1. Chronic Kidney Disease

2. Chronic Kidney Disease
Progressive, irreversible damage to the nephrons and glomeruli

3. Major causes are Diabetes and high blood pressure
Type 1 and type 2 diabetes mellitus
High blood pressure (hypertension)
Glomerulonephritis
Polycystic kidney disease
Use of analgesics - acetaminophen(Tylenol) and ibuprofen (Motrin, Advil
Clogging and hardening of the arteries(atherosclerosis) 
Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings), or cancers. 
HIV infection, sickle cell disease, heroin abuse, amyloidosis, kidney stones, chronic kidney infections, and certain cancers.

4. Kidney functions - monitored regularly
Diabetes mellitus type 1 or 2 
High blood pressure 
High cholesterol
Heart disease
Liver disease 
Amyloidosis 
Sickle cell disease 
Systemic Lupus erythematosus 
Vascular diseases such as arteritis, vasculitis, or fibromuscular dysplasia 
Vesicoureteral reflux (a urinary tract problem in which urine travels the wrong way back toward the kidney) 
Require regular use of anti-inflammatory medications 
A family history of kidney disease

5. Chronic Renal Failure End Stage Renal Disease (ESRD)
Protein and waste metabolism accumulates in the blood (azotemia)
90% of kidney function is lost (kidney cannot adequately function)
Hypothesis: Nephrons remains intact, others progressively destroyed.
Adaptive response maintains function until ¾ are destroyed
Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately
The kidney has a remarkable renal reserve. Up to 80% of the GFR (reflected in creatinine clearance measurement may be lost with few overt changes in functioning of the body.

6. Table 1. Stages of Chronic Kidney Disease
*GFR is glomerular filtration rate, a measure of the kidney's function.
Stage
Description
GFR* mL/min/1.73m2 1
Slight kidney damage with normal or increased filtration
More than 90 2
Mild decrease in kidney function
60-89 3
Moderate decrease in kidney function
30-59 4
Severe decrease in kidney function
15-29 5
Kidney failure
Less than 15 (or dialysis)

7. Chronic Kidney Disease - Pathophysiology
Modifiable Factors
-Diabetic Mellitus
-Hypertension
-Increase Protein and Cholesterol Intake
-Smoking
-Use of analgesics
Non-Modifiable Factors
-Hereditary
-Age greater than 60 years old
-Gender
-Race
Decreased renal blood flow
Primary kidney disease
Damage from other diseases
Urine outflow obstruction
Chronic Kidney Disease - Pathophysiology
BUN
Serum Creatinine
Decreased glomerular filtration
Hypertrophy of remaining nephrons
Dilute Polyuria
Inability to concentrate urine
Loss of Sodium in Urine
Hyponatremia
Dehydration
Further loss of nephron function
Loss of nonexcretory renal function
2 a
Failure to convert inactive forms of calcium
Failure to produce eryhtropoietin
Impaired insulin action
Production of lipids
Immune disturbance s
Disturbances in reproduction
Erratic blood glucose levels
Advanced atherosclerosis
Calcium absorption
Anemia
Pallor
Delayed wound healing
Infection
Libido
Infertility 1

8. Loss of excretory renal function
Hypocalcemia 1
Osteodystrophy
Loss of excretory renal function
Excretion of nitrogenous waste
Decreased sodium reabsorption in tubule
Decreased potassium excretion
Decreased phosphate
excretion
Decreased hydrogen excretion
Uremia
Hyperkalemia
Hyperphosphate mia
Metabolic acidosis
Water Retention
BUN,
Creatinine
Uric Acid
Decreased calcium absorption
Hypertension
Heart Failure
Edema
Proteniuria
Hypocalcemia
Peripheral nerve changes
Hyperparathyroidis m
Decreased potassium excretion
Pericarditis
Increased potassium
CNS changes
Pruritus
Altered Taste
Bleeding Tendencie s

9. Weakness and tiredness/ fatigue.
Nocturia is often an early symptom
Itchiness of the skin which can progressively worsen
Pale skin which is easily bruised
Muscular twitches, cramps and pain
Pins and needles in the hands and feet
Nausea

10. As the condition worsens the symptoms progress to:
Oedema (swelling of the face, limbs and abdomen)
Oliguria (greatly reduced volume of urine)
Dyspnoea (breathlessness)
Vomiting
Confusion
Seizures
Severe lethargy
Very itchy skin
Breath that smells of ammonia

11. Associated complications of chronic Kidney Disease would be:
Anaemia, mostly due to deficiency of erythropoietin
Bleeding which is caused by impairment of platelet function
Metabolic Bone Disease (known as Renal Osteodystrophy)

12. Associated complications of chronic Kidney Disease would be:
Cardiovascular Disease
- hypertension, (which may further exacerbate
the renal failure)
-accelerated atherosclerosis
-pericarditis. 80% of those with chronic renal
failure develop hypertension which must be
treated

