CKD, Dialysis, PD, HD, AV Fistula and Grafts

CKD

• Progressive, irreversible loss of kidney function
• Increased prevalence related to Age, obesity, DM, HTN
• Over half a million Americans receiving treatment for ESRD; high mortality rate

Kidney disease improving global outcomes (KDIGO) defines CKD as:

• Kidney damage
—Pathologic abnormalities
—Markers of damage (Blood, urine, imaging tests)
• Low glomerular filtration rate (GFR)
—<60 mL/min/1.73m2 for longer than 3 months

CKD Leading Causes

• Diabetes—50%
• Hypertension—25%
• Other: glomerulonephritis, Cystic/Urologic diseases
• Persons with CKD often asymptomatic; ~ 70% aware
• Underdiagnosed and untreated

Result of retained substances CKD

Uremia
• Syndrome which kidney function declines to point that symptoms in multiple body systems
• When GFR less than or equal to 15 mL/min-ESRD
• Manifestations vary depending on cause, co-morbidities, age, drug adherence

Hyperkalemia CKD

• Most serious electrolyte disorder in kidney disease
• Fatal dysrhythmias
— serum potassium 7 to 8 mEq/L (7 to 8 mmol/L)
• Low excretion, breakdown of cellular protein, bleeding, metabolic acidosis increases K+
• Other sources: food, supplements, drugs, IV infusions

CKD Sodium

• May be high, normal, low
• Impaired excretion causes sodium/water retention
• Dilutional hyponatremia (Edema, HTN, HF)

Hypermagnesemia CKD

• Ingestion of magnesium (e.g., milk of magnesia, magnesium citrate,
antacids)
• Absence of reflexes, Low mental status, dysrhythmias, hypotension, respiratory failure

Hypocalcemia/Phosphorous

Weakened bones, osteoporosis, bone fracture with trauma

Hypertension CKD

• Both cause and consequence of CKD
• From sodium/water retention
• Increased renin production may contribute

HTN, ECF overload, anemia =

LV hypertrophy

=

cardiomyopathy, HF

Labs & Diagnostics CKD

• History/Physical exam
• Dipstick evaluation - protein
• Albuminuria
• Urinalysis
• Renal US, CT scan, biopsy
• Albumin-to-creatinine ratio (first AM void)
• Serum BUN, creatinine/clearance, electrolytes, lipids, Hgb, Hct
• GFR

Drug therapy CKD

• Hyperkalemia
Sodium polystyrene sulfonate (Kayexalate)
—Cation-exchange resin; bowel exchanges Na+ for K+ ions
—Osmotic laxative (diarrhea)
Patiromer (Veltessa)—binds K+ in GI tract
—May bind other oral meds; take 6 hours before/after ; delayed onset
• Dialysis—most effective

Hypertension CKD Care

• Weight loss
• Lifestyle changes
• DASH Diet
• Antihypertensive drugs; two/more
• If diabetic—give ACE inhibitors, ARBs

CKD-MBD (mineral bone disorder) Drug Tx

• Phosphate binders
• Administered with each meal
• Side effect: constipation
• Avoid aluminum and magnesium preparations

Nutritional therapy CKD

• Sodium restriction
• Vary from 2-4 g/day
• Avoid high-sodium foods
• Salt substitutes be avoided because they contain potassium chloride

Dialysis

• Movement of fluid/molecules across a semipermeable membrane from one compartment to another
• Corrects fluid and electrolyte imbalances and removes waste products in kidney
failure
• Treat drug overdoses

Dialysis Cont.

• Started when patient’s uremia no cannot be treated conservatively; GFR < 15 mL/min/1.73 m2
• Nephrologist determines when to start
• Uremic complications require dialysis

Peritoneal Dialysis (PD)

• Peritoneal access - inserting catheter through anterior abdominal wall
• Usually surgery
• PD may start right away or bed delayed until site healed
• Aseptic technique - avoid peritonitis
• Performed at home

Exit site infection, PD Complication

• Redness, tenderness, drainage
• Treat with antibiotics

Peritonitis—Exit site/Tunnel infection (PD Complication)

• Abdominal pain, rebound tenderness, cloudy effluent with increased WBCs/bacteria, fever
• GI: diarrhea, vomiting, distention, Hyperactive sounds
• Antibiotics
• Repeated infections = adhesions

Hemodialysis (HD)

• HD requires rapid blood flow and access to a large blood vessel.
• Obtaining vascular access is one of most difficult problems
Types of access
• Arteriovenous fistulas and grafts
• Temporary vascular access

HD

• Created in forearm or upper arm— preferred access
• Fistula allows arterial blood to flow through vein; “arterialized”
• Increase vein size and wall thickness
• Placed 3 months before HD; needs to mature
• Feel “thrill” or hear “bruit” due to high velocity of blood flow

AV Fistula and Grafts Risks

• Distal ischemia (steal syndrome)
• Pain distal to access site
• Numbness or tingling of fingers
• Poor cap refill
• Aneurysms

AV Fistula and Grafts, SAFETY ALERT

• No BP, venipunctures, IV lines
—Post signs in room or labeled arm band
• Prevent infection and clotting

Complications of HD, Hypotension

• Hypovolemia, decreased CO/SVR
• Tachycardia, light-headed, nausea, seizures, vision changes, chest pain
• Tx: lower volume of fluid removal and IV NSS

Complications of HD, Muscle cramps

• Low BP, hypovolemia, high ultrafiltration, low-sodium dialysate
• Tx: lower ultrafiltration/IV fluids