Chronic Renal Failure (End Stage Renal Disease “ESRD”) Dr. Belal Hijji, RN, PhD April 18 & 23, 2012

Learning Outcomes At the end of this lecture, students will be able to: Recognise what ESRD means and its causes. Discuss the pathophysiological changes associated with ESRD. Describe the clinical manifestations of ESRD, and related assessment and diagnostic findings. Describe the medical management of a patient with ESRD. Discuss the nursing management of a patient with ESRD.

Introduction Chronic renal failure, or ESRD, is a progressive and irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in retention of urea and other nitrogenous wastes in the blood. Diabetes mellitus may cause ESRD. Other causes may be hypertension, chronic glomerulonephritis, pyelonephritis, obstruction of the urinary tract, heredity, as in polycystic kidney disease, vascular disorders, infections, medications, or toxic agents.

Pathophysiology of ESRD As renal function declines, the end products of protein metabolism accumulate in the blood. Uremia develops and adversely affects every system in the body. The greater the buildup of waste products, the more severe the symptoms. ESRD occurs when there is less than 10% nephron function remaining. All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired.

Pathophysiology of ESRD (Continued….) The rate of decline in renal function and progression of chronic renal failure is related to the underlying disorder, the urinary excretion of protein, and the presence of hypertension. The disease tends to progress more rapidly in patients who excrete significant amounts of protein or have elevated blood pressure than in those without these conditions.

Clinical Manifestations of ESRD Because virtually every body system is affected by the uremia of chronic renal failure, patients exhibit a number of signs and symptoms. The severity of these signs and symptoms depends in part on the degree of renal impairment, other underlying conditions, and the patient’s age. The clinical manifestations accompanying certain disorders associated with ESRD are presented next.

Clinical Manifestations of ESRD Cardiovascular: These are hypertension (due to sodium and water retention), heart failure and pulmonary edema (due to fluid overload), and pericarditis (due to irritation of the pericardial lining by uremic toxins). Dermatologic symptoms: Severe itching (pruritus) is common. Other systemic manifestations: GI signs and symptoms (anorexia, nausea, vomiting, and hiccups) are common. Neurologic changes (altered levels of consciousness, inability to concentrate, muscle twitching, and seizures) were reported. It is generally thought that the accumulation of uremic waste products is the probable cause.

Assessment and Diagnostic Findings Glomerular filtration rate: GFR (see next slide) is decreased resulting in a decrease in creatinine clearance, whereas the serum creatinine and BUN levels increase. Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body. Sodium and water retention: In ESRD, some patients retain sodium and water, increasing the risk for edema, heart failure, and hypertension. Other patients may lose salt and run the risk of developing hypotension and hypovolemia.

Nephron

Assessment and Diagnostic Findings (Continued…) Metabolic acidosis: This condition develops as the kidney cannot excrete increased loads of acid. Decreased acid secretion primarily results from inability of the kidney tubules to excrete ammonia (NH3) and to reabsorb sodium bicarbonate (CHNaO3). Anemia: Anemia results from inadequate erythropoietin (stimulates bone marrow to produce RBCs) production by kidneys, the shortened life span of RBCs, nutritional deficiencies, and blood loss during hemodialysis.

Medical Management Pharmacologic therapy: Antacids: Hyperphosphatemia and hypocalcemia are treated with aluminum-based antacids that bind dietary phosphorus in the GI tract. To avoid the potential long-term-toxicity of aluminum and its association with neurologic symptoms, calcium carbonate is prescribed. Antihypertensive and Cardiovascular Agents: Hypertension is managed by intravascular volume control (via dietary salt restriction) and a variety of antihypertensive agents. Heart failure and pulmonary edema may also require treatment with fluid restriction, low-sodium diets, diuretic agents, inotropic agents such as digitalis or dobutamine, and dialysis.

Pharmacologic therapy (Continued……): Antiseizure Agents: Neurologic abnormalities such as seizures are controlled via intravenous diazepam (Valium) or phenytoin (Dilantin). The side rails of the bed should be padded to protect the patient. Erythropoietin: Anemia associated with chronic renal failure is treated with recombinant human erythropoietin (Epogen). Anemic patients (hematocrit less than 30%) are treated with Epogen to achieve a hematocrit of 33% to 38%, which generally alleviates the symptoms of anemia. Epogen is administered either intravenously or subcutaneously three times a week, and it may take 2 to 6 weeks for the hematocrit to rise.

Nutritional therapy: Protein is restricted because urea, uric acid, and organic acids accumulate rapidly in the blood. The allowed protein must be of high biologic value (dairy products, eggs, meats). Usually, the fluid allowance is 500 to 600 mL more than the previous day’s 24-hour urine output. Calories are supplied by carbohydrates and fat to prevent wasting. Vitamin supplementation is necessary because a protein-restricted diet does not provide the necessary complement of vitamins. Additionally, the patient may lose water-soluble vitamins from the blood during dialysis.

Hemodialysis: Hyperkalemia is usually prevented by ensuring adequate dialysis treatments with potassium removal and careful monitoring of all medications for their potassium content. The patient is placed on a potassium-restricted diet. Dialysis is usually initiated when the patient cannot maintain a reasonable lifestyle with conservative treatment.

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. Interventions: The nurse should: 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.

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. 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

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. 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.

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.