Chronic Kidney Disease Notes

Urinary Tract Infections (UTI)

• Most common infection and second most common bacterial disease in women.
• Causes:
  • Most common pathogen: Escherichia coli (E. coli).
  • Second: Candida albicans; associated with indwelling catheters or asymptomatic colonization.
  • Fungal and parasitic infections are uncommon.

Classification of UTI

• Location:
  • Upper: Renal parenchyma, pelvis, and ureters (pyelonephritis).
  • Lower: Bladder (cystitis) and urethra (urethritis).
• Systemic spread: Urosepsis; life-threatening.
• Uncomplicated: Bladder only.
• Complicated: Occurs with structural or functional problems in the urinary tract.

Etiology and Pathophysiology

• The urinary tract above the urethra is normally sterile.
• Defense mechanisms:
  • Complete emptying with voiding.
  • Ureterovesical junction competence.
  • Ureteral peristalsis propels urine toward the bladder.
  • Acidic pH (6.0 - 7.5).
  • High urea.
  • Glycoproteins inhibit bacterial growth.
• Organisms from the perineum ascend the urethra.
• Contributing factors: Urologic instrumentation and sexual intercourse.
• UTIs: Most common health-care associated infection (HAI).
  • Catheter-associated urinary tract infections (CAUTIs): E. coli or Pseudomonas.
  • Increased length of stay, costs, morbidity, mortality.

Risk Factors for UTI

• Obstruction.
• Retention.
• Renal impairment.
• Foreign bodies.
• Anatomic factors.
• Compromised immune response.
• Functional disorders.
• Other factors.

Clinical Manifestations

• Lower urinary tract symptoms (LUTS):
  • Emptying symptoms.
  • Storage symptoms.
  • Hematuria and/or cloudy appearance.
• Upper urinary tract symptoms:
  • Flank pain, chills, fever.
• Other symptoms:
  • Older adults may present differently.

Diagnostic Studies

• Initial: Dipstick for nitrates, WBCs, and leukocyte esterase.
• Urine culture/sensitivity.
• History:
  • Recurring UTIs (more than 2 to 3/year).
  • Complicated UTIs.
  • CAUTIs or HAI UTIs.
  • UTI unresponsive to empiric therapy.
• Imaging: Ultrasound or CT scan.

Interprofessional Care

• Diagnosis: History & Physical, Urinalysis, Culture & Sensitivity, Imaging.
• Management (Uncomplicated):
  • Patient teaching, adequate fluids.
  • Drug therapy: Phenazopyridine and antibiotics (empiric) for ~3 days.

UTIs: Intraprofessional Care

• Drug therapy
  • Uncomplicated or initial UTIs
    • Trimethoprim/sulfamethoxazole (TMP-SMX)
    • Nitrofurantoin
    • Cephalexin
    • Fosfomycin
    • Other: ampicillin, amoxicillin, or cephalosporins
  • Complicated: fluoroquinolones
  • Fungal: fluconazole
  • Urinary analgesic: phenazopyridine (azo dye)

Nursing Assessment

• Subjective data
  • Past health history
  • Medications
  • Surgery or other treatments
  • Functional health patterns
    • Health perception–health management
    • Nutritional–metabolic
    • Elimination
    • Cognitive–perceptual
    • Sexuality–reproductive
• Objective data
  • General
  • Urinary
  • Possible diagnostic findings

Nursing Management: UTI

• Nursing diagnoses/Nursing Problems:
  • Impaired urinary system function
  • Acute pain
  • Lack of knowledge
• Planning: Goals
  • The patient will have:
    • relief from bothersome symptoms
    • no upper urinary tract involvement

Health Promotion

• Recognize at-risk patients
• Patient teaching
  • Empty bladder regularly and completely
  • Evacuate bowel regularly
  • Wipe front to back
  • Adequate fluid intake
• Hospitalized patients: routine and thorough perineal hygiene

Nursing Implementation

• Prevention of CAUTI
  • Avoid unnecessary catheterizations
  • Early removal of indwelling catheters
  • Aseptic technique
• Acute care
  • Adequate fluid
  • Heating pad to suprapubic or lower back
  • Patient teaching:
    • What to report to HCP?
• Ambulatory care
  • Patient and caregiver teaching
    • Take antimicrobials as ordered
    • Void: regularly and before and after intercourse
    • Stop using diaphragm (temporarily)
  • Follow up Care
  • Hand hygiene
  • Gloves for catheter care

