Disease/Condition: CKD

Definition:

Chronic Kidney Disease- it is progressive & irreversible loss of kidney

function. It is either the presence of kidney damage or a decreased GFR <60
ml/min/1.73 m2 for longer than 3 months.

DESCRIPTION GFR (ml/min/1.73 m2) CLINICAL ACTION PLAN

STAGE 1 (Kidney damage >90 Diagnosis & treatment
with normal or increased CVD risk reduction
GFR) Slow progression
STAGE 2 (Kidney damage 60-89 Estimating progression
with mild decrease GFR)
STAGE 3 (Moderate 30-59 Evaluating & treating
decreased GFR) complications
STAGE 4 (Severe 15-29 Preparing for kidney
decreased GFR) replacement therapy
STAGE 5 (Kidney Failure) <15 (for dialysis) Kidney replacement (if
uremia present & patient
desires treatment)
S/Sx & Complications:

Result of retained substances (urea, creatinine, phenols, hormones, electrolytes,

water & many other substances) *Uremia is a syndrome in w/c kidney function
declines to the point that symptoms develop in multiple body systems (often occurs
when GFR is <10 ml/min)

Urinary System: As CKD progresses, patients will have difficulty with fluid
retention & require diuretic therapy. Once on dialysis & after a period of time
in dialysis, patients may develop anuria.
Metabolic Disturbances
Waste Product Accumulation
As the GFR decreases, BUN & serum creatinine levels increase.
BUN increases because of renal failure, increased protein intake,
fever, corticosteroid & catabolism. As BUN increases, this will
result to GI & central nervous systems due to accumulation of
waste product:
N/V
Lethargy/fatigue
Impaired thought processes
HA
Altered CHO Metabolism
It is caused by impaired glucose use resulting from cellular
insensitivity to the normal action of insulin. Moderate
hyperglycemia & hyperinsulinemia occur. Patients with DM who
become uremic may stop insulin therapy with kidney disease
Disease/Condition: CKD

progression because insulin, w/c is dependent on the kidneys for

excretion, remains in circulation longer.
Elevated Triglycerides
Hyperinsulinemia stimulates hepatic production of triglycerides.
This will develop:
Dyslipidemia
Elevated VLDLs
Normal or decreased LDLs
Decreased HDLs

*this will develop decreased levels of enzyme lipoprotein

lipase (for lipoprotein breakdown) that will progress to CVDs

Electrolyte & Acid-base Imbalances

Hyperkalemia
Most serious electrolyte disorder associated w/ kidney disease
This results from decreased excretion of potassium by the
kidneys, breakdown of cellular protein, bleeding, metabolic
acidosis, food consumed, dietary supplements, drugs & IV
infusions
Fatal Dysrhythmias can occur when K levels is 7-8 mEq/L
Muscle weakness
Hypernatremia
Impaired sodium excretion sodium along w/ water is retained,
Edema
HTN
HF
Hypocalcemia & Hyperphosphatemia
Less Vit D is converted hypocalcemia stimulates PTH bone
demineralization (releasing Ca from bones); weakened bone
matrix & higher risk for fractures Hyperphosphatemia due to
decreased phosphate excretion from kidneys
CKD mineral & bone disorder (CKD-MBD): a common
complication of CKD (osteomalacia; osteo fibrosa)
Uremic Red Eye: irritation of deposits
Intracardiac calcifications: disrupts conduction system & cause
cardiac arrest
Hypermagnesemia
It is generally not a problem unless patient is ingesting Mg (milk
of magnesia, magnesium citrate, antacids containing Mg) Here
are some of the manifestations:
Absence of reflexes
Decreased mental status
Cardiac dysrhythmias
Hypotension
Respiratory failure
Metabolic Acidosis
Disease/Condition: CKD

