Etiology

I. Predisposing factor
Present
Ages 55 and Above If you have one or more family members who have CKD, are on dialysis, or have a kidney transplant, you Family History of Kidney Disease may be at higher risk. One inherited disease, polycystic kidney disease, causes large, fluid-filled cysts that eventually crowd out normal kidney tissue. Diabetes and high blood pressure can also run in families. Be aware of your family history and share it with your doctor. This can ensure that you are screened for risk factors regularly and get the care you need.

Rationale/ Justification
During this age, kidney function is decreased.

II.

Precipitating Factor
Present Rationale/ Justification
Smoking can cause vasoconstriction that could lead to hypertension. High blood pressure puts more stress on blood vessels throughout the body, including the kidney filters (nephrons). Hypertension is the number two cause of kidney failure. This is the most common cause of Kidney failure due to sluggishness of blood flow brought

Lifestyle - smoking

Hypertension

Diabetes Mellitus

by viscous blood leading to decrease oxygen supply in kidney cause thus causing nephrotic that damage. This could

Recurrent infections Acute Renal Failure

glomerulonephritis

damages the nephrons. This may follow CRF if not treated. Glomerulonephritis is d/t recurrent infections

Glomerulonephritis

that may lead to damaged nephrons and decrease GFR. Autoimmune disease can cause

SLE

glomerulonephritis.

III.
Renal

Symptomatology

o Increase creatinine

Increase in creatinine level may be caused by decrease renal function. Aldosterone sodium leading and

o Oliguria o Anuria

secretion water

causes retention

o Proteinuria

to oliguria and anuria. D/t increased permeability, may be large filtered like

capillary molecules protein

causing proteinuria.

Cardiovascular o Hypertension o Heart failure o Atherosclerotic heart disease o Pericarditis o Myocardiopathy o Pericardial Effusion

The

most

common abnormality and is is

Cardiovascular present

hypertension which is usually pre-ESRD abbreviated by sodium retention and increased extracellular fluid volume. In some individuals increased renin production could also contribute to hypertension. The vascular changes from long standing, hypertension and accelerated atherosclerosis from elevated triglyceride levels are responsible for many cardiovascular complications. (MI

and stroke) These are leading causes of death for patients receiving long term dialysis. Left ventricular from hypertrophy long standing

resulting

hypertension, extracellular fluid volume overload, and anemia leads to cardiomyopathy and heart failure. Cardiac dysrythmias may result from hyperkalemia, hypokalemia and decreased coronary artery perfusion. Uremic pericarditis can develop and occasionally progresses to pericardial effusion and cardiac tamponade. Pericarditis is manifested by a friction rub, chest pain and low grade fever. Hypertension could also cause retinopathy, encephalopathy and Gastrointestinal o Anorexia o Nausea o Vomiting o GI bleeding o Peptic Ulcer nephropathy. Every port of the GI system is affected caused Mucosal as of by a result the of urea. found inflammation mucosa

excessive

ulcerations,

throughout the GIT are caused

o Stomatitis o Gastritis o Constipation

by

the

decreased by the

ammonia bacterial

produced

breakdown of urea. Anorexia, nausea and vomiting caused by the irritation of the GIT contribute to weight loss and malnutrition. GI bleeding is also a risk because of mucosal irritation coupled with the platelet defect, diarrhea may occur because of hyperkalemia calcium and altered metabolism.

Constipation may be due to the ingestion of iron salts and or calcium containing phosphate binders. Constipation can be made worst by limited fluid intake Endocrine/Reproductive o Hyperparathyroidism o Thyroid abnormalities o Amenorrhea o Infertility o Sexual dysfunction o Azoospermsia and inactivity Many patients with CKD exhibit some clinical manifestations of hypothyroidism. Tests of thyroid function may yield low to lownormal levels for serum T1 and T4 levels neither the clinical significance nor the exact cause of these findings is known. Both sexes characteristically infertility and a

experience

decrease libido.

Women usually have decreased levels of estrogen, progesterone LTH causing anovulation and menstrual changes. Sexual dysfunction in both sexes may also be caused by anemia which causes fatigue and decreased libido. Sexual function may improve with maintenance dialysis and may become normal Metabolic o Carbohydrate intolerance o Hyperlipidemia o Nutritional deficiencies o Gout with successful transplantation. As the GFR decreases, the BUN and Serum Creatinine levels increase. The BUN is increased not only by the kidney failure but also by protein intake, fever, corticosteroids, and catabolism. For this reason, and more Serum Creatinine are accurate

Creatinine clearance considered BUN.

determinations

indicators of kidney function than

As the BUN increases, nausea, vomiting, lethargy, fatigue, impaired thought processes and headaches become common as a result of the effects of waste

products on the central nervous and GI systems. The Serum Creatinine level in adult patient will be lowered than the younger person with the same degree of renal dysfunction. Decreased muscle mass and muscle activity from aging account for this finding because Creatinine is an end product of muscle metabolism. Defective COH metabolism is caused by impaired glucose use resulting from cellular insensitivity to a normal action of insulin. The exact nature of this insulin resistance is unclear, but it may be related to circulating insulin antagonist, alterations in hormone abnormalities mechanisms. receptors, of or transport Moderate

hyperglycemia, hyperinsulinemia, and abnormal glucose tolerance tests may be seen. Insulin and glucose improve, metabolism but not to may normal

values, after dialysis.