Bladder Dysfunction

Urinary Incontinence (UI)

• Involuntary leakage of urine
  • More prevalent with older adults (women more than men) but not a natural consequence of aging
  • Gender differences
    • Men—common with BPH or prostate cancer; overflow incontinence from urinary retention
    • Women—stress and urge incontinence
• Bladder pressure greater than urethral closure pressure
  • Interference with bladder or sphincter control
• DRIP
  • D: delirium, dehydration, depression
  • R: restricted mobility, rectal impaction
  • I: infection, inflammation, impaction
  • P: polyuria, polypharmacy

Types of Urinary Incontinence

• Stress
• Urge
• Overflow
• Reflex
• Incontinence after trauma or surgery
• Functional incontinence
• May have more than 1 type

Diagnostic Studies

• Basic evaluation:
• Physical exam:
• Diagnostic studies: Urinalysis, post void residual, urodynamic studies, ultrasound

Interprofessional Care

• Many can be cured or improved
  • Treat transient, reversible factors first
  • Interventions depend on type
  • Individualized to patient preference, type and severity, and anatomic defects.
• Lifestyle modifications
• Scheduled voiding regimens
• Pelvic floor muscle rehabilitation
• Antiincontinence devices
• Containment devices

Urinary Retention

• Inability to empty bladder with voiding or the accumulation of urine because of inability to void
• Acute urinary retention—inability to pass urine; medical emergency
• Chronic urinary retention—incomplete emptying despite urination
  • Post void residual (PVR)—normal 50 to 75 mL
    • More than 100 mL—repeat or further evaluation with UTIs
    • More than 200 mL—further evaluation
• Men—enlarged prostate

Renal Failure & CKD

Kidney (Renal) Failure

• Partial or complete impairment of kidney function that results in inability to excrete metabolic waste products and water
• Affects all body systems
• Treatments and dietary changes are challenging
  • Impacts lifestyle, occupation, family relationships, and self-image

Chronic Kidney Disease

• Progressive, irreversible loss of kidney function
• Greater than 26 million American adults have CKD; more common than AKI
• Over half a million Americans are receiving treatment for ESRD; high mortality rate

Clinical Manifestations

• Result of retained substances
  • Urea
  • Creatinine
  • Phenols
  • Hormones
  • Electrolytes
  • Water
  • Uremia

Uremia

• Syndrome in which kidney function declines to the point that symptoms occur in multiple body systems
• Manifestations vary depending on cause, co-morbidities, age, and adherence to medical regimen

Early Stages

• No change in urine output
• Polyuria may be present related to diabetes.
  • CKD progression—increasing fluid retention; need diuretic
  • After a period on dialysis, patients may become anuric

Clinical Manifestations

Altered Carbohydrate Metabolism

• Caused by impaired glucose metabolism
  • From cellular insensitivity to normal action of insulin
  • Mild-moderate hyperglycemia and hyperinsulinemia

Elevated Triglycerides

• Hyperinsulinemia stimulates hepatic production of triglycerides

Altered Lipid Metabolism

• Decreased levels of enzyme lipoprotein lipase
  • Important in breakdown of lipoproteins
  • Increased VLDLs and LDLs, decreased HDLs
  • Most patients with CKD die from CV disease

Clinical Manifestations

• Potassium (K+)
• Sodium (Na+)
• Calcium and phosphate
• Magnesium

Metabolic Acidosis

• Results from
  • Impaired ability of kidneys to excrete excess acid

Anemia

• Due to decreased production of erythropoietin
  • Hormone stimulates bone marrow to make RBCs

Clinical Manifestations

• Psychologic
  • Anxiety
  • Depression
• Neurologic
  • Fatigue
  • Headache
  • Sleep disturbances
  • Encephalopathy
  • Peripheral neuropathy
  • Paresthesias
  • Restless legs syndrome
• Cardiovascular
  • Hypertension
  • Heart failure
  • Coronary artery disease
  • Pericarditis
  • Peripheral artery disease
• Ocular
  • Hypertensive retinopathy
• Gastrointestinal
  • Anorexia
  • Nausea
  • Vomiting
  • Gastrointestinal bleeding
  • Gastritis
• Pulmonary
  • Pulmonary edema
  • Uremic pleuritis
  • Pneumonia
• Endocrine/Reproductive
  • Hyperparathyroidism
  • Thyroid abnormalities
  • Amenorrhea
  • Erectile dysfunction
• Metabolic
  • Carbohydrate intolerance
  • Hyperlipidemia
• Hematologic
  • Anemia
  • Bleeding
  • Infection
• Integumentary
  • Pruritus
  • Ecchymosis
  • Dry, scaly skin
• Musculoskeletal
  • Vascular and soft tissue calcifications
  • Osteomalacia
  • Osteitis fibrosa

