1. Publication MO-08-06-CKD November This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy Kidneys and Kidney Disease November 11, 2008 Sharon Bunnell BSN RN CNN Program Manager, CKD Primaris

2. Objectives Gain an understanding of kidney functions Learn possible causes of kidney disease Learn types of kidney disease Learn symptoms of kidney disease Understand emotional aspects of kidney disease Learn type and care of dialysis access Urinary catheter care

3. Anatomoy and Purpose Most people have two kidneys. Main purpose is to clean the blood by removing water, salt and other waste products

4. Other Kidney Functions Balance body fluids and chemical levels Keep valuable substances Release hormones Control blood pressure Make red blood cells Maintain healthy bones

5. Filtering the Blood Kidneys remove wastes and excess water (fluid) collected by, and carried in, the blood as it flows through the body. About 190 liters (335 pints) of blood enter kidneys daily via renal arteries. Millions of tiny filters, called glomeruli, inside the kidneys separate wastes and water from the blood. Most unwanted substances come from what we eat and drink. Kidneys automatically remove the right amount of salt and other minerals from the blood, leaving only needed quantities. The cleansed blood returns to the heart and recirculates through the body. Excess wastes and fluid leave kidneys in the form of urine. Urine is stored in bladder until it is full, then exits via the urethra. Most people pass about 2 liters (4 pints) of urine daily.

6. Balancing Fluid Levels By removing proper amount of excess fluid, healthy kidneys maintain what is called the body's fluid balance. In women, fluid content stays at about 55% of total weight; in men about 60%. Kidneys maintain these proportions by balancing the amount of fluid that leaves the body against the amount entering the body. Fluid comes into our bodies from what we drink and from high-liquid foods like soup. If we drink a lot, healthy kidneys remove the excess fluid and we pass a lot of urine. If we don't drink much, kidneys retain fluid and we don't pass much urine. Fluid also leaves the body through sweat, breath, and feces. If weather is hot and we lose a lot of fluid by sweating, the kidneys will not pass much urine. As kidneys fail, maintaining balance becomes difficult. Proper diet and fluid intake are vital.

7. Symtoms of Excess Fluid Swelling or Edema Feet or legs Facial Lower back (Sacral area) Elevated Blood Pressure Blood pressure elevates due to excess fluid in blood vessels Shortness of Breath Difficulty talking Sleeping in chair or with extra pillows

8. Controlling Blood Pressure An important kidney function is regulating blood pressure. Healthy kidneys make hormones such as renin and angiotensin. These hormones regulate how much sodium (salt) and fluid the body keeps and how well blood vessels can expand and contract. This, in turn, helps control blood pressure.

9. Kidneys Control Amount of water in the body Too much water (fluid overload) blood pressure rises. Too little water (dehydration) blood pressure drops. Width of arteries Arteries constantly change in width as blood flows through them. The narrower the arteries, the higher the blood pressure. Renin helps control narrowing of the arteries. Failing kidneys often make too much renin. This raises blood pressure. If your blood pressure is high, your heart is working harder than normal to pump blood through your body.

10. Helping Make Red Blood Cells Healthy kidneys produce a hormone called erythropoeitin (EPO), which is carried in blood to bone marrow where it stimulates production of red blood cells. These cells carry oxygen throughout the body. Without enough healthy red blood cells a person develops anemia, a condition which makes them feel weak, cold, tired, and short of breath

11. Maintaining Strong Healthy Bones Healthy kidneys keep bones strong by producing the hormone calcitriol. Calcitriol maintains the right levels of calcium and phosphate in the blood and bones. Calcium and phosphate balance are important to keep bones healthy. When the kidneys fail they may not produce enough calcitriol. This leads to abnormal levels of phosphate, calcium, and vitamin D, causing Renal Bone Disease

12. Types of Kidney Disease Acute kidney failure occurs when kidneys suddenly stop working. Often this condition is temporary. The cause may be disease, serious injury, poisons or chemicals in the system. Dialysis treatment supports the patient while the kidneys recover. In some cases acute kidney failure may progress to chronic kidney failure and require dialysis or kidney transplant.

13. Chronic Kidney Disease Chronic kidney failure occurs when kidneys gradually lose their ability to do their job. The causes of kidney disease are not always known, but conditions such as diabetes and high blood pressure clearly increase the risks of kidney failure. Sometimes people are unaware that their kidneys are not functioning properly. This is because kidneys are very adaptable. Even when most of a kidney is not working the remaining portion will increase its activity to compensate for the loss.

14. Symtoms of Kidney Disease Swelling Weakness, fatigue, feeling cold, shortness of breath Poor concentration, trouble sleeping Changes in urination Rash or itchy, dry skin Metallic taste in mouth, lack of appetite, nausea Restless, cramped or sore legs

15. Swelling When kidneys are failing, excess fluid builds up in the body and can lead to a condition known as edema, which is swelling in the hands, ankles, feet, or face (especially around the eyes, when you first wake up). Fluid can also collect in the lungs, which may cause shortness of breath.

16. Weakness, Fatigue, Feeling Cold or Shortness of Breath Kidney damage can slow down production of a hormone called erythropoeitin, which leads to a low red blood cell count. This causes anemia, a common and treatable complication of kidney disease that can make you feel tired very quickly

17. Poor Concentration or Trouble Sleeping Anemia can prevent your brain from getting enough oxygen, which can lead to difficulty in sleeping or concentrating, and dizziness

18. Changes in Urination Your kidneys make urine; kidney disease can cause urine to change. Urination problems include foamy or bloody urine, more or less urine than normal, a change in frequency, or pressure or difficulty urinating.

