Chronic Kidney Disease Management and care

Chronic kidney disease (CKD) is defined as the presence of kidney damage or an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 mt2, persisting for 3 months or more, irrespective of the cause.

1. Mr. Sachin Dwivedi College of Nursing, AIIMS Rishikesh Chronic kidney Disease

2. Chronic kidney Disease

3. Chronic kidney disease (CKD) Chronic kidney disease (CKD) consists of a spectrum of different pathophysiologic processes associated with abnormal kidney function, and a progressive decline in glomerular filtration rate (GFR).

4. Acc. To National kidney foundation , It is defined as………. 1.Kidney damage for ≥3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either: Pathological abnormalities or Markers of kidney damage 2. GFR <60ml/min/ for ≥3mths, with or without kidney damage.

5. Epidemiology CKD has a high global prevalence with a consistent estimated global CKD prevalence of between 9.1 to 13% with the majority stage 3. (2022) 4 to 20% prevalence of CKD in India. (2023) Common cause of CKD in India- Diabetic nephropathy.

6. Risk factors Older age, A family history of renal disease, A previous episode of acute renal failure, Diabetes mellitus, Hypertension, Autoimmune disease, Structural abnormalities of the urinary tract.

7. Causes of chronic kidney disease Primary glomerular diseases:   Glomerulonephritis, IgA nephritis. Systemic disease: diabetes mellitus, hypertension, SLE, Hereditary nephropathies: Hereditary nephritis.

8. Cont… Vascular causes: Large vessel disease such as bilateral renal artery stenosis  Small vessel disease such as ischemic nephropathy and vasculitis. Obstructive causes: such as bilateral kidney stones and Diseases of the prostate, urinary system tumors,

9. Compensatory hypertrophy of surviving nephrons adaptive hyper filtration & hypertrophy. Loss of excretory function Loss of non- excretory renal function. sclerosis of remaining nephrons, & total function loss. Decreased ph, k+, nitrogenous waste excretion. Like failure to produce erythropoietin & to convert inactive form of calcium Pathophysiology

10. Classification of Chronic Kidney Disease (CKD) Stage Description GFR, ml/min With risk factors. >90, 1 Kidney Damage with normal GFR. ≥90, 2 Kidney Damage with mild ↓ in GFR. 60-89 3 Moderate ↓ in GFR. 30-59 4 Severe ↓in GFR. 15-29 5 End stage Renal Disease. <15 http://www.kidney.org/

11. Stage 5 CKD  is also called  established chronic kidney disease and is synonymous with the now outdated terms  end-stage renal disease (ESRD) ,  chronic kidney failure (CKF)  or  chronic renal failure  (CRF).

12. End-stage renal disease The term represents a stage of CKD where the accumulation of toxins, fluid, and electrolytes normally excreted by the kidneys results in the Uremic syndrome . No more compensation; all other organ systems will end up with some kind of dysfunction. This syndrome leads to death unless the toxins are removed by renal replacement therapy, using dialysis or kidney transplantation.

13. Clinical manifestations Neurological – Central: Slurred speech Asterixis and myoclonus Seizures Disorientation and confusion Increased muscle fatigability

14. Clinical manifestations Failure of kidneys to remove excess fluid may cause: Edema of the legs, ankles, feet, face and/or hands Shortness of breath due to extra fluid on the lungs (may also be caused by anemia) hypertension and/or congestive heart failure

15. Metabolic changes 1.An increase in serum creatinine or BUN. High levels of urea in the blood, which can result in: Vomiting and/or diarrhea, which may lead to dehydration. Weight loss Nocturnal urination. Azotemia and ultimately uremia.

16. Metabolic changes 1.Metabolic acidosis 2.Proteinuria 3.Hyperphosphatemia 4. Hyperkalemia may cause: Abnormal heart rhythms

17. Hematological changes Erythropoietin synthesis is decreased leading to anemia , which causes: Feeling tired and/or weak Memory problems Difficulty concentrating Dizziness

18. GIT changes Appetite loss, a bitter, metallic or salty taste in the mouth Fishy or ammonia-like smell in breath Difficulty sleeping constipation

19. Cardiovascular changes 50%-65% deaths occur due to cardiac complications of CKD. Hypertention Left ventricular hypertrophy Electrolyte imbalance

20. Respiratory changes Pulmonary edema Pleuritis Tachypnea

21. DIAGNOSTIC MEASURES 1.Urine tests: Urinalysis: dipstick test, urine albumin & creatinine. Twenty-four-hour urine tests : The urine may be analyzed for protein and waste products Glomerular filtration rate: As kidney disease progresses, GFR fall

22. DIAGNOSTIC MEASURES 2. Blood tests: Creatinine and urea (BUN) in the blood Electrolyte levels and acid-base balance Blood cell counts Erythropoietin 3. Other tests: Abdominal ultrasound :Kidneys with CKD are usually smaller (< 9 cm) than normal kidneys. Renal Biopsy Abdominal CT scan Abdominal MRI Renal scan

23. MANAGEMENT Goals of treatment: To preserve renal function To delay the need for dialysis or transplantation as long as feasible. To alleviate extra renal manifestations as much as possible. To improve body chemistry values. To provide an optimal quality of life for the client & significant others.

24. Preserve renal function & delay dialysis: PHARMACOLOGICAL THERAPY: Antihypertensive : goal is to keep blood pressure at or below 130/80 mmHg. ACE inhibitors or angiotensin receptor blockers (ARB) are usually prescribed. Cardiovascular agents : diuretics, ianotropic agents. Antacids: phosphorus binding antacids ( Fosrenol ) Metabolic acidosis : sodium bicarbonate, dialysis. Anemia: Erythropoietin Control of blood glucose levels.

25. Alleviate extra renal manifestations: Seizures :Antiseizure agents, safety measures to protect patient.

26. Improve body chemistry: Medications Diet management Renal replacement therapy: dialysis , renal transplantation .

27. Dietary management: General dietary guidelines: Protein restriction: Decreasing protein intake may slow the progression of chronic kidney disease. Salt restriction: Limit to 2 grams a day to avoid fluid retention and help control high blood pressure. Restrict Fluid intake

28. Dietary management: Potassium restriction : High levels of potassium can cause abnormal heart rhythms. Examples of foods high in potassium include bananas, oranges, nuts, and potatoes.  Phosphorus restriction: Decreasing phosphorus intake is recommended to protect bones. Eggs, beans, cola drinks, and dairy products are examples of foods high in phosphorus. High calorie diet Vitamin supplements

29. Nursing management Assessment: 1. Complete history taking: Past & present history regarding illness, any medication, diet, wt. changes, patterns of urination etc. 2. Assess pt for the multiple effects of CRF on all body systems. 3. Assess the pt’s understanding of CRF, the diagnostic tests,& the treatment regimens . 4. Assess the pt’s need for dialysis. 5. Assess the significant other’s understanding of the treatment regimen.

30. Nursing diagnosis. Excess fluid volume related to Decline GFR. Imbalanced nutrition: less than body requirements. Activity intolerance related to fatigue, anemia, retention of waste products, dialysis. Risk for impaired skin integrity.

31. Nursing diagnosis. 5. Risk for infection. 6. Risk for injury. 7. Disturbed self- esteem related to dependency, role, change in body image.

32. REFERENCES Brunner & Suddarth’s, Textbook of Medical Surgical Nursing.10th ed. Lippincott. Black M. Joyce, Hawks Hokanson Jane, Medical Surgical nursing.7th ed.2005, Saunders http://www.emedicinehealth.com/