Chronic Kidney Disease

Chronic Kidney Disease

• Progressive and irrevocable loss of nephrons
• Nephrons are resilient therefore more that 75% of nephrons must be lost before
clinical manifestations appear.
• Defined as either decreased kidney function or damage for 3 or more months based
on blood test, urinalysis, and imaging.
• May also be defined as a glomerular filtration rate (GFR) < 60 ml/min/1.73 m2 for
3 months
• Final stage of CKD is called Chronic Renal Failure or End-Stage Renal Disease
(ESRD)
 CKD Progression
• Stage 1
• Patients’ BP and lab are usually normally and patient is asymptomatic
• Stage 2
• Patients may be asymptomatic, without lab value changes
• Important to identify in stage 1 or 2 to reduce associated risks
• Stage 3
• Classified as having CKD, may be asymptomatic, HTN is nearly always noted
 Stages of CKD
• Stage 4
• Manifestations are usually apparent with significant decline in renal function
• Planning for ESRD should occur
• Stage 5
• Manifestations of ESRD are present and renal function is so impaired that dialysis or
transplant are required.
 Risk Factors
• Complication of many other conditions
• Diabetes
• Hypertension
• Acute Renal Failure
• Kidney Disease
• Family history
• Exposure to toxins and smoking
• Age greater than 65
• Black, White, and Mexican ethnicity
 Risk Factors
• Developmental/congenital
conditions
• Renal agenesis
• Aplastic kidneys
• Renal hypoplasia
• Ectopic/Displaced kidneys
• Fused Kidneys
 Risk Factors
• Neoplasms • Hyperparathyroidism
• Infections • Liver failure/cirrhosis
• Pyelonephritis • Gout
• Renal tuberculosis • Amyloidosis
• Glomerulonephritis • Scleroderma
• Goodpasture syndrome
• Systemic lupus erythematosus
(produces glomerulonephritis)
 Progression of CKD
• When damage to nephrons occur the remaining nephrons compensate by
enlarging and increasing their clearance capacity.
• Renal function remains normal until 75% to 80% of nephrons are damaged or
nonfunctional
• Compensatory mechanisms cause further damage to remaining nephrons.
 Hypertension
• The thickening and narrowing of the Renal artery reduces blood to the
nephrons
• Reduced blood flow reduces the GFR which signals the release of Renin
• Increased Renin activates RAAS increased heart rate furthering increasing blood
pressure with further thickening and narrowing of the blood vessels
• Leads to Glomerulosclerosis the thickening and hardening of the vessels within the
glomerulus leading to ischemic injury to the nephron
 Diabetes
• Leads to diabetic nephropathy
• Mesangial cell expansion and proliferation
• Podocytopathy
• Glomerular Basement Thickening
• Sclerosis
• Hyperglycemia leads to Reactive Oxygen Species (ROS)
• Growth Factors
• Proinflammatory Cytokines
• Oxidative Stress
 Clinical Manifestations
• Increased sodium and fluid retention
• Increase in potassium retention
• Metabolic acidosis
• Mineral Balance and Osteodystrophy
 Complications
• Hypertension
• Cardiovascular disease
• Uremic Syndrome
• Malnutrition
• Anemia
 Clinical Management
• Treatment directed at slowing progression to ESRD and managing
complications.
• As death normally is the result of cardiovascular changes management of
these complications is important
 Treatment of CKD
• Monitor and treat and prevent fluid volume excess, HTN, and Cardiovascular disease
• Prevent and treat metabolic acidosis
• Fluid and electrolyte imbalance
• Prevent and treat bone and mineral disorders
• Prevent and treat uremia
• Prevent and treat infection
• Prevent and treat anemia
• Control pain
 Nursing management
• Regular blood and urine testing
• ABG, BUN, Creatinine, Hgb (for anemia), electrolytes
• Assess for signs and symptoms of metabolic acidosis
• Patient teaching about need to monitor and regulate BP
 Questions
• A cllient with chronic renal failure has been prescribed calcium carbonate.
What is the rationale for this particular medication?
1) Diminishes incidence of gastric ulcer formation
2) Alleviates constipation
3) Binds with phosphorus to lower concentration
4) Increase tubular reabsorption of sodium
• 3: Clients with CKD have hyperphosphatemia. Clients are prescribed
calcium-based phosphate binders to improve excretion of phosphorus.
 Question
• A client with chronic renal failure has an internal venous access site for
hemodialysis on her left forearm. What action will the nurse take to protect
this access site?
1) Irrigate with heparin and NS q8 hrs
2) Apply warm moist packs to the area after hemodialysis
3) Do not use the left arm to take blood pressure readings.
4) Keep the arm elevated above the level of the heart.
• 3: Protect the arm with the functioning shunt. No blood pressure readings
should be taken from that arm, and there should be no needle sticks. The
access is not irrigated with Heparin.