Chronic Renal Disorders and Kidney Transplants

Chronic Renal Disorders

• Chronic Kidney Disease (CKD) and Kidney Transplants are discussed

Chronic Renal Disease Risk Factors

• Risk factors include chemical/environmental toxin exposure, low birth weight, high-sodium diet and heart failure
• Contact sports/trauma, medications, hypertension, frequent urinary tract infections, and family history of renal disease are risk factors
• Race is a risk factor due to increased rates of diabetes mellitus (DM) and hypertension (HTN)

Chronic Kidney Disease

• CKD involves progressive loss and ongoing deterioration of kidney function
• Characterized by a glomerular filtration rate (GFR) of less than 60 mL/minute for at least 3 months
• Progression is based on the degree of proteinuria
• CKD is irreversible, resulting in uremia or end-stage kidney disease (ESKD)
• Dialysis or kidney transplantation are required to maintain life

Classification of CKD Stages

• A GFR less than 60 for 3 months or more indicates chronic kidney disease
• Stage 1: Normal or increased GFR ≥ 90 mL/min per 1.73 m2, with kidney damage
• Stage 2: Mildly decreased GFR 60-89 mL/min per 1.73m2, with kidney damage
• Stage 3: Moderately decreased GFR 30-59 mL/min per 1.73m2
• Stage 4: Severely decreased GFR 15-29 mL/min per 1.73 m2
• Stage 5: Kidney failure GFR < 15mL/min per 1.73 m2
• No symptoms occur in early stages, even with slow decline
• GFR starts to decline at Stage 3 even though damage is starting in earlier stages

CKD Associated Labs and Clinical Manifestations

• As GFR declines, plasma creatinine increases to maintain a constant excretion rate
• When GFR decreases to 25%, there is an obligatory loss of 20-40 mEq of sodium per day with osmotic water loss
• Kidneys lose their ability to regulate sodium and water balance causing retention, leading to edema and hypertension
• Total body potassium can increase to life-threatening levels, requiring dialysis
• Urea, creatinine, potassium, and sodium are elevated
• Phosphate is elevated, while calcium, bicarbonate, and pH are decreased
• Creatinine is a late marker of kidney injury used in clinical settings

Calcium, Phosphate, Bone, Protein and Albumin in CKD

• Changes begin when GFR decreases to 25% or less
• Hypocalcemia is accelerated by impaired renal synthesis
• Renal excretion of phosphate decreases, increasing serum phosphate and binding calcium, further contributing to hypocalcemia
• Acidosis contributes to a negative calcium balance
• Decreased serum calcium stimulates parathyroid hormone to mobilize calcium from bone
• There is an increased risk of fractures
• Monitor protein and albumin excretion and measure the urine protein- or albumin-to-creatinine ratio every few months using a first-morning void

CKD Neurological Manifestations

• Neurological manifestations include asterixis,(tremor of the hand when the wrist is extended) ataxia (alteration in gait), and coma
• Inability to concentrate or decreased attention span, myoclonus(involuntary twitching of a muscle),and paresthesias (sensation of tingling, tickling burning) can occur
• Seizures and slurred speech

CKD Cardiovascular Manifestations

• Cardiovascular manifestations include cardiac tamponade, cardiomyopathy and heart failure
• Additional manifestations include stroke, pericarditis, hypertension and pericardial effusion
• Peripheral edema, dyslipidemia, ischemic heart disease, and sudden cardiac death are mainfestations

CKD Respiratory Manifestations

• Respiratory manifestations include crackles (pulmonary edema), deep sighing/yawning and depressed cough reflex
• Additional manifestations are Kussmaul's respirations, pulmonary hypertension, pleural effusion and shortness of breath in response to pulmonary edema, Tachypnea- required to improve gas exchange and "uremic breath" .

CKD Gastrointestinal and Immune Manifestations

• GI manifestations: Anorexia, changes in taste acuity/sensation and constipation
• Other include uremic gastroenteritis, nausea, vomiting, GI bleeding, and diarrhea
• A suppressed immune system including phagocytosis, antibody/cell-mediated immune responses, and deficient responses to vaccinations
• Increases risk for infection
• Risk of virus associated cancers (EBV, HPV, Hep B & C) as well as malnutrition, metabolic acidosis and Hyperglycemia due to Immunosuppression

CKD Clinical Manifestations

• Clinical manifestations include decreased skin turgor, dry skin, ecchymosis, pruritus, purpura, and yellow-gray pallor
• Bone pain, muscle weakness/cramping, and pathological fractures
• Manifestations affecting renal function are urine that is diluted/straw-colored, hematuria, oliguria(later), and polyuria(early)
• Reproductive includes : Decreased fertility/libido, impotence, and frequent or absent menses

Hemodialysis

• Cleanses the blood of accumulated waste products
• Removes by-products of protein metabolism, such as ammonia, urea, creatinine, and uric acid
• It removes excess body fluids and corrects electrolyte levels but does not replace hormones
• Assess a person with an arteriovenous fistula for BP and a thrill

Hemodialysis Complications

• Disequilibrium syndrome occurs due to removal of urea, leading to greater concentration in the brain, with manifestation like headaches/nausea/vomiting
• Cerebral Edema due to Disequilibrium syndrome, confusion, decr LOC, twitching and convulsions
• Hypotension related to rate and amount of fluid removed and can cause transfusion reactions/shock
• Transfusion, dysrhythmias(due to hypotension, fluid overload, or rapid potassium removal), sepsis, transfusion, dysrhythmias and psychological problems

Peritoneal Dialysis

• Peritoneal dialysis involves diffusion of fluid and solutes from the bloodstream through the peritoneum into the dialysate solution, peritoneum acts as natural filter with high access for blood supply(capillaries)
• Dialysis is a movement of solutes accomplished through osmosis
• Peritonitis and Abdominal pain as well as Bladder or bowel perforation
• Monitoring for the presents of Insertion site infection such as PEG tubes and fever, nausea and cloudy fluid outflow is imperative!

