PERPETUAL HELP COLLEGE OF MANILA

COLLEGE OF NURSING
A PARTIAL REQUIREMENT FOR NCM 204

CASE STUDY ON CHRONIC KIDNEY DISEASE

Submitted to : Mrs. May Flores-Lugay Submitted by: Lucky Bryan S. Abala

CHRONIC KIDNEY DISEASE

Definition Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis.[1] Chronic kidney disease is identified by a blood test for creatinine. Higher levels of creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products. Creatinine levels may be normal in the early stages of CKD, and the condition is discovered if urinalysis (testing of a urine sample) shows that the kidney is allowing the loss of protein or red blood cells into the urine. To fully investigate the underlying cause of kidney damage, various forms of medical imaging, blood tests and often renal biopsy (removing a small sample of kidney tissue) are employed to find out if there is a reversible cause for the kidney malfunction.[1] Recent professional guidelines classify the severity of chronic kidney disease in five stages, with stage 1 being the mildest and usually causing few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms endstage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).[1] There is no specific treatment unequivocally shown to slow the worsening of chronic kidney disease. If there is an underlying cause to CKD, such as vasculitis, this may be treated directly with treatments aimed to slow the damage. In more advanced stages, treatments may be required for anemia and bone disease. Severe CKD requires one of the forms of renal replacement therapy; this may be a form of dialysis, but ideally constitutes a kidney transplant Introduction Chronic Kidney Disease (CKD) is a rapidly growing health problem. Estimates are that 11% of the U.S population or 19.2 million people have CKD. The centers for disease control and prevention in Atlanta has recently established a chronic kidney disease program to enhanced surveillance and prevention programs for CKD at the federal and state levels. The many diseases described in this chapter can lead to CKD, and the etiology will differ by disease. Recognition of the type of kidney disease and etiology may be useful to prevent or slow progression of the disease.

Patient Profile: Name: Ms. E. E Age: 41 Sex: Female Address: Manila Chief complaint: difficulty of breathing Admitting diagnosis: Chronic Kidney disease 2 chronic glomerulonephritis Patient health history: Patient experienced difficulty of breathing 2 years and 3 months ago, while she was working abroad. She worked as OFW at South Korea and she verbalized that while working she was a light drinker and she stay up late in the evening. Family health history: The patient verbalized that she and her family also have a history of hypertension.

Anatomy and Physiology

The human kidney anatomy is well equipped to perform all its crucial functions. The following kidney diagram represents the structure of a kidney... sliced vertically.

KIDNEY DIAGRAM

KIDNEY ANATOMY The kidneys are dark-red, bean-shaped organs. One side of the kidney bulges outward (convex) and the other side is indented (concave). There is a cavity attached to the indented side of the kidney, called the Renal Pelvis... which extends into the ureter. Each Kidney is enclosed in a transparent membrane called the renal capsule... which helps to protect them against infections and trauma. The kidney is divided into two main areas... a light outer area called the renal cortex, and a darker inner area called the renal medulla. Within the medulla there are 8 or more cone-shaped sections known as renal pyramids. The areas between the pyramids are called renal columns. Kidney Anatomy and Excretion The most basic structures of the kidneys are nephrons. Inside each kidney there are about one million of these microscopic structures. They are responsible for filtering the blood... removing waste products. The renal artery delivers blood to the kidneys each day. Over 180 liters (50 gallons) of blood pass through the kidneys every day. When this blood enters the kidneys it is filtered and returned to the heart via the renal vein. The process of separating wastes from the body's fluids and eliminating them is known as excretion. The body has four organ systems that are responsible for excretion. The urinary system is one of the main organ systems responsible for excretion. It excretes a broad variety of metabolic wastes, toxins, drugs, hormones, salts, hydrogen irons and water. The kidneys are the main organs of the urinary system. The kidneys are full of blood vessels. Blood vessels are integral to efficient kidney function. Every function of the kidney involves blood, therefore, it requires a lot of blood vessels to facilitate these functions. Together, the two kidneys contain about 160 km of blood vessels.

KIDNEY LOCATION The normal kidney location is towards the back of the abdominal cavity, just above the waist. If you put your hands on your hips, your kidneys are located just about where your thumbs are. One kidney is normally located just below the liver, on the right side of the abdomen and the other is just below the spleen on the left side. In rare cases, however, one or both kidneys may be located much lower in the abdomen. This is not necessarily a problem except probably in the case of pregnancy. As the fetus begins to develop in the womb this could sometimes place pressure on the kidney which is located in the lower abdomen.

