Topic 9: CKD and Dialysis

kidney failure

partial/complete impairment of kidney function that results in the inability to excrete metabolic waste products and water, affecting all body systems, with difficult treatments, dietary, and life style changes

CKD

progressive and irreversible loss of kidney function

• DM (MC)

• HTN

• glomerulonephritis

• cystic diseases

• urologic disease

• age over 60

• obesity

• CVD

• ethnic minorities (Blacks, Native Americans, Hispanics)

• Exposure to nephrotoxic drugs

• Family history of CKD

what are the main causes/RF of CKD

< 60 for longer than 3 months

what GFR is indicative of CKD

stage 1

stage of CKD in which GFR > 90, the least severe

stage 5

stage of CKD in which GFR < 15, the most severe and not sustainable of life

uremia

a syndrome in which kidney function declines to the point that symptoms develop in multiple body systems, and often occurs when the GFR is 15 mL/min or less

• uremia and uremia frost

• anxiety and depression

• MI, HTN, HF, CAD, pericarditis, PAD

• Anorexia, N/V, bleeding, gastritis, stomatitis, metallic taste in mouth, periodontal disease, weight loss, malnutrition, constipation

• hyperparathyroidism, thyroid abnormalities, amenorrhea, ED

• Defective carbohydrate metabolism causes mild to moderate hyperglycemia and hyperinsulinemia, leading to hyperlipidemia

• anemia, bleeding, infection

• fatigue, HA, sleep disturbances, encephalopathy, irritability, decreased ability to concentrate, altered mental ability, B/L foot drop, muscular weakness and atrophy, loss of DTR, asterixis, nighttime leg cramps, seizures, coma

• pulmonary edema, pneumonia, Kussmaul breathing, dyspnea

• pruritus, ecchymosis, dry/scaly skin

• vascular and soft tissue calcification, osteomalacia

• paresthesia, restless leg syndrome, peripheral neuropathy

• as GFR decreases, BUN increases → N/V, lethary, fatigue, imapired

• hyperkalemia, hyper/hyponatremia

• metabolic acidosis

what are the S/S of CKD

• dipstick evaluation of protein in urine

• albuminuria

• urinalysis

• GFR

what are the ways to diagnose CKD

are nephrotoxic, increase BP, interfere with other meds, accumulate in the body

when assessing a patient with signs or with CKD what medications should concern you

• fluid imbalance

• electrolyte imbalance

• impaired cardiac function

• difficulty coping

what are the clinical problems associated with CKD

• regular checkup with routine urinalysis and GFR calculations

• if have DM: urine checked for albuminuria routinely and report any change in urine appearance, odor, frequency, or volume to HCP

• Glycemic and BP control

• quit smoking

what does health promotion include for those at risk for CKD

• restrict high-potassium food and drugs

• if acute can give IV glucose and IV 10% calcium gluconate

what are the ways to lower potassium in those with CKD

• weight loss if needed

• lifestyle changes: exercise, avoid alcohol, smoking cessatin

• DASH diet

• antihypertensives

  • measure with the patient supine, sitting, and standing to see effects

• teach how to monitor at home

what are the ways to lower BP in those with CKD

• limit phosphorous intake to 1 g/day

• give phosphate binders with each meal

  • be aware of constipation as a side effect, may need stool softeners

• supplement with vitamin D

• control hyperparathyroidism

• do not use magnesium containing antacides

what are the ways to manage CK-MBD

• give exogenous EPO

• may take 2-3 weeks for Hgb and Hct to increase

• Higher doses increase risk fo thromboembolic events and death from MI/stroke so use the lowest dose possible

• do not give if they have uncontolled BP

• may lead to iron deficiency so give iron supplents

  • do not take at same time as phosphate binders

what are the ways to lower anemia in those with CKD

phosphate binders

• calcium based binders that bind to phosphate in the bowel and then excrete it in the stool

• should be given with each meal

• constipation is frequent side effect so may need stool softeners

• calcium supplements, phosphate binders, or both

• antihypertensives

• ACE inhibitors or ARBs

• EPO therapy

• lipid-lowering drugs

what drug therapy is available for CKD

• altered metabolism

• anemia

• dental problems

• anorexia

• nausea

• depression

• complex diets that restrict protein, phosphorus, potassium, and sodium

what factors lead to malnutrition in those with CKD

• stages 1-4: normal intake

• HD: not routinely restricted, but should avoid high diets as it may overburden the diseased kidneys

