Chronic Kidney Disease (CKD) PDF

2/22/24, 2:40 PM Realizeit for Student Introduction Chronic kidney disease (CKD) is a condition characterized by a gradual loss of kidney function over time. Because of this, excess fluid and waste from blood remain in the body and may cause other health problems, such as heart disease and stroke. C...

2/22/24, 2:40 PM Realizeit for Student Introduction Chronic kidney disease (CKD) is a condition characterized by a gradual loss of kidney function over time. Because of this, excess fluid and waste from blood remain in the body and may cause other health problems, such as heart disease and stroke. CKD has varying levels of seriousness. It usually gets worse over time though treatment has been shown to slow progression. If left untreated, CKD can progress to kidney failure and early cardiovascular disease. End-Stage Kidney Disease or Chronic Kidney Disease When a patient has sustained enough kidney damage to require RRT on a permanent basis, the patient has moved into the fifth or final stage of CKD, also referred to as ESKD. In 2017, 86.9% of patients newly diagnosed with ESKD began RRT with HD, 10.1% started with PD, and 2.9% received a preemptive kidney transplant. A preemptive transplant is when a patient undergoes kidney transplantation from a living donor before dialysis is initiated. Of great concern is that 33% of patients diagnosed with ESKD had received little or no pre-ESKD nephrology care and 19.2% received no nephrology care prior to requiring RRT. As of December 31, 2017, 62.7% of all patients previously diagnosed with ESKD were receiving HD therapy, 7.1% were being treated with PD, and 29.9% had a functioning kidney transplant. Among patients being treated with HD, 98.0% used in-center HD (USRDS, 2019). In July 2019, the President, the U.S. Department of Health and Human Services (HHS) Secretary, and the Administrator of the Centers for Medicare and Medicaid Services (CMS) issued an Executive Order, with the goal of improving the lives of Americans with ESKD by expanding treatment options and reducing health care costs. As part of this Executive Order, a mandatory payment model promotes moving patients from in-center to home dialysis (both PD and home HD) and increasing the number of patients receiving kidney transplants. There is much work and policy development that will need to be done to reach this goal by the projected date of 2025 (Kear, Bednarski, Smith, et al., 2019). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 1/6 2/22/24, 2:40 PM Realizeit for Student Pathophysiology As renal function declines, the end products of protein metabolism (normally excreted in urine) accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more pronounced the symptoms. The rate of decline in renal function and progression of ESKD is related to the underlying disorder, the urinary excretion of protein, and the presence of hypertension. The disease tends to progress more rapidly in patients who excrete significant amounts of protein or have elevated blood pressure than in those without these conditions (Mahaffey, 2017). Clinical Manifestations Because virtually every body system is affected in ESKD, patients exhibit a number of signs and symptoms. The severity of these signs and symptoms depends in part on the degree of renal impairment, other underlying conditions, and the patient’s age. Cardiovascular disease is the predominant cause of death in patients with ESKD (Subbiah et al., 2016). Peripheral neuropathy, a disorder of the peripheral nervous system, is present in some patients, especially those with diabetes. Patients complain of severe pain and discomfort. Restless leg syndrome and burning feet can occur in the early stage of uremic peripheral neuropathy. The precise mechanisms for many of these systemic signs and symptoms have not been identified. However, it is generally thought that the accumulation of uremic waste products is the probable cause. Assessment and Diagnostic Findings Glomerular Filtration Rate As the GFR decreases (due to nonfunctioning glomeruli), the creatinine clearance decreases, whereas the serum creatinine and BUN levels increase. Serum creatinine is a more sensitive indicator of renal function than BUN. The BUN is affected not only by kidney disease but also by protein intake in the diet, catabolism (tissue and RBC breakdown), parenteral nutrition, and medications such as corticosteroids. Sodium and Water Retention The kidney cannot concentrate or dilute the urine normally in ESKD. Appropriate responses by the kidney to changes in the daily intake of water and electrolytes, therefore, do not occur. Some patients retain sodium and water, increasing the risk for edema, heart failure, and hypertension. Hypertension may also result from activation of the renin–angiotensin–aldosterone axis and the concomitant increased aldosterone https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 2/6 2/22/24, 2:40 PM Realizeit for Student secretion. Other patients have a tendency to lose sodium and run the risk of developing hypotension and hypovolemia. Vomiting and diarrhea may cause water depletion, which may worsen the uremic state. Acidosis Metabolic acidosis occurs in ESKD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3−) and to reabsorb sodium bicarbonate (HCO3−). There is also decreased excretion of phosphorus and other organic acids. Anemia Anemia develops as a result of inadequate erythropoietin production, the shortened lifespan of RBCs, nutritional deficiencies, and the patient’s tendency to bleed, particularly from the GI tract. Erythropoietin, a substance normally produced by the kidneys, stimulates bone marrow to produce RBCs. In ESKD, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath (Evans, 2017). Calcium and Phosphorus Imbalance Another abnormality seen in ESKD is a disorder in calcium and phosphorus metabolism. Serum calcium and phosphate levels have a reciprocal relationship in the body: As one increases, the other decreases. With a decrease in filtration through the glomerulus of the kidney, there is an increase in the serum phosphorus level and a reciprocal or corresponding decrease in the serum calcium level. The decreased serum calcium level causes increased secretion of parathormone from the parathyroid glands. However, in kidney disease, the body cannot respond normally to the increased secretion of parathormone. As a result, calcium leaves the bone, often producing bone changes and bone disease as well as calcification of major blood vessels in the body. In addition, the active metabolite of vitamin D (1,25-dihydroxycholecalciferol) normally manufactured by the kidney decreases as kidney disease progresses (Brooks, 2017). Uremic bone disease, often called renal osteodystrophy, develops from the complex changes in calcium, phosphate, and parathormone balance. There is also evidence of calcification of blood vessels. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 3/6 2/22/24, 2:40 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 4/6 2/22/24, 2:40 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 5/6 2/22/24, 2:40 PM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zYjdcLReD0xWqoW33TqQEI8BS%2f7OmZzvGp21HqGixm2HQ… 6/6