I. Introduction II. Anatomy and Physiology III. Pathophysiology IV. Synthesis of the Disease A. Chronic Kidney Disease 1.

Definition of the Disease Chronic kidney disease occurs when one suffers from gradual and usually permanent loss of kidney function over time. This happens gradually, usually months to years. Chronic kidney disease is divided into five stages of increasing severity (see Table 1 below). The term "renal" refers to the kidney, so another name for kidney failure is "renal failure." Mild kidney disease is often called renal insufficiency. With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney. Loss of kidney function also causes other problems such as anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and fatty acids, and bone disease. Stage 5 chronic kidney disease is also referred to as kidney failure, end-stage kidney disease, or end-stage renal disease, wherein there is total or near-total loss of kidney function. There is dangerous accumulation of water, waste, and toxic substances, and most individuals in this stage of kidney disease need dialysis or transplantation to stay alive. Unlike chronic kidney disease, acute kidney failure develops rapidly, over days or weeks. Acute kidney failure usually develops in response to a disorder that directly affects the kidney, its blood supply, or urine flow from it. Acute kidney failure is often reversible, with complete recovery of kidney function. Some patients are left with residual damage and can have a progressive decline in kidney function in the future. Others may develop irreversible kidney failure after an acute injury and remain dialysis-dependent. Stages of Chronic Kidney Disease Stage 1 2 3 4 GFR* mL/min/1.73m2 Slight kidney damage with normal or More than 90 increased filtration Mild decrease in kidney function 60-89 Moderate decrease in kidney function 30-59 Severe decrease in kidney function 15-29 Description

Less than 15 (or dialysis) *GFR is glomerular filtration rate, a measure of the kidney's function.

Kidney failure

2. Non modifiable and Modifiable Risk factors Non modifiable Factors  Genetic Abnormalities A hereditary lesion such as polycystic kidney disease affects the normal functioning of the kidneys. Polycystic kidney disease (PKD) is passed down through families (inherited), usually as an autosomal dominant trait. If one parent carries the gene, the children have a 50% chance of developing the disorder. The cysts cause the kidney to swell, disrupting kidney function and leading to chronic high blood pressure and kidney infections. The cysts may cause the kidneys to increase production of erythropoietin, a hormone that stimulates production of red blood cells. This leads to too many red blood cells, rather than the anemia seen in chronic kidney disease.  Age The amount of blood flow through the kidney and ability of the kidney to filter blood is about half that of younger ages. This is caused by the age-related structural and anatomic changes within the kidney. Some studies show that as much as one-third of older adults have no change in their urine creatinine (creatinine clearance is a measure of how well the kidney is able to filter the blood, the glomerular filtration rate or GFR). However other studies show decline that begins at 40 years. Age-related kidney changes create more risks for fluid and electrolyte imbalance and renal damage from medications or diagnostic contrast materials. Renal function decreases as a person ages, due to deteriorating process of the kidneys.  Gender Some studies suggest that male individuals are more prone of having kidney failure compare to female individuals because of their lifestyle. Another thing is that men are more prone of having kidney stones than women is because of the larger muscle mass as compared to women. Thus, the daily breakdown of the tissue results in increased metabolic waste and a predisposition of stone formation. The other more significant cause is because of the male urinary tract

being more complicated than the female urinary tract. The enlargement of the prostate gland as men grow older, can result in a condition known as benign prostrate hypertrophy, which can result in difficulty in emptying the bladder. With the obstruction of the bladder outflow, crystals and stones may be formed. Modifiable Factors  Obesity Excess weight is a common, strong and modifiable risk factor for chronic kidney disease and end-stage renal disease. Even individuals who are not overtly obese are at risk. Excess weight contributes to chronic kidney disease and end-stage renal disease over and above its role in hypertension and diabetes. Weight loss may represent a novel intervention to reduce risk of chronic kidney disease development and progression.  Anemia Anemia may contribute to kidney injury by reducing renal oxygen delivery, worsening oxidative stress, and impairing homeostasis.  Diabetes Mellitus One of the most common systemic diseases affecting the kidneys is Diabetes mellitus. Diabetic nephropathy, a progressive process, commonly leads to renal failure.  Hypertension The renal circulation receives about 20% of the cardiac output. Renal function can affect or can be affected by cardiovascular changes. Hypertension could result to significant changes of the vessels found in kidneys. Due to increase blood pressure, it results to degenerative changes in the arterioles and interlobular arteries.  Nephrotoxins Some medications have nephrotoxic effects to the kidneys that may lead to renal impairment. Because the kidneys are the major route of excretion from many antibiotics and analgesics, the renal tissues are directly exposed to these compounds.

