Fluid & Electrolytes Fall 2024 Student Copy PDF

Fluid & Electrolytes Exemplar: Chronic kidney disease Fall 2024 Rebecca Jones MN, RN, GNC(C) Objectives Demonstrate an understanding of the definition of Chronic Kidney Disease (CKD) Demonstrate an understanding of the classification of CKD Discuss the risk factors, both non-modif...

Fluid & Electrolytes Exemplar: Chronic kidney disease Fall 2024 Rebecca Jones MN, RN, GNC(C) Objectives Demonstrate an understanding of the definition of Chronic Kidney Disease (CKD) Demonstrate an understanding of the classification of CKD Discuss the risk factors, both non-modifiable and modifiable, for CKD Identify early detection and evaluation methods for CKD Describe the management approach for patients with CKD Kidneys…anatomy review! We are born with two kidneys – they are a vital organ in the body! They are our body’s natural filter Shaped like kidney beans and about 11-14cm long (around size of a fist) Located deep in our abdomen, just below rib cage closer to our spine Very well vascularized and receive about 25% of our cardiac output at rest What are the functions of the kidneys? Anatomy Review The renal cortex, renal medulla, and renal pelvis are the three main internal regions found in a kidney Renal Capsule – Thin membranous sheath that covers the outer surface of each kidney. Helps hold shape and protect vital underlying tissue Renal Cortex – Filtration of blood occurs here – Produces erythropoietin (stimulates RBC production) Renal Medulla – Contains the majority of the length of nephrons, the main functional component of the kidney that filters fluid from blood Renal Pelvis – Contains the hilium - the concave part of the bean-shape – Blood vessels, ureters and nerves enter and exit the kidney Ureters – The urine-bearing tubes that exit the kidney and empty into the urinary bladder Anatomy Review Nephron – Functional unit of the kidney – these actually produce the urine – Contains microscopic filters called glomeruli that are constantly filtering blood. Located extending from the cortex to the medulla – Glomeruli (glomerulus) - tuft of capillaries where waste products are filtered Afferent arteriole – A branch of the renal artery – Deliver blood to the glomerulus Efferent arterioles – Carry away blood from glomerulus back to rest of kidneys and renal vein for circulation Flow of blood through the kidney Kidneys are amazing! They receive over 1L of blood each minute and eliminate about 1.5 L of urine per day efficiently getting rid of excess waste products and water We eliminate water soluble waste products in urine (e.g. urea, sodium & potassium) 1. Oxygenated blood flows into kidney glomerular filtration 2. Tubular reabsorption - filtered fluid flows through the renal tubule - most water & important solutes absorbed by cells (tubule) into the blood 3. Tubular secretion - cells along the tubule secrete additional wastes- e.g. drugs into the fluid, excessive electrolytes 4. Fluid drains into the renal pelvis & is excreted as urine via ureter Glomerular Filtration Rate (GFR) GFR is a measure of how well your kidneys filters blood and determines the extent/stage of kidney disease Oxygenated blood enters kidney through renal artery Enters tiny clumps of arterioles called glomeruli where it is filtered Filtrate (filtered material) then goes to the renal tubule to ureter to bladder The rate this happens if the GFR (how much blood passes through kidneys in one minute) What is the normal GFR for a healthy individual? Creatinine (serum) Creatinine – Males - 53-106 mmol/L – Females - 44-97 mmol/L A waste product of creatine phosphate. Byproduct of protein breakdown (mostly skeletal muscle). Normally filtered by kidneys to urine If there is an issue with kidneys, creatinine will build up in blood Excellent evaluator of renal dysfunction We use this to estimate GFR (eGFR) Discussion Point: Kidneys release 3 important hormones…do we know what they are? Chronic Kidney Disease (CKD) Chronic kidney disease (CKD) involves the progressive, irreversible loss of kidney function Can develop rapidly for some, over years for others – What is considered acute? – What is considered chronic? Failure can progress to the point where the kidney can’t filter nitrogenous waste and fluid and electrolytes leading to fluid and electrolyte and acid- base imbalance The final stage of CKD is known as End Stage Renal Disease (ESRD) Chronic Kidney Disease in Canada Around 2 million Canadians are estimated to have CKD The leading causes of End-Stage Renal Disease (ESRD) in Canada are diabetes and hypertension Major public health problem Prevalence of ESRD is about twice as common among Indigenous people than non-Indigenous people – In Canada, a disproportionate rise in the rate of ESRD has occurred in the Indigenous population Increasing prevalence ~ one reason is growing elderly population CKD is a major risk factor for death and cardiovascular-related morbidity Substantial burden on the Canadian Health Care System for dialysis – Hemodialysis costs ~$60,000 per pt/yr Chronic Kidney Disease (CKD) Kidneys have a remarkable reserve. Up to 80% of the glomerular filtration rate (GFR) may be lost with minimal changes of functioning in the body A person is born with 2 000 000 nephrons and can survive without dialysis until almost 90% of nephrons are lost For this reason, individuals often remain asymptomatic in early CKD because remaining nephrons over compensate CKD Glomerular filtration rate (GFR) – 3 , this is considered a positive criterion for CKD as well Risk Factors What are some risk factors for CKD? Clinical Manifestations How is our patient going to present? Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 CKD Onset and progression of CKD depend on the occurrence of both: Modifiable risk factors – Obesity, smoking, poorly controlled hypertension or diabetes, diet Non-modifiable risk factors – Age, gender, race, genetics Early intervention is critical to restore normal kidney function! The two main causes of CKD are… 1. ? 2. ? Uremia Uremia - a serious complication of both CKD and AKI Occurs when urea (and other waste products) build up as kidneys are unable to (or slower to) to eliminate them. Prolonged or severe fluid buildup (edema) may make the uremic syndrome worse Urea in high levels is toxic Symptoms to be aware of: – Nausea, vomiting, loss of appetite, and weight loss – Changes in mental status, such as confusion, reduced awareness, agitation, psychosis, seizures, and coma – Abnormal bleeding, such as bleeding spontaneously or profusely from a very minor injury – Heart problems, such as an irregular heartbeat, inflammation in the sac that surrounds the heart (pericarditis), and increased pressure on the heart – Shortness of breath from fluid buildup in the space between the lungs and the chest wall (pleural effusion) Once uremia raises to dangerous levels, the only way to remove it in ESRD is dialysis Note: Uremic pruitis is something we see often in patients. Build up of uremia causes an itch (only relieved with decrease of uremia) – Medications like hydroxyzine can help Activity How does CKD affect the following lab values (high and low)? Sodium Potassium Calcium Phosphorus Magnesium Albumin Creatinine CBC pH CKD – Diagnostics Adverse outcomes of CKD can often be prevented or delayed through early detection and treatment – History and physical examination – Dipstick evaluation – Albumin–creatinine ratio (first morning void) – GFR Renal ultrasound CT scan Renal biopsy CKD – Checklist – Diabetes Canada SCREEN with random urine albumin creatinine ratio (ACR) and serum creatinine for estimated glomerular filtration rate (eGFR) DIAGNOSE with repeat confirmed ACR ≥2.0 mg/mmol and/or eGFR