CKD,ESRD,CRF notes on each one included .pptx

Brief note on CKD, ESRD, CRF notes for studying

1. Chronic kidney disease (CKD)

2. DEFINITION CKD involves progressive , irreversible loss of kidney function .

3. DEFINITION CRF/ CKD/ESRD is a progressive deterioration of renal function , which ends fatally in uremia ( an excess of urea and other nitrogenous wastes in the blood ) and its complications unless dialysis or a kidney transplantation is performed

4. KIDNEY DISEASE IMPROVING GLOBAL OUTCOME (KDIGO) Clinical Practice Guidelines defines CKD “as either the presence of kidney damage or a decreased GFR less than 60mL/min/1.73m2 for longer than 3 months”

5. ESRD occurs when the GFR is less than 15mL/min At this point renal replacement therapy is required to maintain life

6. INCIDENCE The incidence of ESRD has increased by almost 8% per year for the past 5 years. 60% of patients with HTN and DM Men & women are equally affected More incidence in middle aged people.

7. RISK FACTORS

8. ETIOLOGY

9. Diabetic glomerulosclerosis CRF develops in about 30% of type I and type II diabetics Peak incidence at about 15 years after the development of diabetes mellitus

10. Predictors of the development of diabetic glomerulosclerosis are   Hypertension Poor glycemic control Microalbuminuria

11. Hypertensive nephrosclerosis   Long standing hypertension leads to renal arteriosclerosis and ischemia resulting in glomerular destruction and tubular atrophy. Glomerulonephritis Bilateral inflammatory process of the glomeruli leads to ischemia, nephron loss ,and shrinkage of kidney.

12. Chronic pyelonephritis Chronic infection commonly associated with an obstructive or neurologic process and vesicoureteral reflux leads to nephropathy ( renal scarring , atrophy, dilated calyces).

13. Polycystic kidney disease Multiple bilateral cysts gradually destroy normal renal tissue by compression.  SLE Basement membrane damage by circulating immune complexes . Nephrotoxic drugs.

14. Tubulo interstitial disease Obstructive nephropathy (stones, BPH)

15. pathophysiology

16. Etiology Normal function of kidney even 75% nephrons damaged total GFR decreases. Accumulation of waste products in body. Nephrons work hard to eliminate this waste.

17. Increased production of urine. Decreased urine concentration Decreased tubular reabsorption . Sodium loss

18. Again decrease in GFR. Renal damage Uremia & death ( if untreated)

19. PATHOPHYSIOLOGY

20. Decreased renal blood flow Primary KD Damage from diabetes/hypertension Urine outflow obstruction Decreased GF Hypertrophy of remaining nephrons Inability to concentrate urine Kidney transplantation Treatment of the underlying problem Increased S.Creatinine Increased BUN Dilute polyuria Dehydration Loss of sodium in urine Hyponatremia

21. Further loss of nephron function Loss of excretory renal function dialysis Loss of nonexcretory renal function Disturbance in reproduction Decreased libido Infertility Immune disturbance Delayed wound healing Infection

22. Increased production of lipids Impaired insulin action Advanced atherosclrosis Erratic blood glucose level Failure to produce erythropoietin Anemia Pallor Failure to convert inactive forms of calcium Decreased calcium absorption Osteodystrophy Hypocalcemia

23. Stages of chronic kidney diseases Description GFR(ML/min/1.73m2) Clinical action plan STAGE 1 Kidney damage with normal or increased GFR STAGE 2 Kidney damage with mild decrease in GFR ≥ 90 60-89 Diagnosis and treatment CVD risk reduction slow progression Estimation of progression

24. Description GFR(Ml/min/1.73m2) Clinical action plan STAGE 3 a Moderate decrease in GFR STAGE 3b Moderate decrease GFR STAGE 4 Severe decrease GFR STAGE 5 Kidney failure 45-59 40-44 15-29 <15 (for dialysis ) Evaluation and treatmen t of complications More aggressive treatment of complications Preparation for renal replacement therapy Renal replacement therapy

25. CLINICAL FEATURES The clinical features are a result of retained substances, including Urea, Creatinine Phenols Hormones, electrolytes, water and many other substances.

26. ELECTROLYTES AND ACID IMBALANCES Potassium: Hyperkalemia is the most serious electrolyte disorder associated with kidney disease. Fatal dysrhythmias can occur when serum potassium level reaches 7-8 mEq /L)

27. Sodium: May be normal or low in renal failure. Impaired sodium excretion : sodium along with water is retained.

28. CONTINUATION If large quantities of body water retained, dilutional hyponatremia occurs. Sodium retention can contribute to edema, hypertension, and heart failure.

