Chronic Kidney Disease (CKD)

Chronic Kidney Disease (CKD)

1. Implementation (American Kidney Fund, 2019;Bonner, et al., 2014, Lewis et al., 2014)

   • Renal Replacement Therapies including
     • Dialysis; hemodialysis and peritoneal dialysis. This will artificially remove waste products and excess fluid from bloodstream
       • The vascular surgery & general surgery teams insert the access ports for both types of dialysis, and monitor the status of these incisions.
     • Transplant; a surgical procedure to put a donor kidney into the recipient, the kidney can from a living or deceased donor
   • Medications (NHS Foundation, 2019, Johns et al., 2015)
     • Iron supplements will be used due to the risk of anemia with dialysis. These are given via injection for easy absorption
     • Diuretics are used to increase the rate of excretion of fluids from the body, flushing system of harmful substances. A primary example is Furosemide.
     • Anti-hypertensives will be used as hypertension can damage the blood vessels supplying the kidneys, therefore lowering it will provide increased flow. Some common antihypertensives include Atenolol, Rampiril, Doxazosin, and Irbesartan.
     • Erythropoietin will be administered to stimulate bone marrow to healthy red blood cells, as kidney failure will inhibit this process
     • Phosphate binders are given to both prevent itchiness as well as reducing the risk of heart problems associated with chronic kidney disease
     • Sodium bicarbonate is used to counteract acids to prevent acid buildup in body as a result of decreased kidney excretion
     • Statins will be used to lower cholesterol levels in order to decrease the risk of congestive heart failure. Some common examples include Atorvastin, Simvastatin, and Pravastatin.
     • A pharmacist will collaborate with the MD and patient regarding medication review, dosing, and adherance
   • Patient teaching consists of (Ormandy, 2008, Johns et al., 2015)
     • How kidneys work and what happens when they fail
     • what can be done to protect the remaining healthy kidney or slow the progression
     • Life expectancy with or without treatment and possibility of death if treatment is refused. Patients with a GFR of 60 and ages 30-50 years have anywhere between 12 and 24 years (Landry, 2017)
     • Education about the impact this disease will have on their lifestyle
       • Lifestyle Changes such as; no smoking or using tobacco, limit alcohol consumption, adhering to treatment schedule, and will need to start or continue to exercise
       • Diet/Nutrition changes
         • Protein restriction are required because BUN is the end product of protein metabolism & CKD already causes BUN levels to increase. Protein intake must have all essential amino acids; milk, poultry, meat or eggs
         • Sodium & Fluid Restriction
           • Fluid intake depends on the daily output & fluid balance. If the patient is not on dialysis, there is no fluid restriction , if patient is on hemodialysis fluid allowance is 600ml + amount equal to previous days' urine output
           • 2-4g of sodium allowed depending on if the patient is presenting with hypertension and/or edema. Avoid sodium rich foods such as cured meats, pickled foods or canned soups
           • Avoidance of salt substitutes because they contain potassium chloride and contribute to hyperkalemia
         • Potassium Restriction (2-4g/day) avoid potassium-rich food such as oranges, tomatoes, bananas
         • Phosphate Restrictions (1000mg/day), avoid phosphate rich foods such as dairy products
         • Collaborative care between MD, dietician, and patient (Johns et al., 2015)
     • Encourage leisure activities such as; walking, swimming, cycling, skiing, aerobic dancing or other activities that allow the movement of large muscle groups. No heavy lifting. (National Kidney Foundation, 2019)
     • How to cope or treat their symptoms at home that may result from their treatment
     • Financial implications & information on any additional support available
     • What are their medications' purpose, how they will work, and possible side effects
     • information on why the different tests are being performed
     • How to adapt and cope with dialysis; HCPs could allow the patient to visit the dialysis ward if applicable, to meet health care team and talk with other patients. Give information on community support groups.
     • Discussion of each patient's prognosis, and the risks and benefits of treatments including dialysis and transplantation. The transplant team can further provide information regarding the options/processes for transplantation. They also assess the eligibility of candidates for transplant
     • May be done by members of the interdisciplinary team including MD, pharmacist, dietician, advanced practitioners, nephrologists.
   • Treat Reversible Causes; cardiac failure, nephrotoxins, infections, renal stenosis, urinary tract obstruction, dehydration

