Chronic Kidney Disease

Sachin kr. Rana(58)Sakshi mittal(60)

Outline

• Definition• Briefly discuss it’s epidemiology,.• pathophysiology,• causative factors• Staging• Clinical features• Screening methods• Investigations• treatment

DEFINITION

Chronic Kidney Disease is defined as a slow lose of renal function over time. This leads to a decreased ability to remove waste products from the body and perform homeostatic functions.

Clinical Definition

• GFR of less than 60 ml/minute or 1.73m2 per body surface area (normal is 125ml/min) .

• Presence of kidney damage, regardless of the cause, for three or more months

Some important definitions

1.1. AzotemiaAzotemia - elevated blood urea nitrogen (BUN - elevated blood urea nitrogen (BUN >28mg/dL) and creatinine (Cr>1.5mg/dL) >28mg/dL) and creatinine (Cr>1.5mg/dL)

2.2. UremiaUremia - azotemia with symptoms or signs of renal - azotemia with symptoms or signs of renal failure failure

3.3. End Stage Renal Disease (ESRD) End Stage Renal Disease (ESRD) – GFR <15 ml/min + – GFR <15 ml/min + uremia requiring transplantation or dialysis uremia requiring transplantation or dialysis

4.4. Chronic Renal Failure (CRF) Chronic Renal Failure (CRF) - irreversible kidney - irreversible kidney dysfunction with azotemia >3 months dysfunction with azotemia >3 months

5.5. Creatinine Clearance (CCr) Creatinine Clearance (CCr) - the rate of filtration of - the rate of filtration of creatinine by the kidney (GFR marker) creatinine by the kidney (GFR marker)

6.6. Glomerular Filtration Rate (GFR) Glomerular Filtration Rate (GFR) - the total rate of - the total rate of filtration of blood by the kidney filtration of blood by the kidney

Epidemiology

• CKD affects about 26 million people in the US• Approximately 19 million adults are in the

early stages of the disease – On the rise do to increasing prevalence of

diabetes and hypertension

• Total cost in treating ESRD in US was approximately $40 billion in 2008

Pathophysiology

•Primary kidney disease-> decrease in nephron no. -> adaptive change in the remaing nephrons to maintain renal function-> hypertrophy &vasodilation of surving nephron -> leads to increase glomerular pressure & filteration-> over a peroid of time leads to glomerular sclerosis ->failure of adaptive function -> further reduction of kidney fuction

Staging of Chronic Kidney Disease

Stage Description GFR (ml/min/1.73 m2)

At increased risk >=90 (with CKD risk factors)

1 Kidney damage with normal or increased GFR

90

2 Mildly decreased GFR 60-89

3 Moderately decreased GFR 30-59

4 Severely decreased GFR 15-29

5 Renal Failure <15 (or dialysis)

Symptoms• Hematuria• Flank pain• Edema• Hypertension• Signs of uremia• Lethargy and fatigue• Loss of appetite• If asymptomatic may have elevated serum

creatinine concentration or an abnormal urinalysis

C/F of CKD

Stage 1 and 2 Asymptomatic, Features of hypertension like irritibility ,

headache dizziness, palpitation, easy fatigablity , epistaxis, blurring of vision.

C/F of CKD Stage 3 and 4

Anemia – fatigue , weakness, loss of concentration Decreasing appetite; poor nutrition Electrolyte Abnormalities Calcium: backpain, kidney stone, spasm, mental

confusion Sodium: high b.p, weakness ,muscle Cramps,

nausea, abd. discomfort Water: oedema potassium: weakness , fatigue , nausea

C/F of CKD

Stage 5 All of the above – accentuated; eventually

overt uremia

Symptoms of Uremia

Screening Methods

Serum CreatinineEstimated glomerular filtration rate (GFR)Urine testing :

Serum Creatinine

Sr creatinine is poor reflection of early renal disease/failure

Damage < 60% sr creatinine still normal

Almost all early renal failure patients are asymptomatic

SCREENING IS THEREFORE VERY IMPORTANT

Estimated Glomerular Filtration rate

• Estimate of GFR by the Cockcroft and Gault equation

Cockroft Gault Formula (140 – age) X Body Weight (Kg)/

72 X Serum Creatinine (mg/dL) Multiply by 0.85 for women

Urine Testing

Urine for proteinDipstick24 hour urinary protein

Urine microscopic examinationFor RBC / Pus Cell / Cast

Urine for microalbuminuriaOn morning urine sampleusing strip for microalbumin

Targets for Screening

Hypertensive patients Diabetic patients Cardiovascular disease Those on regular NSAID/Herbs Renal calculi Anemia of unknown aetiology First and second degree relatives of ESRD Autoimmune disease (SLE/RA) Reduction of kidney mass(Nephrectomy

False +ve CKD

Urinary Tract Infection

Sepsis

Heart Failure

Strenous exercise

Heavy protein intake

Menses

Significance of proteinuria

A dominant risk factor for deterioration of renal failure (besides HT)

