Chronic Kidney Disease and End Stage Renal Disease

what is chronic kidney disease

progressive and irreversible loss of kidney function

symptoms of CKD

Urine: albumin in urine, very dark urine, oliguria

Systemic: edema, pain, weakness

Skin: yellow skin, uremic frost (crystals on skin) decreased skin oils and turgor, pruritis

Pulmonary: shortness of breath, uremic lung (yellow, inflamed lung from uric crystals), hypertension,

Blood: hyperlipidemia, anemia, acidic, increased bleeding time

Heart: palpations, heart abnormalities if K is to k=high

GI: halitosis, stomatitis

musculoskeletal: pain, weakness, decreased bone density

Labs for CKD

• GFR if lower than 90 indicates CKD

• BUN - will be increased

• Creatinine - if CKD is present, will be increased

• sodium - decreased in early stages, then increased

• potassium - increased

• serum phosphorus levels - will be increased

• serum calcium levels - will be increased, bones will be weakened

• Mg levels - will be increased

• ABG - will show metabolic acidosis

• urinalysis will show increased protein, WBC and glucose. will show decreased osmolarity in early stages and increased osmolarity in late stages

• proteinurea present

• xray of hands may show mineral bone disease

risks for developing CKD

hypertension, diabetes, cv disease, nephrotoxic drugs, family history,

stages of CKD

5 stages based on GFR

1 is GFR above 90

2 is between 79 and 90

3 is between 30 and 60

4 is between 15 and 30

5 is below 15

Effects of CKD on the body

Heart:

• hypertension and hyperlipidemia

Blood:

• acidosis due to H ions not being excreted by kidneys

• potassium increasing. can damage heart

• phosphorus building up in blood, triggering PTH hormone to activate and pull calcium out of bones, increasing serum calcium levels. this leads to…

• hypercalcemia wit symptoms like chvosteks sign, trousseaus sign, fractures.

• anemia, due to decreased RBCs being made because of uremia (waste in blood)

Pulmonary:

• pulmonary edema due to fluid buildup. symptoms of crackles, SOB, wheezing, etc.

GI changes

• halitosis and stomatitis from ammonia buildup. (mouth)

• Peptic ulcer disease also, for unknown reasons

Brain:

• encephalopathy causing confusion, fatigue, lethargy

nursing considerations for treating CKD

• what are the main complications to look out for

monitor for hyperkalemia

monitor for mineral and bone disorder brought on by decreased clearance of phosphorus

fluid overload/pulmonary edema

Drugs for CKD

increase fluid clearance/decrease hypertension/pulmonary edema:

• loop diuretics

• thiazide diuretics

• ace inhibitors

• arbs

• CCBs

calcium supplements (for the bone leaching)

• vitamin d

• calcitriol

• paracalcitriol (doesn’t replace lost ca, just decreases PTH hormone that causes leaching)

• cinacalcet (also a PTH modifier)

Phosphate binders: for the phosphate excess

• calcium acetate

• calcium carbonate

• lanthanum carbonate

• sevelamer

vitamins for deficiencies

• folic acid

• cyanacobalamin

irons - for anemia

• ferrous sulfate

• ferrous gluconate

Erethropoetin stimulating factors (for lack of RBCs being made)

• epoetin alfa

• darepoetin alfa

Diet considerations for CKD

low sodium diet - 1-3 g a day

low phosphorus and low potassium

monitor fluids

protein increase

parameters to monitor in patients with CKD

daily weights,

blood pressure - keep under 135/85

potassium levels at 60-70 a day

keep phosphorus at 700 mg a day

lasix for CKD

• classification

• action

• side effects

• adverse reactions

• loop diuretic

• inhibits water reabsorption in the loop of henle

• ototoxicity, hypokalemia, dehdyration, gout, hypovolemia

calcium drugs

• what are they

• what is the use

• side effects

• adverse reactions

• calcium gluconate, calcitriol, ponicalcitrol

• used to supplement calcium in the patient with CKD bc they often excrete calcium

• hypercalcemia

phosphate binders

• use

• types

• side effects

• adverse effects

• to prevent hyper-phosphatemia which is common in ppl with CKD. they bind to phosphate so it is not absorbed and is instead excreted

• calcium acetate, calcium carbonate, also non-calcium based ones like lanthanum carbonate and sevelamer.

• GI symptoms like constipation, N/V. blockage or tearing possible with lanthanum carbonate.

erythopoetin

• use for CKD

• types

• side effects

• adverse effects

• stimulates the bone marrow to make more RBC

• epoetin alpha, donbepoetin alpha

• thromboembolism, stroke, MI, clotting disorders

what is a combo that can be given for hyperkalemia

insulin plus dextrose

what is given for iron deficiency

what is given for calcium deficiency

• ferrous sulfate, ferrous fumarate, ferrous gluconate,

• low calcium: vitamin d, calcitriol, panicalcitrol, calcium gluconate

• high calcium: cinacalcet - a PTH stimulating hormone, reduces calcium in serum

what is CKD mineral bone density disorder

increased phosphorus levels caused by inefficient kidney clearance lead to excess PTH hormone being released which causes hyper-calcemia in the blood and leaching of calcium from the bones

bone weakness, brittleness, breaking, pain.

how to treat CKD mineral bone density disorder

• drugs

• therapeutic

• vitamin d, calcitriol, panicalcitrol, calcium gluconate, all increase calcium levels to help replace what was taken away

• cinacalcet is a PTH modifiying hormone that reduces PTH levels

how to treat CKD hyperkalemia

insulin with glucose IV

sodium bicarb - can cause shift of K+ into cells

calcium gluconate IV- this increases the threshold for cardiac excitability, reducing risk of arrhythmias brought on by hyperkalemia

hemodialysis

sodium polystyrene sulfate

dietary restrictions

patiromer (oral suspension, binds K+ in the GI tract)