Diagnostic Studies

• History and physical examination
• Dipstick evaluation of protein
• Albuminuria
• Urinalysis
• Renal ultrasound, scan, CT scan, biopsy
• Albumin-to-creatinine ratio (first am void)
• Serum BUN, creatinine, creatinine clearance, electrolytes, lipids, hemoglobin, hematocrit
• GFR

Interprofessional Care

• Management
  • Stages 1 to 4
    • Control HTN, hyperparathyroid disease, CKD-MBD, anemia, and dyslipidemia
    • Correct of ECF volume overload or deficit
    • Treat CV disease
    • Nutritional therapy
    • Drug therapy

Hypertension

• Weight loss (if indicated)
• Therapeutic lifestyle changes
• Diet recommendations (DASH Diet)
• Antihypertensive drugs; often need two or more
  • If diabetic—give ACE inhibitors and ARBs

Interprofessional Care

Drug Therapy

• Hyperkalemia
  • Restriction of high-potassium foods and drugs
  • Acute
    • IV glucose and insulin
    • IV 10% calcium gluconate
  • Sodium polystyrene sulfonate (Kayexalate)
    • Cation-exchange resin; bowel exchanges Na+ for K+ ions
    • Osmotic laxative action (diarrhea)
  • Patiromer (Veltessa)—binds K+ in GI tract
    • May bind other oral meds; take 6 hours before or 6 hours after ; delayed onset
  • Dialysis—most effective

Anemia

• Erythropoietin (EPO)
  • Epoetin alfa (Epogen, Procrit)
  • Darbepoeitin alfa (Aranesp)
  • Given IV or subcutaneously
  • Side effects: thromboembolism, HTN
• Iron supplements
  • If plasma ferritin level is <100 ng/mL
  • Side effects: gastric irritation, constipation
  • May make stool dark in color
• Folic acid supplements
• Avoid blood transfusions
  • Increase the development of antibodies
  • May lead to iron overload

Interprofessional Care

Drug Therapy

• Dyslipidemia
  • Statins (HMG-CoA reductase inhibitors)
  • Fibrates (fibric acid derivatives)
• Complications
  • Drug toxicity
    • Digoxin
    • Diabetic agents
    • Antibiotics
    • Opioid medications

Nutritional Therapy

• Designed to maintain good nutrition
  • Dietician referral
  • Calorie-protein malnutrition
  • Monitor laboratory parameters
• Protein intake
  • should be limited in CKD until Dialysis is initiated. Then can be restricted less.
• Fluid restriction with HD
  • Intake depends on daily urine output
• Sodium restriction
  • Diets vary from 2 to 4 g/day
• Potassium restriction
  • Limit: 2 to 3 grams

Nursing Assessment

• Complete history
• Long-term health problems
• Medications: prescribed, OTC, herbal
• Dietary habits
• Support systems
• Fluid imbalance
• Electrolyte status
• Difficulty coping
• Impaired nutritional imbalance

Nursing Planning

• Overall goals
  • Show knowledge and compliance
  • Plan of care and future treatments
  • Have effective coping strategies
  • Activities of daily living

Health Promotion

• Identify people at risk for CKD
• Regular checkups with urinalysis and GFR.
• What to report to PCP
• Prevent progression of CKD and CV disease if identified as risk
• Acute care
  • Out-patient versus In-patient
• Ambulatory care

Dialysis

• Two methods of dialysis available
  • Peritoneal dialysis (PD)
  • Hemodialysis (HD)
• Started when patient’s uremia can no longer be adequately treated conservatively; GFR < 15 mL/min/1.73 m^2
• Nephrologist determines when to start
• Uremic complications require dialysis
• ESRD treated with dialysis because
  • There is a lack of donated organs
  • Some patients are physically or mentally unsuitable for transplantation
  • Some patients do not want transplants
• Movement of fluid/molecules across a semipermeable membrane from one compartment to another
• Used to correct fluid and electrolyte imbalances and removes waste products in kidney failure

General Principles of Dialysis

• Diffusion: > to <
• Osmosis: < to >
• Ultrafiltration
  • PD—glucose in dialysate
  • HD—pressure gradient

