Chronic kidney disease
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Chronic Kidney Disease. Progressive, irreversible damage to the nephrons and glomeruli. Chronic Kidney Disease. Major causes are. Diabetes and high blood pressure Type 1 and type 2 diabetes mellitus High blood pressure (hypertension) Glomerulonephritis Polycystic kidney disease

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Chronic Kidney Disease

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Chronic kidney disease

Chronic Kidney Disease


Chronic kidney disease1

Progressive, irreversible damage to the nephrons and glomeruli

Chronic Kidney Disease


Major causes are

Major causes are

  • Diabetes and high blood pressure

  • Type 1 and type 2 diabetes mellitus

  • High blood pressure (hypertension)

  • Glomerulonephritis

  • Polycystic kidney disease

  • Use of analgesics - acetaminophen(Tylenol) and ibuprofen (Motrin, Advil

  • Clogging and hardening of the arteries(atherosclerosis) 

  • Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings), or cancers. 

  • HIV infection, sickle cell disease, heroin abuse, amyloidosis, kidney stones, chronic kidney infections, and certain cancers.


Kidney functions monitored regularly

Kidney functions - monitored regularly

  • Diabetes mellitus type 1 or 2 

  • High blood pressure 

  • High cholesterol

  • Heart disease

  • Liver disease 

  • Amyloidosis 

  • Sickle cell disease 

  • Systemic Lupus erythematosus 

  • Vascular diseases such as arteritis, vasculitis, or fibromuscular dysplasia 

  • Vesicoureteral reflux (a urinary tract problem in which urine travels the wrong way back toward the kidney) 

  • Require regular use of anti-inflammatory medications 

  • A family history of kidney disease


Chronic renal failure end stage renal disease esrd

Protein and waste metabolism accumulates in the blood (azotemia)

90% of kidney function is lost (kidney cannot adequately function)

Hypothesis: Nephrons remains intact, others progressively destroyed.

Adaptive response maintains function until ¾ are destroyed

Hypertrophy continues kidneys begin to lose their ability to concentrate the urine adequately

Chronic Renal FailureEnd Stage Renal Disease (ESRD)


Chronic kidney disease

Table 1. Stages of Chronic Kidney Disease

*GFR is glomerular filtration rate, a measure of the kidney's function.


Chronic kidney disease

Modifiable Factors

-Diabetic Mellitus

-Hypertension

-Increase Protein and Cholesterol Intake

-Smoking

-Use of analgesics

Non-Modifiable Factors

-Hereditary

-Age greater than 60 years old

-Gender

-Race

Decreased renal blood flow

Primary kidney disease

Damage from other diseases

Urine outflow obstruction

Chronic Kidney Disease - Pathophysiology

BUN

Serum Creatinine

Decreased glomerular filtration

Hypertrophy of remaining nephrons

Dilute Polyuria

Loss of Sodium in Urine

Hyponatremia

Inability to concentrate urine

Dehydration

Further loss of nephron function

Loss of nonexcretory renal function

2a

Failure to convert inactive forms of calcium

Failure to produce eryhtropoietin

Impaired insulin action

Production of lipids

Immune disturbances

Disturbances in reproduction

Erratic blood glucose levels

Advanced atherosclerosis

Anemia

Pallor

Calcium absorption

Delayed wound healing

Infection

Libido

Infertility

1


Chronic kidney disease

2a

1

Hypocalcemia

Osteodystrophy

Loss of excretory renal function

Excretion of nitrogenous waste

Decreased sodium reabsorption in tubule

Decreased potassium excretion

Decreased phosphate

excretion

Decreased hydrogen excretion

Uremia

Hyperkalemia

Hyperphosphatemia

Metabolic acidosis

Water Retention

BUN,

Creatinine

Uric Acid

Decreased calcium absorption

Hypertension

Heart Failure

Edema

Proteniuria

Hypocalcemia

Peripheral nerve changes

Hyperparathyroidism

Decreased potassium excretion

Pericarditis

Increased potassium

CNS changes

Pruritus

Altered Taste

Bleeding Tendencies


Chronic kidney disease

  • Weakness and tiredness/ fatigue.