Hyperinsulinemia stimulates liver production Uremia hyperlipidemia of may with triglycerides. develop elevated/

decreased LDL and decreased HDL. This is due to decreased level of lipoprotein lipase (for breakdown of lipoproteins). Hyperlipidemia is a risk factok for Hematologic o o o Anemia Bleeding tendencies Infection atherosclerosis. Anemia. It is due to decreased production of erythropoietin by the kidneys, renal caused tubular by cell decreased functioning. Thrombocytopenia. platelet aggregation Impaired and

impaired release of platelet factor III may lead to bleeding. Infection. It is caused by changes in the leukocyte function and altered immune response. Inflammatory decreased due response to is altered

chemotactic response by both neutrophils and monocytes. This decreases accumulation of WBC Neurologic o Fatigue o Headache o Sleep disturbances at the site of injury or infection. This is attributed by increased by nitrogenous acidosis, waste axonal products, atrophy, electrolyte imbalances, metabolic

o Lethargy o Muscular irritability o Seizure o Confusion o Coma

demyelination of nerve fibers. High level of waste products implies axonal damage. Depression of the CNS will result to lethargy, apathy, decreased ability to concentrate, fatigue, irritability ability. Seizures and coma may result from increased BUN. Peripheral neuropathy is due to slow nerve conduction of extremities. Restless legs syndrome may also occur and may describe it as bugs crawling inside the legs. Paresthesias motor involvement may lead to bilateral foot drop, muscle weakness, and loss DTR. Muscle twitching, jerking, asterixis (hand-flapping tremor), and altered mental

Skeletal o Ocular o Bone pain/joint Hypertensive

and nocturnal leg cramps. Due to hypocalcaemia, impaired activation of Vitamin D. It is due to vasoconstriction of the retinal arteries and veins.

retinopathy

Pulmonary o o o o o o o reflex o Respiratory Acidosis Liver o Increase BUN o Decrease clotting factor o Decrease platelet count o Hepatomegaly Uremic lung Pulmonary edema Uremic pleuritis Dyspnea Tachypnea Pneumonia Depressed cough

There is decreased blood flow in the This lungs may which lead causes to its decrease in tissue perfusion. different manifestations mentioned. Respiratory acidosis occurs due decrease blood flow in the lungs which results to decrease oxygen supply to it. Carbon dioxide dominates in the lungs. Carbon dioxide is acidic in nature. D/t increase working activity of the liver brought by fluid volume excess, hypertrophy which leads to hepatomegaly will happen. This altered liver function, there is decrease clotting activity d/t decrease platelet count. The most noticeable change is a yellow gray discoloration of the skin. This change is a result of absorption and retention of urinary pigments that normally give the characteristic color to urine. The skin also appears pale d/t anemia and is dry and scaly d/t decrease in oil and sweat gland activity.

Integumentary o Pallor o Pigmentation Changes o Pruritus o Ecchymosis o Dry scaly skin

Decreased perspiration is d/t decrease in the sweat gland size. Pruritus is d/t a combination of a dry skin, calcium in the phosphate skin, and deposition

sensory neuropathy. Uremic frost happens when urea crystallizes on the skin and is usually seen only when BUN levels are extremely high. The hair is dry and brittle and may fall out. Nails are thin brittle and ridged. Ecchymosis Electrolyte and Acid- Base Balance Hyperkalemia Normal/Hyponatremia Hypermagnesemia Metabolic Acidosis is d/t platelet

abnormalities. Potassium. Hyperkalemia is d/t decreased kidneys, excretion the by the of breakdown

cellular protein, bleeding and metabolic acidosis. Sodium. Sodium may be normal or low d/t impaired could sodium cause excretion which

dilutional hyponatremia because of large quantities of water is retained. Sodium retention can

cause edema hypertension and heart failure. Magnesium. Hypermagnesemia may occur and cause by excessive intake of drug such antacid containing magnesium and magnesium citrate. Metabolic acidosis is d/t inability of the kidney to excrete acid load and from defective reabsorption and regeneration of bicarbonate.