Chronic Kidney Disease

Chronic Kidney Disease

1. Pathophysiology (Lewis et al., 2014)

   • Stages
     • 1
       • Kidney damage with normal or high GFR (≥ 90 mL/min/1.73m2)
     • 2
       • Kidney damage with mild reduced GFR (60-89 mL/min/1.73m2)
     • 4
       • Kidney damage with severe reduced GFR (15-29mL/min/1.73m2)
     • 5
       • Kidney failure (less than 15mL/min/1.73m2 for dialysis)
     • 3
       • Kidney damage with moderate reduced GFR (30-59mL/min/1.73m2)
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2. Etiology (Malkina, 2014)

   • Hemolytic-Uremic Syndrome
   • Diabetic Nephropathy
   • Polycystic Kidney Disease
   • Benign Prostatic Hyperplasia
   • Postinfectious Glomerulonephritits
   • Systemic Lupus Erythematosus
   • IgA Nephropathy
   • Hypertensive nephrosclerosis
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3. Diagnostic Studies (Lewis et al., 2014), (Malkina, 2014)

   • Medical Imaging
     • Kidney Ultrasound, CT Scan, Renal Scan
   • Lab Work
     • Hb, BUN, Creatine, Iron Indices, eGFR, Serum Electrolytes, Urinalysis, Urine Culture, 24Hr Urine Collection, Biopsy

4. Clinical Manifestations (Lewis et al., 2014) (Malkina, 2014)

   • Cardiovascular
     • HTN, Peripheral & Coronary Artery Disease, CHF, Anemia, Bleeding Tendency, Edema
   • Respiratory
     • Dyspnea, Pulmonary Edema, Pleural Effusion, Uremic Pneumonitis, Pneumonia
   • Urinary
     • Polyuria progressing to oliguria and then eventually anuria
   • Neurological
     • Depression, anxiety, personality and behavioral changes, emotional lability, headache, sleep problems, irritability
   • Reproductive
     • Amenorrhea, erectile dysfunction, infertility, decreased libido
   • Musculoskeletal
     • Osteomalacia, osteitis fibrosa, vascular and soft tissue calcification
   • Gastrointestinal
     • Nausea, vomiting, unpleasant taste in the mouth, anorexia, weight loss, constipation
   • Electrolyte and Acid-Base Disturbances
     • Hyperkalemia, hyponatremia or normal level of sodium, metabolic acidosis
   • Integumentary
     • Pruritis, Dry skin, Scaly Skin
   • Other
     • Lethargy, fatigue, hyperglycemia, hyperlipidemia , prone to infection

5. Nursing Plan of Care

   • Assessment (Lewis et al., 2014) (Haves et al., 2017)
     • Obtain A Complete Health History
       • Genetics: Some renal diseases are hereditary, Any Existing Health Conditions? Dietary Habits Nutritional Status, Height, Any recent weight loss or gain?
     • Medications
       • Assess current and past medications, any OTC drugs they may be taking
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     • Presenting Signs/Symptoms
       • Fatigue, Lethargy and Pruritus are often early symptoms. Hypertension and urinary changes are first signs.
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     • Coping
       • Are there any self image issues? What is their emotional state? Do they have support systems in place?
   • Diagnosis (Lewis et al., 2014)
     • Excess Fluid Volume
       • Related to inability of the kidneys to excrete excess fluid. Patient may present with edema, hypertension, bounding pulse, weight gain, shortness of breath, and pulmonary edema
         • Nursing Intervention & Rationale Monitor BP, periorbital, sacral and peripheral edema, dyspnea, which are indictors of fluid excess. Monitor weight, intake and output to determine effect of treatment of volume status. Provide appropriate diet instruction to help control edema and hypertension Instruct patient and or caregiver on measures instituted to treat the hypervolemia (e.g., daily weights, fluid restriction) to help monitor and control fluid overload and related hypertension
     • Decreased Functional Ability
       • This is due to anemia resulting from iron deficiency and kidney's inability to produce erythropoietin
         • Assess patient for dyspnea, excess fatigue, tachycardia, palpitations, chest pain, which are indictors of anemia. Monitor trends in hemoglobin and iron states (e.g., ferritin, total iron-binding capacity and transferring saturation to determine effect of treatment of anemia
     • Risk for Impaired Skin Integrity
       • Related to pruritus resulting from elevated phosphorous and fluid volume excess as evidenced by dry skin, scratching, and peripheral edema
   • Planning (Lin et al., 2017)
     • Participate in decision making for the plan of care and future treatment modality
     • Continue with activities of daily living within physiological limitations
     • Demonstrate knowledge and ability to comply with the therapeutic regimen
     • Demonstrate effective coping strategies
   • Nursing Implementation (Lewis et al., 2014)
     • Health Promotion
       • Identify clients at risk (family history of renal disease, hypertension, diabetes mellitus, and reoccurring UTIs. - Monitoring BUN, serum creatinine, and urinalysis - Managing diabetes, controlling and monitoring blood pressure, lifestyle modifications
     • Care Consideration
       • Teach client and family about drugs, diet and nutrition, and follow-up appointments for interventions. The patient should check weight daily, teach how to take blood pressure, and teach signs & symptoms of hyperkalemia, other electrolyte imbalances, and fluid overload. Teach client on specific drugs to avoid such as NSAIDs and natural and herbal preparations. Encourage and motivate the client to take the primary role in the management of the disease
     • Home Care and Ambulatory
       • Continue to educate the patient and the family. Provide information on further treatments such as dialysis and transplantation, if necessary
   • Evaluation (Lewis et al., 2014) (Lin et al., 2017)
     • Patient maintains an acceptable body weight and fluid balance Reports decreased fatigue. Improved exercise tolerance and increased quality of life. Hemoglobin values and transferrin percent saturation and ferritin levels are within normal rang
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6. Treatment