  • Nocturia is often an early symptom

  • Itchiness of the skin which can progressively worsen

  • Pale skin which is easily bruised

  • Muscular twitches, cramps and pain

  • Pins and needles in the hands and feet

  • Nausea


As the condition worsens the symptoms progress to

As the condition worsens the symptoms progress to:

  • Oedema (swelling of the face, limbs and abdomen)

  • Oliguria (greatly reduced volume of urine)

  • Dyspnoea (breathlessness)

  • Vomiting

  • Confusion

  • Seizures

  • Severe lethargy

  • Very itchy skin

  • Breath that smells of ammonia


Associated complications of chronic kidney disease would be

Associated complications of chronic Kidney Disease would be:

  • Anaemia, mostly due to deficiency of erythropoietin

  • Bleeding which is caused by impairment of platelet function

  • Metabolic Bone Disease (known as Renal Osteodystrophy)


Associated complications of chronic kidney disease would be1

Associated complications of chronic Kidney Disease would be:

  • Cardiovascular Disease

    - hypertension, (which may further exacerbate

    the renal failure)

    -accelerated atherosclerosis

    -pericarditis. 80% of those with chronic renal

    failure develop hypertension which must be

    treated


Associated complications of chronic kidney disease would be2

Associated complications of chronic Kidney Disease would be:

  • Nervous system – neuropathy caused by the loss of myelin from nerve fibres – may improve when dialysis is established

  • Gastrointestinal complications - anorexia, nausea and vomiting, and a higher incidence of peptic ulcer disease


Associated complications of chronic kidney disease would be3

Associated complications of chronic Kidney Disease would be:

  • Skin disease – itching, which is attributed to the retention of metabolic waste products. It often improves with dialysis. Dry skin can also occur

  • Muscle dysfunction - myopathy leading to muscle cramps and the “restless leg” syndrome


Associated complications of chronic kidney disease would be4

Associated complications of chronic Kidney Disease would be:

  • Metabolic dysfunction - involving lipids, insulin and uric acid (gout). Metabolic acidosis is also associated


Diagnosis

Diagnosis

  • Urine Tests

  • Urinalysis

  • Twenty-four hour urine tests 

  • Glomerular filtration rate (GFR)

  • Blood Tests

  • Creatinine and urea (BUN) in the blood

  • Estimated GFR (eGFR)

  • Electrolyte levels and acid-base balance  

  • Blood cell counts 

  • Other tests

  • Ultrasound:

  • Biopsy


Treatment modalities

Decrease fluid 1000ml/day

Decrease protein (.5-1kg body weight)

Decrease sodium (1-4gm variable)

Decrease potassium

Decrease phosphorous (<1000mg/day)

Dialysis (periotoneal, hemodialysis)

RBC, Vitamin D (calcitrol replacement) etc.

Treatment Modalities


Dialysis hemodialyis hemo peritoneal pd

General Principal: Movement of fluid and molecules across a semi permeable membrane from one compartment to another

Hemodialysis – Move substances from blood through a semi permeable membrane and into a dialysis solution (dialysate –bath) (synethetic membrane)

Peritoneal – Peritoneal membrane is the semi permeable membrane

Dialysis Hemodialyis(Hemo)Peritoneal (PD)


Osmosis diffusion ultrafiltration

Diffusion - movement of solutes (particles) from an area of > concentration to area of < concentration [Remove urea, creatinine, uric acid and electrolytes, from the blood to the dialystate bath] RBC, WBC, Large plasma proteins do not go through

Ultrafiltration – Water and fluid removed when the pressure gradient across the membrane is created, by increase pressure in the blood compartment & decrease pressure in the dialysate compartment

Osmosis-Diffusion-Ultrafiltration

Osmosis - movement fluidfrom an area of< to >

concentration of solutes(particles)


Peritoneal dialysis

Catheter placement – anterior abdominal wall

Tenckoff (25cm length with cuff anchor and migration)

Dialysis solution (1-2 liters sometimes smaller)

Three phases of PD

Inflow (fill) approximately 10 minutes, could be in cycles)

Dwell (equilibration) (approximately 20-30 min or 8 hours+)

Drain (approximately 15 minutes)

These 3 phases are called Exchanges

Peritoneal Dialysis


Peritoneal dialysis1

Peritoneal Dialysis


Hemodialysis

Vascular access for high blood flow

Shunts, (teflon, external)

Arteriovenous fistulas and grafts (AV)

Anastomosis between an artery and vein

Fistulas are native vessels (4-6 wks maturity)

Grafts are artificial/synthetic material

Hemodialysis


Hemodialysis1

Hemodialysis

AV Fistula Communication

AV Graph Access


Hemodialysis2

Hemodialysis

Hemodialysis Circuit

Hemodialysis Machine


Pd advantages and disadvantages

Immediate initiation

Less complicated

Portable (CAPD)

Fewer dietary restrictions

Short training time

Less cardio stress

Choice for diabetics

Bacterial/chemical peritonitis

Protein loss

Exit site of catheter

Self image

Hyperglycemia

Surgical placement of catheter

Multiple abdominal surgery

PD Advantages and Disadvantages

Advantages

Disadvantages


Hemo advantages disadvantages

Rapid fluid removal

Rapid removal of urea & creatinine

Effective K+ removal

Less protein loss

Lower triglycerides

Home dialysis possible

Temporary access at the bedside

Vascular access problems

Dietary & fluid restrictions

Heparinization

Extensive equipment

Hypotension

Added blood lost

Trained specialist

Hemo Advantages & Disadvantages

Advantages

Disadvantages


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

Disequalibrium Syndrome


The following are general dietary guidelines

The following are general dietary guidelines: 

