End stage renal disease and its management

End stage renal disease and its management

1. MANAGEMENT OF PATIENTS WITH END STAGE RENAL DISEASE PRESENTED BY: MISS.SHWETA SHARMA M.SC. NURSING 1ST YEAR AIIMS, JODHPUR

2. FUNCTIONS?????

3. INTRODUCTION Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uraemia or azotaemia (retention of urea and other nitrogenous wastes in the blood).

4. The incidence of ESRD has increased by almost 8% per year for the past 5 years, with more than 300,000 patients being treated in the United States. The estimated age-adjusted incidence of end-stage renal disease (ESRD) is 229 per million population whereas more than one lakh new patients enter renal replacement programs annually in India.

5. ETIOLOGY

6. NEPHROTOXIC MEDICATIONS

7. RISK FACTORS Diabetes with poor blood sugar control Kidney disease that affects the glomeruli, the structures in the kidneys that filter wastes from the blood Polycystic kidney disease Kidney disease after a kidney transplant High blood pressure Tobacco use African-American descent Male sex Older age

8. PATHOPHYSIOLOGY H

9. Stage 1 Reduced renal reserve, characterized by a 40% to 75% loss of nephron function. The patient usually does not have symptoms because the remaining nephrons are able to carry out the normal functions of the kidney.

10. Stage 2 Renal insufficiency occurs when 75% to 90% of nephron function is lost. At this point, the serum creatinine and blood urea nitrogen rise, the kidney loses its ability to concentrate urine and anemia develops. The patient may report polyuria and nocturia.

11. Stage 3 End-stage renal disease (ESRD), the final stage of chronic renal failure, 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.

12. ESRD is evidenced by elevated creatinine and blood urea nitrogen levels as well as electrolyte imbalances. Once the patient reaches this point, dialysis is usually indicated. 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.

13. CLINICAL MANIFESTATIONS Cardiovascular manifestations •Hypertension (due to sodium and water retention or from activation of the renin–angiotensin–aldosterone system) •Heart failure and pulmonary oedema (due to fluid overload) •Pericarditis (due to irritation of the pericardial lining by uremic toxins) •Pitting oedema (feet, hands, sacrum) and periorbital oedema

14. Pericardial friction rub Engorged neck veins Pericardial effusion Pericardial tamponade Hyperkalaemia and hyperlipidaemia

15. Neurologic manifestations •Weakness and fatigue •Confusion •Inability to concentrate •Disorientation •Tremors •Seizures •Asterixis •Restlessness of legs •Burning of soles of feet • Behaviour changes

16. Integumentary manifestations • Gray -bronze skin color •Dry, flaky skin •Pruritus •Ecchymosis •Purpura •Thin, brittle nails •Coarse, thin hair

17. Pulmonary manifestations •Crackles •Thick, tenacious sputum •Depressed cough reflex •Pleuritic pain •Shortness of breath •Tachypnoea • Kussmaul -type respirations •Uremic pneumonitis

18. Gastrointestinal manifestations •Ammonia odour to breath (“uremic fetor”) •Metallic taste •Mouth ulcerations •Bleeding •Anorexia •Nausea and vomiting •Hiccups •Constipation or diarrhoea •Bleeding from gastrointestinal tract

19. Hematologic manifestations •Anaemia •Thrombocytopenia Reproductive manifestations •Amenorrhea •Testicular atrophy •Infertility •Decreased libido

20. Musculoskeletal manifestations •Muscle cramps •Loss of muscle strength •Renal osteodystrophy •Bone pain •Bone fractures •Foot drop

21. ASSESSMENT AND DIAGNOSTIC FINDINGS Glomerular filtration rate •Decreased GFR can be detected by obtaining a 24-hour urinalysis for creatinine clearance. •Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body. The BUN is affected not only by renal disease but also by protein intake in the diet, catabolism, parenteral nutrition, and medications such as corticosteroids.

22. Sodium and water retention •The kidney cannot concentrate or dilute the urine normally in ESRD. Some patients retain sodium and water, increasing the risk for oedema , heart failure, and hypertension. Hypertension may also result from activation of the renin–angiotensin–aldosterone axis and the concomitant increased aldosterone secretion. •Episodes of vomiting and diarrhoea may produce sodium and water depletion, which worsens the uremic state.

23. Acidosis 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 (HCO3). There is also decreased excretion of phosphates and other organic acids.

24. Anemia Inadequate erythropoietin production Shortened life span of RBCs Nutritional deficiencies Patient’s tendency to bleed Particularly from the GI tract

25. Calcium and phosphorus imbalance The decreased serum calcium level causes increased secretion of parathormone. In renal failure, however, the body does not respond normally to the increased secretion of parathormone; as a result, calcium leaves the bone, often producing bone changes and bone disease. Uremic bone disease, often called renal osteodystrophy, develops from the complex changes in calcium, phosphate, and parathormone balance.

