Transcript Gerontology Nursing Review - Urinary and Reproductive Problems

Ruth Ann Fritz RN CNS-BC CCRN CNN
April 16, 2011
Objectives
 Identify normal changes in GU system
 Identify causes and care of End Stage Renal Disease in
the older adult population
 Calculate GFR
 Discuss pharmacological management of Diabetes,
Hyperlipidemia, and Hypertension in the geriatric renal
patient
 Identify proper renal doses for classes of medications
 Name two interventions to protect patient’s kidneys
AGE RELATED CHANGES
 Decreased body mass and malnutrition
 Genitourinary
 Male- Enlarged prostate - difficulties emptying bladder
 Females - Urgency, frequency, nocturia - Thin mucosa,
loss of muscle tone
 BPH, incontinence, and UTI complications
 Renal changes
 Decreased renal blood flow
 Decreased tubular function
 Decreased glomerular filtration rate (GFR)
AGE RELATED CHANGES
 Renal changes – cont.
 Decreased ability to regulate H+ ion and concentrate
urine
 Nephron degeneration - Decrease GFR (by age 70 - 3350% less)
 More difficulty maintaining homeostasis and fluid
balance
 Glomerular filtration rates decrease 6.5ml/ 10 years
 Creatinine level alone not reflect renal function as
decreased body mass and less creatinine production
ANATOMY
 Kidney
 Renal artery
 Cortex
 Medulla
 1 million nephrons each
 Renal pelvis
 Ureter
ANATOMY
 Nephron
 Glomerulus
 Tubules
 Loop of Henle
 Arterioles


Afferent
Efferent
 Capillaries
 Veins
Benign Prostatic Hypertrophy
 Anatomy and physiology
PHYSIOLOGY
 Endocrine function
 Renin, Prostaglandins,
 Erythropoietin
 Metabolic function
 Activation Vitamin D
 Gluconeogenesis - 10%
 Metabolism of
endogenous
compounds-insulin /
steroids- Enzymes
(Cytochrome P450)
 Excretory function –
(fluid, toxins, acid/base)
 Glomerular Filtration
 Passive
 Most proteins to large
 Tubular Secretion
 Active transport
 Proximal tubule
 Tubular reabsorption
 Water - fluid
 Solutes/drugs
CHRONIC KIDNEY DISEASE
 Incidence in elderly
 Older adults increased risk - CV system
 Due to age-related changes & BPH - renal pathology
 Hypertension results in 50-60 % deaths due to CRF
 Acute Renal Injury vs. CKD
 Elderly on dialysis increased by >50% in last decade
 Risk factors/ Causes
 Diabetes Mellitus and Hypertension
 Chronic illnesses, infections, nephrotoxic factors examples - X ray dye, NSAIDS, antibiotics
GLOMERULAR FILTRATION RATE
 GFR – equal to the total of the filtration
rates of all the functioning nephrons in
the kidney
 All functions associated with GFR
 Calculations based on BSA calculations
 GFR indicator of ability of kidney to
eliminate drugs from the body
 Calculation
 24hr Creatinine Clearance
 Estimates calculated from creatinine
level, gender, age, weight, and race
GLOMERULAR FILTRATION RATE
 Calculation ---(NKF web site)
 Estimates



Cockcroft-Gault Equation (CG)
Modification of Diet in Renal Disease –
(MDRD) – more accurate when GFR<60
2009 Chronic Kidney Disease
epidemiology collaboration (CKD-Epi)more accurate when GFR > or < 60
 Decreased GFR in elderly
 Predictor of adverse outcomes such as
death and cardiovascular disease
 Requires adjustment in drug doses
GLOMERULAR FILTRATION RATE
 Example -(NKF web site)

22 year old black male
 Creatinine – 1.2
 GFR – 98ml – normal or stage 1 CKD if damage

