Chronic Kidney Disease

• Chronic kidney disease (CKD) means irreversible kidney damage.
  • A glomerular filtration rate (GFR) of less than 15 indicates end-stage kidney disease, with only 15% kidney function.
  • Leading causes of CKD include diabetes and hypertension.
  • Clinical manifestations involve changes in hormones and electrolytes.

Waste Accumulation

• Increased urea and creatinine levels.
• Uremia occurs.
• Polyuria results from the kidneys' inability to concentrate urine.
  • Oliguria develops as CKD worsens.
  • Anuria is urine output of ≤100 ml/day.
  • Oliguria is urine output of 400ml/day.
  • Polyuria is urine output of 2L/day.
• High blood urea nitrogen (BUN) due to waste product accumulation.
• Elevated triglycerides: hyperinsulinemia.
• Hyperkalemia (high potassium) and hyponatremia (low sodium).
• Hyperphosphatemia and hypocalcemia.
  • Phosphate binds to calcium, stimulating the parathyroid gland.
  • This leads to brittle bones and easy fractures.
• Metabolic acidosis.
• Anemia results from a lack of renin and erythropoietin due to chronic disease, impairing blood pressure maintenance.

Medications and Treatments

• Angiotensin receptor blockers (ARBs).
• Erythropoietin shots address anemia symptoms: paper-white skin color.
  • Caution must be taken when administering one unit of packed red blood cells due to the risk of hypervolemia.
  • If crackles and shortness of breath occur, administer before dialysis.
• IV contrast for chronic kidney disease patients should be given just before dialysis due to risk of infection.

Clinical Manifestations

• Fluid overload, hypertension, heart failure, left ventricular hypertrophy, peripheral edema, dysrhythmias, uremic pericarditis, cardiac arrhythmias, Kussmaul respiration, dyspnea, pulmonary edema, uremic pleuritis, pleural effusion, stomatitis (oral ulcerations), uremic fetor, GI bleeding, anorexia, confusion, coma, nausea, vomiting, metabolic acidosis, axonal atrophy, demyelination, seizures, dialysis encephalopathy.
• Low calcium stimulates the parathyroid hormone, causing calcium to be drawn from bones, leading to brittle bones and fractures.
• Pruritus (itchy skin), depression, withdrawal, emotional lability, hypertension, shortness of breath, pulmonary edema, low oxygen saturation, low and concentrated urine output, and high magnesium levels.
• CKD is not reversible.

Diagnostic Tests

• CT scan.
• Urine dipstick for albumin and creatinine ratio.

Management

• Correct fluid overload.
• Manage diet.
• Administer calcium, which requires vitamin D for absorption.
• Administer phosphate binders.
• Lower potassium levels.

Drug Therapies

• Kayexalate is used for high potassium levels due to kidney damage.

Hypertension Management

• Weight loss, lifestyle changes, dietary recommendations, and sodium and fluid restrictions.
• Antihypertensive drugs: diuretics, calcium channel blockers, ACE inhibitors, ARB agents.
• Phosphate restriction along with calcium carbonate to bind phosphate.
• Renagel is used to lower cholesterol.
• Calcium carbonate (Caltrate) is taken with meals to bind phosphorus in the stomach and small intestines, preventing absorption.
• Vitamin D is needed for calcium absorption.
• Sensipar controls the parathyroid hormone to prevent calcium absorption from bones.
• Erythropoietin shots are needed during dialysis for anemia.
• Iron tablets, thiamin, multivitamins, and folic acid are needed, as dialysis washes them out.
• Calcitriol helps with hypertension.
• Epoetin alfa is used for anemia.
• Blood transfusions should be avoided to prevent fluid overload, only done before dialysis in emergencies.
• Statins are for dyslipidemia to lower LDL.
• Complications arise from digitalis, antibiotics, and pain medication (Demerol, NSAIDs).
  • Careful medication administration is needed, checking kidney function in absorbing medications.
• Water, sodium, potassium, and phosphate restrictions.
• Nursing management includes daily weight monitoring, assessing lung sounds, renal diet, medication education, and awareness of fluid overload or hyperkalemia signs.
• Conservative therapy fails, transplantation is considered.

IV Fistula

• Connects an artery to a vein.
• Blood from the artery flows quickly to be purified and returned via the venous site.
• Assessment involves checking the site, listening for a bruit, and feeling for a thrill. If absent, the physician must be called.
• Blood pressure will be low 3-5 hours post-dialysis.
• Check blood pressure before the patient goes to the dialysis room. Blood loss requires clamping the site first if disconnected.
• Dialysis catheters can be temporary or permanent (tunneled).
  • IV fistulas and IV grafts connect to an artery and vein.
• Dialysis filters blood through a semi-permeable membrane.
• For acute kidney disease (AKD), an IV fistula needs 4 months to heal; a temporary catheter is needed.
• Dialysis occurs 3 days a week, assessing BP, VS, consent, Hepatitis B status, listening for bruits, feeling for thrills, checking weight, orders, lab values, neurological status, and assessing 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 dialysis.
• Albumin 50 ml is given for BP drops during dialysis, not normal saline (used only to wash the blood); if the patient crashes, administer albumin.
• Normal saline is used for blood loss.
• Administer antibiotics after dialysis to prevent them from being washed out.

Complications

• Hypotension, muscle cramps, and blood loss.
• Reduce the amount of fluid removal.

This lesson discusses chronic kidney disease (CKD), which involves irreversible kidney damage. Topics covered include glomerular filtration rate (GFR), leading causes such as diabetes and hypertension, and clinical manifestations involving hormonal and electrolyte changes. Waste accumulation, polyuria, oliguria, and electrolyte imbalances are also discussed.