1. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (Chapter 47, “Nursing Management: Cronic Kidney Disease,” in the Lewis textbook- Modified by L. Copenhaver)

2. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease (CKD) Involves progressive, irreversible loss of kidney function Involves progressive, irreversible loss of kidney function Defined as either presence of Defined as either presence of Kidney damage Kidney damage Pathological abnormalities Pathological abnormalities Glomerular filtration rate (GFR) Glomerular filtration rate (GFR) <60 ml/min for 3 months or longer <60 ml/min for 3 months or longer

3. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Disease staging based on decrease in GFR Disease staging based on decrease in GFR What is the normal GFR? What is the normal GFR? What diagnostic test reflects GFR? What diagnostic test reflects GFR? Last stage of kidney failure Last stage of kidney failure End-stage renal disease (ESRD) occurs when GFR <15 ml/min End-stage renal disease (ESRD) occurs when GFR <15 ml/min

4. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Leading causes of ESRD Leading causes of ESRD Diabetes Diabetes Hypertension Hypertension

5. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Uremia Uremia Syndrome that incorporates all signs and symptoms seen in various systems throughout the body Syndrome that incorporates all signs and symptoms seen in various systems throughout the body

6. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Manifestations of Chronic Uremia Fig. 47-5

7. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Urinary system Polyuria Polyuria Results from inability of kidneys to concentrate urine Results from inability of kidneys to concentrate urine Occurs most often at night Occurs most often at night Specific gravity fixed around 1.010 Specific gravity fixed around 1.010

8. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Urinary system Oliguria Oliguria Occurs as CKD worsens Occurs as CKD worsens Anuria Anuria Urine output <40 ml per 24 hours Urine output <40 ml per 24 hours

9. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Metabolic disturbances Waste product accumulation Waste product accumulation As GFR ↓, BUN ↑ and serum creatinine levels ↑ As GFR ↓, BUN ↑ and serum creatinine levels ↑ BUN ↑ BUN ↑ Not only by kidney failure but by protein intake, fever, corticosteroids, and catabolism Not only by kidney failure but by protein intake, fever, corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and headaches occur N/V, lethargy, fatigue, impaired thought processes, and headaches occur

10. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Potassium Potassium Hyperkalemia Hyperkalemia Most serious electrolyte disorder in kidney disease Most serious electrolyte disorder in kidney disease Fatal dysrhythmias Fatal dysrhythmias

11. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Sodium Sodium May be normal or low May be normal or low Because of impaired excretion, sodium is retained Because of impaired excretion, sodium is retained Water is retained Water is retained Edema Edema Hypertension Hypertension CHF CHF

12. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Electrolyte/acid–base imbalances Calcium and phosphate alterations Calcium and phosphate alterations Magnesium alterations Magnesium alterations Metabolic acidosis Metabolic acidosis Results from Results from Inability of kidneys to excrete acid load (primary ammonia) Inability of kidneys to excrete acid load (primary ammonia)

13. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Hematologic system Anemia Anemia Due to ↓ production of erythropoietin Due to ↓ production of erythropoietin From ↓ of functioning renal tubular cells From ↓ of functioning renal tubular cells Bleeding tendencies Bleeding tendencies Defect in platelet function Defect in platelet function

14. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Hematologic system Infection Infection Changes in leukocyte function Changes in leukocyte function Altered immune response and function Altered immune response and function Diminished inflammatory response Diminished inflammatory response

15. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Cardiovascular system Hypertension Hypertension Heart failure Heart failure Left ventricular hypertrophy Left ventricular hypertrophy Peripheral edema Peripheral edema Dysrhythmias Dysrhythmias Uremic pericarditis Uremic pericarditis

16. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Respiratory system Kussmaul respiration-Why? Kussmaul respiration-Why? Dyspnea-Why? Dyspnea-Why? Pulmonary edema-Why? Pulmonary edema-Why? Uremic pleuritis-Why? Uremic pleuritis-Why? Pleural effusion Pleural effusion Predisposition to respiratory infections Predisposition to respiratory infections Depressed cough reflex Depressed cough reflex “Uremic lung” “Uremic lung”

17. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Gastrointestinal system Every part of GI is affected Every part of GI is affected Due to excessive urea Due to excessive urea Mucosal ulcerations Mucosal ulcerations Stomatitis Stomatitis Uremic fetor (urinous odor of the breath) Uremic fetor (urinous odor of the breath) GI bleeding GI bleeding Anorexia Anorexia N/V N/V

18. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Neurologic system Expected as renal failure progresses Expected as renal failure progresses Attributed to Attributed to Increased nitrogenous waste products Increased nitrogenous waste products Electrolyte imbalances Electrolyte imbalances Metabolic acidosis Metabolic acidosis Demyelination of nerve fibers Demyelination of nerve fibers Altered mental ability Altered mental ability Seizures and Coma Seizures and Coma Dialysis encephalopathy Dialysis encephalopathy Peripheral neuropathy Peripheral neuropathy

19. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Neurologic system Restless leg syndrome Restless leg syndrome Muscle twitching Muscle twitching Irritability Irritability Decreased ability to concentrate Decreased ability to concentrate

20. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Musculoskeletal system Renal osteodystrophy Renal osteodystrophy Syndrome of skeletal changes Syndrome of skeletal changes Result of alterations in calcium and phosphate metabolism Result of alterations in calcium and phosphate metabolism Weaken bones, increase fracture risk Weaken bones, increase fracture risk Two types associated with ESRD: Two types associated with ESRD: Osteomalacia Osteomalacia Osteitis fibrosa Osteitis fibrosa

21. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Renal Osteodystrophy Fig. 47-6

22. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Integumentary system Most noticeable change Most noticeable change Yellow-gray discoloration of the skin Yellow-gray discoloration of the skin Due to absorption/retention of urinary pigments Due to absorption/retention of urinary pigments Pruritus Pruritus Uremic frost Uremic frost Dry, pale skin Dry, pale skin

23. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Integumentary system Dry, brittle hair Dry, brittle hair Thin nails Thin nails Petechiae Petechiae Ecchymoses Ecchymoses

24. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Clinical Manifestations Reproductive system Infertility Infertility Experienced by both sexes Experienced by both sexes Decreased libido Decreased libido Low sperm counts Low sperm counts Sexual dysfunction Sexual dysfunction

25. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

26. Chronic Kidney Disease Diagnostic Studies Laboratory tests (cont’d) Laboratory tests (cont’d) Urinalysis Urinalysis Urine culture Urine culture Hematocrit Hematocrit Hemoglobin Hemoglobin Renal ultrasound Renal ultrasound Renal scan Renal scan

27. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Hyperkalemia Hyperkalemia IV insulin and glucose IV insulin and glucose IV 10% calcium gluconate IV 10% calcium gluconate Raises threshold for excitation Raises threshold for excitation Sodium bicarbonate Sodium bicarbonate Shift potassium into cells Shift potassium into cells Correct acidosis Correct acidosis

28. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Hyperkalemia (cont’d) Hyperkalemia (cont’d) Sodium polystyrene sulfonate (Kayexalate) Sodium polystyrene sulfonate (Kayexalate) Cation-exchange resin Cation-exchange resin Resin in bowel exchanges potassium for sodium Resin in bowel exchanges potassium for sodium Evacuates potassium-rich stool from body Evacuates potassium-rich stool from body Educate patient that diarrhea may occur due to laxative in preparation Educate patient that diarrhea may occur due to laxative in preparation

29. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Hypertension (cont’d) Hypertension (cont’d) Antihypertensive drugs Antihypertensive drugs Diuretics Diuretics β-Adrenergic blockers β-Adrenergic blockers Calcium channel blockers Calcium channel blockers Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blocker agents Angiotensin receptor blocker agents

30. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy Renal osteodystrophy Phosphate intake restricted to <1000 mg/day Phosphate intake restricted to <1000 mg/day Phosphate binders Phosphate binders Calcium carbonate (Tums) Calcium carbonate (Tums) Bind phosphate in bowel and excreted Bind phosphate in bowel and excreted Sevelamer hydrochloride (Renagel) Sevelamer hydrochloride (Renagel) Lowers cholesterol and LDLs Lowers cholesterol and LDLs

31. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy (cont’d) Renal osteodystrophy (cont’d) Phosphate binders (cont’d) Phosphate binders (cont’d) Should be administered with each meal Should be administered with each meal Side effect: Constipation Side effect: Constipation Supplementing vitamin D Supplementing vitamin D Calcitriol (Rocaltrol) Calcitriol (Rocaltrol) Serum phosphate level must be lowered before administering calcium or vitamin D Serum phosphate level must be lowered before administering calcium or vitamin D

32. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Renal osteodystrophy (cont’d) Renal osteodystrophy (cont’d) Controlling secondary hyperparathyroidism Controlling secondary hyperparathyroidism Calcimimetic agents Calcimimetic agents Cinacalcet (Sensipar) Cinacalcet (Sensipar) ↑ Sensitivity of calcium receptors in parathyroid glands ↑ Sensitivity of calcium receptors in parathyroid glands Subtotal parathyroidectomy Subtotal parathyroidectomy

33. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Anemia Anemia Erythropoietin Erythropoietin Epoetin alfa (Epogen, Procrit) Epoetin alfa (Epogen, Procrit) Administered IV or subcutaneously Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3 weeks Increased hemoglobin and hematocrit in 2 to 3 weeks Side effect: Hypertension Side effect: Hypertension

34. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Anemia (cont’d) Anemia (cont’d) Iron supplements Iron supplements If plasma ferritin <100 ng/ml If plasma ferritin <100 ng/ml Side effect: Gastric irritation, constipation Side effect: Gastric irritation, constipation May make stool dark in color May make stool dark in color

35. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Anemia (cont’d) Anemia (cont’d) Folic acid supplements Folic acid supplements Needed for RBC formation Needed for RBC formation Removed by dialysis Removed by dialysis Avoid blood transfusions Avoid blood transfusions

36. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Drug therapy Complications Complications Drug toxicity Drug toxicity Digitalis Digitalis Antibiotics Antibiotics Pain medication (Demerol, NSAIDs) Pain medication (Demerol, NSAIDs)

37. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Nutritional therapy Protein restriction Protein restriction 0.6 to 0.8 g/kg body weight/day 0.6 to 0.8 g/kg body weight/day Water restriction Water restriction Intake depends on daily urine output Intake depends on daily urine output

38. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Nutritional therapy Sodium restriction Sodium restriction Diets vary from 2 to 4 g depending on degree of edema and hypertension Diets vary from 2 to 4 g depending on degree of edema and hypertension Sodium and salt should not be equated Sodium and salt should not be equated Patient should be instructed to avoid high-sodium foods Patient should be instructed to avoid high-sodium foods Salt substitutes should not be used because they contain potassium chloride Salt substitutes should not be used because they contain potassium chloride

39. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Nutritional therapy Potassium restriction Potassium restriction 2 to 4 g 2 to 4 g High-potassium foods should be avoided High-potassium foods should be avoided Oranges Oranges Bananas Bananas Tomatoes Tomatoes Green vegetables Green vegetables

40. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Collaborative Care Phosphate restriction Phosphate restriction 1000 mg/day 1000 mg/day Foods high in phosphate Foods high in phosphate Dairy products Dairy products Most foods high in phosphate are also high in calcium Most foods high in phosphate are also high in calcium

41. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses Excess fluid volume Excess fluid volume Risk for injury Risk for injury Imbalanced nutrition: Less than body requirements Imbalanced nutrition: Less than body requirements Grieving Grieving Risk for infection Risk for infection

42. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation Health promotion Health promotion Identify individuals at risk for CKD Identify individuals at risk for CKD History of renal disease History of renal disease Hypertension Hypertension Diabetes mellitus Diabetes mellitus Repeated urinary tract infection Repeated urinary tract infection Regular checkups and changes in urinary appearance, frequency and volume should be reported Regular checkups and changes in urinary appearance, frequency and volume should be reported

43. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Gerontologic Considerations Diminished cardiopulmonary function Diminished cardiopulmonary function Impaired cognition Impaired cognition Altered drug metabolism Altered drug metabolism Bone loss Bone loss Immunodeficiency Immunodeficiency

44. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Kidney Disease Gerontologic Considerations Most common cause of death in the elderly ESRD patient Most common cause of death in the elderly ESRD patient Cardiovascular disease (MI, stroke) Cardiovascular disease (MI, stroke) Withdrawal from dialysis Withdrawal from dialysis