NORMAL KIDNEY SIZE

The normal kidney size of an adult human is about 10 to 13 cm (4 to 5 inches) long and about 5 to 7.5 cm (2 to 3 inches) wide. It is approximately the size of a conventional computer mouse. A kidney weighs approximately 150 grams. Kidneys weigh about 0.5 percent of total body weight.

The human kidney anatomy, though relatively simple, enables it to perform extremely complex but essential functions. If any area of the kidney is damaged or becomes diseased, this could significantly affect its ability to perform these functions. The function of the kidney is primarily to rid the body of toxins, but this is not the only function of the kidney. The kidney plays a crucial role in keeping the blood clean and regulating the amount of fluid in the body. It has a unique anatomy and is equipped to efficiently discharge its functions. Most humans are born with two kidneys, although one kidney is capable of performing the normal functions of both kidneys. In rare cases a person may be born with one kidney or may lose a kidney through injury, disease or surgery (for example when a person donates a kidney). Amazingly, such people are still able to lead normal lives, without any adverse effects to their health.

The function of the kidney is primarily to rid the body of toxins, but this is not the only function of the kidney. The kidney plays a crucial role in keeping the blood clean and regulating the amount of fluid in the body. It has a unique anatomy and is equipped to efficiently discharge its functions. Most humans are born with two kidneys, although one kidney is capable of performing the normal functions of both kidneys. In rare cases a person may be born with one kidney or may lose a kidney through injury, disease or surgery (for example when a person donates a kidney). Amazingly, such people are still able to lead normal lives, without any adverse effects to their health. Key Kidney Functions If you asked anyone what is the function of the kidney, they might respond by saying that it produces urine. They will, of course, be correct but this is not the only kidney function. While this is one of the major functions of the kidney, this remarkable organ does a lot more. You might be amazed to discover just how extensive is the role of the kidney, as it pertains to maintaining overall human health. The main function of the kidney is the removal of toxic waste products from the blood. Chief among these waste products are urea and uric acid. If too many of these waste products are allowed to accumulate in the blood stream, this will result in life threatening illnesses. Fortunately, these two deadly substances are easily expelled from the body by the kidneys... through the process of excretion. Excretion is a process which continuously cleans the blood... keeping it free of unwanted and dangerous substances. This very important job is performed by microscopic structures in the kidneys called nephrons. The kidneys are in fact the main organs of the urinary system... responsible for removing waste substances from the body, in the form of urine. Regulating the amount of water and salt in the blood is another important function of the kidney. As you may know, the body is made up primarily of water. Water is indeed necessary for many of the body's biological functions. Too much water, however, could dilute the blood... negatively affecting the environment in which the cells operate. Let's suppose that you drink a lot of water quickly. The water is absorbed from your gut into the bloodstream, and it has the effect of diluting the blood. The diluted blood reaches the kidney, which takes excess water out of it and passes it into the urine. Salt is dealt with in the same way. If you had a salty meal the salt is absorbed into your blood. When the salty blood reaches the kidney the salt is removed from it and passed into the urine. This is an extremely important function of the kidney. The relative amount of water and salt in the blood give the blood a particular concentration. By regulating the amount of salt and water in the blood, the kidneys ensure that the concentration and volume of the blood stays more or less the same all the time.

Another crucial function of the kidney is to regulate blood-pressure. They secrete an enzyme called renin, which activates hormonal mechanisms that controls blood pressure and electrolyte balance. When, for instance, blood-pressure begins to fall, the kidneys release the enzyme renin. This enzyme converts blood protein into a hormone called angiotensin. Angiotensin then induces the adrenal gland to release another hormone called aldosterone. This hormone causes sodium and water to be reabsorbed into the blood, thereby increasing blood-volume and blood-pressure. The response of the kidneys to aldosterone helps to regulate the level of salt in the blood.

Etiology and risk factors The increasing incidence of CKD partially reflects increased obesity-related hypertension and diabetes Mellitus in sedentary, well-nourished populations. Since cardiovascular disease and Diabetes mellitus are frequently co-morbid conditions associated with CKD, aggressive treatment of the disease and risk factors can slow progression of the illness and limit morbidity and mortality. The National Kidney Foundation (NKF) Kidney DISEASE Outcome Quality initiative (K/DOQI) defined CKD as kidney damage with a glomerular filtration rate (GFR) <60 ML/MINUTE/1.73 M2 for more than 3 months. The NKF (Developed a classification system for the stages of CKD. Traditionally, the classification of the type of kidney disease has been focused on pathology and etiology. The K/DOQI classification system focuses on the GFR, but it remains important to diagnose the cause of CKD.