2. Diagnosis (Lewis et al., 2014)

   • Routine laboratory measurements to look for proteinuria (earliest marker for kidney damage)
     • Patients with diabetes, hypertension, autoimmune disease, vascular disease, or eGFR <60mL/min are at high risk for CKD and should be screened routineley
   • Urinalysis to look for presence of WBCs, RBCs, glucose, casts, and protein
   • Ultrasound to determine the size of the kidneys, any obstructions, and image of kidneys
   • eGFR will be taken to determine stage of CKD
     • 5 stages of CKD (American Kidney Fund, 2019)
       • Stage 2 chronic kidney disease will be mild with little to no symptoms and an eGFR of 60-89%
       • Stage 1 chronic Kidney disease will be very mild with no symptoms and an eGFR>90%
       • Stage 3a chronic kidney disease will be of moderate severity with symptoms of polyuria, swelling, back pain, and a eGFR of 45-54%
       • Stage 4 chronic kidney disease with be severe with complications of gout, heart disease, and hyperkalemia as well as the symptoms present in stage 3a/b. It will maintain an eGFR of 15-30%
       • Stage 5 chronic kidney disease will result in total kidney failure leading to death without dialysis or treatment. Alongside all other complications there will be excessive nausea/vomitting, dificulty breathing, and abdominal cramping. It will maintain a eGFR<15%.
       • Stage 3b chronic kidney disease will possess the same symptoms as stage 3a with added complications of anemia, hypternsion, and bone disease. It will have a eGFR of 30-44%
   • Renal biopsy

3. Outcome/Planning

   • Goals for Patients with CKD (Prasad-Reddy et al., 2017, Lewis et al., 2014, Johns et al., 2015)
     • Prevention of further CKD progression (CDC, 2017, Johns et al., 2015)
       • Keep your kidneys healthy by taking meds as prescribed, reduce salt intake, eat more fruit, keep cholesterol levels in a healthy range, stay active and have a targeted blood pressure range recommended by the doctor
       • If you have Diabetes; Get your urine and blood tests for CKD done yearly, try and meet blood sugar targets, get your A1C test done up to 4 times a year with a minimum of 2 times a year, check your blood pressure regularly and talk to your doctor about ways to combat high blood pressure and discuss medications that are harmful to your kidneys with your doctors
       • Be proactive; quit smoking, if you are an at-risk patient, be sure to have screening tests done regularly, try to lose excess weight, find CKD early to treat it early with urine and blood tests; visit your family doctor for annual check-ups
       • Other preventative measures include receiving treatment for metabolic acidosis and avoiding nephrotoxins
     • Diabetics with CKD may require less insulin because insulin will remain in the body longer due to impaired excretion; patient's insulin dose may be lowered or hyperinsulinemia may occur
     • Diabetic patients should maintain their HGBA1C <7%
     • Manage cardiovascular issues; hypertensive patients should maintain their BP <140/90mmhg, and may require ACE inhibitors or ARBs to do so
     • Patients with hyperlipidemia should reduce the occurrence of atherosclerosis and cardiovascular events
     • Preserve existing renal function
     • Treat clinical manifestations
     • Educate patient and family. Prepare patient and family for the possibility of developing ESRD

