Chronic Kidney

Disease

Prepared by D. Chaplin
 Chronic Kidney Disease
Progressive, irreversible damage to the nephrons
and glomeruli

Prepared by D. Chaplin
 Major causes are
 Diabetes and high blood pressure
 Type 1 and type 2 diabetes mellitus
 High blood pressure (hypertension)
 Glomerulonephritis
 Polycystic kidney disease
 Use of analgesics - acetaminophen(Tylenol) and ibuprofen (Motrin,
Advil
 Clogging and hardening of the arteries(atherosclerosis)
 Obstruction of the flow of urine by stones, an enlarged prostate,
strictures (narrowings), or cancers.
 HIV infection, sickle cell disease, heroin abuse, amyloidosis, kidney
stones, chronic kidney infections, and certain cancers.

Prepared by D. Chaplin
Kidney functions - monitored regularly
 Diabetes mellitus type 1 or 2
 High blood pressure
 High cholesterol
 Heart disease
 Liver disease
 Amyloidosis
 Sickle cell disease
 Systemic Lupus erythematosus
 Vascular diseases such as arteritis, vasculitis, or fibromuscular
dysplasia
 Vesicoureteral reflux (a urinary tract problem in which urine travels
the wrong way back toward the kidney)
 Require regular use of anti-inflammatory medications
 A family history of kidney disease

Prepared by D. Chaplin
 Chronic Renal Failure
End Stage Renal Disease (ESRD)
Protein and waste metabolism accumulates in the
blood (azotemia)
90% of kidney function is lost (kidney cannot
adequately function)
Hypothesis: Nephrons remains intact, others
progressively destroyed.
Adaptive response maintains function until ¾ are
destroyed
Hypertrophy continues kidneys begin to lose their
ability to concentrate the urine adequately

Prepared by D. Chaplin
 Table 1. Stages of Chronic Kidney Disease
*GFR is glomerular filtration rate, a measure of the kidney's function.

GFR*
Stage Description
mL/min/1.73m2

Slight kidney damage with normal

1 More than 90
or increased filtration

2 Mild decrease in kidney function 60-89

Moderate decrease in kidney

3 30-59
function
Severe decrease in kidney
4 15-29
function
Less than 15 (or
5 Kidney failure
dialysis)

Prepared by D. Chaplin
 Modifiable Factors
Non-Modifiable Factors -Diabetic Mellitus
-Hereditary -Hypertension
-Age greater than 60 years -Increase Protein and
old Cholesterol Intake
-Gender -Smoking
-Race -Use of analgesics

Decreased renal blood flow

Primary kidney disease
Damage from other
diseases
Urine outflow obstruction

Decreased Serum
BUN glomerular Creatinine
filtration

Hypertrophy of
remaining
Dilute
nephrons
Polyuria
Inability to Loss of Sodium
Hyponatremia
concentrate urine in Urine
Dehydration

Further loss of
nephron function

Loss of 2
nonexcretory renal a
function

Failure to convert Failure to Impaired Production of Immune Disturbances in

inactive forms of produce insulin action lipids disturbance reproduction
calcium eryhtropoietin s

Advanced
Calcium Erratic blood
Anemia atherosclerosis Delayed Infection Libido Infertility
absorption glucose
Pallor levels wound
healing
Prepared1 by D. Chaplin
 2
1 a
Hypocalcemia
Osteodystrophy
Loss of excretory
renal function

Excretion of Decreased Decreased Decreased Decreased

nitrogenous sodium potassium phosphate hydrogen
waste reabsorption in excretion excretion excretion
tubule
Uremia
Water Hyperkalemia Hyperphosphate Metabolic
Retention mia acidosis
BUN,
Creatinine Decreased
Uric Acid calcium
Hypertension absorption
Heart Failure
Edema
Proteniuria
Hypocalcemia

Hyperparathyroidis
Peripheral m
nerve
changes Decreased
potassium
excretion
Pericarditis
Increased
potassium

CNS
changes

Pruritus

Altered
Taste

Bleeding
Prepared by Tendencie
D. Chaplin
 Weakness and tiredness/ fatigue.
Nocturia is often an early symptom
Itchiness of the skin which can progressively worsen
Pale skin which is easily bruised
Muscular twitches, cramps and pain
Pins and needles in the hands and feet
Nausea