29. Calcium and phosphate Calcium decrease and phosphate increase . Magnesium: Hypermagnesemia – absence of reflux, decreased mental status, arrhythmias, hypotension and respiratory failure.

30. Metabolic changes. Metabolic acidosis results from the impaired ability of the kidney to excrete the acid load (primarily ammonia) and from defective reabsorption and regeneration of bicarbonate.

31. Hematologic system Anemia due to decreased production of the erythropoietin by the kidneys. Other factors contributing to anemia are nutritional deficiencies . decreased RBC life span .

32. Hematologic system Bleeding Tendencies : Defect in platelet function. Infection : Changes in leukocyte function and altered immune response and function.

33. Gastrointestinal system Every part of GI system is affected by excessive urea Stomatitis with exudates and ulcerations, Metallic taste in the mouth Breath commonly smells ammonia like Oesophagitis , gastritis, colitis, anorexia , nausea,

34. Gastrointestinal system Peptic ulcer gastric ulcer, due to accumulation of gastrin GI bleeding Increased S. amylase Constipation - from phosphate binding agents, restriction of fluid and fiber.

35. Immunological. Impairment in the immunity causing infection. Depression of antibody formation.

36. Cardiovascular system Hypertension , is aggravated by sodium retention. Cardiac dysrhrythmias may result from hyperkalemia, hypocalcemia and decreased coronary artery perfusion. Uremic pericarditis , pericardial effusion and cardiac tamponade . CHF, ventricular hypertrophy.

37. Atherosclerosis – abnormal carbohydrate and fat metabolism. Impaired fibrinolysis – leads micro thrombi. Arterial calcification Vascular calcification.

38. Respiratory system Kussmaul breathing Dyspnea from fluid overload , Pulmonary edema, Uremic pleuritis (pleurisy), Pleural effusion

39. Respiratory system Respiratory infections Uremic lung Thick and tenacious sputum

40. Musculoskeletal system. Renal osteodystrophy : is a bone disease due to impaired calcium and phosphorus in the blood Osteomalacia , osteoporosis. Abnormal calcium and phosphate stimulate release of parathyroid hormone It mobilizes calcium from the bone for phosphate excretion.

41. Neurologic system A general depression of the CNS Lethargy, apathy, decreased ability to concentrate, fatigue, irritability and altered mental ability. Seizures and coma - bun and hypertensive encephalopathy. Peripheral neuropathy.

42. Restless leg syndrome – Inability to find a comfortable position for the legs and the feet. Gait changes, foot drop, paraplegia. Slow nerve conduction, deep tendon reflexes Alter the senses.

43. Reproductive changes Infertility and decreased libido Women – decreased hormones – anovulation and menstrual changes. Men – testicular atrophy – oligospermia , reduced sperm motility.

44. Urinary system In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine . more often at night, and the patient must arise several times to urinate ( nocturia ).

45. Urinary system Because of the decrease in renal concentrating ability, the specific gravity of urine gradually become fixed at around 1.1010. As CKD worsens oliguria develops and eventually anuria (urine output<100ml /24hr) occurs.

46. Endocrine system Thyroid abnormalities . Changes in insulin utilization, parathyroid function Increase in growth hormone and prolactin

47. DIAGNOSTIC MEASURES History and physical examination Identification of reversible kidney disease Renal ultrasound, renal scan , ct scan Renal biopsy Bun, S. Creatinine , creatinine clearance level

48. DIAGNOSTIC MEASURES Serum electrolytes Lipid profile Urinalysis Hematocrit and Hb levels

49. MEDICAL MANAGEMENT Conservative treatment does not cure CKD,but it may slow the progress of the disease. The following are the five goals of medical management. To preserve existing kidney function. To delay the need for dialysis or transplantation as long as feasible.

50. MANAGEMENT The goal of management Preserve renal function Delay the need for dialysis and transplantation Alleviate extra renal manifestations Improve body chemistry value Provide an optimal quality of life.

51. MANAGEMENT Correction of extracellular fluid volume overload / deficit Renal replacement therapy( dilaysis,kidney transplant) Nutritional therapy Measures to lower potassium

52. PHARMACOLOGIC THERAPY Hyperkalemia: Restriction of food and drugs contain K. IV glucose and insulin or IV calcium Gluconate. Sodium polystyrene sulfonate . Bulk laxatives.