58 year old white male
 Creatinine – 1.2
 GFR – 66 ml – stage 2 CKD if damage

80 year old white female
 Creatinine 1.2
 GFR – 46 ml – stage 3 CKD
DEFINITION OF CKD
 Kidney damage for >/=3months, as defined by
structural or functional abnormalities of the kidney,
with or without decreased GFR, manifest by either:
 Pathological abnormalities; or
 Markers of kidney damage, including abnormalities in
the composition of the blood or urine, or abnormalities in
imaging tests
 GFR<60 mL/min for >/= 3 months, with or without
kidney damage
MARKERS OF CKD
 Proteinuria – main marker
 Spot total protein/creatinine ratio >200 mg/g
 False positives or negatives / two or more positive tests
 Associated with complications - early detection
 Prognostic finding – decrease in proteinuria correlated
with slower loss of kidney function
 Hematuria
 Other urine sediment abnormalities – casts, crystals
 Abnormal blood tests
STAGES OF CKD
INTERVENTIONS
 Increased risk for CKD GFR>90
 Screen for risk factors
 Stage 1 GFR >/= 90 – markers of damage
 Diagnose cause of CKD and treat
 Screen and treat risk factors
 Treat co-morbid conditions
 Screen and treat cardiovascular risk factors
 Stage 2 GFR60-89 mild complications
 Adjust medication doses
 Minimum yearly assess rate of GFR decline
INTERVENTIONS
 Stage 3 GFR 30-59 – moderate complications
 Minimum bi-yearly GFR assessment
 Screen for complications every 3 months and treat if present
 Stage 4 GFR15-29 – severe complications
 Refer for preparation for renal replacement therapy
 Management of complications
 Stage 5 GFR<15 – uremia, cardiovascular disease
 Begin replacement therapy if uremic and patient desirable
 Stage 6 – on replacement therapy
RENAL DOSES OF MEDS
 Check references and calculate doses of medications
based on GFR
 Age, sex, lab
 Race - AA, non AA
 Loading doses – no renal dose adjustments
 Maintenance doses – adjust two ways
 Reduce dose at regular intervals
 Lengthen dosing intervals
 If on hemodialysis may need to time meds after
treatment
PROTEINURIA MANAGEMENT
 Monitor spot protein/creatinine ratio goal 500-1000mg/g
 ACE Inhibitors/ARBs -renal/cardio protective
 Slow progression of diabetic kidney disease and
nondiabetic kidney disease with proteinuria
 Reduce proteinuria
 May have 15% drop in GFR in week 1 - usually returns
to baseline in 4-6 weeks
 Stop ACE Inhibitor / ARB


Potassium 5.6 or higher despite treatment
GFR decline > 30% in 4 months without explanation
MALNUTRITION
 Protein-energy malnutrition develops with CKD or
with age and associated with adverse out comes
 Low protein
 Low calorie intake
 Anorexia
 Other causes – proteinuria, GI issues, metabolic
acidosis, chronic inflammatory state in CKD
 Nutrition – Dietary consult – complex patients
 Megace, protein supplements – caution K level
DIABETES
 #1 cause of CKD
 Intensive management of diabetes goal Hgb A1C 6 or less
 Metformin (Glucophage)- risk of Lactic acid
 Avoid creatinine >1.5 men/>1.4 women
 GFR<50 -50% dose, GFR 10-50- 25% dose
 Avoid over age 80 or chronic heart failure
 Sulfonylureas – risk of hypoglycemia, long ½ life drugs
 Glipizide (Glucotol)/ glimepride (Amaryl) safe
 Avoid Glyburide (DiaBeta) and Chlorpropamide (Diabinese)
 Insulin management
HYPERTENSION
 #2 cause of CKD - complication of CKD- risk ESRD and
Cardiovascular disease - JNC 7 and KDOQI Guidelines
 Target BP less than 130/80 or lower
 Lifestyle changes (CKD diet)
 Preferred agents
 Diabetic or Proteinuria – ACE inhibitor or ARB
 Caution : If patient hypotensive and on ACE - reduced GFR
 Potential hyperkalemia with ACE/ARB, or with Potassium
supplements with diuretics
 Compelling indications, - Heart failure, DM, post MI
 Beers list –avoid Alpha blockers (Cardura), Clonidine
HYPERTENSION /FLUID MANAGEMENT
 Education -low sodium diet, BS control, and daily weights
 Monitor lab, GFR, BP, Dehydration
 Thiazide diuretics


