Chronic Kidney Disease (CKD) Overview

• Chronic Kidney Disease (CKD) involves the progressive, irreversible loss of kidney function.
• Precursors to CKD include pathological abnormalities and pharmaceuticals.
• Albumin excretion of ≥30mg per day is indicative of CKD.
• A Glomerular Filtration Rate (GFR) of <60mL/min/1.73m indicates CKD.
• The conditions defining CKD must persist for at least three months.
• Up to 80% of GFR may be lost while the body exhibits few functional changes.
• CKD often involves multiple organs and is progressive.
• Symptoms of CKD should be assessed from a systems approach.
• Assessments for CKD should account for comorbidities (like diabetes), complications (such as neuropathy), and patient-specific risk factors (like pneumonia or DVT).
• Assessments of CKD should weigh the benefits and negative implications of medications and lab/DI studies.

Stages of CKD

• Stage 1: Normal kidney function has a GFR >90, usually no symptoms beyond possible hypertension.
• Stage 1 Interventions: Healthy diet and exercise, healthy lifestyle practices (smoke cessation, glycemic control), and comorbid condition management.
• Stage 2: Mild damage is indicated by a GFR of 60-89, subtle symptoms may include hypertension and increasing serum creatinine/urea
• Stage 2 Interventions: focus on risk factor reduction, the use of antihypertensives, and lipid-lowering medications.
• Stage 3: Moderate damage with a GFR of 30-59 requires you to follow the same interventions as stage 2.
• Stage 4: Severe damage is determined by a GFR of 15-29, possible symptoms; salt/water retention, electrolyte abnormalities, hypertension, elevated cholesterol, hyperkalemia, erythropoietin deficiency/anemia or iron deficiency anemia, and potential metabolic acidosis.
• Stage 4 Interventions: Restrict fluids/proteins/electrolytes, antihypertensives, lipid-lowering medications, drug therapy for hyperkalemia, erythropoietin-stimulating agents, iron supplements, phosphate binders, and Vitamin D and sodium bicarbonate.
• Stage 5: End-stage kidney failure defined by GFR <15 Interventions: dialysis, kidney transplant and or conservative kidney management.

Nursing Management Planning:

• Goals: demonstrate and carry out therapeutic goals, participate in decision-making, demonstrate effective coping strategies, continue activities of daily living within psychological limitations

Nursing Management Implementation:

• Need to Implement these considerations: acute intervention, thorough and systematic head-to-toe assessments, daily weight, monitor intake and output, monitor vital sign trends (especially BP), identify signs and symptoms of fluid overload/hyperkalemia, strict dietary adherence, medication education, encourage mobility and strength, motivate management of the disease.

Goals of Treatment by Progression:

• Prevention: healthy diet and lifestyle, management of co-morbid conditions (hypertension, elevated cholesterol, glycemic control).
• Slow disease progression: restrict fluids, proteins, and electrolytes; check daily weight; lipid-lowering medication, antihypertensives, drugs to correct hyperkalemia, erythropoietin-stimulating agents, phosphate inhibitors, vitamin D, and sodium bicarbonate.
• End-stage Failure Options: dialysis, kidney transplant, conservative kidney management.

Renal Diet Recommendations:

• Protein: =< 0.8g/kg/day, increase plant sources.
• Potassium: Individualize to maintain K within the normal range.
• Calcium: 1.5 g/day from dietary + medication sources.
• Phosphorus: 0.8-1g/day or individualize, increase vegetable sources and reduce processed foods.
• Carbohydrate/fat: 30-35 kcal/kg/day, <30% total calories from fat and <10% from sat fat, follow DASH diet patterns.
• Fiber: 25-38 g/day

Medication for Dyslipidemia

• Statins: use for mild-severe kidney impairment, reduces LDL cholesterol, and lowers atherosclerosis risk

Medication for Hypertension

• Types: Diuretics, ACE inhibitors, ARB agents, Calcium channel blockers

Medication for Hyperkalemia:

• Shift Potassium into Cells: IV insulin (administer w/ glucose to control hypoglycemia), Albuterol (Ventolin), Sodium bicarb.
• Enhance Potassium Removal: Polystyrene sulfonate (Kayexalate), Loop diuretic, Dialysis.
• Stabilize Myocardium: Calcium Gluconate IV.

Mechanisms of Chronic Kidney Disease (Mineral and Bone)

• Kidney failure causes a decrease in GFR, decreased PO4 excretion, decreased activation of Vitamin D and vascular/soft tissue calcifications.
• Decreased activation of Vit D leads to an impaired absorption of Ca from the gut.
• Osteitis fibrosa and osteomalacia (bone demineralization) can result because decreased serum Ca increases PTH.