   • Kidney Transplantation (Lewis et al., 2014)
     • Pre- Operative Care
       • Ensure Consent Obtained by Physician
       • Education on procedure and postoperative expectations
       • Patient in optimal shape for surgery run labs, ECG, chest radiograph
     • Post- Operative Care
       • Living Donor
         • Monitor renal functioning (BUN, serum creatinine & urinalysis)
         • Support and acknowledge the patient
         • Assess for bleeding
         • Pain management
       • Reciepient
         • Maintenance of fluids and electrolytes
         • Postoperative teaching (include immunosuppressive therapy)
         • Monitor renal functioning (BUN, serum creatinine & urinalysis)
         • Monitor Urine Output
         • Pain Management
         • Assess for bleeding
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     • Potential Complications
       • Recurrence of original renal disease
       • Rejection
       • Infection
       • Cardiovascular Disease
       • Corticosteroid-related complications
       • Malignancies
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   • Dialysis (National Kidney Foundation, 2017)
     • Hemodialysis
       • Blood cleaned outside the body via dialyzer Vascular access via a graft, fistula or catheter Can be done in hospital, dialysis centre or home Done 3x/wk for 4 hrs in dialysis centre or 4-7x/wk if at home Nrsg Mgmt: Prior: Assess fluid status, vascular access site, weight. During: Assess VS q 30-60 mins with focus on BP Complications: Hypotension, blood loss, sepsis
     • Peritoneal Dialysis
       • Blood cleaned inside body; peritoneum used as filter Catheter surgically placed in abdomen via anterior abdominal wall Complications: peritonitis, exit-site infection, protein loss, hernia
         • Two Types
           • Continuous Ambulatory Peritoneal Dialysis (CAPD)
             • No machine needed 4-5 x per day, Dialysate placed into peritoneal cavity and drained 4-5 hrs later, Can be done at work, school or home
           • Automated Peritoneal Dialysis (APD)
             • Uses a machine called a ‘cycler’, Cycles are done every 1-1.5hrs, Usually done at home in the night while patient sleeps
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7. Drug Therapy (Lewis et al., 2014) (Hanudel, 2018)

   • Bone Issues
     • Vitamin D Supplement, Phosphate binders (Tums, Caltrate, Ferric Citrate)
   • Hyperkalemia
     • IV calcium gluconate, IV glucose and Insulin
   • Hypertension
     • ACE inhibitors, ARBs, Thiazide Diuretics, Loop Diuretics
   • Anemia
     • IV or SC Erythropoiesis-Stimulating Agents, Iron and Folic acid Supplements
   • Hyperlipidemia
     • HMG-CoA Reductase Inhibitors
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8. Nutrition (Lewis et al., 2014)

   • Protein
     • Hemodialysis Patient
       • 1.2 – 1.3 g/kg of body weight/day
     • Peritoneal Dialysis Patient
       • 1.2 – 1.3 g/kg of body weight/day
     • CKD Stage 3-4
       • 0.6 – 0.75 g/ kg of body weight/day if Cr clearance is < 25mL/min
   • Sodium
     • CKD Stage 3-4
       • 2-3 g/day
     • Hemodialysis Patient
       • 2 - 3 g/day
     • Peritoneal Dialysis Patient
       • 2 – 4 g/day
     • Avoid processed meats, pickled foods, salad dressings
   • Potassium
     • CKD Stage 3-4
       • 2 – 3 g/day
     • Hemodialysis Patient
       • 2 -3 g / day
     • Peritoneal Dialysis Patient
       • 3 – 4 g / day or no restriction depending on pt.
     • Avoid foods such as bananas, tomatoes, prunes, dark green and yellow veggies
   • Fluids
     • CKD Stage 3-4
       • Daily output + 600mL
     • Peritoneal Dialysis
       • No Restriction
     • Hemodialysis Patient
       • Daily output + 600mL
     • Jell-O and ice cream are taken into account, Space fluids to avoid thirst throughout the day
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9. Client-Centred Care (Lissanu et al, 2019)

   • Often find it difficult to manage dietary restricitons
   • Many lack access info. and teaching surrounding proper diet
   • Many are often optimistic post diagnosis
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10. Definition (Lewis et al., 2014)

    • Progressive, irreversible kidney damage
    • GFR <60 ml/min/1.73 m2
    • ≥ 3 months
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11. Image 8

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