It results from the impaired ability to excrete the acid load

(ammonia) & from defective reabsorption& regeneration of
bicarbonate
Plasma bicarbonate falls to anew steady state at around 16-20
mEq/L
A decrease in plasma bicarbonate reflects its use in buffering
metabolic acids
Hematologic System
Normocytic, Normochromic Anemia
Bleeding tendencies (impired platelet aggregation & impaired release
of platelet factor III & increased concentrations of both factor VIII &
fibrinogen)
Infection
Cardiovascular System
Hypertension
HF
CAD
Pericarditis
PAD
Respiratory System
Kussmaul respirations (metabolic acidosis)
Dyspnea from fluid overload
Pleural effusion
Respiratory infections (decreased pulmonary macrophages)
Pulmonary edema
Uremic pleuritis
Pneumonia
GIT System
Stomatitis w/ exudates
Ulcerations
Anorexia
N/V
Weight loss & malnutrition
Diabetic gastroparesis (delayed gastric emptying)
GI bleeding (platelet defect)
Constipation (ingestion of iron salts or calcium containing phosphate
binders)
Neurologic System
Fatigue
HA
Sleep disturbances
Encephalopathy
Seizures & coma
Parasthesias
Peripheral neuropathy (DM)
Musculoskeletal System
Disease/Condition: CKD

CKD mineral & bone disorder

Integumentary System
Pruritus (due to dry skin, calcium-phosphate deposition in the skin &
sensory neuropathy) itching may be intense & may lead to
bleeding/infection
Uremic frost (a rare condition in w/c urea crystallizes on the skin & is
usually seen when BUN levels are extremely high)
Ecchymosis
Reproductive
Decreased libido & infertility
Anovulation amenorrhea
Low sperm count

Anatomy & Physiology:

1. Urinary System: The kidney and urinary systems help the body to eliminate
liquid waste called urea, and to keep chemicals, such as potassium and
sodium, and water in balance. Urea is produced when foods containing
protein, such as meat, poultry, and certain vegetables, are broken down in
the body. Urea is carried in the bloodstream to the kidneys, where it is
removed along with water and other wastes in the form of urine. Other
important functions of the kidneys include blood pressure regulation and the
production of erythropoietin, which controls red blood cell production in the
bone marrow. Kidneys also regulate the acid-base balance and conserve
fluids.
2. Kidneys: This pair of purplish-brown organs is located below the ribs toward
the middle of the back. Their function is to remove liquid waste from the
blood in the form of urine; keep a stable balance of salts and other
substances in the blood; and produce erythropoietin, a hormone that aids the
formation of red blood cells. The kidneys remove urea from the blood through
tiny filtering units called nephrons. Each nephron consists of a ball formed of
small blood capillaries, called a glomerulus, and a small tube called a renal
tubule. Urea, together with water and other waste substances, forms the
urine as it passes through the nephrons and down the renal tubules of the
kidney.
3. Ureters: These narrow tubes carry urine from the kidneys to the bladder.
Muscles in the ureter walls continually tighten and relax forcing urine
downward, away from the kidneys. If urine backs up, or is allowed to stand
still, a kidney infection can develop. About every 10 to 15 seconds, small
amounts of urine are emptied into the bladder from the ureters.
4. Bladder: This triangle-shaped, hollow organ is located in the lower abdomen.
It is held in place by ligaments that are attached to other organs and the
pelvic bones. The bladder's walls relax and expand to store urine, and
contract and flatten to empty urine through the urethra. The typical healthy
adult bladder can store up to two cups of urine for two to five hours.
Disease/Condition: CKD

5. Urethra: This tube allows urine to pass outside the body. The brain signals the
bladder muscles to tighten, which squeezes urine out of the bladder. At the
same time, the brain signals the sphincter muscles to relax to let urine exit
the bladder through the urethra. When all the signals occur in the correct
order, normal urination occurs.

Nursing Management:

Perform Hx taking & PE

Monitor lab & diagnostic tests
Assess the patients dietary habits
Measure height & height & recent changes
Advise the patient to follow necessary dietary (CHON, Na, K, PO) & fluid
restrictions
Observe for electrolyte imbalances & s/sx (weight gain >2kg, increasing BP,
dyspnea, edema, fatigue, confusion)
Educate the client on prescribed drugs & common S/E:
Phosphate binders should be taken with meals; constipation is a
common S/E
Calcium supplements should be taken on an empty stomach (but not
the same time as iron supplements)
Iron supplements should be taken between meals
Sodium polystyrene sulfonate: tell patient to expect some diarrhea
because it contains sorbitol that has an osmotic laxative action &
ensures evacuation of potassium from the bowel)
Advise patient to avoid antacids & NSAIDs w/ analgesics
Administer stool softeners as ordered (constipation)
Maintain BP <130/80 & 125/75 for patients with CKD & w/ significant
proteinuria
Administer medications as ordered
Perform preoperative assessment & obtain informed consent
Encourage client to verbalize feelings of lifestyle changes, living w/ chronic
illness & decisions about type of dialysis or transplantation
Assist w/ the intraoperative procedure & provide care
Perform postoperative care:
Strict aseptic technique (AT)
Strict reverse AT
Advise significant others about the procedure & strictly no visitors
allowed for now
Monitor VS to observe signs of tissue rejection
Monitor urine output (should be increased)
Instruct to do early ambulation
Instruct client to take two drugs for lifetime (steroids &
immunosuppresants to prevent tissue rejection)
Disease/Condition: CKD