Peritoneal Dialysis

Dialysis Solutions and Cycles

• Three phases of PD cycle (manual):
  • Inflow (fill)—2 to 3 L over 10 minutes
  • Dwell (equilibration) 20 to 30 minutes—8 hours
  • Drain 15 to 30 minutes
  • Cycle is repeated
    • Called an exchange
    • Volume depends on size of peritoneal cavity
  • Dextrose—osmotic agent
• Automated peritoneal dialysis (APD)
  • Cycler delivers the dialysate during sleep Times and controls fill, dwell, and drain phases; alarms and monitors for safety
• Continuous Ambulatory peritoneal dialysis (CAPD)
  • Manual exchange four times during the day

Peritoneal Dialysis Complications

• Exit site infection
• Peritonitis
• Hernias
• Lower back problems
• Bleeding
• Protein loss
• Pulmonary complications
  • Decreased lung expansion
• Protein loss—monitor nutrition

Peritoneal Dialysis Effectiveness of Chronic PD

• Short training program; 3 to 7 days
• Advantages
  • Simplicity
  • Home-based program
  • Increasing patient participation
  • No need for special water systems
  • Equipment set-up is relatively simple

Hemodialysis (HD) Vascular Access Sites

• 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

Arteriovenous Fistulas and Grafts

• Created in forearm or upper arm—preferred access for HD
• Fistula allows arterial blood to flow through vein; becomes “arterialized;
• 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

Arteriovenous Grafts (AVGs)

• Synthetic material surgically placed under the skin to form a “bridge” between artery (brachial) and vein (antecubital)
• Healing time—2 to 4 weeks
• More likely to get infected or form clots
  • If infected, may need removed

AV Fistulas and Grafts

• Risks:
  • Distal ischemia (steal syndrome)
    • Pain distal to access site
    • Numbness or tingling of fingers
    • Poor capillary refill
  • Aneurysms
• Safety alert for AVF and grafts
  • No BP, venipunctures, or IV line
  • Post signs in room or labeled arm band
  • Prevent infection and clotting

Temporary Vascular Access

• Catheter insertion of internal jugular or femoral vein when immediate access is needed
• Double lumen
  • Blood removal
  • Blood return
• Risks: high infection, dislodgment, and malfunction

Hemodialysis

• Dialyzers
  • Plastic cartridge that contain thousands of parallel hollow tubes or fibers; semipermeable membranes
  • Blood is pumped from top into fibers
  • Dialysate pumped from bottom and bathes the outside of the fibers
  • Ultrafiltration, diffusion and osmosis occur
  • When blood reaches end—returned via single tube to patient

Hemodialysis Procedure

Before HD Treatment

• Assess fluid status
• Assess vascular access
• Assess temperature
• Monitor VS every 30 to 60 minutes
• Two large bore needles placed in fistula or graft
• Heparin is added to prevent clotting
• Dialysate delivery and monitoring system is used

After

• Dialyzer/blood lines primed with saline solution to eliminate air
• Terminated by flushing with saline to return all blood to patient
• Needles removed and firm pressure applied

Hemodialysis Settings and Schedules

• Most treated in a community-based center
  • Dialyzed for 3 to 4 hours, 3 days/wk
• Other schedule options
  • Short daily HD
  • Long nocturnal HD
  • Home HD

Hemodialysis--Complications

• Hypotension
• Muscle cramps
• Loss of blood
• Hepatitis—8% to 10% hepatitis C

Hemodialysis Effectiveness

• Cannot fully replace normal functions of kidneys
• Can ease many of symptoms
• Can prevent certain complications
• CV disease carries high mortality rate
• Infectious complications 2nd leading cause of death
• Individual adaptation
  • Positive
  • Ambivalent
  • Depressed
• Nursing goals: help the patient to:
  • have a healthy self-image
  • return to highest level of function

Continual Renal Replacement Therapy (CRRT)

• CRRT versus HD
  • Blood pump is slower than HD
  • Continuous rather than intermittent
  • Fluid volume can be removed over days versus hours
  • Solute removal by convection (no dialysate required) in addition to osmosis and diffusion
  • Less hemodynamic instability
  • Does not require constant monitoring by HD nurse (need ICU nurse)
  • Does not require complicated HD equipment
• Specific nursing interventions
  • Obtain weights
  • Monitor and document laboratory values daily for fluid and electrolyte balance
  • Assess hourly intake and output, VS, and hemodynamic status
  • Care for site to prevent infection