3. Signs and symptoms  Hyperkalemia The kidneys become inefficient in excreting potassium leading to increase level of potassium in the blood.  Elevated creatinine level The creatinine level is a marker if the kidneys function normally. An increase in level of creatinine results from the inability of the kidneys to filter the blood and excrete metabolic wastes.  Elevated blood urea nitrogen (BUN) As the glomerular filtration rate decreases, the BUN level increases steadily at a rate dependent on the degree of catabolism, renal perfusion and protein intake.  Anemia The primary hematologic effect of renal failure is anemia, usually normochromic and normocytic. It occurs because the kidneys are unable to produce erythropoietin, a hormone necessary for red blood cell production.  Heart failure Heart failure may result due to increase/excess body fluid and may also result from electrolyte imbalances.  Dysrhythmias Dysrhythmias may result due to increase potassium level in the blood, which was not excreted by the kidneys. Potassium is crucial to heart function and plays a key role in skeletal and smooth muscle contraction, making it important for normal digestive and muscular function, too.  Edema Due to loss of excretory function, the kidneys will not be able to excrete excess body fluid that causes edema.

 Pulmonary edema Pulmonary edema can occur due to fluid overload.  Pruritus Itchiness may occur due to accumulation of metabolic waste in the skin.

4. Diagnostic Procedures High blood pressure is almost always present during all stages of chronic kidney disease. A neurologic examination may show signs of nerve damage. The health care provider may hear abnormal heart or lung sounds with a stethoscope. A urinalysis may show protein or other changes. These changes may appear 6 months to 10 or more years before symptoms appear. Tests that check how well the kidneys are working include:  Creatinine levels Creatinine is a chemical waste molecule that is generated from muscle metabolism. Creatinine is produced from creatine, a molecule of major importance for energy production in muscles. Approximately 2% of the body's creatine is converted to creatinine every day. Creatinine is transported through the bloodstream to the kidneys. The kidneys filter out most of the creatinine and dispose of it in the urine. The kidneys maintain the blood creatinine in a normal range. Creatinine has been found to be a fairly reliable indicator of kidney function. As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys. It is for this reason that standard blood tests routinely check the amount of creatinine in the blood. A more precise measure of the kidney function can be estimated by calculating how much creatinine is cleared from the body by the kidneys and it is referred to creatinine clearance.  Blood Urea Nitrogen A blood urea nitrogen (BUN) test measures the amount of nitrogen in the blood that comes from the waste product urea. Urea is made when protein is

broken down in the body. Urea is made in the liver and passed out of the body in the urine. A BUN test is done to see how well kidneys are working. If the kidneys are not able to remove urea from the blood normally, BUN level rises. Heart failure, dehydration, or a diet high in protein can also make BUN level higher. Liver disease or damage can lower BUN level. A low BUN level can occur normally in the second or third trimester of pregnancy.

 Creatinine Clearance Creatinine is a breakdown product of creatine, which is an important part of muscle. The creatinine clearance test compares the level of creatinine in urine with the creatinine level in the blood. (Creatinine is a breakdown product of creatine, which is an important part of muscle.) The test helps provide information on kidney function.