26. COMPLICATIONS •Hyperkalaemia •Pericarditis, pericardial effusion, and pericardial tamponade •Hypertension •Anaemia •Bone disease and metastatic calcifications

27. MEDICAL MANAGEMENT Antacids •Hyperphosphatemia and hypocalcaemia are treated with aluminium -based antacids that bind dietary phosphorus in the GI tract. However, concerns about the potential long-term toxicity of aluminium and the association of high aluminium levels with neurologic symptoms and osteomalacia have led some physicians to prescribe calcium carbonate in place of high doses of aluminium -based antacids. •This medication also binds dietary phosphorus in the intestinal tract and permits the use of smaller doses of antacids. Both calcium carbonate and phosphorus binding antacids must be administered with food to be effective. Magnesium-based antacids must be avoided to prevent magnesium toxicity.

28. Antihypertensive and Cardiovascular Agents •Hypertension is managed by intravascular volume control and a variety of antihypertensive agents. Heart failure and pulmonary oedema may also require treatment with fluid restriction, low-sodium diets, diuretic agents, inotropic agents such as digitalis or dobutamine, and dialysis.

29. Antiseizure Agents •The patient must be observed for early evidence of slight twitching, headache, delirium, or seizure activity. •If seizures occur, the onset of the seizure is recorded along with the type, duration, and general effect on the patient. •Intravenous diazepam (Valium) or phenytoin (Dilantin) is usually administered to control seizures. The side rails of the bed should be padded to protect the patient.

30. Erythropoietin • Anaemia associated with chronic renal failure is treated with recombinant human erythropoietin (Epogen). •Epogen therapy is initiated to achieve a haematocrit of 33% to 38%, which generally alleviates the symptoms of anaemia . Epogen is administered either intravenously or subcutaneously three times a week. •It may take 2 to 6 weeks for the haematocrit to rise; therefore, Epogen is not indicated for patients who need immediate correction of severe anaemia .

31. • Adverse effects of Epogen therapy: Hypertension (especially during early stages of treatment) Increased clotting of vascular access sites Seizures Depletion of body iron stores Influenza-like symptoms

32. • Management: Adjustment of heparin to prevent clotting of the dialysis lines during haemodialysis treatments Frequent monitoring of haematocrit Periodic assessment of serum iron and transferrin levels Monitoring blood pressure and serum potassium level to detect hypertension and rising serum potassium levels, which may occur with therapy and the increasing RBC mass. Contraindication: Hypertension that cannot be controlled

33. Patients who have received Epogen have reported decreased levels of fatigue, an increased feeling of well-being, better tolerance of dialysis, higher energy levels, and improved exercise tolerance. Additionally, this therapy has decreased the need for blood transfusion and its associated risks, including bloodborne infectious disease, antibody formation, and iron overload.

34. NUTRITIONAL THERAPY •Dietary intervention includes careful regulation of protein intake, fluid intake to balance fluid losses, sodium intake to balance sodium losses, and some restriction of potassium. •Protein is restricted because urea, uric acid, and organic acids—the breakdown products of dietary and tissue proteins—accumulate rapidly in the blood when there is impaired renal clearance. The allowed protein must be of high biologic value (dairy products, eggs, meats). •Fluid- 500 to 600 mL more than the previous day’s 24-hour urine output. •Calories- by carbohydrates and fat to prevent wasting. •Vitamin supplementation

35. Salt restriction: Limit to 4-6 grams a day to avoid fluid retention and help control high blood pressure .  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. 

36. DIALYSIS Dialysis is usually initiated when the patient cannot maintain a reasonable lifestyle with conservative treatment. Hyperkalaemia is usually prevented by ensuring adequate dialysis. The patient is placed on a potassium-restricted diet. Occasionally, Kayexalate, a cation-exchange resin, administered orally, may be needed.

37. Nursing diagnosis 1. Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water. 2. Imbalanced nutrition: less than body requirements related to anorexia, nausea and vomiting, dietary restrictions, and altered oral mucous membranes. 3. Activity intolerance related to fatigue, anaemia , retention of waste products, and dialysis procedure. 4. Low self-esteem related to dependency, role changes, changes in body image, and sexual dysfunction. 5. Deficient knowledge regarding condition and treatment regimen.

38. Teaching Patients Self-Care. The patient is taught how to check the vascular access device for patency and how to take precautions, such as avoiding venipunctures and blood pressure measurements on the arm with the access device. Warning signs: •Worsening signs and symptoms of renal failure (nausea, vomiting, change in usual urine output [if any], ammonia odour on breath) •Signs and symptoms of hyperkalaemia (muscle weakness, diarrhoea , abdominal cramps) •Signs and symptoms of access problems (clotted fistula or graft, infection) These signs and symptoms of decreasing renal function, in addition to increasing BUN and serum creatinine levels, may indicate a need to alter the dialysis prescription.