  • Protein restriction:

  • Salt restriction

  • Fluid intake:

  • Potassium restriction:

  • Phosphorus restriction:

  • Control blood pressure and/or diabetes; 

  • Stop smoking; and

  • Lose Excess Weight


Avoided or used with caution

Avoided or used with caution:

  • Certain analgesics: Aspirin; ibuprofen

  • Fleets or phosphosoda enemas because of their high content of phosphorus 

  • Laxatives and antacids containing magnesium and aluminum such as magnesium hydroxide

  • Ulcer medication H2-receptor antagonists: cimetidine, ranitidine

  • Decongestants such as pseudoephedrine  especially if they have high blood pressure 

  • Herbal medications


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.

Nursing Care Pre, Post Dialysis


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)

Renal Transplant


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


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


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

Immunological Analysis


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

Immulogical Analysis


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.

Surgery


Complications post transplant1

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


Complications post transplant2

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


Complications post transplant3

Infection

Hypertension

Malignancies (lip, skin, lymphomas, cervical)

Recurrence of renal disease

Retroperiotneal bleed

Arterial stenosis

Urine leakage

Complications Post Transplant


Chronic kidney disease

100 patients with eGFR < 60

(Tuesday morning in Outpatients)


Chronic kidney disease

Tuesday morning 1 year later: 1 patient needs RRT, 10 patients have died (> 50% CV death)


Chronic kidney disease

Tuesday morning 10 years later: 8 patients need RRT, 65 patients have died, 27 have ongoing CKD


Chronic kidney disease

The majority of patients with CKD 1-3 do not progress to ESRF.

Their risk of cardiovascular death is higher than their risk of progression.


Optimise risk factors

Cardiovascular disease

Proteinuria

Hypertension

Diabetes

Smoking

Obesity

Exercise tolerance

Optimise risk factors

TAKE HOME MESSAGE


Chronic kidney disease

Nursing Care Plan of a Patient With ESRD

  • Nursing diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water.

  • Goal: Maintenance of ideal body weight without excess fluid.


Chronic kidney disease

  • Assess fluid status (Daily weight, intake and output balance, skin turgor and presence of edema, distention of neck veins, blood pressure, pulse rate, and rhythm, respiratory rate and effort).

  • Limit fluid intake to prescribed volume.

  • Identify potential sources of fluid (medications and fluids used to take medications; oral and intravenous, foods).

  • Explain to patient and family rationale for restriction.


Chronic kidney disease

Nursing Care Plan of a Patient With ESRD (Cont…)

  • Nursing diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea, vomiting, and dietary restrictions.

  • Goal: Maintenance of adequate nutritional intake.


Chronic kidney disease

  • Interventions: The nurse should:

  • Assess nutritional status (weight changes, serum electrolyte, BUN, creatinine, protein, transferrin, and iron levels).

  • Assess patient’s nutritional dietary patterns (diet history, food preferences, calorie counts).

  • Assess for factors contributing to altered nutritional intake (Anorexia, nausea, or vomiting, diet unpalatable to patient, depression, lack of understanding of dietary restrictions, stomatitis).

  • Provide patient’s food preferences within dietary restrictions.

  • Promote intake of high biologic value protein foods


Chronic kidney disease

Nursing Care Plan of a Patient With ESRD (Cont…)

  • Nursing diagnosis: Deficient knowledge regarding condition and treatment.

  • Goal: Increased knowledge about condition and related treatment.


Chronic kidney disease

  • Interventions: The nurse should:

  • Assess understanding of cause of renal failure, its meaning and consequences, and its treatment.

  • Provide explanation of renal function and consequences of renal failure at patient’s level of understanding and guided by patient’s readiness to learn.

  • Provide oral and written information as appropriate about renal function and failure, fluid and dietary restrictions, medications, reportable problems, signs, and symptoms, follow-up schedule, community resources, and treatment options.


Chronic kidney disease

Nursing Care Plan of a Patient With ESRD (Cont…)

  • Nursing diagnosis: Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure.

  • Goal: Participation in activity within tolerance.

  • Interventions: The nurse should:

  • Assess factors contributing to fatigue (anemia, fluid and electrolyte imbalances, retention of waste products, depression)

  • Promote independence in self-care activities as tolerated; assist if fatigued.

  • Encourage alternating activity with rest.

  • Encourage patient to rest after dialysis treatments.

TAKE HOME MESSAGE


Chronic kidney disease

THANK YOU

Have a check on your blood pressure

Sugar & Salt / year


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