HCTZ, Metolazone
Avoid <30GFR – creatinine >2.5, or has gout
 Loop diuretics


Lasix, Demadex, Bumex
All CKD stages
 Potassium sparing


Spirolactone, Triamterene, Amiloride
Caution/avoid renal disease, ACE, potassium supplements
 Dialysis - ESRD
ELECTROLYTES/ACIDOSIS
 Potassium supplementation/restriction
 Diuretic use
 CKD – monitor lab, diet instructions
 Hemodialysis - great caution
 Peritoneal – may need supplementation
 Bicarbonate – metabolic acidosis
 Calcium
 Magnesium - caution
 Aluminum – avoid (caution Sucrafate)
CARDIOVASCULAR DISEASE
 Risk for CVD – CAD, Cerebral vascular, and or
peripheral vascular disease
 Perfusion – atherosclerosis/calcification
 Cardiac function – CHF, LVH
 Most patients die of CVD not CKD
 Hyperlipidemia management, stop smoking, cardiac
evaluations , modification of medications
 Potential for Digoxin Toxicity with decreasing GFR –
adjust dose and schedule
 Anticoagulation –Caution Lovenox/Aggrenox
HYPERLIPIDEMIA
 Statin doses
GFR >/=30 <30/dialysis
 Simvastatin (Zocor)
20-80
5-40
 Atovastatin (Lipitor)
10-80
10-80
 Pravastatin (Pravachol)
20-40
10-40
 Fluvastatin (Lescol)
20-80
10-40
 Lovastatin (Mevacor) – avoid <30 GFR
 Dose adjustments for pt on Cyclosporine or Tacrolimus
 Nicotinic acid – Niacin / Fish oil
 Bile acid sequestrant – Cholestid
 Zetia
INFECTION MANAGEMENT
 CKD patient at increased risk for infections, elderly
prone to develop UTI/sepsis
 Antibiotics – long ½ life and some are nephrotoxic and
need drug levels – Check dosages
 Penicillin
 Avoid Penicillin G
 Amoxicillin – 500mg TID or BID
 Avoid
 Imipenum/cilastatin – seizures
 Tetracyclines except doxycycline – exacerbates uremia
INFECTION MANAGEMENT
 Avoid
 Nitrofurantoin (Macrobid)– metabolite cause peripheral
neuritis/ nephrotoxic
 Aminoaglycosides – if possible
 Examples of dosages
 Cipro 250-500 daily
 Levaquin 250 QOD**
 Vancomycin – 1gm load/ 500mg- 750mg dose-ESRD –
end of treatment-Drug levels
 Z pack no change – lasts longer
 Bactrim – decrease 50% GFR 15-30, avoid < 15 GFR
NEUROPATHY
 Common complication – level of CKD
 Encephalopathy
 Peripheral polyneuropathy
 Autonomic dysfunction
 Sleep disorders – restless legs
 Peripheral mononeuropathy
 Dialysis, - PD/HD, transplant, Epogen, vitamins
 Tricylic antidepressants – avoid Elavil (Amtriptiline)–
Beers list
 Anticonvulsants -Neurontin (Gabapentin) adjust dose on
CKD level
 Lidocaine patch, Lyrica, Requib
PAIN MANAGEMENT
 Avoid
 All NSAIDS and Cox inhibitors – Toradol
 Darvocet, Demerol, and Codeine, Benadryl (Beers list),
Cymbalta – avoid <30 GFR
 Caution
 Tylenol (max 3 gm/day)( in Lortab)
 Reduce dose –Neurotin, Allopurinol, Morphine
 Tramadol (Ultram/Ultracet) check seizure 200mg/day
 Topical Lidocaine, capsaicin
 Treat depression, insomnia- (Rozerem/Trazadone)
GASTOINTESTIONAL CARE
 Antacids
 Laxatives – avoid MOM, Mag citrate
 GERD treatment
 H2 – avoid Tagament
 PPIs
 Nausea – constipation, gastroparesis
 GI preps – caution with phosphate preparations -
GoLytely
 Enema – Avoid fleets phos soda - Phos
ANEMIA MANAGEMENT
 Early complication of CKD – increased Cardiovascular
risk – Target 11-12 hemoglobin
 Lab for anemia workup
 Supplemental Iron IV/Oral – caution constipation
 Erythropoietin Therapy
 Procrit -predialysis/Epogen – dialysis
 Aranesp
 Renal Vitamin with Folic Acid
 Malnutrition plays role -Albumin level
BONE AND MINERAL
 Abnormal mineral metabolism of CKD leads to
secondary hyperparathyroidism and bone disease
and other related complications (fractures)
 Early complication due to abnormal mineral
metabolism and treatments in CKD. Can result in
calcification of arterial system and cardiovascular
disease
BONE AND MINERAL
 Lab–Ca, phos, PTH, Vitamin D 25/ 1,25
 Dietary Phosphorous Management/oral Vitamin D
 Phosphate Binders
 Ca based – Tums, Phoslo
 Non Ca based – Renagel, Fosrenal
 Activated Vitamin D Therapy oral/IV
 Calcijex /Rocaltrol
 Zemplar
 Hectoral
 Sensipar
HERBAL MEDICATION
 St John's wort and ginkgo – increase metabolism of
other meds
 Ginkgo bleeding risk if on ASA, warfarin, or ibuprofen
 Alfalfa, dandelion, and noni juice contain potassium
 If contain heavy metals and Chinese products with
aristolochic acid are nephrotoxic
 Vasoconstrictive additives can cause hypertension
PROTECTION OF KIDNEY
 NSAID use risk – Arthritis in elderly
 Contrast Protections
 Monitor lab prior to procedures – Calculate GFR
 Mucomyst
 Sodium Bicarbonate/NS Infusion
 Non Ionic contrast – minimal amt
 Avoid hypotension
 Avoid nephrotoxic meds/ proper dosages of meds
 Avoid dehydration, control co-morbids, and Educate !!
GERIATRIC MEDICATION ISSUES
 Polypharmacy
 Different providers
 Name brand or generic
 Simple dosing schedule as possible
 Be sure can afford – try to make meds last
 Encourage use of aids- pillboxes, calendars
 Instruct relatives and caregivers - use Home health,
pharmacy that delivers
 Caution when prescribe – review meds – check side
effects, and interactions
QUESTIONS