Pathophysiology There are many diseases that cause CKD; each has its own pathophysiology. However, there are common mechanisms for disease progression. Pathologic features include fibrosis, loss of renal cells, and infiltration of renal tissue by monocytes and macrophages. Proteinuria, hypoxia, and excessive angiotensin II production all contribute to the pathophysiology. In an attempt to maintain GFR, the glomerulus hyper filtrates; this results in endothelial injury. Proteinuria results from increased glomerular permeability and increased capillary pressure. Hypoxia also contributes to disease progression. Angiotensin II increases glomerular hypertension, which further damages the kidney. Clinical Manifestations The clinical manifestations of CKD are highly variable. Many people with CKD have few if any complaints. In sage 1, clients usually have normal blood pressure, no laboratory test abnormalities, and no clinical manifestations. Clients in stage 2 are generally asymptomatic, but mat develop hypertension, and laboratory test abnormalities exist. In stage 3, clients are still usually asymptomatic but laboratory values suggest abnormalities in several organ systems, and hypertension is frequently present. By stage

4, clients begin to experience clinical manifestations associated with CKD such as fatigue and poor appetite. At stage 5, full-blown clinical manifestations of end-stage renal disease (ESRD) are evident. Proteinuria is one of the strongest predictors of progression of CKD. As the GFR declines, clients may show not only proteinuria but also hypertension, a wide range of lab abnormalities, and manifestation resulting from disorders in other organs. These disorders include anemia, metabolic acidosis, dyslipidemia, bone disease, protein-energy malnutrition, and neuropathy.

Stages of Chronic Kidney Disease

STAGE DESCRIPTION Kidney damage with normal glomerular filtration rate Kidney damage with mild decrease in GFR Moderate decrease in GFR Severe decrease in GFR Kidney failure Other Terms used At risk GFR (ml/min/1.73m2) >90

Chronic renal insufficiency (CRI) CRI, chonic renal failure (CRF) CRF

60_89

30-59

3 4

15-29

Ed-stage renal disease (ESRD)

<15

National KIDNEY Foundation Classification of Chronic Kidney Disease

Stage --

Severity At increased risk

GFR Ml/min 60

Kiney damage damage: normal or Increase GFR Kidney damge: Mild GFR

90

Progression (Chronic kidney disease risk factors present ) None apparent

Symptoms None

None

60-89

3 Moderate GFR

30-59

Increasing PTH Early bone disease Erythropoietin deficiency anemia

Subtle

Mild

Severe:

GFR

15-29

End-stage kidney disease; Kidney failure

<15

Increased triglycerides Metabolic acidosis Hyperkalemia Salt/water retention uremia

Moderate

Severe

Adapted from National Kidney Foundation, Clinical practice Guide Guidelines for Chronic Kidney Disease: Evaluation, classification, stratification: dentition and classification of stages of chronic kidney disease, 2002; Available at http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm

Factors Representing Progression of Chronic Renal Failure Factor Proteinuria Creatinine and urea clearance Sodium and water balance Phosphate and calcium balance Characteristics
Glomerular hyper filtration of protein contributes to tubular interstitial injury by accumulating in the interstitial space and promoting inflammation and progressive fibrosis. In chronic renal failure, the GFR falls and the plasma creatinine concentration increases by a reciprocal amount; because there is no regulatory adjustment for creatinine , plasma levels continue to rise and serve as an index of changing glomerular function. As GFR declines, urea clearance increases, (NOTE: Urea is both filtered and reabsorbed and varies with the state of hydration. In chronic renal failure, sodium load delivered to nephrons exceed normal, so excretion must increased, thus less is reabsorbed. Obligatory loss occurs, leading to sodium deficits and volume depletion. As GFR is reduced, ability to concentrate and dilute urine diminishes. Changes in acid-base balance affect phosphate and calcium balance. The major disorders associated with chronic renal failure are reduced renal phosphate excretion, decreased renal synthesis of 1, 25(OH)2 Vitamin D3, and hypocalcemia. Hypocalcemia leads to secondary hyperparathyroidism, GFR falls, and progressive hyperphoshatemia, hypocalcemia, and dissolution of bone result. Because of anemia that accompanies chronic renal failure, lethargy, dizziness, and low hematocrit are common. In chronic renal failure, tubular secretion of potassium increases until oliguria develops. Use of potassium- sparring diuretics also may precipitate elevated serum potassium levels. As disease progresses, total body potassium levels can rise to life-threatening levels and dialysis is required. In early renal insufficiency, acid excretion and bicarbonate reabsorption are increase to maintain normal pH. Metabolic acidosis begins when GFR Reaches 30% to 40%. Metabolic acidosis and hyperkalemia may be severe enough to require dialysis when end-stage renal failure develops. Chronic hyperlipidemia may induce glomerular and tubolointerstitial injury, contributing to the progression of chronic renal disease.

