Transcript Chronic Kidney Disease
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Chronic Kidney Disease
Chronic Kidney Disease
Progressive, irreversible damage to the nephrons and glomeruli
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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.
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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
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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
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Stage 1 Table 1. Stages of Chronic Kidney Disease *GFR is glomerular filtration rate, a measure of the kidney's function.
Description GFR* mL/min/1.73m
2 Slight kidney damage with normal More than 90 or increased filtration 2 3 4 5
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Mild decrease in kidney function 60-89 Moderate decrease in kidney function Severe decrease in kidney function Kidney failure 30-59 15-29 Less than 15 (or dialysis)
Non-Modifiable Factors -Hereditary -Age greater than 60 years old -Gender -Race BUN Dilute Polyuria Modifiable Factors -Diabetic Mellitus -Hypertension -Increase Protein and Cholesterol Intake -Smoking -Use of analgesics Decreased renal blood flow Primary kidney disease Damage from other diseases Urine outflow obstruction Decreased glomerular filtration Hypertrophy of remaining nephrons Inability to concentrate urine Serum Creatinine Loss of Sodium in Urine Dehydration Further loss of nephron function Failure to convert inactive forms of calcium Calcium absorption Loss of nonexcretory renal function Failure to produce eryhtropoietin Anemia Pallor Impaired insulin action Erratic blood glucose levels Production of lipids Advanced atherosclerosis Immune disturbance Delayed wound healing s Infection Hyponatremia Disturbances in reproduction Libido 2 a Infertility
Hypocalcemia 1 Osteodystrophy Excretion of nitrogenous waste Uremia BUN, Creatinine Uric Acid Proteniuria Decreased sodium reabsorption in tubule Water Retention Hypertension Heart Failure Edema Peripheral nerve changes Pericarditis CNS changes Pruritus Altered Taste Bleeding
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s 2 a Loss of excretory renal function Decreased potassium excretion Hyperkalemia Decreased phosphate excretion Hyperphosphate mia Decreased calcium absorption Hypocalcemia Hyperparathyroidis m Decreased potassium excretion Increased potassium Decreased hydrogen excretion Metabolic acidosis
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
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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
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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
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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
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Associated complications of chronic Kidney Disease would be:
Metabolic dysfunction - involving lipids, insulin and uric acid (gout). Metabolic acidosis is also associated
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Diagnosis
Urine Tests Urinalysis Twenty-four hour urine tests Glomerular filtration rate (GFR) Blood Tests Creatinine and urea (BUN) in the blood
Estimated GFR (eGFR) Electrolyte levels and acid-base balance Blood cell counts Other tests Ultrasound: Biopsy
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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.
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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 > c
oncentration 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 pressure gradient
removed when the across the membrane is created, by increase pressure in the
blood compartment
decrease pressure in the
dialysate compartment
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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
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Peritoneal Dialysis
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
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Hemodialysis
AV Fistula Communication
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AV Graph Access
Hemodialysis
Hemodialysis
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Circuit Hemodialysis Machine
PD Advantages and Disadvantages
Advantages Immediate initiation Less complicated Portable (CAPD) Fewer dietary restrictions Short training time Less cardio stress Choice for diabetics Disadvantages Bacterial/chemical peritonitis Protein loss Exit site of catheter Self image Hyperglycemia Surgical placement of catheter Multiple abdominal surgery
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Hemo Advantages & Disadvantages
Advantages Rapid fluid removal Rapid removal of urea & creatinine Effective K + removal Less protein loss Lower triglycerides Home dialysis possible Temporary access at the bedside Disadvantages Vascular access problems Dietary & fluid restrictions Heparinization Extensive equipment Hypotension Added blood lost Trained specialist
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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
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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
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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
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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.
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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)
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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
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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.
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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
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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
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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.
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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
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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
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Complications Post Transplant Infection Hypertension Malignancies (lip, skin, lymphomas, cervical) Recurrence of renal disease Retroperiotneal bleed Arterial stenosis Urine leakage
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100 patients with eGFR < 60 (Tuesday morning in Outpatients)
Tuesday morning 1 year later: 1 patient needs RRT, 10
Tuesday morning 10 years later: 8 patients need RRT, 65 patients have
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.
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Optimise risk factors
Cardiovascular disease
Proteinuria
Hypertension
Diabetes
Smoking
Obesity
Exercise tolerance TAKE HOME MESSAGE
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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.
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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.
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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.
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•
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
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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.
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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 resources, and treatment options.
schedule, community
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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.
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TAKE HOME MESSAGE
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THANK YOU Have a check on your blood pressure Sugar & Salt / year