Chronic Kindey Disease

what is chronic kidney disease

• a gradual irreversible condition of the kidney

  • GFR of less than 60 mL/min for more than 3 months

  • diminished fucntioning of the nephrons

  • reductiong of the kidneys ability to remove waste and maintain homeostasis

  • casues uremia = toxins to build up becuase of lack of filtration

  • may be asymptomatic until >40% of nephrons are lost

caused of CKD

• diabetes mellitis (45% of cases)

• HTN

  • exacerbates damage to renal disease

  • evidence based guidelines keep BP <130/80

• Glomerulonephritis

inherited disease causes of CKD

• polycystic kidney disease

• urinary tract obstructions

• immune disorders

• infections

• vesouretal reflex

metabolic causes of CKD

• DM, gout, amyloisosis (folded protiens build up in organs and body cannot break then down)

obstrictive causes

• urethral structure

• urethral constriction

• renal tract calculi

• hydronephrosis

immunologic disorders that cause CKD

• glomerularnephritis

  • inflammation of the glomerulu due to an antigen antibody reaction in the glomerulus

  • characterized by hematuria, proteinuria, elecated BUN and Creatinine, decreaed GFR, edema, HTN, Na + retention

• lupus

  • causes nephron damage

• goodpasture’s syndrome

  • characterized by antibodies to the glomerular basement membrane. can affect lung tissue. immunosuppressants and steroids

what is nephrotic syndrome

• group of symptoms that include protein in the urine, low blood protein levels, high cholesterol levels, high triglyceride levels and swelling

• syndrome caused by different disorders that damage the kidneys - not one specific disease

• occurs with many renal disease and systemic diseases that cause glomerular damage

• not a specific disease but a constellation of clinical findings that result from glomerular damage

complications of nephrotic syndrome

• infection

• throboembolism (esp in renal vein)

• pulmonary emboli (clot)

• acute renal failure

• accelerated atherosclerosis

treatment of nephrotic syndrome

• diuretics

• ace inhibitors

• lipid-lowering agrents

• anticoagulants

polycystic kidney disease - inherited kidney disease

• genetic disorder

• characterized by the growth of numerous cysts in the kidnets

• cysts filled with fluid, from in the kidneys destroying nephrons

• no cure, will need dialysis or transplant

• genetic counseling

manifestations of polycystic kidney disease

• hematuria

• polyuria

• HTN

• Protienuria

• frequent renal stones

• UTIs

Vascular causes of CKD

• hypertension

  • too much strain causing damage on the kidneys

  • extrea fluid volume in the kidneys

  • treat with aces, arbs, and beta blockers

• infarctions

goals of management with chronic kidney disease

• delay progression of renal failure

• prevent buildup pf toxic metabolic waste products and nutrient excesses

• prevent complciations

  • growth failure, wasting syndrome, bone disease, HTN, edema, CHF

• foster pt well being

management of CKD

• ideal BP of a systolic <130 and diastolic <80

• treat underlying cause

• regular lab assessments

• early initiation of renal replacement therapies

• treating hyperglycemia and anemia

• prevention of complications by controlling cardiovascular risk factors

• smoking cessation, wt loss, exercise program

• no NSAIDs or other harmful meds

gerontologic considerations with CKD

• aging kidney is less able to compensate for changes in fluid volume, solute load, and cardiac output

  • number of functioning nephrons decrease with age

  • decreased renal clearance of certain meds and dyes

5 stages of CKD

• stage 1

  • does not show any ss of disease

  • normal or elevated GFR (≥90 mL/min) and may have other risk factors.

• stage 2

  • damage with mild decrease in funcion

• stage 3

  • moderate decrease in kidney unction

• stage 4

  • severe kidney function decrease

• stage 5

  • renal failure

  • kidneys cannot remove any toxins or perform any regulatory functions

  • renal replacement therapies are necessary (dialysis or transplant).

stage 1 of CKD

• GFR > 90

• kidney damage with normal GFR

• diagnosis and treatment of underlying conditions

• no symptoms

• diminished renal reserve (lower threshold to have AKI)

stage 2 of CKD

• damage with mild decrease in kidney function

• GFR 60-89 mL/min

• may have hypertension or other risk factors.

stage 3 of CKD

• moderate decrease in kidney function

• GFR 30-59 mL/min

• may experience symptoms such as fatigue or anemia.

• evaluate and treatment of complications

stage 4 of CKD

• severe decrease in kidney function

• GFR 15-29 mL/min

• prepare for renal replacement therapy or transplant; put in fustula for dialysis

stage 5 of CKD

• kidney failure requiring dialysis or transplantation

• GFR less than 15 mL/min

• significant symptoms and complications may be present.

• need renal replacement therapy for survival

• “end stage renal disease”

uremia

• can occur in stage 4&5 of CKD

• as renal function declines, the end products of protein metabolism accumulates in the blood

  • uric acid (noramlly excreted in the urine)

• uremia develops and affects every system in the body

acid - base imbalance with uremia

• metabolic acidosis

  • kidnet not excreteing H+ ions

  • defective reabsorption and regeneration of bicarb

  • treatment: dialysis

  • may treat acitely with bicarb - PO or IV

• compensation

  • respiratory

  • bittering form boen causing demineralization

  • abnormalities in Ca+ and Phos

peripheral nervous system effects of uremia

• atrophy and demyelination of nerves

• restless leg syndrome

• burning of soles of eet

• impaired motor function

• muscle twitching

neurological effects of uremia

• related to uremic toxins and electrolyte imbalances:

