Chronic Kidney Disease

Chronic Kidney Disease

1. Causes

   • 50% Diabetes 25% Hypertension Polycystic Kidney Disease, Systemic Lupus erythematosus
   • Diabetes
   • Hypertension
   • Other Glomerulonephritis, Cystic Disease Diabetic Neuropathy, Hypertensive nephrosclerosis, Chronic Pyelonephritis, Systemic Lupus Disease, & Urologic Diseases

2. Signs & Symptoms

   • Retain:  Urea, Creatinine, Phenols, Hormones, Electrolytes & Water (Uremia)
   • Uremia
   • GI:  No appeitite
   • Diagnostics
     • Hx & Physical  Dipstick 
     • Urine Specific Gravity
       • 1.01 Specific Gravity or Lower 
     • Renal Biopsy
     • Renal CT scan
     • Dipstick
       • 1st Test measures the amount of protein or albuminuria in the urine. (1+ protein on standard dipstick 2 or more times over a 3 month period)
     • GFR
       • MDRD equation (Modification of diet renal disease) or Cockcroft Gualt Formula. Normal GFR is 125ml/min. 
     • Albumin to Creatine (First Morning)
       • 300mg Albumin to 1g of Creatinine signals CKD. Needs to be 1st voided 
     • Blood & Urine Test
     • Ultrasound
       • This checks if there is an obstruction and the Size of the Kidneys.
   • 5 stages
     • Stage 1: >90  Stage 2: 60-90 Stage 3: 30-59 Stage 4: 15-29 Stage 5:  <15
   • Polyuria, Oliguria, Anuria
     • Polyuria initially and as the disease progresses symptoms will appear as oliguria/anuria. Anuria usually when on dialysis 40ml per 24hrs. 
   • Integument
     • Pruritis
   • Lab Values
     • Potassium
       • Muscle Weakness, Parasthesias & ECG changes
       • Hyperkalemia
         • Peak T wave & Widened QRS waves
     • BUN/Creatine
       • Increased contributes to N&V, Lethargy, Fatigue, ImpairedThough Processes and headache. 
     • High Blood Sugar
       • Hyperglycemia- The body cannot metabolize Carbohydrates. 
     • GFR >60ml/min
       • The lower the % of the GFR value the more progressive the disease
     • HDL/LDL
       • Increased LDL  & Decreased HDL. Elevated Triglycerides. Most CKD patient die from CV disease. 
     • Calcium
       • Hypocalcemia- Bones fragile
     • Metabolic Acidosis
       • Impaired ability to excrete acid and defective reabsorption & Regeneration of Bicarbonate. 
     • Anemia
       • This is due to decreased EPO Production
     • Hyperphosphatemia & Hypocalcemia
     • Hypermagnesia
       • AVoid Mg containing Antacids
     • Salt & water Rention
   • Cardiovascular
     • Calcification
     • Cardiac Dysrthmias
   • Gastronintestinal
     • Uremic Fetor
     • Metallic taste in Mouth
   • Respiratory
     • Kassmaul Breathing
       • This type of breathing is attempt for the body to compensate for metabolic acidosis by breathing off CO2. 
     • Pulmonary Edema (Dyspnea)
       • This is a result of fluid overload
   • Musculoskeletal
     • CKD Bone Mineral Disorder
       • Disease process prevents body from converting the Vitamin D to the active form. Calcium is therefore not being Absorbed. When calcium is Low in the Blood stream the body Releases PTH! This causes bone demineralization
     • Vacular Calcification
   • Reproductive
     • Can Experience Infertility
     • Decreased Libido
   • Psychological
     • Grieve
     • Fatigue, Lethargy
   • Uremia

