Chronic Kidney Disease (CKD)

• Chronic Kidney Disease (CKD) involves irreversible kidney damage.
  • Kidney function at or below 15% indicates end-stage kidney disease.
  • Diabetes and hypertension are leading causes of CKD.
  • CKD causes changes in hormone and electrolyte levels.

Manifestations of CKD

• Increased urea and creatinine levels are observed.
  • Uremia, polyuria, oliguria, and anuria are common conditions.
    • Polyuria results from the kidneys' inability to concentrate urine.
    • Oliguria occurs as CKD worsens, defined as urine output of 400ml/day
    • Anuria is defined as a urine output of -100 ml/day.
    • Polyuria is defined as a urine production of 2l/day .
  • Waste product accumulation leads to high BUN (blood urea nitrogen) levels.
  • Elevated triglycerides result from hyperinsulinemia.
  • Hyperkalemia (high potassium) and hyponatremia (low sodium) are electrolyte imbalances.
  • Hyperphosphatemia and hypocalcemia occur due to phosphate binding with calcium.
    • Parathyroid gland stimulation can lead to brittle bones and fractures.
  • Metabolic acidosis is a common acid-base imbalance.
  • Anemia results from a lack of renin and erythropoietin.
    • CKD impairs the maintenance of blood pressure.
• Angiotensin receptor blockers are used as medication.
• Erythropoietin shots manage anemia symptoms like pale skin.
  • Be cautious with packed red blood cell units to avoid hypervolemia.

Clinical Manifestations

• Fluid overload, hypertension, heart failure, and left ventricular hypertrophy can occur.
• Peripheral edema, dysrhythmias, uremic pericarditis, and cardiac arrhythmias are noted.
• Kussmaul respiration, dyspnea, pulmonary edema, uremic pleuritis, and pleural effusion are respiratory issues.
• Stomatitis (oral ulcerations), uremic fetor, GI bleeding, anorexia, nausea, vomiting, confusion, and coma are gastrointestinal and neurological symptoms.
• Metabolic acidosis, axonal atrophy, demyelination, seizures, and dialysis encephalopathy can occur.
• Low calcium, brittle bones, bone fractures, itchy skin (pruritus), depression, withdrawal, and emotional lability are additional symptoms.
• Hypertension, shortness of breath, pulmonary edema, low oxygen saturation, low urine output, and high magnesium levels are observed.
• The effects of CKD are non-reversible.

Diagnostics

• CT scans and dipstick tests (albumin and creatinine ratio) are used for diagnosis.

Management

• Focus on fixing fluid overload and managing diet.
• Calcium supplements are administered with vitamin D to aid absorption.
• Phosphate binders are used to manage phosphate levels.
• Medications like Kayexalate are given to lower potassium.

Drug Therapy

• Weight loss, lifestyle changes, dietary recommendations, and sodium/fluid restrictions are recommended.
• Diuretics, calcium channel blockers, ACE inhibitors, and ARB agents treat hypertension.
• Calcium carbonate is used for phosphate restriction.
• Renagel lowers cholesterol.
• Phosphorus absorption is managed with calcium carbonate (Caltrate) taken with meals.
• Vitamin D aids calcium absorption, and Sensipar controls the parathyroid to prevent calcium absorption from bones.
• Erythropoietin shots, iron tablets, thiamin, multivitamins, and folic acid are needed during dialysis.
• Calcitriol aids calcium absorption.
• Epoetin alfa is used to treat anemia.
• Blood transfusions should be avoided due to fluid overload risk.
• Statins are used for dyslipidemia to lower LDL.

Complications

• Exercise caution with digitalis, antibiotics, and pain medications like Demerol and NSAIDs.
• The kidney's ability to absorb medications should be monitored.
• Water, sodium, potassium, and phosphate restrictions are necessary.
• Daily weight monitoring is crucial.
• Assess the patient's lungs and educate about medications and signs of fluid overload or hyperkalemia.
• Conservative therapy and transplantation are treatment options when conservative therapy is no longer effective.

Vascular Access

• IV fistula involves connecting a vein and an artery.
  • Arterial blood is purified and returned to the venous site.
  • Assess the site for bruit and thrill; contact the physician if absent.
• Blood pressure may be low 3-5 hours after dialysis.
• Ensure the patient's blood pressure is checked when going to the dialysis room.
• Blood loss is a risk if disconnected, requiring immediate attention.
• Dialysis catheters can be temporary or permanent (tunneled).
• IV fistulas and IV grafts connect to an artery and vein.

Dialysis

• Dialysis involves filtration of blood through a semi-permeable membrane.
  • For AVF (Arteriovenous Fistula), allow 4 months for healing.
  • Patients may need a temporary catheter while waiting for the AVF to heal.
• Dialysis is typically performed three days a week.
  • Assess BP, VS, consent, Hepatitis B status, and check for bruits/thrills.
  • Check weight, physician's orders, lab values, neurological status, and assess lung and heart sounds.
• Dialysis catheters are placed in the jugular, subclavian, or femoral vein.
• Monitor VS every 5 minutes during dialysis.
  • If BP drops, return the blood and stop the process. Albumin is administered for BP drops during dialysis, not normal saline (except to wash the blood); if the patient crashes albumin needs to be administered.
• Blood loss is managed with normal saline.
• Administer antibiotics after dialysis to prevent them from being washed out.

Complications of Dialysis

• Hypotension, muscle cramps, and blood loss are potential complications.
  • Reducing the amount of fluid removal can mitigate these issues.

This lesson covers Chronic Kidney Disease (CKD), including end-stage kidney disease, common causes like diabetes and hypertension, and hormonal and electrolyte changes. It also discusses manifestations such as increased urea and creatinine levels, uremia, and altered urine production (polyuria, oliguria, anuria). Waste product accumulation, electrolyte imbalances and other complications are also discussed.