Chronic kidney disease changes the results of several other tests. Every patient needs to have the following checked regularly, as often as every 2 - 3 months when kidney disease gets worse:      Potassium Sodium Albumin Phosphorous Calcium     Cholesterol Magnesium Complete blood count (CBC) Electrolytes

Causes of chronic kidney disease may be seen on:  Abdominal CT scan An abdominal CT scan is an imaging method that uses x-rays to create cross-sectional pictures of the belly area. CT stands for computed tomography. An abdominal CT rapidly creates detailed pictures of the structures inside the belly area (abdomen). This test may help detect or diagnose:  The cause of abdominal pain or swelling  Hernia  The cause of a fever

    

Masses and tumors, including cancer Infections or injury Kidney stones Appendicitis

Abdominal MRI An abdominal MRI (magnetic resonance imaging) scan is a imaging test that uses powerful magnets and radio waves to create pictures of the inside of the belly area. It does not use radiation (x-rays). Single MRI images are called slices. The images can be stored on a computer or printed on film. One exam produces dozens or sometimes hundreds of images.

Abdominal ultrasound Abdominal ultrasound is an imaging procedure used to examine the internal organs of the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The blood vessels that lead to some of these organs can also be looked at with ultrasound. An ultrasound machine creates images that allow various organs in the body to be examined. The machine sends out high-frequency sound waves, which reflect off body structures to create a picture. A computer receives these reflected waves and uses them to create a picture. Unlike with x-rays or CT scans, there is no ionizing radiation exposure with this test.

Renal scan A renal scan is a nuclear medicine exam in which a small amount of radioactive material (radioisotope) is used to measure the function of the kidneys. A renal scan reveals the size, position, shape, and function of the kidneys. It is particularly useful when a person is sensitive or allergic to the contrast (dye) material used in an IVP or other x-rays, or when they have reduced kidney function. A renal scan is commonly performed after a kidney transplant to check kidney function and to look for signs of transplant rejection. It may also be done on those with high blood pressure to check differential kidney function.

5. Treatment The goal of treatment for chronic kidney disease is to prevent or slow further damage to your kidneys. Another condition such as diabetes or high blood pressure

usually causes kidney disease, so it is important to identify and manage the condition that is causing your kidney disease. It is also important to prevent diseases and avoid situations that can cause kidney damage or make it worse. One of the most important parts of treatment is to control the disease that is causing kidney damage. If the patient has diabetes, it is important to control the blood sugar levels with diet, exercise, and medicines. A persistently high blood sugar level can damage the blood vessels in the kidneys. If the patient has high blood pressure, it is also important to control the blood pressure with diet, exercise, and any medicines that the physician would prescribe. The goal is to keep the blood pressure less than 130/80. This also slows progression of chronic kidney disease. It is often useful to monitor blood pressure at home. Blood pressure medications known as angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) have special benefit in protecting the kidneys. These medicines are used to reduce protein in the urine and help manage high blood pressure. Avoid long term use of medications that has toxic effect to the kidneys or nephrotoxic. It is important to advise patient to talk to his doctor about all prescription, over-the-counter, and herbal products that the patient takes. Some examples of common medicines that can cause problems include: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as: Ibuprofen (for example, Advil). Aspirin (for example, Excedrin). Naproxen sodium (for example, Aleve). Celecoxib (Celebrex). Acetaminophen (such as Tylenol), which may be harmful if it is overused. Herbal products. Chinese herbs used for weight loss have caused kidney disease in some people. Avoid products that have aristolochic acid in the ingredient list.

   

Encourage patient to have a healthy lifestyle by: Following a diet that is easy on kidneys such as Low Sodium, Low Fat diet and with a right amount of fluid and protein, making exercise a routine part of life, not using substances that can harm your kidneys, such as alcohol, any kind of tobacco, or illegal drugs. As the disease gets worse, symptoms-such as fatigue, nausea, and loss of appetite-may occur more often or become more severe. If the patient develop anemia, he may need to take medicine called human recombinant erythropoietin (rhEPO). It helps the body make new red blood cells and