Drug Therapy (Mineral and Bone Disease)

• Phosphate binders: Calcium Carbonate (Tums, Caltrate), Sevelamer hydrochloride (Renagel)
• Administer phosphate binders with each meal to decrease the amount of phosphate absorbed.
• Side Effect: Constipation
• Contraindications: Do not administer w/ iron supplements to allow for effective medication absorption

Vitamin D Therapy:

• Calcitriol (Rocaltrol) can be administered so long as serum phosphate levels are lowered prior to administering Ca or Vitamin D.

Pharmaceutical Interventions for Anemia

• Erythropoietin-Stimulating Agents: Epoetin alfa (Epogen, Procrit) can be administered subcutaneously or intravenously.
• Check hemoglobin (Hgb) and hematocrit (HCT) in 2–3 weeks
• Consderations: May cause hypertension (increased cardiovascular effects w/ increased Hgb)

Iron Supplements:

• Indicated for transferrin saturation <=20% and/or serum ferritin is <=100ng/mL
• Oral is the most common route, but includes side effects -> gastric irritation
• Do not take at the same time as phosphate binders
• Intravenous can quickly correct anemia or severe anemia (faster resolution)
• Side Effects: can cause allergic/infusion reactions

Pharmaceutical Interventions for Metabolic Acidosis:

• Administer Sodium Bicarbonate in chronic CKD
• Route: Administered orally for CKD
• Monitoring: Perform the right assessment (volume status) and consider how sodium bicarbonate contributes to increased volume.

Drug Toxicity

• Avoid Oral hypoglycemics (metformin, glyburide), Contrast dye, Aminoglycosides (antibiotics) Opioids (hydromorphone, morphine), NSAIDS, Digoxin with caution.

End-stage Kidney Failure Options:

• Kidney transplant: offers best quality of life.
• Dialysis: Hemodialysis and Peritoneal Dialysis can be used
• Conservative approach: end-of-life approach.

Medication and verification:

• Always verify safe dose in kidney disease through monograph guidelines.

Kidney Transplant:

• Is the preferred treatment for end-stage kidney disease becaus it has a better quality of life and reduces mortality rate, compared to maintenance dialysis.
• Post-Operative Priorities: hemodynamic stability, sings and symptoms of bleeding, kidney function tests, infection prevention and surveillance.
• Patient Education: importance of taking immunosuppressants, signs and symptoms of rejection, monitor for infection, lifestyle precautions (avoid infectious people), monitor malignancies/cardiovascular diseases

Indications for Dialysis:

• Uremic encephalopathy, pericarditis, life-threatening hyperkalemia, refractory acidosis, hypervolemia causing end-organ complications (pulmonary edema), failure to thrive/malnutrition, peripheral neuropathy, intractable gastrointestinal symptoms, asymptomatic patients (with a GFR of 5–9 mL/min/1.73 m²), some toxic ingestions

Hemodialysis v Peritoneal Dialysis:

• Hemodialysis: you can not take blood pressure readings, use needles, or do blood draws in the same arm.
• Dialysis and nursing involve specialized clinical competencies needing certification.

Post-Dialysis Nursing Priorities:

• Hemodialysis: vitals, head-to-toe assessments are needed, it is important to note that Students are not to interact with the fistula, but it can be inspected without access or touching.
• Peritoneal Dialysis: vitals, head-to-toe with GI, assess for abdominal pain/swelling, or pressure; and constipation (affects catheter).

Drug therapy for hyperparathyroidism:

• Calcimimetic agents such as Cinacalcet (Sensipar)

Postoperative Interventions (Parathyroidectomy):

• Monitor hemodynamic stability, incision line (dressing intact), site/surrounding area for signs/symptoms of bleeding, swelling, hematoma, provide clarification for food/drink orders, monitor lytes/CBC/serum calcium.

Conservative Management (End of Life):

• Palliative care as means to continue or discontinue the treatment to meet their needs
• Interventions: consider symptoms, use nutrition and hydration, encourage gentle exercise when the individual can, optimize sleep and recognize conservation strategies
• Pruritus: topical treatments are used in the instance of gabapentin to improve patients comfort
• Pain: Palliative strategy to improve pain while receiving dialysis
• Dyspnea: correct fluids can gentle air, diuretics may need to be adjusted
• Nausea and Vomiting: change portion sizes, and avoiding certain foods that will offset treatment. Haloperidol and metoclopramide may be prescribed.

Nursing Management Evaluation:

• Assess maintenance of ideal body weight, acceptance with chronic disease, determine if there is infection/edema, and maintain hematocrit, hemoglobin, in balance of serum levels.