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Chronic Kidney Disease CKD Dialysis Renal Transplant Slide 2 Bones can break, muscles can atrophy, glands can loaf, even the brain can go to sleep without immediate danger to survival. But -- should kidneys fail.... neither bone, muscle, nor brain could carry on. Homer Smith, Ph.D. Slide 3 Functions of the Kidney Primary function _________________________ Other functions ______________________ Slide 4 Review What are nephrons? Why would a person with kidney disease have anemia? What happens to the serum calcium? Why? How does the kidney control blood pressure? Slide 5 Biopsy Ultrasound X-Rays Labs Anything else? Slide 6 Diagnostic studies Blood Tests BUN Creatinine K+ PO4 Ca Urinalysis Specific gravity Protein Creatinine clearance Slide 7 BUN and Creatinine BUN- Normal 6-20 mg/dl Nitrogenous waste product of protein metabolism By itself: Unreliable in measurement of renal function Creatinine- Normal 0.6 - 1.3 mg/dl A waste product of muscle metabolism 2 times normal = 50% damage 8 times normal = 75% damage 10 times normal = 90% damage Exception -_______________________ Slide 8 Glomerular Filtration Rate GFR- Cannot be directly measured Uses Serum creatinine Gender Ethnicity Age Weight Why would you need to estimate GFR? Slide 9 Glomerular Filtration Rate Creatinine Clearance 24 hour urine for creatinine clearance Most accurate indicator of Renal Function Reflects GFR Formula: urine creatinine X urine volume serum creatinine What is a normal GFR? Slide 10 Chronic Kidney Disease (CKD) Slow and progressive, irreversible loss of kidney function occurring over months to years National Kidney Foundation- Presence of kidney damage or decreased GFR < 60 mL/min for longer than 3 months End Stage Renal Disease -GFR Slide 11 Chronic Kidney Disease (CKD) Cause & onset often unknown Loss of function _________ lab abnormalities Lab abnormalities ________ symptoms Symptoms (usually) evolve in orderly sequence Renal size is usually decreased Slide 12 Chronic Kidney Disease Causes _________________ Cystic disorders Developmental /Congenital Infectious Disease Slide 13 Chronic Kidney Disease Causes Neoplasms Obstructive disorders Autoimmune diseases Hepatorenal failure Scleroderma Amyloidosis Drug toxicity Slide 14 Stages of CKD Stage 1: GFR >/= 90 ml/min despite kidney damage Stage 2: Mild reduction -GFR 60 89 ml/min 1. GFR of 60 may represent 50% loss in function 2. Parathyroid hormones starts to increase Slide 15 CKD During Stage 1& 2 No symptoms Serum creatinine doubles Up to 50% nephron loss Why does PTH increase? (2 reasons) Slide 16 Stages of CKD Stage 3: Moderate reduction -GFR 30-59 ml/min 1. Calcium absorption decreases 2. Malnutrition onset 3. Anemia 4. Left ventricular hypertrophy Why? Slide 17 Stages of CKD Stage 4: Severe reduction -GFR 15-29 ml/min 1. Serum triglycerides increase 2. Hyperphosphatemia 3. Metabolic acidosis 4. Hyperkalemia Why? Slide 18 Stages of CKD During Stage 3-4 Signs and symptoms worsen if kidneys are stressed Decreased ability to maintain homeostasis 75% nephron loss Slide 19 Stages of CKD During Stage 3 &4 Decreased: __________ Symptoms: elevated BUN & Creatinine mild azotemia anemia Slide 20 Stages of CKD Stage 5: Kidney failure -GFR < 15 ml/min Azotemia Residual function < 15% of normal Excretory, regulatory and hormonal functions severely impaired. Metabolic acidosis Slide 21 Marked increase in: ___________ Marked decrease in: ___________ Fluid overload Slide 22 CKD Stage 5 Uremic syndrome develops affecting all body systems can be diminished with early diagnosis & treatment Last stage of progressive CKD Fatal if no treatment Slide 23 Slide 24 CKD Manifestations Urinary Early may be no change in urine output May see polyuria (not related to kidney disease) why? Later- Fluid retention, edema Dialysis- may develop anuria Slide 25 CKD Manifestations Metabolic Waste Products Accumulate Altered carbohydrate Metabolism Insulin resistance Elevated triglycerides Slide 26 CKD Manifestations Electrolyte and acid Base Potassium Sodium Calcium and Phosphorus Magnesium Metabolic Acidosis Volume expansion and fluid overload Change in urine specific gravity Slide 27 CKD Manifestations Endocrine Hyperparathyroidism Hypothyroidism Erythropoietin production decreased Parathyroid hormone and Vitamin D 3 Reproductive Amennorrhea Erectile dysfunction Gonadal dysfunction Slide 28 CKD Manifestations Hematologic Anemia Bleeding tendencies Platelet dysfunction Infection Slide 29 CKD Manifestations Cardiovascular Hypertension Congestive heart failure Pericarditis Atherosclerotic vascular disease Cardiac dysrhythmias Respiratory Pulmonary edema Pleural effusions Slide 30 CKD Manifestations GI tract Uremic fetor Anorexia, nausea, vomiting GI bleeding Musculoskeletal Muscle cramps Soft tissue calcifications Weakness Renal Osteodystrophy Slide 31 CKD Manifestations Psychologic Anxiety Depression Neurologic