Prepared by D. Chaplin
 As the condition worsens the symptoms
progress to:
 Oedema (swelling of the face, limbs and
abdomen)
 Oliguria (greatly reduced volume of urine)
 Dyspnoea (breathlessness)
 Vomiting
 Confusion
 Seizures
 Severe lethargy
 Very itchy skin
 Breath that smells of ammonia
Prepared by D. Chaplin
 Associated complications of chronic
Kidney Disease would be:
 Anaemia, mostly due to deficiency of
erythropoietin

 Bleeding which is caused by impairment of platelet

function

 Metabolic Bone Disease (known as Renal

Osteodystrophy)

Prepared by D. Chaplin
 Associated complications of chronic
Kidney Disease would be:

 Cardiovascular Disease
- hypertension, (which may further exacerbate
the renal failure)
-accelerated atherosclerosis
-pericarditis. 80% of those with chronic renal
failure develop hypertension which must be
treated

Prepared by D. Chaplin
 Associated complications of chronic
Kidney Disease would be:

 Nervous system – neuropathy caused by the loss

of myelin from nerve fibres – may improve when
dialysis is established

 Gastrointestinal complications - anorexia,

nausea and vomiting, and a higher incidence of
peptic ulcer disease

Prepared by D. Chaplin
 Associated complications of chronic
Kidney Disease would be:

 Skin disease – itching, which is attributed to the

retention of metabolic waste products. It often
improves with dialysis. Dry skin can also occur

 Muscle dysfunction - myopathy leading to

muscle cramps and the “restless leg” syndrome

Prepared by D. Chaplin
 Associated complications of chronic
Kidney Disease would be:

 Metabolic dysfunction - involving lipids, insulin

and uric acid (gout). Metabolic acidosis is also
associated

Prepared by D. Chaplin
Prepared by D. Chaplin
 Diagnosis

 Urine Tests
 Urinalysis
 Twenty-four hour
urine tests
 Glomerular filtration
rate (GFR)
 Blood Tests
 Creatinine and urea
(BUN) in the blood
Prepared by D. Chaplin
 Estimated GFR (eGFR)
 Electrolyte levels and
acid-base balance
 Blood cell counts
 Other tests
 Ultrasound:
 Biopsy
 Treatment Modalities

Decrease fluid 1000ml/day

Decrease protein (.5-1kg body weight)
Decrease sodium (1-4gm variable)
Decrease potassium
Decrease phosphorous (<1000mg/day)
Dialysis (periotoneal, hemodialysis)
RBC, Vitamin D (calcitrol replacement) etc.

Prepared by D. Chaplin
 Dialysis Hemodialyis(Hemo)Peritoneal (PD)

General Principal: Movement of fluid and

molecules across a semi permeable membrane
from one compartment to another

Hemodialysis – Move substances from blood

through a semi permeable membrane and into a
dialysis solution (dialysate –bath) (synethetic
membrane)

Peritoneal – Peritoneal membrane is the semi

permeable membrane
Prepared by D. Chaplin
 Osmosis-Diffusion-Ultrafiltration
Osmosis - movement fluid from an area of < to >
concentration of solutes (particles)
Diffusion - movement of solutes (particles) from an
area of > concentration to area of < concentration
[Remove urea, creatinine, uric acid and electrolytes,
from the blood to the dialystate bath] RBC, WBC,
Large plasma proteins do not go through

Ultrafiltration – Water and fluid removed when the

pressure gradient across the membrane is created,
by increase pressure in the blood compartment &
decrease pressure in the dialysate compartment

Prepared by D. Chaplin
 Peritoneal Dialysis
Catheter placement – anterior abdominal wall
Tenckoff (25cm length with cuff anchor and
migration)
Dialysis solution (1-2 liters sometimes smaller)
Three phases of PD
Inflow (fill) approximately 10 minutes, could
be in cycles)
Dwell (equilibration) (approximately 20-30
min or 8 hours+)
Drain (approximately 15 minutes)
These 3 phases are called Exchanges
Prepared by D. Chaplin
 Peritoneal Dialysis

Prepared by D. Chaplin
 Hemodialysis

Vascular access for high blood flow

Shunts, (teflon, external)
Arteriovenous fistulas and grafts (AV)
Anastomosis between an artery and vein
Fistulas are native vessels (4-6 wks
maturity)
Grafts are artificial/synthetic material