53. Hypertension. Sodium and fluid restriction. Antihypertensive drugs eg : diuretics, beta adrenergic blockers, calcium channel blockers, ACE inhibitors. Check BP supine, sitting and standing position.

54. Renal osteodystrophy. Restrict phosphate intake. Supplemental calcium Active forms of vit D Again it remain parathyroidectomy and transplant parathyroid tissues in the forearm.

55. Treatment of secondary hyperparathyroidism in end stage kidney disease patients requires the activated form of vit D , because the kidneys no longer possess the ability to activate vitamin D. Active vitamin D is available as oral or IV calcitriol,IV paricalcitrol,or oral or IV doxercalciferol , and can reduce the elevated level of PTH.

56. Antacids. Hyperphosphatemia and hypocalcemia - aluminum-based antacids that bind dietary phosphorus in the GI tract. Both calcium carbonate and phosphorus binding antacids must be administered with food to be effective. Magnesium-based antacids must be avoided

57. Hypertension is managed by intravascular volume control and a variety of antihypertensive medications. Weight loss(if obese),therapeutic life style changes ( exercise,avoidance of alcohol,smoking cessations), diet recommendation. (DASH) Dietary approaches to stop hypertension. An eating plan rich in fruits, whole grains,fish,poultry , nuts,legumes . Hyperphosphatemia and hypocalcemia are treated with aluminum based antacids that bind dietary phosphorus in the gastrointestinal tract. Limiting dietary phosphorus.1g/ day.phosphate binders include, calcium based binders:calcium acetate and calcium carbonate. Both calcium carbonate and phosphorus – binding antacids must be administered with food to be effective.

58. Cardiovascular 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 , dialysis.

59. Anti seizure Agents Intravenous diazepam (Valium) Phenytoin is usually administered to control seizures.

60. Erythropoietin. Anemia associated with chronic renal failure is treated with recombinant human erythropoietin. Administered either intravenously or subcutaneously three times a week. It may take 2 to 6 weeks for the hematocrit to rise. Eg : Darbepoetin alfa long acting

61. ERYTHROPOIETIN : Anemia associated with chronic renal failure is treated with recombinant human erythropoietin (Epogen). Anemic patients present with nonspecific symptoms, such as malaise, general fatigability, and decreased activity tolerance. Epogen is administered either intravenously or subcutaneously three times a week. It may take 2 to 6 weeks for the hematocrit to rise.

62. Diuretics: Diuretics such as furosemide or other loop diuretics may be prescribed to reduce the extra cellular fluid volume and edema. It can also cause potassium diuretics and cause potassium wasting, lowering serum potassium level.

63. NUTRITIONAL THERAPY Protein restriction Fluid restriction Sodium and potassium restriction Phosphate restriction

64. Protein 0.6 to 0.75 g/kg protein intake If dialysis started – 1.2 – 1.3 gm/kg protein. Vitamin: patients should take a multivitamin containing water-soluble vitamins. Calories from carbohydrate and fat.

65. Water restriction Daily urine out put + 500 – 600 ml/day. Foods that are liquid at room temperature ( gelatin , ice cream) consider as fluid. Use small glass. Fluid allotment should spread through out the day.

66. Dialysis Movement of fluid and molecules across a semi- permeable membrane from one compartment to another It is a technique in which substances moves from the blood through a semipermeable membrane and into a dialysis solution ( dialysate )

67. Dialysis is begun when the patients uremia can no longer be adequately treated with conservative medical management. Dialysis is initiated when the GFR is less than 15mL/min/1.73m2

68. Two methods of dialysis available are peritoneal dialysis (PD) and hemodialysis (HD) .

69. DIALYSIS Dialysis is  a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly . It often involves diverting blood to a machine to be cleaned.

70. Kidney transplantation involves transplanting a kidney from a living donor or human cadaver to a recipient who has ESRD. Patient choose kidney transplantation for a variety of reasons, such as the desire to avoid dialysis or to improve their sense of well being and the wish to lead a more normal life.

71. Nursing management Excess fluid volume related to impaired kidney function Risk for electrolyte imbalance related to impaired kidney function resulting in hyperkalemia , hypocalcemia , hyperphosphatemia and altered vitamin D metabolism

72. Nursing management Imbalanced nutrition less than body requirement related to restricted intake of nutrients , nausea , vomiting , anorexia and stomatitis Impaired skin integrity related to decrease in oil and sweat gland activity.

73. Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure  Deficient knowledge regarding condition and treatment regimen  Low self-esteem related to dependency, role changes, changes in body image, and sexual dysfunction