Mood swings Impaired judgment Inability to concentrate and perform simple math functions Tremors, twitching, convulsions Peripheral Neuropathy Slide 32 CKD Manifestations Skin Pale, grayish-bronze color Dry scaly Severe itching Bruise easily Uremic frost Calcium/Phos deposits Eyes Visual blurring Blindness Slide 33 Slide 34 Treatment Options Conservative Therapy Hemodialysis Peritoneal Dialysis Transplant Nothing Slide 35 Conservative Treatment GOALS: Detect & treat potentially reversible causes of renal failure Preserve existing renal function Treat manifestations Prevent complications Provide for comfort Slide 36 Conservative Treatment Control Hyperkalemia Hypertension Hyperphosphatemia Hyperparthryoidism Anemia Hyperglycemia Dyslipidemia Hypothyroidism Nutrition : Describe a renal diet Slide 37 Control Hyperkalemia limit ex: citrus, meats, fish, avocado, beans, spinach Hypertension -- weight loss, dec. etoh, smoking, DASH diet, meds, fluids Hyperphosphatemia meds, low phos diet ex: milks & cheese Hyperparthryoidism -- deal with Calcium/Phos issue Anemia procrit/epogen (could take 2-3 weeks to see a change in HH) Why dont we transfuse these patients? Hyperglycemia oral anti-diabetic meds, insulin, diet Dyslipidemia -- statins, keep LDL Monitoring Transplant Function ATN? (acute tubular necrosis) Urine output >100Slide 85 Fluid & Electrolyte Balance Accurate I & O CRITICAL TO AVOID DEHYDRATION Output normal - >100Slide 86 Prevention of Infection Major complication of transplantation due to immunosuppression What do you teach? Slide 87 Rejection Hyperacute preformed antibodies to donor antigen function ceases within 24 hours Rx = removal Accelerated same as hyperacute but slower, 1st week to month Rx = removal Slide 88 Rejection Acute First 6 months 50% experience must differentiate between rejection and cyclosporine toxicity Rx= Usually reversible with additional immunosuppressants- put at higher risk for infection Slide 89 Rejection Chronic gradual process over months or years Irreversible Repeated rejection episodes that have not been completely resolved with treatment Rx = return to dialysis or re-transplantation Slide 90 Immunosuppressant Drugs Need to balance suppression with maintenance of adequate defense Side effects- Infection Malignancies Toxicity Require frequent monitoring Lowest dose to get response will least side effects Slide 91 Immunosuppressant Drugs 2 categories: Induction agents Powerful antirejection medications used at the time of transplant Maintenance agents Antirejection medications used for the long term. Slide 92 Immunosuppressant Drugs Maintenance agents -4 classes 1. Calcineurin Inhibitors: Tacrolimus,Cyclosporine 2. Antiproliferative agents:Mycophenolate Mofetil 3. mTOR inhibitor: Sirolimus 4. Steroids: Prednisone Used in combination Triple therapy Wean off steroids or avoid use Slide 93 Immunosuppressant Drugs Cyclosporine Azathioprine (Imuran) Prednisone OKT 3 Atgam Cytoxan - in place of Imuran less toxic FK506 - 100 x more potent than Cyclosporine Prograf CellCept Slide 94 Immunosuppressant Drugs many medications and food and supplements can alter blood levels Grapefruit juice St. John's Wort Erythromycin anti TB medications antiseizure medications common blood pressure medications (cardizem or diltiazem, and Verapamil Slide 95 Patient Education Signs of infection Prevention of infection Signs of rejection ____________ Medications _____________ Slide 96 The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the clients temperature is 100.2. Which of the following is the most appropriate nursing action? Encourage fluids Notify the physician Monitor the site of the shunt for infection Continue to monitor vital signs Slide 97 A client is diagnosed with chronic renal failure and told she must start hemodialysis. Client teaching would include which of the following instructions? Follow a high potassium diet Strictly follow the hemodialysis schedule There will be a few changes in your lifestyle. Use alcohol on the skin and clean it due to integumentary changes. Slide 98 A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the dwell clamp is opened to allow the dialysate to drain. The nurse notes that the drainage has stopped and only 500 ml has drained; the amount the dialysate instilled was 1,500 ml. Which of the following interventions would be done first? Change the clients position. Call the physician. Check the catheter for kinks or obstruction. Clamp the catheter and instill more dialysate at the next exchange time. Slide 99 A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of 200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%. He complains of shortness of breath, and +2 pedal edema is noted. His last hemodialysis treatment was yesterday. Which of the following interventions should be done first? Administer oxygen Elevate the foot of the bed Restrict the clients fluids Prepare the client for hemodialysis.