Prepared by D. Chaplin
 Hemodialysis

AV Fistula Communication

Prepared by D. Chaplin AV Graph Access

 Hemodialysis

Hemodialysis Circuit Hemodialysis Machine

Prepared by D. Chaplin
 PD Advantages and Disadvantages
Advantages Disadvantages
Immediate initiation Bacterial/chemical
peritonitis
Less complicated
Protein loss
Portable (CAPD)
Exit site of catheter
Fewer dietary Self image
restrictions
Hyperglycemia
Short training time Surgical placement of
Less cardio stress catheter
Choice for diabetics Multiple abdominal
surgery
Prepared by D. Chaplin
 Hemo Advantages & Disadvantages
Advantages Disadvantages
Rapid fluid removal Vascular access
Rapid removal of urea problems
& creatinine Dietary & fluid
Effective K+ removal restrictions
Less protein loss Heparinization
Lower triglycerides Extensive equipment
Home dialysis possible Hypotension
Temporary access at Added blood lost
the bedside Trained specialist

Prepared by D. Chaplin
 Disequalibrium Syndrome
Fluid removal and decrease in BUN during
hemodilaysis which cause changes in blood
osmolarity.These changes trigger a fluid shift from the
vascular compartment into the cells. In the brain, this
can cause cerebral edema, resulting in increase
intracranial pressure and visible signs of decreasing
level of consciousness. Symptoms: Sudden onset of
headache, nausea and vomiting, nervousness, muscle
twitching, palpitation, disorientation and seizures

Treatment: Hypertonic saline, Normal saline

Prepared by D. Chaplin
The following are general dietary guidelines:

 Protein restriction:
 Salt restriction
 Fluid intake:
 Potassium restriction:
 Phosphorus restriction:
 Control blood pressure and/or diabetes;
 Stop smoking; and
 Lose Excess Weight

Prepared by D. Chaplin
 Avoided or used with caution:
 Certain analgesics: Aspirin; ibuprofen
 Fleets or phosphosoda enemas because of their high
content of phosphorus
 Laxatives and antacids containing magnesium and
aluminum such as magnesium hydroxide
 Ulcer medication H2-receptor
antagonists: cimetidine, ranitidine
 Decongestants such as pseudoephedrine especially if
they have high blood pressure
 Herbal medications

Prepared by D. Chaplin
 Nursing Care Pre, Post Dialysis

Weigh before & after

Assess site before & after (bruit, thrill,

infection, bleeding etc.)

Medications (precautions before & after)

Vital signs before and after etc.

Prepared by D. Chaplin
 Renal Transplant
Living and Cadaveric donors
Predialysis: obtain a dry weight free of excess
fluids and toxins
More preparation time from a living donor vs.
cadaveric – transplant within 36 hours of
procurement
Delay may increase ATN
Pre-transplant: Immunotherapy (IV
methylprednisolone sodium succinate,
(A –methaPred, Solu-Medrol), cyclosporine
(Sandimmune and azathioprine ((Imuran)
Prepared by D. Chaplin
 Complications Post Transplant
Rejection is a major problem

Hyperacute rejection: occurs within minutes

to hours after transplantation

Renal vessels thrombosis occurs and the

kidney dies

There is no treatment and the transplanted

kidney is removed
Prepared by D. Chaplin
 Immunological Compatibility
of Donor and Recipient

Done to minimize the destruction (rejection) of

the transplanted kidney
HUMAN LEUKOCYTE ANTIGEN (HLA)
This gives you your genetic identity (twins share
identical HLA)
HLA compatibility minimizes the recognition of
the transplanted kidney as foreign tissues.

Prepared by D. Chaplin
 Immunological Analysis

WHITE CELL CROSS MATCH (the

recipient serum is mixed with donor
lymphocytes to test for performed
cytotoxic (anti-HLA) antibodies to the
potential donor kidney

A positive cross match indicates that the

recipient has cytotoxic antibodies to the
donor and is an absolute
contraindication to transplantation
Prepared by D. Chaplin
 Immulogical Analysis
MIXED LYMPHOCYTE CULTURE

The donor and recipient lymphocytes are

mixed. Result = HIGH SENTIVITY,
this is contraindicated for renal
transplantation.

ABO BLOOD GROUPING

ABO blood group must be compatible

Prepared by D. Chaplin
 Surgery

LLQ of the abdomen outside of the

peritoneal cavity

Renal artery and vein anastomosed to

the corresponding iliac vessels

Donor ureters are tunneled into the

recipients’ bladder.