• PD: must be increased to compensate for loss through the peritoneal membrane so the nitrogen balance is maintained

• 1.2 g/kg of ideal body weight

what does protein intake/restrictions look like for someone with CKD

• stages 1-5 and PD not restricted and diuretics used to reduce fluid retention

• HD: more restricted

  • usually 600 mL plus an amount equal to the previous day’s urine output

• foods that are liquid at room like like gelatin and ice are counted as intake

• space intake throughout the day so they do not become thirsty

• limit so weight gains are not more than 1-3 kg between dialyses

what does fluid intake/restrictions look like for someone with CKD

• restricted to 2-4 g/day

• avoid processed meats, canned soups and stews, cold cuts, many dressings, and salt substitutes (often contain potassium too)

what does sodium intake/restrictions look like for someone with CKD

• restrictions range from 2000-3000 mg/day

• HD: avoid high foods

• PD: usually no restriction

what does potassium intake/restrictions look like for someone with CKD

• limit to 1 g/day

• avoid high foods: meat and dairy products, milk, icre cream, cheese, yogurt, pudding

what does phosphate intake/restrictions look like for someone with CKD

• diet and fluid intake/restriction teaching

• common problems with modifying diet and fluid

• S/S of electrolyte imbalances and fluid overload

• alternate ways to reduce thirst: sucking on ice cues, lemon, or hard candy

• reasons for prescribed drugs and common SE

  • take phosphate binders with meals

  • take calcium supplements on an empty stomach and not at the same time as iron supplements

  • take iron supplements between meals

  • encourage use of a pillbox, write down drugs/times to take them

• report any weight gain > 4 lbs, increasing BP, SOB, edema, increasing weakness/fatigue, confusion, or lethargy to HCP

• encourage patients to plan and active role in care

• take daily BP readings

• avoid OTC meds like NSAIDs, and aluminum and magnesium-based laxatives/antacids

• Meet with a dietitian regularly

• can complete an evaluation for a kidney transplant prior to the need to start dialysis, and may receive one before even needing to start dialysis

• explain what is involved in PD or HD

• inform that while on dialysis, transplant is still an option, and if transplant fails, the patient can return to dialysis

• discuss palliative care as needed

what does education for a patient with CKD include

dialysis

movement of fluid/molecules across a semipermeable membrane from one compartment to another; used to correct fluid and electrolyte imbalances and remove waste products in kidney failure or to treat overdoses; types or peritoneal dialysis or hemodialysis

PD

The peritoneum acts as a semipermeable membrane, and excess fluid is removed by increasing the osmolality of the dialysate by adding glucose via access through a catheter (surgically and aseptically placed) in the anterior abdominal wall, with the tip in the peritoneal cavity

• before: empty bladder and bowel, weigh patient, obtain signed consent

• after placement it can start at once with low-volume exchanges or be delayed for 2 weeks pending healing and sealing of the site

• once healed the patient may shower and then pat dry the catheter and the exit site

• teach how to check the site for signs of infection

what are the pre and post op considerations for the placement of the catheter for PD

• inflow (fill)

• dwell (equilibrium)

• drain

what are the 3 phases in a PD cycle

inflow (fill)

stage of PD cycle in which 2-3 L is infused over 10 minutes, flow rate can be slow down if pt is experiencing pain inflow clamp in closed after completion

dwell (equilibrium)

stage of PD cycle in which diffusion and osmosis occur between the patient’s blood and peritoneal cavity, taking around 4-6 hours

drain

stage of PD cycle that takes 15-30 minutes and may be facilitated by gently massaging the abdomen or changing positiong

exchange

what the cycle of PD is called

dextrose

what is the osmotic agent in PD

automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD)

what are the types of PD

APD

• the most popular form of PD because the cycler delivers the dialysate during sleep times and controls fill, dwell, and drain phases; alarms and monitors are there for safety

• cycles 4 or more exchanges per night with 1-2 hours per exchange

• patient disconnect from the machine in the morning and usually leaves fluid in the abdomen during the day

• hard to achieve required solute and fluid clearance with nighttime APB and 1-2 daytime manual exchanges may be needed to ensure adequate dialysis