Marker of Increased Risk for CV mortality and morbidity (DM & non-DM)

e.g. Microalbuminuria is associated with a 100- 150% increase in death rate

Chronic Kidney DiseaseChronic Kidney DiseaseDiagnostic StudiesDiagnostic Studies

• TESTS INTERPRETATION1.Urinalysis haematuria & protenuria may indicate cause. Protenuria in- dicate progression of ckd

2.urea&creatinine to assess stability/progresn :compare to previous result

• TESTS INTERPRETATION3.Electrolytes to identify hyperkalemia & acidosis4.calcium, to assess osteodystrophyPhosphate,Pth hormone

5.Albumin low : consider malnutrition, inflamation6.CBC ( fe , ferritin, rule out anemiaFolate, B12)

• TESTS INTERPRETATION7.Lipid profile cvs disease risk is high in ckd

8.Glucose , HbA1c rule out diabities

9.Renal usg to exclude obstruction ,small kidneys suggest chronicity

10.ECG if pt. is >40yrs or hyperklemic

• TESTS INTERPRETATION

11.hepatitis& if dialysis or transplant is HIV planned

12.CXR rule out pul. Oedema , uremic pericardial effusion

TREATMENT

Nursing ImplementationNursing Implementation

• Health promotionHealth promotion• Identify individuals at risk for CKDIdentify individuals at risk for CKD

• History of renal diseaseHistory of renal disease• HypertensionHypertension• Diabetes mellitusDiabetes mellitus• Repeated urinary tract infectionRepeated urinary tract infection

• Regular checkups and changes in urinary Regular checkups and changes in urinary appearance, frequency and volume appearance, frequency and volume should be reportedshould be reported

LIFE STYLE MODIFICATION

Nutritional therapyNutritional therapy• Protein restrictionProtein restriction

• 0.6 to 0.8 g/kg body weight/day0.6 to 0.8 g/kg body weight/day

• Water restriction Water restriction • Intake depends on daily urine outputIntake depends on daily urine output

CONT.

Nutritional therapyNutritional therapy• Sodium restrictionSodium restriction

• Diets vary from 2 to 4 g depending on Diets vary from 2 to 4 g depending on degree of edema and hypertensiondegree of edema and hypertension

• Sodium and salt should not be equated Sodium and salt should not be equated • Patient should be instructed to avoid Patient should be instructed to avoid

high-sodium foodshigh-sodium foods• Salt substitutes should not be used because they Salt substitutes should not be used because they

contain potassium chloridecontain potassium chloride

CONT.

Nutritional therapyNutritional therapy• Potassium restrictionPotassium restriction

• 2 to 4 g2 to 4 g• High-potassium foods should be High-potassium foods should be

avoidedavoided• OrangesOranges• BananasBananas• TomatoesTomatoes• Green vegetablesGreen vegetables

CONT.

• Phosphate restrictionPhosphate restriction• 1000 mg/day1000 mg/day• Foods high in phosphateFoods high in phosphate

• Dairy products ( milk, cheese , eggs)Dairy products ( milk, cheese , eggs)

• Most foods high in phosphate are also Most foods high in phosphate are also high in calciumhigh in calcium

MEDICAL THERAPYDrug therapyDrug therapy

• HyperkalemiaHyperkalemia• Drugs that Stablise cell membrane potentialDrugs that Stablise cell membrane potential

• IV 10 ml 10% calcium gluconateIV 10 ml 10% calcium gluconate• Raises threshold for excitationRaises threshold for excitation

• Shifts potassium into cells Shifts potassium into cells • IV insulin and glucoseIV insulin and glucose• bicarbonatebicarbonate

• Shift potassium into cellsShift potassium into cells• Correct acidosisCorrect acidosis

• Beta agonist - salbutamolBeta agonist - salbutamol

CONT.Drug therapyDrug 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 sodiumResin in bowel exchanges potassium for sodium• Evacuates potassium-rich stool from bodyEvacuates potassium-rich stool from body• Educate patient that diarrhea may occur due to laxative in Educate patient that diarrhea may occur due to laxative in

preparationpreparation• 3. remove potassium from body3. remove potassium from body

iv furosemide &normal salineiv furosemide &normal saline

Ion exchange resin ex: resonium oral or per rectal Ion exchange resin ex: resonium oral or per rectal

dialysisdialysis

CONT.

Drug therapyDrug therapy• Hypertension (cont’d)Hypertension (cont’d)

• Antihypertensive drugsAntihypertensive drugs• DiureticsDiuretics• ββ-Adrenergic blockers-Adrenergic blockers• Calcium channel blockersCalcium channel blockers• Angiotensin-converting enzyme (ACE) Angiotensin-converting enzyme (ACE)

inhibitorsinhibitors• Angiotensin receptor blocker agentsAngiotensin receptor blocker agents

CONT.

