formation)

Peritoneal Dialysis : Effectiveness and Adaptation

1. Short training program
2. Independence
3. Ease of traveling
4. Fewer dietary restrictions
5. Greater mobility than with HD

Hemodialysis: Vascular Access Sites

1. Obtaining vascular access is one of most difficult problems
2. Types of access include
a. Shunts
b. Internal arteriovenous fistulas and grafts
i. Body feels the graft as FOREIGN and more likely to clot
c. Temporary vascular access

Vascular Access for Hemodialysis

1. Long plastic cartridge that contains thousands of parallel hollow tubes or fibers
2. Fibers are the semipermeable membrane

Procedure
1. Two needles placed in fistula or graft
2. Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer
3. Blood returned from dialyzer to patient through second needle or blue catheter
4. Dialyzer/blood lines primed with saline solution to eliminate air
5. Heparin added to blood as it flows to dialyzer
a. Patient at risk for bleeding

6. Terminated by flushing dialyzer with saline to remove all blood

a. High risk for blood borne disease (HIV and virus
7. Needles removed and firm pressure applied
8. Before treatment nurse should
a. Complete assessment of fluid status, condition of access, temperature, skin condition
9. During treatment nurse should
a. Be alert to changes in condition
b. Perform vital signs every 30 to 60 minutes
10. Monitor for signs of fluid volume changes

11.Assess access site: Present at site

a. Auscultate for bruit
 b. Palpate for thrill
c. If no whoosing that means, there is a CLOT. Revise graft and remove clot.
12. Monitor weight:
a. Non invasive fluid status
b. Physician will determine how much fluid needs to be removed from the patient and looking for how much fluid they
gained between treatments
i. Pre-dialysis
ii. Post-dialysis
c. Removing a lot of fluid – hypotension
d. After dialysis – patient at risk for hypotension due to volume deficit
e. Before dialysis – hypertension r/t fluid volume excess

Hemodialysis: Complications

1. Hypotension r/t removal of fluid

2. Muscle cramps

3. Loss of blood – heparin = risk for bleeding

4. Hepatitis – sharing equipment with patient of blood borned disease
5. Sepsis - because we are introducing a needle into the vascular system
Hemodialysis : Effectiveness and Adaptation
1. Cannot fully replace metabolic and hormonal functions of kidneys
2. Can ease many of the symptoms
3. Can prevent certain complications