may help improve the patients appetite and general sense of well-being. The patient may also need an iron supplement if you have an iron deficiency. If the patient develop uremic syndrome (uremia), he will need to have wastes and fluids removed through dialysis or your kidney replaced through a kidney transplant. When the kidneys function has fallen below a certain point, it is called kidney failure. Kidney failure has harmful effects throughout the body. It can cause serious heart, bone, and brain problems and make the patient feel very ill. This is when the patient will be required to undergo dialysis or a kidney transplant. Dialysis Dialysis is a process that performs the work of healthy kidneys by clearing wastes and extra fluid from the body and restoring the proper balance of chemicals (electrolytes) in the blood. There are two types of dialysis 1) hemodialysis (in-center or home) and 2) peritoneal dialysis. Before dialysis can be initiated, a dialysis access has to be created. Hemodialysis involves circulation of blood through a filter or dialyzer on a dialysis machine. The dialyzer has two fluid compartments and is configured with bundles of hollow fiber capillary tubes. Blood in the first compartment is pumped along one side of a semipermeable membrane, while dialysate (the fluid that is used to cleanse the blood) is pumped along the other side, in a separate compartment, in the opposite direction. Concentration gradients of substances between blood and dialysate lead to desired changes in the blood composition, such as a reduction in waste products (urea nitrogen and creatinine); a correction of acid levels; and equilibration of various mineral levels. Excess water is also removed. The blood is then returned to the body. Hemodialysis may be done in a dialysis center or at home. In-center hemodialysis typically takes three to five hours and is performed three times a week. You will need to travel to a dialysis center for in-center hemodialysis. Some centers may offer the option of nocturnal (night-time) hemodialysis wherein the therapy is delivered while you sleep. Long nocturnal dialysis offers patients a better survival and an improvement in their quality of life. Home hemodialysis is possible in some situations. A care partner is needed to assist you with the dialysis treatments. A family member or close friend are the usual options, though occasionally people may hire a professional to assist with dialysis. Home hemodialysis may be performed as traditional three times a week treatments, long nocturnal (overnight) hemodialysis, or short daily hemodialysis. Daily hemodialysis and long nocturnal hemodialysis offer advantages in quality of life and better control of high blood pressure, anemia, and bone disease.

Peritoneal dialysis utilizes the lining membrane (peritoneum) of the abdomen as a filter to clean blood and remove excess fluid. Peritoneal dialysis may be performed manually (continuous ambulatory peritoneal dialysis) or by using a machine to perform the dialysis at night (automated peritoneal dialysis). About 2 to 3 liters of dialysis fluid are infused into the abdominal cavity through the access catheter. This fluid contains substances that pull wastes and excess water out of neighboring tissues. The fluid is allowed to dwell for two to several hours before being drained, taking the unwanted wastes and water with it. The fluid typically needs to be exchanged four to five times a day. Peritoneal dialysis offers much more freedom compared to hemodialysis since patients do not need to come to a dialysis center for their treatment. You can carry out many of your usual activities while undergoing this treatment. This may be the preferable therapy for children. Most patients are candidates for both hemodialysis and peritoneal dialysis. There are little differences in outcomes between the two procedures. Your physician may recommend one kind of dialysis over the other based on your medical and surgical history. It is best to choose your modality of dialysis after understanding both procedures and matching them to your lifestyle, daily activities, schedule, distance from the dialysis unit, support system, and personal preference. Kidney Transplantation Kidney transplantation offers the best outcomes and the best quality of life. Successful kidney transplants occur every day in the United States. Transplanted kidneys may come from living related donors, living unrelated donors, or people who have died of other causes (cadaveric donors). A person who needs a kidney transplant undergoes several tests to identify characteristics of his or her immune system. The recipient can accept only a kidney that comes from a donor who matches certain of his or her immunologic characteristics. The more similar the donor is in these characteristics, the greater the chance of long-term success of the transplant. Transplants from a living related donor generally have the best results. Transplant surgery is a major procedure and generally requires four to seven days in the hospital. All transplant recipients require lifelong immunosuppressant medications to prevent their bodies from rejecting the new kidney. Immunosuppressant medications require careful monitoring of blood levels and increase the risk of infection as well as some types of cancer. 6. Nursing Care Plans

B. Hypertension II

V. Summary and Conclusion VI. Recommendations VII. Learning Derived