  • fatigue, lethargy, weakness

  • HA, impaired thinking, difficultly concentrating and confusion

  • irritabiliy

  • insomnia

  • confusion

  • seizures, coma

psychologlical effects of uremia

• depression

• anxiety

• denial

• psychosis

• related to their diagnosis and outlook on life/treatment

msk effect sof uremia

• bone pain and fractures

• related to impaired calcium absorbtion

• kidneys failure to activate vitamin D

• and activation of the parathyroid hormone

• muscle cramps, loss of muscle

• foot drop

cardiovascular effects of CKD and uremia

• HTN

• NA and fluid retention: RAAS

• heart failure

  • pitting edema, periorbital edema

  • fluid overload

• pericarditis: excess pericardial fluid and fubrin formation on epicardium can cause tampinade

• atherosclerosis

• hyperK

• heart and kidneys closely combined - cardiorenal syndrome

  • heart damage leading to kidney damage or visaversa

respiratory effects of uremia

• uremic lung: uremic pneumonitis or intersitital edema

• pulmonary edema: dyspnea, SOB, crackles, tachypnea

• Uremic pleuritis (inflammation of pleural space

• pneumonia (immunocompromised): thick, tenacious sputum

• Kussmauls breathing to decrease CO2: deep labored breathing (to compensate for acidosis)

GI effects of uremia

• stomach lining may be inflamed

• NAVD

• GI bleeding

• gastristis

• stomatitis

• Uremic fetor (urine smelling breath): salivary urea broken down to ammonia

• diarrhea

• hyperK

dermatologic effects or uremia

• bronze-grey skin color

  • uremic deposits - uremic frost

  • pallor

• dry skin

  • brittle dry hair and nails

• decreased perspiration

  • atrophy of sweat glands and dehydration

• ecchymosis

• purpura (bleeding under the skin)

uremic frost

• causes itching and skin fragility due to waste product excretion through skin

• treat with creams, cool baths, oatmeal baths

• adequate nutrition and hydration

• antihistamines for pruritus

• nutrition

hematologic effects of uremia

• impaired kidneys will cause anemia of chronic disease

  • loss of erythripoietin

  • the shorted lifespan of a RBC

• bleeding tendency

  • thrombocytopenia

  • platelet defects

immunologic effects of CKD and uremia

• suseptibility to infection

• changes in WBC function

• primary sites:

  • urine

  • resp

  • wounds

  • dialysis sites

  • lines

    • want to avoid foleys

    • central lines

    • keep aseptic technique

endocrine and reproducts effects of CKD

• hypothyroidsism

• hyperparathyroidosm

• infertility

• amenorrhea

• testicular atrophy

• sexual dysfunction

  • impotence

  • decreased libido

  • infertility

electrolyte imbalances in kidney failure

• hyper K

• hyper or hypo natremia

• hyperphosphatemia

• hypocalcemia

• hypermagnesemia

why hyper K occurs in renal disease

• more hydrogen ions than potassium ions are selectively secreted in exchange for sodium ions

• decreased ability to excrete means build up

ss of hyper K

• potassium > 6.5

  • myocardial depression

  • flat P wave, peaked T, widened QRS, bradycardia, heart block, asystole

• sooth muscle weakness

• NAVD

• drowsiness, irritable, confusion

hyponatremia in ckd

• fluid volume overload resulting in hypernatremia

• fluid wants to go to into the cells to balance levels

  • this leads to brain swelling

• ss

  • confusion

  • convulsions and seizures

  • cerebral edela

  • fatigue

  • HA

  • irritability

  • loss of appetite

  • MSK spasms, cramps, weakness

  • NA/V

  • restlessness

hyperphosphatemia in ckd

• common in ckd

• ckd pts on phos respetcion

  • restrict: red meats, beans, legume, nuts, dairy, eggs, milk products, beer, tofu, chocolate, PB

• phosphate binders

  • given with each meal

hypocalcemia in ckd

• usually low (inverse ralationship with phos)

• renal octeodystrphy/osteomalacia

• impaured vit D metabolism causes imapred CA absorbtion

ss of hypocalcemia

• irritable, drpessed

• muscle cramps

• tetany

• chvosteks/trousseau signs

• psychosis

• seizures

treatment of hypocalcemia and vit D deficiency

• calciuim suppplemets

  • high calcium foods

  • tuma

  • vit D

• rocatrol - active form of Vit D

  • must take with meals

  • check serum phos

  • binds with phos and provides calcium

hypermagnesemia in ckd

• not usually a problem inless ingesting extra

• manifestations:

  • absense of reflexes

  • decreased mental status

  • dysrhythmias

  • resp failure

treatment of anemia

• replace erythropoietin

  • meds: Epogen, procritt, aranesp (LA)

  • decrease need for transfusions

  • wont take effect for 2-6 weeks

• along with iron sups, folic acid, B12

• blood transfusions

  • however it can supress erythropoiesis

  • if H/H too low of pt symtomatic

  • risk for fluid volume overload

• goals HG 11-12

• goal Hit 33-36%

renal diet

• low protien before dialysis, increase once on dialysis

• low phosphate, sodium, potassium

• fluid restriction

• vitamins

• calcium supplements

• maintain adequate calorie intake (>35 cal/kg/day)

diet to limit formation of uremic toxins

• low protein (0.6-0.7 g/kg/ IBW*day)

  • eggs, meat, poultry

  • supplement with amino acids and ketoanalogues

  • aim for complete proteins and high quality

  • once on dialysis want to increase protien to 1.2-1.3 g/kg IBW*/day)

• obtain cals from carbs and fat

vitamin supplements with ckd

• water soluble vitamins

  • may develop deficiencies

  • vitamins lost during hemodialysis and there is a moor intake of vitamins

• nephro caps which includes

  • vitamin D, c, thiamine, riboflavin, B vitamins and folic acid

  • supplementation of fat solyble vitamins not necessary