39. Continuing Care •Follow-up examinations and treatment because of changing physical status, renal function, and dialysis requirements. •Referral for home care. •The home care nurse also assesses the patient for further deterioration of renal function and signs and symptoms of complications resulting from the primary renal disorder, the resulting renal failure, and effects of treatment strategies (e.g., dialysis, medications, dietary restrictions). Many patients need ongoing education and reinforcement on the multiple dietary restrictions required, including fluid, sodium, potassium, and protein restriction.

40. GERONTOLOGIC CONSIDERATIONS Because alterations in renal blood flow, glomerular filtration, and renal clearance increase the risk for medication-associated changes in renal function, precautions are indicated with all medications. The incidence of systemic diseases, such as atherosclerosis, hypertension, heart failure, diabetes, and cancer, increases with advancing age, predisposing older adults to renal disease associated with these disorders. The acute problems need to be prevented if possible or recognized and treated quickly to avoid kidney damage.

41. KIDNEY TRANSPLANTATION Kidney transplantation has become the treatment of choice for most patients with ESRD. Patients choose kidney transplantation for various 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. Additionally, the cost of maintaining a successful transplantation is one-third the cost of treating a dialysis patient.

42. The success rate increases if kidney transplantation from a living donor is performed before dialysis is initiated. A nephrectomy of the patient’s own native kidneys may be performed before transplantation. The transplanted kidney is placed in the patient’s iliac fossa anterior to the iliac crest. The ureter of the newly transplanted kidney is transplanted into the bladder or anastomosed to the ureter of the recipient .

43. PREVENTION •Lose weight •Be active most days •Eat a balanced diet of nutritious, low-sodium foods •Control blood pressure •Take medications as prescribed •Have cholesterol levels checked every year •Control blood sugar level •Don't smoke or use tobacco products •Get regular check-ups

44. RESEARCH ARTICLES 1.Treatment adherence and perception in patients on maintenance haemodialysis : a cross – sectional study from Palestine Karam Sh. Naalweh et al conducted a cross-sectional study of HD patients at An-Najah National University Hospital in 2016. Self-reported adherence behaviour was obtained using a valid and reliable questionnaire (End-Stage Renal Disease Adherence Questionnaire: ESRD-AQ). A total of 220 patients answered all questions pertaining to ESRD-AQ. The mean age of participants was 56.82 years. Dietary adherence was observed in 24% while that of fluid restriction adherence was observed in 31% of studied patients. Reported adherence to HD sessions was 52% while that for medications was 81%. Overall, 122 (55.5%) patients had good adherence, 89 (40.5%) had moderate adherence, and 9 (4.1%) had poor adherence behaviour . Male patients had significantly higher overall adherence scores than females. Multivariate analysis indicated that elderly male patients who were city residents had higher odds of having higher adherence score. There was a good percentage of patients who had overall moderate or poor adherence. ESRD-AQ could be used to assess some aspects of HD adherence. Counselling and education of patients on HD are important to improve therapeutic outcome.

45. 2.Assess the Illness Perception and Treatment Adherence among Patients with End-Stage Renal Disease Sekar Suganthi , Arjunan Porkodi and Poomalai Geetha conducted a descriptive cross-sectional study among patients at Sri Ramachandra Institute of Higher Education and Research, Chennai, India during October and November 2017 . Data were collected through interview. Adherence behaviours were measured using ESRD-AQ in four dimensions. The study had 120 patients with ESRD with male to female ratio of 2:1 where the majority (35.80%) were in the age group of 51–60. The mean scores were higher in the sub-dimension of emotional representations, consequences and personal control. Among 120 patients, 63 (52.50%) had adherence to dietary restriction. A statistically significant association was observed between timeline with Body Mass Index (BMI) and comorbidity. The higher mean score in the sub-dimensions of emotional representations indicates a higher degree of emotional distress due to low adherence to prescribed medications.

46. SUMMARY AND CONCLUSION As discussed throughout the presentation, learning about end stage renal disease and its management will help nurses to care for patients with end stage renal disease. Nurses can do assessment of patients with end stage renal disease, observe the sign and symptoms, provide the necessary nursing care, prevent complications and support the patient psychologically. Nurses can also counsel the patients and their family for various options available in treatment for end stage renal disease.

47. REFERENCES 1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no.1325-1328. 2.MAYOCLINIC. End-stage renal disease. Available from https://www.mayoclinic.org/diseases-conditions/end-stage-renal-disease/symptoms-causes/syc-20354532 [cited 30 Mar 2020] 3.SpringerLink. Treatment adherence and perception in patients on maintenance haemodialysis: a cross – sectional study from Palestine. Available from https://link.springer.com/article/10.1186/s12882-017-0598-2 [cited 30 Mar 2020] 4.PubMed. Assess the Illness Perception and Treatment Adherence among Patients with End-Stage Renal Disease. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952918/ Iran J Nurs Midwifery Res. 2020 Jan-Feb; 25(1): 12–17. doi : 10.4103/ijnmr.IJNMR_74_19 [cited 30 Mar 2020]