End Stage Renal Disease p.pdf

End Stage Renal Disease Kidney Overview Kidney function of urine elimination ○ Excretion of waste ○ fluid/electrolyte balance ○ Acid-base balance Hormone secretion Chronic Kidney Disease 15% of adults in US have disease (about 37 million people) (CDC,2019) Number of affected people increasing About...

End Stage Renal Disease Kidney Overview Kidney function of urine elimination ○ Excretion of waste ○ fluid/electrolyte balance ○ Acid-base balance Hormone secretion Chronic Kidney Disease 15% of adults in US have disease (about 37 million people) (CDC,2019) Number of affected people increasing About 90% do not know they have the disease Gradual→ months to years Lasts more than 3 months Two most common causes: ○ DIABETES MELLITUS ○ HYPERTENSION Varies by stage but generally symptomatic with 75% loss Dialysis with 90-95% loss Progressive and permanent (irreversible) End Stage Kidney Disease or End Stage Renal disease When kidney function too poor to sustain life called ESKD or (ESRD) Treatment and lifestyle can slow progression and delay onset of ESRD Glomerular Filtration Rate ○ Blood passes thru glomerulus to form a filtrate, controlled by b/p and blood flow ○ Filtration rate expressed in mm/min ○ Direct measurement of a urine creatinine with a 3 hour or 24 hour urine collection 5 stages based on glomerular filtration rate (GFR) Albuminuria Stages in CKD ○ Check albumin in urine ( 3 stages) which shows kidney damage ○ Albumin to creatinine ratio in urine A1 (microalbuminuria) 0-mild albumin and creatinine up to 29 mg/g A2 creatinine up to 30-300 mg/g A3 creatinine greater than 300 mg/g ○ Albumin shows kidney damage ○ GFR shows kidney function CKD and Reduced GFR cause problems, All systems affected Problems Across all systems Kidney Changes Abnormal urine production/ kidney continues to work harder to achieve homeostasis until ¾ function lost/ BUN increasing, urine output decreasing/ Metabolic Changes Hyponatremia (fewer healthy nephrons reabsorb Na+) In later stages have hypernatremia as urine production goes down and Na+ levels rise/ Na+ retention causes hypertension Hyperkalemia in later stages if urine output goes below 500ml/day (“Normal” urine output 2-2.5 liters/day). Can be life threatening: cardiac rate/rhythm affected Metabolic Acidosis: As more nephrons are lost, acid excretion reduced and metabolic acidosis results Need more respiratory action to keep blood pH normal/ Kussmaul respirations: increased rate and depth of breathing to blow off more CO2 Cardiac Changes Hypertension: could be cause or result of CKD Damages kidney arterioles and reduces perfusion Renin released to improve kidney blood flow, but this produces angiotensin and aldosterone Aldosterone raises blood pressure As renin is increased causes vasoconstriction of arterioles and b/p increases Hyperlipidemia Heart failure: heart is working too hard Pericarditis Hematological and Immunity Changes Anemia: reduced erythropoietin and RBC production Uremia disrupts WBC production (Uremia=Accu mulation of nitrogenous wastes in the blood) Reduced immunity causes more vulnerability to infection Electrolyte abnormalities more can cause inflammation GI changes Enzyme urease causes halitosis and stomatitis Peptic ulcer disease common Blood loss can lead to hemorrhage from GI system Calcium/phosphorus balance affected: renal phosphate reduced so get hyperphosphatemia, hypocalcemia: bone density loss Bone-mineral loss causes bone pain, fractures Calcium deposited in plaques in blood vessels and metastatic calcifications Signs and symptoms ○ nausea/vomiting, anorexia, hiccups, diarrhea, constipation (elimination problems) ○ Neuro symptoms: lethargy, seizures, coma, cognition problems, sensory changes ○ Weakness in upper/lower extremities: uremic neuropathy ○ Skin changes: yellowish ○ Cardiovascular symptoms ○ Respiratory symptoms ○ Hematology problems ○ GI symptoms ○ Skeletal symptoms ○ Urinary symptoms: often less urine production Secondary Prevention ○ Assess weight loss (result of anorexia from uremia) or gain (fluid retention) ○ Medical/family history ○ Urine testing: ○ Urinalysis: Protein, glucose, RBC’s, WBC’s ○ As disease progresses output decreases and osmolarity increases ○ 3 hour to 24 hr. urine to assess creatinine clearance ○ Serum creatinine and BUN determine degree of uremia ○ May do ultrasound or CT to rule out obstruction ○ CBC ○ Electrolytes (blood) Tertiary Prevention ○ Improve Cardiac Function Control hypertension: Meds, daily b/p’s ○ Enhance Nutrition Prevent malnutrition and avoid complications from CKD Refer to dietician Early restriction of protein → prevents problems and preserves kidney function / Build up of waste products from protein the main cause of uremia However, in ESKD on dialysis need more protein because it is lost through dialysis Na restriction with low urine output needed to maintain fluid/electrolyte balance K restriction because high K can cause dysrhythmias Phosphorus restriction to avoid renal osteodystrophy Vitamin and mineral supplement (Ca, D, Fe) Dialysis: Kidney not functioning ○ Hemodialysis More efficient clearance of waste Short time needed for treatment (about 4 hrs) Can be done at home or dialysis center Need AV fistula, Av graft or central venous catheter Can’t put in if severe vascular disease, bleeding disorders or severe cardiac disease Nursing care Check which drugs should be held till after treatment (don’t want drugs taken out of body) Monitor for several hours after treatment: ○ Check for headache, n & v, hypotension, dizziness, muscle cramps Heparin given during treatment increases risk of bleeding Dialysis disequilibrium syndrome: ○ Mental status changes due to rapid reduction of electrolytes Infectious diseases: ○ A long complication if dialysis long term ○ Peritoneal Dialysis Flexible schedule for exchanges Fewer dietary and fluid restrictions Intra abdominal catheter Simpler, easier to complete at home compared to at home hemodialysis Nursing Care: Meticulous sterile technique: ○ prevent peritonitis Warm dialysate bags (cold ones cause discomfort) Assess for signs of infection Assure drainage bag lower than abdomen Check for leakage from bags Check that drainage is clear or slightly yellow Kidney Transplant ○ ○ ○ ○ Criteria for recipient and donor Immunologic studies Need tissue typing with Human Leukocyte Antigen (HLA) studies Blood typing More similar antigens of donor are to recipient less chance of rejection Patient requires dialysis within 24 hours of surgery and often a blood transfusion before surgery Blood from donor often transfused into recipient Transplant Complications Rejection Body reacts to new kidney as foreign body and attacks it/most common problem Thrombosis of major renal blood vessels 2-3 days after transplant Sudden decrease in urine may signal impaired perfusion resulting from thrombosis Check ultrasound May need emergency surgery Infection From immunosuppressive drugs (ie, corticosteroids) Immunosuppressive drugs also cause cardiovascular death (most common cause of death in transplant recipients) Transplant Follow Up Consistent medication follow up Consistent medical exams for kidney function and control of other comorbidities Teaching on nutrition and lifestyle changes Teaching on infection control, reiterating need for vaccines, hygiene