Hematocrit Potassium balance Acid-base balance

Dyslipidemia

Laboratory test: Result Cholesterol Creatinine Glucose (FBS) Triglycerides Uric acid (BUA) Urea nitrogen (BUN) Sodium (Na) Potassium (K) Chloride(Cl) 210.6 mg/dl 14.5 mg/dl 82.mg/dl 145 mg/dl 11.8 mg/dl 91.7 mg/dl 139.4 mg/dl 4.63 mg/dl 104.5 mg/dl Normal value 0-200 0.5-1.2 74-106 0-200 91.7 6-20 135-145 3.4-4.0 92-102 Interpretation

Serology Test Anti- HCV Patient count 0.018 Cut off value 0.140 Result Non reactive

hemoglobin Hematocrit RBC WBC Neutrophils Lymphocytes Monocytes Eosinophil Platelet count

Result 129.2 .38 4.1 7.4 .65 .33 .01 .01 Adeq.

Normal values Female: 120 -160 g/l 0.37 0.47 4.0-5.5 x 10 g/l 5-10x10 g/l 0.50-0.66 0.20-0.40 0.02-0.06 0.01-0.03 150-400 x10 g/l

Interpretation

Test name HBSAg-11 Anti-HBS

Cut-off value 1.00 10.00

Patients count 0.36 2.00

result negative negative

MEDICAL MANAGEMENT: Ideal outcomes of medical management include the following: controlling blood pressure (BP) to below 130/80 mmHg managing blood glucose level to maintain HbA1c Below 7% managing hyperlipidemia with diet and cholesterol-lowering drugs(usually statins) Managing and treating emerging manifestations of renal failure including anemia, hyperphosphatemia and hyperparathyroidism, hyperkalemia, and metabolic acidosis. Preparing clients for renal replacement therapy when necessary

Reduce blood pressure Hypertension in CKD increases the risk of loss of kidney function. The lower the BP, the lower the risk of cardiovascular disease. At blood pressures above 115/75 mmHg, the risk of cardiovascular mortality doubles for each increase of 20 mmHg Systolic and 10 mm Hg diastolic BP. Clinical practice guidelines suggest that systolic BP should be maintained below 130 mmHg and diastolic BP below 80 mm Hg in people with less than 1 g proteinuria/day <125/75 mmHg in people with >1 g of proteinuria/day. Reduce serum lipids Cardiovascular mortality is elevated among people with CKD. For this reason,low-fat diets and administration of cholesterol-lowering medications, particularly statins, are indicated. The NKF recommends maintaining LDL<100mg/dl, non-HDL <130 mg/dl, and tiglycerides <500 mg/dl. Hyperlipidemia should be managed aggressively to reduce the risk of atherosclerotic cardiovascular disease.

Controlling phosphorus intake Elevations in the levels of serum phosphorus, calcium-phosphorus product, and parathyroid hormone substantially increase the risk of death. The NKF recommends that serum phosphorus level be maintained between 2.7 and 4.6 mg/dl for those with stage 3 or 4 CKD, dietary phosphorus intake should be limited, and phosphorus binders started of necessary.

Nursing management of the medical client Assessment: for any client with CKD, take a comprehensive history that includes medications and diet currently prescribed. Check blood pressure. Monitor urine studies including micro albumin and albumin levels as well as blood creatinine level, GFR, red blood cell count, and levels of electrolytes, glucose and lipids for changes suggesting increasing renal failure. Physical assessment findings that suggest progressing renal failure may include fatigue, peripheral edema, shortness of breath, adventitious lung sounds, heart murmurs or gallops, bruising, memory loss, GI disturbances, impaired wound healing, and increased infections. Control blood glucose level- dietary management, exercise, anti diabetic agents, and insulin therapy are essential aspects of managing blood glucose. Encourage smoking Cessation- Smoking cessation assistance is another important area for prevention of risk factors. The mechanisms of the effect of smoking on kidney disease progression are unclear, but studies have shown an association between smoking and decreasing renal function, smoking increases the risk of developing type 2 diabetes mellitus and micro albuminuria, and furthering progression of diabetic nephropathy. Smoking was related to the development of kidney disease in a longitudinal study of 2585 people with no previous history of kidney disease with a mean follow-up of 18.5 years, there are many nursing strategies to facilitate smoking cessation, but this is a difficult addiction to overcome and repeated and varied interventions may be necessary.