Encourage client to follow regular check-ups (first 3 months: monthly

check-up, if stable VS: every 2 or 3 months, then 3-4 times per year)
Advise client to avoid body contact sports (basketball, volley ball,
football that may traumatize the transplanted kidney)

Medical Management:

1. Lab &Diagnostic Studies

o Renal UTZ
o Renal Scan
o CT Scan
o Renal Biopsy
o BUN, serum creatinine & creatinine levels
o Serum electrolytes
o Lipid profile
o Protein to creatinine ratio in the first morning voided specimen
o Urinalysis (deep stick evaluation of protein in the urine or evaluation of
microalbuminuria)
*Albumin-creatinine ratio (greater than 300 mg albumin per 1 g
creatinine signals CKD)
o Hct & Hgb levels
2. Medications
o Hyperkalemia
Regular insulin IV
Potassium moves into cells when insulin is given
IV glucose is given concurrently to prevent hypoglycaemia
When effects of insulin diminish, potassium shifts back out of
cells
Sodium Bicarbonate
Corrects acidosis & cause a shift to potassium into cells
Calcium Gluconate IV
Used in cardiac toxicity (evidence of hyperkalemic ECG changes)
Raises the threshold for excitation, resulting in dysrhythmias
Dialysis
Most effective to remove potassium in a short period of time
Sodium Polystyrene Sulfonate (Kayexalate)
A cation-exchange resin, used in lowering potassium in stage 4
o Hypertension
Diuretics
Calcium channel blockers
ACE inhibitors
Angiotensin receptor blocker (ARB) agents
o CKD-MBD
Calcium acetate , a phosphate binder
Calcium carbonate, a phosphate binder
Vitamin D (oral/IV Calcitriol, oral/IV Doxercalciferol)
Cinacalcet (Sensipar), a calcimimetic agent that mimics calcium
to decrease PTH
Disease/Condition: CKD

o Anemia
Exogenous erythropoietin (EPO) such as Epoetin alfa
administered IV or SubQ 2-3 times/week; Darbepoetin alfa is
longer acting can be administered weekly or biweekly
Iron supplementation if plasma ferritin fall below 100ng/ml
3. Procedures
o Peritoneal Dialysis
Done at hospital
Catheter is inserted between the umbilicus & symphysis pubis 2-
3 finger breadths away
1 inch portion of the catheter is exposed on abd
Attaches a Y-tube w/c is connected to dialysate & has drainage
tube w/c is connected to drainage bag
o Hemodialysis
Catheter is inserted in vascular access sites (AVFs, AVGs &
temporary vascular access sites such as internal jugular or
femoral vein)
o Renal Transplantation
Donor has to be legal age, free from disease w/c can be
transmitted to blood (hepatitis, AIDS, malaria), mentally healthy,
closest genetically
Can be either Living (genetically or not genetically related)/Non-
living donor (not the cadaver)
>80 years of age cannot be considered as a recipient & should
be free from other systemic diseases (cancer or MI)
Composes of two sets of surgery:

OR 1 Perfusion Team OR 2
Donor Assess the condition of the Recipient
donated kidney
Nephrectomy (includes If kidney is healthy
ureters & blood vessels) If kidney becomes the only time
ischemic, the procedure is recipient is opened
Open then close discontinued
Old kidney is not removed due to too much manipulation
New kidney is placed on the lower portion in the iliac
fossa
Ureters are also placed
Duration of procedure is 2 hours

Pathophysiology:
Disease/Condition: CKD
Disease/Condition: CKD