Drug therapyDrug therapy• ACIDOSIS sodium bicarbonate supplement(1g 8 hrly) maintain plasma bicarbonate level >22mmol/l

CONT.

Drug therapyDrug therapy• CVS DISEASE control of dyslipidemia.1.Statins eg Atrovastatin, lovastatin, rosuvastatin2. Cholestrol absorption inhibiter- eg ezetimibe3. Fibrates eg-finofibrate, cinofibrate4.Bile acid sequestrum resin- eg colestyramine,

colestipol. 5. Inhibitor of vldl secretion eg- nicotinic acid

CONT.

Drug therapyDrug therapyHYPERPHOSPHATEMIA phosphate binding drugs adminstered

with foodsto prevent absorptioneg: calcium carbonate , aluminium hydroxide,

lanthanum carbonate.

CONT.

Drug therapyDrug therapy• Renal osteodystrophyRenal osteodystrophy

• Phosphate intake restricted to Phosphate intake restricted to <1000 mg/day<1000 mg/day

• Phosphate bindersPhosphate binders• Calcium carbonate (Tums)Calcium carbonate (Tums)

• Bind phosphate in bowel and excretedBind phosphate in bowel and excreted

• Sevelamer hydrochloride (Renagel)Sevelamer hydrochloride (Renagel)• Lowers cholesterol and LDLsLowers cholesterol and LDLs

CONT.

Drug therapyDrug therapy• Renal osteodystrophy (cont’d)Renal osteodystrophy (cont’d)

• Phosphate binders (cont’d)Phosphate binders (cont’d)• Should be administered with each mealShould be administered with each meal• Side effect: ConstipationSide effect: Constipation

• Supplementing vitamin DSupplementing vitamin D• Calcitriol (Rocaltrol)Calcitriol (Rocaltrol)• Serum phosphate level must be lowered before Serum phosphate level must be lowered before

administering calcium or vitamin Dadministering calcium or vitamin D

CONT.

• Renal osteodystrophy (cont’d)Renal osteodystrophy (cont’d)• Controlling secondary Controlling secondary

hyperparathyroidismhyperparathyroidism• Calcimimetic agentsCalcimimetic agents

• Cinacalcet (Sensipar)Cinacalcet (Sensipar)• ↑↑ Sensitivity of calcium receptors in Sensitivity of calcium receptors in

parathyroid glandsparathyroid glands

• Subtotal parathyroidectomy Subtotal parathyroidectomy

CONT.

Drug therapyDrug therapy

• Anemia Anemia • Iron supplementsIron supplements

• If plasma ferritin If plasma ferritin <100 ng/ml<100 ng/ml• Side effect: Gastric irritation, Side effect: Gastric irritation,

constipationconstipation• May make stool dark in colorMay make stool dark in color

CONT.

• Anemia (cont’d)Anemia (cont’d)• Folic acid supplementsFolic acid supplements

• Needed for RBC formation Needed for RBC formation • Removed by dialysisRemoved by dialysis

• Avoid blood transfusionsAvoid blood transfusions

CONT.

• Anemia(cont’d)Anemia(cont’d)

• ErythropoietinErythropoietin• Epoetin alfa (Epogen, Procrit)Epoetin alfa (Epogen, Procrit)• Administered IV or subcutaneouslyAdministered IV or subcutaneously• Increased hemoglobin and hematocrit in Increased hemoglobin and hematocrit in

2 to 3 weeks2 to 3 weeks• Side effect: HypertensionSide effect: Hypertension

DIALYSIS

Prepared by D. ChaplinPrepared by D. Chaplin

PD Advantages and Disadvantages

Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Bacterial/chemical periotonitis

Protein lossExit site of catheterHyperglycemiaSurgical placement of

catheterMultiple abdominal

surgery

Bacterial/chemical periotonitis

Protein lossExit site of catheterHyperglycemiaSurgical placement of

catheterMultiple abdominal

surgery

AdvantagesAdvantages DisadvantagesDisadvantages

Prepared by D. ChaplinPrepared by D. Chaplin

Hemo Advantages & Disadvantages

Rapid fluid removalRapid removal of urea &

creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at the

bedside

Rapid fluid removalRapid removal of urea &

creatinineEffective K+ removalLess protein lossLower triglyceridesHome dialysis possibleTemporary access at the

bedside

Vascular access problems

Dietary & fluid restrictions

HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist

Vascular access problems

Dietary & fluid restrictions

HeparinizationExtensive equipmentHypotensionAdded blood lostTrained specialist

AdvantagesAdvantages DisadvantagesDisadvantages

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

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

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

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

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

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

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

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.

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

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

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

Complications Post Transplant

InfectionHypertensionMalignancies (lip, skin,

lymphomas, cervical)Recurrence of renal diseaseRetroperiotneal bleedArterial stenosisUrine leakage

SUMMARY

THANK YOU!