13. Associated complications of chronic Kidney Disease would be:
Nervous system – neuropathy caused by the loss of myelin from nerve fibres – may improve when dialysis is established
Gastrointestinal complications - anorexia, nausea and vomiting, and a higher incidence of peptic ulcer disease

14. Associated complications of chronic Kidney Disease would be:
Skin disease – itching, which is attributed to the retention of metabolic waste products. It often improves with dialysis. Dry skin can also occur
Muscle dysfunction - myopathy leading to muscle cramps and the “restless leg” syndrome

15. Associated complications of chronic Kidney Disease would be:
Metabolic dysfunction - involving lipids, insulin and uric acid (gout). Metabolic acidosis is also associated

17. Diagnosis Urine Tests Urinalysis Twenty-four hour urine tests
Estimated GFR (eGFR)
Electrolyte levels and acid-base balance  
Blood cell counts 
Other tests
Ultrasound:
Biopsy
Urine Tests
Urinalysis
Twenty-four hour urine tests 
Glomerular filtration rate (GFR)
Blood Tests
Creatinine and urea (BUN) in the blood

18. Treatment Modalities Decrease fluid 1000ml/day
Decrease protein (.5-1kg body weight)
Decrease sodium (1-4gm variable)
Decrease potassium
Decrease phosphorous (<1000mg/day)
Dialysis (periotoneal, hemodialysis)
RBC, Vitamin D (calcitrol replacement) etc.

19. Dialysis Hemodialyis(Hemo)Peritoneal (PD)
General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another
Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)
Peritoneal – Peritoneal membrane is the semi permeable membrane

20. Osmosis-Diffusion-Ultrafiltration
Osmosis - movement fluid from an area of < to >
concentration of solutes (particles)
Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through
Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment

21. Peritoneal Dialysis Catheter placement – anterior abdominal wall
Tenckoff (25cm length with cuff anchor and migration)
Dialysis solution (1-2 liters sometimes smaller)
Three phases of PD
Inflow (fill) approximately 10 minutes, could be in cycles)
Dwell (equilibration) (approximately min or 8 hours+)
Drain (approximately 15 minutes)
These 3 phases are called Exchanges

22. Peritoneal Dialysis

23. Hemodialysis Vascular access for high blood flow
Shunts, (teflon, external)
Arteriovenous fistulas and grafts (AV)
Anastomosis between an artery and vein
Fistulas are native vessels (4-6 wks maturity)
Grafts are artificial/synthetic material

24. Hemodialysis
AV Fistula Communication
AV Graph Access

25. Hemodialysis
Hemodialysis Circuit
Hemodialysis Machine

26. PD Advantages and Disadvantages
Bacterial/chemical peritonitis
Protein loss
Exit site of catheter
Self image
Hyperglycemia
Surgical placement of catheter
Multiple abdominal surgery
Immediate initiation
Less complicated
Portable (CAPD)
Fewer dietary restrictions
Short training time
Less cardio stress
Choice for diabetics

27. Hemo Advantages & Disadvantages
Rapid fluid removal
Rapid removal of urea & creatinine
Effective K+ removal
Less protein loss
Lower triglycerides
Home dialysis possible
Temporary access at the bedside
Vascular access problems
Dietary & fluid restrictions
Heparinization
Extensive equipment
Hypotension
Added blood lost
Trained specialist

28. Disequalibrium Syndrome
Fluid removal and decrease in BUN during hemodilaysis which cause changes in blood osmolarity.These changes trigger a fluid shift from the vascular compartment into the cells. In the brain, this can cause cerebral edema, resulting in increase intracranial pressure and visible signs of decreasing level of consciousness. Symptoms: Sudden onset of headache, nausea and vomiting, nervousness, muscle twitching, palpitation, disorientation and seizures
Treatment: Hypertonic saline, Normal saline

29. The following are general dietary guidelines:
Protein restriction: 
Salt restriction
Fluid intake: 
Potassium restriction: 
Phosphorus restriction: 
Control blood pressure and/or diabetes; 
Stop smoking; and
Lose Excess Weight

30. Avoided or used with caution:
Certain analgesics: Aspirin; ibuprofen
Fleets or phosphosoda enemas because of their high content of phosphorus 
Laxatives and antacids containing magnesium and aluminum such as magnesium hydroxide
Ulcer medication H2-receptor antagonists: cimetidine, ranitidine
Decongestants such as pseudoephedrine  especially if they have high blood pressure 
Herbal medications

31. Nursing Care Pre, Post Dialysis
Weigh before & after
Assess site before & after (bruit, thrill, infection, bleeding etc.)
Medications (precautions before & after)
Vital signs before and after etc.