19. Rash or Itchy Skin Kidneys remove waste from the bloodstream, so when kidneys fail, the buildup of waste in your bloodstream can cause skin rashes or severe itching.

20. Metallic Taste, Loss of Appetite or Nausea Buildup of waste in the blood (called uremia) can make food taste different or cause bad breath, which can lead to a loss of appetite, vomiting, nausea or weight loss.

21. Restless, Cramped or Sore Legs Build up of waste products can cause nerve damage which may cause restless leg syndrome

22. What Can Be Done to Prevent or Delay CKD Control Blood Sugar Goal A1C <6.5 *Diabetes is the leading cause of CKD Control Blood Pressure <130/80 * Elevated BP causes increased stress on the kidneys Limit Salt and Sodium (Na) intake * Salt causes the body to retain fluid, thus increasing BP Limit Protein and Phosphorus intake * Large amounts of protein causes excess workload on the kidneys. The ability to regulate phosphorus is diminished. Stop Smoking * Smoking causes constriction of the blood vessels reducing blood flow to the kidneys thus increasing BP

23. Emotional Effects of Kidney Disease Most people don't like change. Kidney failure is particularly stressful because it not only involves change in physical health and body image but in work, family, and relationships

24. Emotions resulting from kidney disease Fear---What does the future hold Anger---- Why me Loss of Control ------ Will I be dependent on others

25. Stages of Grief Denial: this isn’t happening to me Anger: why is it happening to me Guilt: I should have done differently Depression: I don’t care anymore Acceptance: I am ready for whatever comes

26. Dialysis Access AV Fistula --- A direct connection of an artery to a vein. --- Once created it is a natural part of the body. --- Preferred type of access; as it matures it gets stronger, provides long-lasting blood flow that can last for decades. --- After surgically created, requires weeks to months to mature and use for hemodialysis.

27. AV Graft An arteriovenous (AV) graft is created by connecting a vein to an artery using a soft plastic tube. After the graft heals, hemodialysis is performed by placing two needles in the graft; one in the arterial side and one in the venous side. Graft allows for increased blood flow.

28. Catheter for Dialysis Catheter is inserted into a large vein in either the neck or chest. A catheter is usually a short-term option; however, in some cases a catheter is used as a permanent access. With most dialysis catheters, a cuff is placed under the skin to help hold the catheter in place. Catheters have a greater tendency to become infected than other access types because it is both inside and outside of the body. A catheter must always be kept clean and dry; swimming or bathing are usually restricted. Getting dressed may disturb the catheter at the exit site, so care needs to be taken

29. Care of Dialysis Access Keep access clean at all times. Access site is only for dialysis. Be careful not to bump or cut access. Don’t put a blood pressure cuff on access arm. Don’t place jewelry or tight clothes over access site. Don’t position client with access arm under their head or body. Check pulse in access every day. DO NOT get catheter site wet.

30. Every Day Living with Chronic Kidney Disease Restrict sodium intake in diet Do not use salt substitutes Follow physician recommended diet Maintain good blood pressure control If diabetic, maintain tight control of blood sugar Practice good foot and skin care

31. Urinary Catheter Care Make sure that urine is flowing out of catheter into the drainage bag. Check area around the urethra for inflammation or signs of infection, such as irritated, swollen, red or tender skin at the insertion site or drainage around the catheter. Make sure urinary drainage bag does not drag and pull on catheter.

32. Catheter Care Clean area around drainage tube twice each day. Use soap and water to carefully wash around drainage tube. Rinse well and dry with a clean towel. Do not tug or pull on the drainage tube Unless you have been instructed otherwise, persons may take a shower wearing urinary catheter.

33. Catheter care cont. Do not apply powder or lotion to the catheter insertion site. Prevent constipation. Make sure you drink enough fluids. Most adults should drink between 8 and 10 glasses of water, noncaffeinated beverages, or fruit juice each day. Include fruits, vegetables, and fiber in your diet each day. Try a stool softener, such as Colace, if your stools are very hard

34. Catheter care cont Keep the drainage bag below the level of the bladder. At night you may wish to hang the bag on the side of your bed. Do not allow the bag to drag and pull on the catheter. Check the drainage tube frequently to make sure it is not kinked. Do not pull or tug on the catheter

35. Draining the Catheter Wash your hands with soap and water. Put on gloves. Always wash your hands before you put on the gloves and after you remove them. Unfasten the tube from the drainage bag. Fasten the tubing clamp and remove the drainage cap. Drain the urine into the toilet. You may also drain the urine into another container and then empty it into the toilet. Avoid touching the tubing or drainage cap on the toilet, the collection container, or the floor. If monitoring fluid intake and output, measure the amount of urine, do so before you have emptied the urine into the toilet. Replace the drainage cap, close the clamp, and refasten the collection tube to the drainage bag. Wash your hands with soap and water

36. When to call the Nurse or Doctor No urine or very little urine is flowing into the collection bag for 4 or more hours. No urine or very little urine is flowing into the collection bag; person feels bladder is full. New pain in abdomen, pelvis, legs, or back. Urine changes color, very cloudy, looks bloody, or has large blood clots in it. Insertion site becomes irritated, swollen, red, or tender, or pus draining from catheter insertion site. Urine has a foul odor. Urine leaking from insertion site. Fever of 100°F (37.8°C) or higher or back or flank pain. Nausea, vomiting, or shaking chills develop.

37. Questions? Contact information Sharon Bunnell BSN RN CNN Primaris sbunnell@primaris.org