3. Interventions

   • Teaching
     • Teach the Patient to Check daily weights & Report Weight Gain greater than 4 pounds. 
     • Nephrollogist
     • Nutrition
       • water, Phosphate, Potassium & Sodium Restricitions
     • Check Weight Daily & Report greater than 4lbs
   • Dialysis
     • Complications
       • Hypotension & Muscle Cramps (when taken out to quickly), Loss of Blood, Pt. gets Cold, Infection. 
     • Dialyzed Out medications?
     • Periotneal Dialysis
       • Warm  (Do NOT want to Cause Hypothermia) . 3-7day training
       • Exchange
         • Drain
           • 15-30min. Massage abdomen or change Position. (Glucose used as osmotic force) 
         • Inflow
           • Inflow of about 10min after done clamp is closed. The amount is 2L and if patient is in Pain  it will be decreased. 
         • Dwell
           • 20-30min to 8hrs. This is where osmosis &n DIffusion happen 
       • Complications
         • Peritonitis
           • Treat with Antibiotics. Usually caused by the exchange making or breaking. 
         • Protein
           • Loss through dialysis 
         • Exit site infections
         • Hernias & Lower back Problems
           • Increased Intraadbominal Pressure. 
         • Pulmonary
           • Repeated upward displacement of the diaphragm, decreases lungs exapansion. 
         • Bleeding
     • Hemodialysis
       • "Hear the Thrilll & Feel the Bruit"
       • AVF/AVG
         • Least Complication of Thrombosis & Infections. Thrill can be palpated & Bruit can be heared.  Maturation takes 6w to a month & should be placed 3m before intiating HD. 
         • Fistula "Gold Standard"
           • Feel a thrill & Hear a Bruit. The Needles 15 or 14 gauge needles. 
         • Steal Syndrome
       • Temporary Vascular ACCESS
         • Internal Jugular or Femoral Vein. Soft flexible double lumen tube attach to a Y Hub. Recirculation rate takes about 5%
       • Complications
         • Loss of Blood
         • Hepatitis
         • Muscle Cramps
           • Rapid removal of water & sodium may cause cramps. NS is the treatment of choice. 
         • Hypotension
     • Increase Protein due to being able to dialyze nitrogenous waste
   • Kidney Transplant
     • Compatible
     • Rejection
       • Hyperacute (Minutes) Acute (Days to Months) Chronic Rejection (Months-Years)
       • Immunosuppressives
         • Teach about signs & Symptoms of Infection. Worsen Hypertension & Hyperlispedemia!!!
         • Tachrolimus
     • Surgery label arm "Dialysis, no procedures"
     • Empty Peritoneal cavity
     • Fluid & Electrolytes post-op 1st priority
       • will have high urine output up to 1L
     • watch out for Acute Tubuler Necrosis
     • Acute Tubular Necrosis
       • Decrease in CVP suggest hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion. 
     • Fluid Volume replaced based on Urine Output
   • CKMD
     • Biopsy is the GOLD STANDARD
     • Limit Dietary Phosphorus
       • NOT restricted usually until the patient requires RRT (limit 1g/day)
     • Administer phosphate binders
       • Calcium Acetate, Calcium Carbonate, They bind to the phosphate in the bowel and are excreted in the stool.  *Administer Non-Calcium Binders Lanthanum Carbonate & Salvelamor Carbonate if Calcification is evident!!! (Most effective with Meals) 
       • Constipation Side effect (may need stool softener)
     • Parathyroidectomy
       • If there is excessive release of parathyroid surgery may be an option and a small portion can be implanted into the forearm. 
     • Calcium & Supplement Vitamin D (cholecalciferol)
       • Oral or IV Calcitriol, IV paricalcitol, Oral or IV Doxercalciferol (Active form) Can reduce PTH. If Hypercalcemia occurs reduce Phosphate Binders and d/c Supplementation. 
     • Cinacalcate
       • Mimic Calcium & increase sensitivity of calcium receptors in the parathyroid gland. 
   • Hyperkalemia
     • Restrict High k+ Foods & Drugs
     • (Acute) IV glucose & Insulin
     • iv Calcium Gluconate
     • Kayexalate (Sodium Polystyrene
       • Commonly used with patient on stage 4 CDK
       • Never give to patient that have Hypoactive bowel (Paralytic ileus)
         • Could lead to Necrotic Bowels
       • Montior for sodium & Water Retention
       • Diarrhea
         • Contains sorbitol a sugar alcohol  that has an osmotic laxative action
   • Anemia
     • Erythropoietin Replacement
       • Eopoietin Alfa (IV or SC) 2-3w  Darbepoetin alfa (longerlasting weekly or biweekly) effects dont kick in until 2-3w
       • Thromboemobolitic
         • Teach about Risk & Benefits. Start LOW 
         • check Hgb!!! higher than 12g/dL
       • Iron Supplements
         • Do not take at same time as Phosphate BINDERS
           • Adherence may not be good because of stomach upset & Constipation. Teach that darker stool is Normal. Calcium binds to Iron 
         • Folic Acid needed for RBC formation
           • Removed by dialysis
   • Hypertension
     • Weight loss, excercise, cessation of Smoking
     • ACE/ARB
       • Use with diabetics and with nondiabetics w/ proteinuria *Must used Cautiously because can further decrease GFR & Increase K+ 
     • Diuretcs
     • Calcium Channel Blockers
     • BP
       • Monitor Blood Pressure in supine, sitting & standing positions. Evaluate if the medications are working. 
   • Dyslipedemia
     • Statins
       • Simvastatin is associated with myopathy if this develops transer to myopathy. 
   • Durgs Caution
     • Digoxin, diabetic agents, antibiotics & opioids

4. Critical Value K+ 6.8

5. Irreversible disease: Presence of Kidney damage or GFR >60ml/min, Longer than 3m