Kidney Transplants

• A human kidney from a compatible donor is placed into the iliac fossa of a recipient
• Anastomosis of the Kidney to the bladder by the ureter
• Performed for irreversible kidney failure, eligibility is established by specific criteria
• Living donors have extensive screenings for two working kidneys and an emotional determination of the donation
• Complete understanding of donation process and outcomes is essential
• Cadaver donors must meet the institution’s criteria of brain death
• The kidney Usually younger than 70 years and has normal renal function
• Contraindications: Presence of malignant outside the CNS and presence of generalized communicable infection are contraindications
• Donors are screened for ABO blood group, tissue-specific antigen,(HLA)human leukocyte antigen, and mixed lymphocyte culture index

Kidney Transplantation Rejection

• Acute rejection is the most common type, occurring within 6 weeks postoperatively
• acute rejection is potentially reversible with increased immunosuppression and can be treated early, high doses of corticosteroids
• Chronic rejection occurs slowly, months to years after transplant, and mimics CKD
• The interventions-immunosuppressive medications and re-transplantation if necessary
• The rate is Between 85-95% of kidney transplants successful after 1 year
• Manifestations of graft : Temperature > 37.7 °C and pain or tenderness Other manifests can include 2-3 lb weight gain in 24 hours, Edema, Hypertension , Malaise and ELEVATED blood urea and serum Creatinine
• Decreased creatinine clearance and elevated white blood cell count as well as Rejection indicated by ultrasound or biopsy

Digestive System - Celiac

• Gl Tract: GI Pathology, Aging, Celiac, Ulcerative Colitis, IBD, Chrons, IBS, Pancreatitis, Hepatitis, Cirrhosis, Esophageal Varacies, Hepatorenal, Transplants
• GI Tract: Pathologies -Muscular tube - problems with muscles-Innervation include: Obstruction, Defiecint/digestive/Absorption -Any of 4 regions of GI tracts include: Blood abnormalities/Ischemia and inflamation. -Esophagus/Gastristis/Colitis/Crohns/Tumors -Regions Specific inclue: Esophahus and stomach and small intertine malabsorption can cause disfunction, Water reabsorbtion

Aging and the Digestive System

• Aging decreases protection of Gl tract- Causes dysphagia as well as descreased:Saliva production/smell and taste, decreased peristalsis and digestive enzymes and liver function

Liver Transplant

• *Adults- Autoimmune and PBC and Liver Cancer • *Children- Biliaray Arteisa +Failaure B • *Liver failure

• To be a Live liver duonar needs to to be free of Drigs and alcohol for 6 month and young for good health

Obesity

• Based on: BMI and Weight. Classifiess: >40%
• Environmentally from, Food choices and genetics
• Measure both BMI+waist Circumferance
• Metabolic abnormalities are Cushing: Polycystic ovarian

Hepatitis

Viral hepatitis can affect the liver functions

• Viral Replication B/C
• The viral load replicates
• Hepatic Damage
• inflammation
• HPC
• Cirrosish and necrosis

Risk for Obesity

• Genotype, Family environment
• Culture and Social Food intake, and physical inactivity

Clinical Practice Guidelines to Care

1. Recognize with chronic diseases the nurse should 2)Asses individuals with obseity
2. Talk about treatment plans

• Nutrition
• Therapy
• Psychological -Pharm

4. There should be a goal of therapy
5. Fallow up are importment

Leptin and Ghrelin

Leptin is released and causes the feeling of fullness and body weight.

• Low level will not suppress appetite.
• Ghrelin: Stimulates appetite and causes the body to hold onto calories Leptin causes weight gain and suppresses that.

Clinical: Glutin/Sensive Anermia

• Celiacs disease affects villi in small intestines.
• This interferes with your body absorbing the necessary nutrition
• Damage to epithelium, malabsorption and malnutrition
• Glycoproteins in gluten(gliadin]antigens that lead to inflammatory, autoimmune response
• Can develop at anytime, and often diagnosed in children; can be at any age to be discovered
• There is genetic+environmental factor involved
• This presents w auto immune diseases.

Ulcerative Colitis vs Chrohs

• Genetics/family and Northern and AJ origin •UC: the limit to Mucosal
• UC. The colon can spread, has higher death causes due to this and stress factors into UC, higher chance, and increase for cancers Uc = mucosa limit

Irratable Bowl Syndrome

• Involves: stress, foods and hormones
• Doesnt have a specific maker

Chronic Pancreatitis:

• Causes continuous inflammation and obstructios. Can obstruct. With protien precip
• Cancer can contribute to this and biliary can cause death as potential cause
• Diagnosies Elevated and treat life
• Elevate: Elevated -Serum Elevated pancreatic enzymes/lipase and CT or life style changes
• Treatment is a life style change.