Chronic Kidney Disease PDF

CHRONIC KIDNEY DISEASE CHRONIC KIDNEY DISEASE (CKD) Progressive, irreversible loss of kidney function Presence of kidney damage OR a decreased GFR less than 60 mL/1.73 m2 for 3 months + Diabetes and HTN Gradual destruction in nephrons results in the kidneys’ inability to: Filter blood Concentrate ur...

CHRONIC KIDNEY DISEASE CHRONIC KIDNEY DISEASE (CKD) Progressive, irreversible loss of kidney function Presence of kidney damage OR a decreased GFR less than 60 mL/1.73 m2 for 3 months + Diabetes and HTN Gradual destruction in nephrons results in the kidneys’ inability to: Filter blood Concentrate urine Eliminate wastes from the body STAGES OF CHRONIC KIDNEY DISEASE Stage 1 Kidney damage, Normal (90-120) GFR Stage 2 Kidney damage, GFR- 60-89 Stage 3a/b Kidney damage, GFR 45-59 Kidney damage, GFR 30-44 Stage 4 Kidney damage, GFR 15-29 Stage 5 Kidney failure, GFR less than 15 CLINICAL MANIFESTATIONS Uremia develops causing every body system to become affected (fig 46.2) Urinary system Metabolic disturbances Electrolyte and acid-base imbalances Hematologic system Cardiovascular system Respiratory system Gastrointestinal system Neurologic system Musculoskeletal system Integumentary system Reproductive system Psychological changes CKD Sodium and water balance HTN Potassium balance Increased vascular volume Elimination of nitrogenous wastes Erythropoietin production Hyperkalemia Pulmonar y edema Lethal arrythmias Acid-base balance Activation of vitamin D Anemia Hypocalcemia Phosphate elimination Hyperphosphate mia Skeletal buffering Uremia Edema Acidosis Heart failure Gastrointestinal manifestations Neurologic manifestations Hyperparathyroidism Osteodystrophy CLINICAL MANIFESTATIONS Urinary System Polyuria  Oliguria  Anuria Results from inability of kidneys to concentrate urine, occurs most often at night Need diuretics, occurs as CKD worsens In ESRD requires dialysis Metabolic Disturbances Waste production accumulation GFR ↓ BUN and serum creatinine levels ↑ Altered carbohydrate metabolism Impaired glucose metabolism Electrolyte and Acid-Base Imbalance Potassium Monitor food, dietary supplements, medications and IV fluids (for potassium) Sodium Sodium retention can lead to edema, HF, HTN Restrict to 2g/day Calcium and Phosphorous ↓calcium r/t impaired vitamin D synthesis ↑phosphorus r/t decreased phosphorous elimination Magnesium Hypermagnesemia Metabolic Acidosis Kidneys cannot excrete acid and defective reabsorption/regeneration of bicarbonate Respiratory System Severe acidosis Dyspnea, also Kussmaul respirations Gastrointestinal System Stomatitis- rare Metallic taste and uremic Breath N/V Anorexia Constipation Neurologic Changes occur as failure progresses Lethargy/Fatigue Confusion Irritability Peripheral neuropathy Asterixis Nocturnal leg cramping Seizure/coma Hematologic Anemia Bleeding tendencies Infection Cardiovascular HTN and Diabetes contributing factors Cardiac dysrhythmias from hyperkalemia and decreased perfusion Dyslipidemia or hyperlipidemia contribute to CAD Musculoskeletal CKD MBD (mineral and bone disorder) Bone portion called renal osteodystrophy Integumentary Pruritis Reproductive Infertility and decreased libido Psychologic Behavioral changes Emotional changes Withdrawal and depression Changes in body image may lead to anxiety and depression Edema Integumentary disturbances Access devices for dialysis DIAGNOSTIC GFR Consistently elevated serum creatinine Decreased creatinine clearance Persistent presence of albuminuria (dipstick test) Urinalysis to detect WBCs, RBCs, protein Renal ultrasound – to detect obstruction and size of kidneys Renal biopsy INTERPROFESSIONAL CARE Goals Preserve kidney function Reduce the risk of cardiovascular disease Prevent complications Ensure patient comfort INTERPROFESSIONAL CARE Drug therapy Hyperkalemia- Potassium binding agents Sodium polystyrene sulfonate (Kayexalate) Patiromer (Veltessa) Sodium zirconium cyclosilicate (Lokelma) Acute Hyperkalemia IV glucose and insulin OR IV calcium gluconate INTERPROFESSIONAL CARE Hypertension Target BP should be less than 130/80 mm Hg Weight reduction, lifestyle changes, diet recommendations Diuretics Antihypertensive drugs (frequently two or more) ACE inhibitors and angiotensin receptor blocker (most common) Anemia (Hgb, TSAT, Ferritin) Need for ESA – Epogen, Procrit, Retacrit (epoetin alfa), Aranesp (darbepoetin alfa) Iron deficiency- Venofer (iron sucrose), Ferrlecit (ferrous gluconate) Also used: Folic acid supplements INTERPROFESSIONAL CARE Dyslipidemia Statins Complications of medications Many drugs are partially or totally excreted by kidneys Examples: opioids, antibiotics, diabetic agents INTERPROFESSIONAL CARE Nutritional Therapy Protein restriction Fluid restriction Sodium and Potassium restriction Depends on degree of edema and hypertension Sodium 2-4 g/day Potassium restriction depends on the kidneys’ ability to excrete potassium Limit to 2-3 g/day; avoid high potassium foods INTERPROFESSIONAL CARE CKD Mineral Bone Disorder Limit dietary phosphorus (Restrict to less than 1000mg/day if patient requires RRT) Administer phosphate binders with meals (calcium carbonate) Lanthanum carbonate (Fosrenol) Sevelamer carbonate (Renvela) Sucroferric oxyhydroxide (Velphoro) Ferric citrate (Auryxia) Supplement Vitamin D Calcitriol Control secondary hyperparathyroidism Calcimimetic agents Cinacalcet (Sensipar) Subtotal parathyroidectomy NURSING MANAGEMENT Assessment Medical history, long term health problems Current medications Dietary habits, height and weight Lab values Support systems Nursing Diagnosis Excess fluid volume related to impaired kidney function Electrolyte imbalance related to impaired kidney function Imbalanced nutrition: less than body requirements Planning- Goal is to have patient Demonstrate knowledge of and ability to comply with the therapeutic regimen Participate in decision making for plan of care and for future treatments Demonstrate effective coping strategies Continue with activities of daily living within physiologic limitations Implementation Health promotion Teach patient about disease, diet, medications and follow up care Daily BPs, identify signs and symptoms of fluid overload, hyperkalemia, and other electrolyte imbalances Diet planning Provide information on treatment options Acute Intervention Daily weight, daily BPs Identify s/s of fluid overload Identify s/s of hyperkalemia Strict dietary adherence Medication teaching Motivate patient to manage their disease Ambulatory and Home Care HD, PD and transplant are treatment options Explain clearly to patient what dialysis and transplant means Evaluation Patient will: Comply with treatment regimen Comply with diet and medications Have fluid and electrolyte levels within normal range Have acceptable weight with no more than 10% weight loss