32. Renal Transplant Living and Cadaveric donors
Predialysis: obtain a dry weight free of excess fluids and toxins
More preparation time from a living donor vs. cadaveric – transplant within 36 hours of procurement
Delay may increase ATN
Pre-transplant: Immunotherapy (IV methylprednisolone sodium succinate, (A –methaPred, Solu-Medrol), cyclosporine (Sandimmune and azathioprine ((Imuran)

33. Complications Post Transplant
Rejection is a major problem
Hyperacute rejection: occurs within minutes to hours after transplantation
Renal vessels thrombosis occurs and the kidney dies
There is no treatment and the transplanted kidney is removed

34. Immunological Compatibility of Donor and Recipient
Done to minimize the destruction (rejection) of the transplanted kidney
HUMAN LEUKOCYTE ANTIGEN (HLA)
This gives you your genetic identity (twins share identical HLA)
HLA compatibility minimizes the recognition of the transplanted kidney as foreign tissues.

35. Immunological Analysis
WHITE CELL CROSS MATCH (the recipient serum is mixed with donor lymphocytes to test for performed cytotoxic (anti-HLA) antibodies to the potential donor kidney
A positive cross match indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation

36. Immulogical Analysis MIXED LYMPHOCYTE CULTURE
The donor and recipient lymphocytes are
mixed. Result = HIGH SENTIVITY, this is contraindicated for renal transplantation.
ABO BLOOD GROUPING
ABO blood group must be compatible

37. Surgery LLQ of the abdomen outside of the peritoneal cavity
Renal artery and vein anastomosed to the corresponding iliac vessels
Donor ureters are tunneled into the recipients’ bladder.

38. Complications Post Transplant
Acute Rejection: occurs 4 days to 4 months after transplantation
It is not uncommon to have at least one rejection episode
Episodes are usually reversible with additional immunosuppressive therapy (Corticosteroids, muromonab-CD3, ALG, or ATG)
Signs: increasing serum creatinine, elevated BUN, fever, wt. gain, decrease output, increasing BP, tenderness over the transplanted kidneys

39. Complications Post Transplant
Chronic Rejection: occurs over months or years and is irreversible.
The kidney is infiltrated with large numbers of T and B cells characteristic of an ongoing , low grade immunological mediated injury
Gradual occlusion renal blood vessels
Signs: proteinuria, HTN, increase serum creatinine levels
Supportive treatment, difficult to manage
Replace on transplant list

40. Complications Post Transplant
Infection
Hypertension
Malignancies (lip, skin, lymphomas, cervical)
Recurrence of renal disease
Retroperiotneal bleed
Arterial stenosis
Urine leakage

41. 100 patients with eGFR < 60 (Tuesday morning in Outpatients)

42. Tuesday morning 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)

43. Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD

44. The majority of patients with CKD 1-3 do not progress to ESRF.
Their risk of cardiovascular death is higher than their risk of progression.

45. Optimise risk factors Cardiovascular disease Proteinuria Hypertension
Diabetes
Smoking
Obesity
Exercise tolerance
TAKE HOME MESSAGE

46. Nursing Care Plan of a Patient With ESRD
Nursing diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water.
Goal: Maintenance of ideal body weight without excess fluid.

47. Assess fluid status (Daily weight, intake and output balance, skin turgor and presence of edema, distention of neck veins, blood pressure, pulse rate, and rhythm, respiratory rate and effort).
Limit fluid intake to prescribed volume.
Identify potential sources of fluid (medications and fluids used to take medications; oral and intravenous, foods).
Explain to patient and family rationale for restriction.

48. Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea, vomiting, and dietary restrictions.
Goal: Maintenance of adequate nutritional intake.

49. Interventions: The nurse should:
Assess nutritional status (weight changes, serum electrolyte, BUN, creatinine, protein, transferrin, and iron levels).
Assess patient’s nutritional dietary patterns (diet history, food preferences, calorie counts).
Assess for factors contributing to altered nutritional intake (Anorexia, nausea, or vomiting, diet unpalatable to patient, depression, lack of understanding of dietary restrictions, stomatitis).
Provide patient’s food preferences within dietary restrictions.
Promote intake of high biologic value protein foods

50. Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Deficient knowledge regarding condition and treatment.
Goal: Increased knowledge about condition and related treatment.

51. Interventions: The nurse should:
Assess understanding of cause of renal failure, its meaning and consequences, and its treatment.
Provide explanation of renal function and consequences of renal failure at patient’s level of understanding and guided by patient’s readiness to learn.
Provide oral and written information as appropriate about renal function and failure, fluid and dietary restrictions, medications, reportable problems, signs, and symptoms, follow-up schedule, community resources, and treatment options.

52. Nursing Care Plan of a Patient With ESRD (Cont…)
Nursing diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure.
Goal: Participation in activity within tolerance.
Interventions: The nurse should:
Assess factors contributing to fatigue (anemia, fluid and electrolyte imbalances, retention of waste products, depression)
Promote independence in self-care activities as tolerated; assist if fatigued.
Encourage alternating activity with rest.
Encourage patient to rest after dialysis treatments.
TAKE HOME MESSAGE

53. THANK YOU
Have a check on your blood pressure
Sugar & Salt / year