Prepared by D. Chaplin
 Complications Post Transplant

Acute Rejection: occurs 4 days to 4 months after

transplantation
It is not uncommon to have at least one rejection
episode
Episodes are usually reversible with additional
immunosuppressive therapy (Corticosteroids,
muromonab-CD3, ALG, or ATG)
Signs: increasing serum creatinine, elevated BUN,
fever, wt. gain, decrease output, increasing BP,
tenderness over the transplanted kidneys
Prepared by D. Chaplin
 Complications Post Transplant
Chronic Rejection: occurs over months or years and
is irreversible.
The kidney is infiltrated with large numbers of T
and B cells characteristic of an ongoing , low
grade immunological mediated injury
Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum creatinine
levels
Supportive treatment, difficult to manage
Replace on transplant list
Prepared by D. Chaplin
 Complications Post Transplant
Infection
Hypertension
Malignancies (lip, skin,
lymphomas, cervical)
Recurrence of renal disease
Retroperiotneal bleed
Arterial stenosis
Urine leakage
Prepared by D. Chaplin
 100 patients with eGFR < 60
Prepared by D. Chaplin (Tuesday morning in Outpatients)
Tuesday morning 1 year later: 1 patient needs RRT, 10
patients have died (> 50% CV death)
Prepared by D. Chaplin
Tuesday morning 10 years later: 8 patients need RRT, 65 patients have
died,
Prepared 27 have
by D. Chaplinongoing CKD
 The majority of patients with CKD 1-3 do
not progress to ESRF.

Their risk of cardiovascular death is higher

than their risk of progression.

Prepared by D. Chaplin
 Optimise risk factors

 Cardiovascular disease
 Proteinuria
 Hypertension
 Diabetes
 Smoking
 Obesity
 Exercise tolerance
Prepared by D. Chaplin TAKE HOME MESSAGE
 Nursing Care Plan of a Patient With ESRD

• Nursing diagnosis: Excess fluid volume related to decreased

urine output, dietary excesses, and retention of sodium and
water.
• Goal: Maintenance of ideal body weight without excess
fluid.

46
Prepared by D. Chaplin
 Assess fluid status (Daily weight, intake and output
balance, skin turgor and presence of edema,
distention of neck veins, blood pressure, pulse rate,
and rhythm, respiratory rate and effort).
 Limit fluid intake to prescribed volume.
 Identify potential sources of fluid (medications and
fluids used
to take medications; oral and intravenous, foods).
 Explain to patient and family rationale for
restriction.
Prepared by D. Chaplin
 Nursing Care Plan of a Patient With ESRD (Cont…)

Nursing diagnosis: Imbalanced nutrition; less than

body requirements related to anorexia, nausea,
vomiting, and dietary restrictions.

• Goal: Maintenance of adequate nutritional intake.

48
Prepared by D. Chaplin
• Interventions: The nurse should:
 Assess nutritional status (weight changes, serum electrolyte,
BUN, creatinine, protein, transferrin, and iron levels).
 Assess patient’s nutritional dietary patterns (diet history, food
preferences, calorie counts).
 Assess for factors contributing to altered nutritional intake
(Anorexia, nausea, or vomiting, diet unpalatable to patient,
depression, lack of understanding of dietary restrictions,
stomatitis).
 Provide patient’s food preferences within dietary restrictions.
 Promote intake of high biologic value protein foods

Prepared by D. Chaplin
 Nursing Care Plan of a Patient With ESRD (Cont…)

Nursing diagnosis: Deficient knowledge regarding

condition and treatment.
• Goal: Increased knowledge about condition and
related treatment.

50
Prepared by D. Chaplin
• Interventions: The nurse should:
 Assess understanding of cause of renal failure, its
meaning and consequences, and its treatment.
 Provide explanation of renal function and
consequences of renal failure at patient’s level of
understanding and guided by patient’s readiness to
learn.
 Provide oral and written information as appropriate
about renal function and failure, fluid and dietary
restrictions, medications, reportable problems, signs,
and symptoms, follow-up schedule, community
resources, and treatment options.
Prepared by D. Chaplin
 Nursing Care Plan of a Patient With ESRD (Cont…)

Nursing diagnosis: Activity intolerance related to fatigue,

anemia, retention of waste products, and dialysis procedure.
• Goal: Participation in activity within tolerance.
• Interventions: The nurse should:
 Assess factors contributing to fatigue (anemia, fluid and
electrolyte imbalances, retention of waste products, depression)
 Promote independence in self-care activities as tolerated; assist if
fatigued.
 Encourage alternating activity with rest.
 Encourage patient to rest after dialysis treatments.

TAKE HOME MESSAGE 52

Prepared by D. Chaplin
 THANK YOU

Have a check on
your blood pressure
Sugar & Salt / year

Prepared by D. Chaplin