CAPD

• PD that requires the manual exchange four times during the day, usually every few hours

• instill 2-3 L of dialysate from a plastic bag into the peritoneal cavity through a disposable admin line and then disconnects it

• after equilibration, the line is reconnected to the catheter, the dialysate is drained, and a new 2-3 L bag is infused

• peritonitis

• hernia

• lower back problems

• bleeding

• pulmonary complications: atelectasis, pneumonia, and bronchitis

• protein loss into dialysate

• hyperglycemia

• surgery is required for catheter placement

• contraindicated in those with multiple abdominal surgeries, trauma, or unrepaired hernias

• a catheter can migrate

• self-image problems with catheter placement

what are the complications and disadvantages of PD

• short training program (3-7 days)

• almost immediate initiation in any hospital

• simple

• less CV stress

• usable in patients with vascular access problems

• fewer dietary restrictions

• less complicated than HD

• home-based program

• increasing patient participation

• no need for special water systems

• equipment set up is relatively simple

what are the advantages of PD

HD

dialysis in which an artificial membrane that is cellulose-based or made of synthetic materials is used as the semipermeable membrane and is in contact with the patient’s blood; gradient is created by increasing pressure in the blood/decreasing pressure in the dialysate so ECF moves dialysate and extra fluid is removed by creating a differential; requires rapid blood flow and access to a large BV; obtaining vascular access is one of the most difficult problems

• fluid status: weight, BP, peripheral edema, heart and lung sounds

  • weight from last post-dialysis and current weight pre-dialysis determnes how muchh fluid is removed

• assess vascular access

• assess temperature

• monitor VS every 30-60 minutes

what should a nurse assess before beginning HD

atriovenous fistula/graft or temporary vascular access

what are the types of access for HD

AVF

HD access that is created in the forearm or upper arm and is the preferred access for HD; allows arterial blood to flow through a vein, and it becomes “arterialized” increasing in size and developing in thicker walls; placed 3 months before HD as it needs to mature and is hard to create for those with a history of severe peripheral vascular disease (DM), prolonged IV drug use, and obese women

feel a thrill or hear a bruit

What must a nurse feels and hears in an AFV

AVG

HD access that is a graft made of synthetic materials is surgically placed under the skin to form a bridge between the brachial artery and antecubital vein, and takes 2-4 weeks to heal, but it may be used earlier and is more likely to get infected and form clots; must be surgically removed if infected

• distal ischemia (steal syndrome)

• aneurysms

• infection and clotting

• cannot take BP, venipuncture, or have IV lines in extremities with AV access to prevent infection and clotting of access

what are the risks of AVF/AVG

temporary vascular access

catheter insertion of the internal jugular or femoral vein when immediate access is needed; has a double lumen with one for blood removal and one for blood return; high risk of infection, dislodgement, and malfunction, and cannot be discharged home with one; uses long-term cuffed catheters to keep in place

long-term cuffed catheters

often used for temporary vascular access when waiting for AVF or if other forms have failed; exit on the upper chest and tunneled to the internal or external jugular vein, tip is in the right atrium, and 1-2 cuffs prevent infection and anchor the catheter, eliminating the need for sutures

• 2 large-bore needles are placed in the fistula/graft

  • 1 to pull blood from the circulation to the HD machine other is used to return dialyzed blood to the patient

• heparin is added to prevent clotting

• a dialysate delivery and monitoring system is used

• dialyzer/bloodlines are primed with saline solution to eliminate air

• terminated by flushing with saline to return all blood to the patient

• Needles are removed, and firm pressure is applied

what is the process of HD

• hypotension

• muscular cramps

• loss of blood

• hepatitis C

• vascular access problems

• diet and fluid restriction

• Heparinization may be necessary

• extensive equipment necessary

• added blood loss that contributes to anemia

• specially trained personnel are necessary

• surgery for permanent acess placement

• self-image problems with permanent access

• cannot fully replace the normal functions of the kidneys

• CV disease carriers have a high mortality rate

• infection complications are the 2nd leading cause of death

what are the complications/disadvantages of HD

• rapid fluid, urea, creatine, and potassium removal

• less protein loss

• lowering of serum triglycerides

• possible at home

• can ease many S/S

• can prevent certain complications

what are the advantages of HD