4. Assessment

   • What Can Cause Kidney Damage? (National Kidney Foundation, 2010, Prasad-Reddy et al., 2017)
     • Risk Factors include: obesity, High blood pressure, being of African American, Hispanic, Asian pacific islander or American Indian decent, diabetes, and having a family history of CKD
     • Diabetes (#1 cause); increased sugar in the blood damages the glomeruli in the kidney's
     • High blood pressure (2nd most common cause) it makes the kidney's worker hard leading to injury
     • Kidney conditions
       • Glomerulonephritis: an infection that affects the glomeruli of the kidneys
       • Polycystic kidney disease: many cysts on the kidneys that take over its tissue and decreases its function; inherited
       • Obstructions; ex. kidney stones
     • Certain medication; bowel cleaners, NSAIDs, and contrast dyes in x-rays and scans
     • Viral infections including hepatitis C and HIV
     • Injuries such as trauma and accidents
     • Other causes; environmental exposure such as toxic chemicals, birth defects, smoking, tumors, lupus, ureter or bladder disease, obesity
     • A nephrologist determines the cause of CKD and determines the care plan for the patient (Johns et al., 2015)
   • Manifestations of CKD (Lewis et al., 2014)
     • Urinary System manifestations; anuria, oliguria and polyuria ussually occuring at night due to kidney's inability to concentrate urine
     • Metabolic manifestations
       • Waste product accumulation such as build up of nitrogenous waste causes vomiting, nausea, fatigue, lethargy, and impaired thought processes
       • Carbohydrate metabolism becomes defective due to impaired glucose use because of cellular insensitivity to normal functions of insulin. This may cause hyperglycaemia, hyperinsulinemia, and abnormal glucose tolerance tests
       • Elevated triglyceride levels due to hyperinsulinemia which stimulates hepatic production of triglycerides
       • Due to decline in serum GFR and an increase in creatinine and BUN levels
       • Dyslipidemia may occur due to decreased levels of lipoprotein lipase, and results in elevated levels of VLDLs, low levels of HDLs, and normal or decreased levels of LDLs
     • Electrolyte and Acid-Base Imbalances include; possible hypermagnesemia causing absence of reflexes, hypotension, respiratory failure, and cardiac dysrhythmias; hypernatremia due to sodium retention or hyponatremia due to water retention; metabolic acidosis due to impaired kidney excretion of acids; hyperkalemia due to drugs, dietary supplements, metabolic acidosis, cellular protein breakdown and decreased kidney excretion
     • Hematological System manifestations; Infections caused by leukocyte function changes, altered immune response, malnutrition, hypoglycemia, & external trauma (catheters, needles); Normocytic & normochromic anemia result of decreased erythropoietin production by the kidneys causing decreased erythropoiesis in bone marrow, nutritional deficiencies, decreased RBC lifespan, GI bleeds, increased hemolysis of RBCs, frequent blood sampling, blood loss from frequent hemodialysis, iron deficiency, and folic acid removal in blood
     • Cardiovascular System manifestations; Hypertension due to increased renin production, increased ECF volume & sodium retention; Chronic hypertension can lead to atherosclerotic vascular disease, infrarenal arterial spasm, left ventricular hypertrophy, renopathy, congestive heart failure, and encephalopathy; Uremic pericarditis which is manifested by friction rub, chest pain and a low-grade fever.
     • Respiratory System manifestations; kassmual's respirations, uremic pneumonia, uremic pleuritis, predisposition to respiratory infections,pleural effusion, dyspnea, and pulmonary edema
     • Gastrointestinal system manifestations include; Constipation due to ingestion of iron salts and/or phosphate binders and fluid restrictions; Inflammation of mucosa due to excessive urea can cause GI bleeding, anorexia, nausea, and vomiting,; stomatitis with exudates and ulcerations; metallic taste in the mouth, and uremic fetor. Patient at risk for weight loss & malnutrition
     • Neurological System manifestations include peripheral neuropathy occurring as the feeling of bugs crawling on legs, parathesis, CNS depression and electrolyte imbalances causeing changes consisting of nitrogenous waste build up, demyelination of nerve fibres, and axonal atrophy
     • Musculoskeletal System manifestations include; Skeletal complications such as; renal osteodystrophy, osteitis fibrosis, osteomalacia, adynamic bone disorder and mixed osteodystrophy. Also, decreased serum Vit.D due to decreased phosphorus elimination, leading to decreased calcium absorptions in the intestine
     • Integumentary System manifestations include; pruritus from calcium-phosphate deposition in the skin, dry skin, or sensory neuropathy; uremic frost due to high levels of BUN creating urea crystals on the skin's surface
     • Reproductive system manifestations
       • Males & females experience sexual dysfunction (possibly due to physical stress, adverse drug effects, physiological problems, and anemia causing fatigue and decreased libido), and infertility,
       • Females experience anovulation and menstrual changes, anorgasmy due to peripheral neuropathy, and decreased levels of estrogen, progesterone, and luteinizing hormone
       • Males experience loss of testicular consistency, impotence due to peripheral neuropathy, low sperm count, and decreased testosterone levels
     • Psychological manifestations include; depression, personality & behavioural changes, emotional lability, body image changes leading to withdrawal, and lifestyle changes

5. Evaluation (Lewis, 2014, Johns et al., 2015)

   • Patient maintains an acceptable body weight and fluid balance with dietary modifications or with peritoneal dialysis or hemodialysis
   • Patient will report having a better quality of life, decreased fatigue and improve ability to exercise/lose excess weight
   • hemoglobin, blood pressure and if applicable blood sugars will be controlled in acceptable ranges
   • Patient will have effective coping mechanism and or will be engaging in support groups or using any additional services needed. Social workers and case managers can provide/assist in finding these services.
   • Patient will adhere to medication regimen
   • Patient's will be knowledgeable about their diagnosis, their chosen treatment and will have collaborated with HCP's to create their careplan

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