Chronic Kidney Disease

Nota:

• 50% Diabetes 25% Hypertension Polycystic Kidney Disease, Systemic Lupus erythematosus

1. Diabetes
2. Hypertension
3. Other Glomerulonephritis, Cystic Disease Diabetic Neuropathy, Hypertensive nephrosclerosis, Chronic Pyelonephritis, Systemic Lupus Disease, & Urologic Diseases

Nota:

• Retain:  Urea, Creatinine, Phenols, Hormones, Electrolytes & Water (Uremia)
• Uremia
• GI:  No appeitite

1. Diagnostics

   Nota:

   • Hx & Physical  Dipstick 
   1. Urine Specific Gravity

      Nota:

      • 1.01 Specific Gravity or Lower 
   2. Renal Biopsy
   3. Renal CT scan
   4. Dipstick

      Nota:

      • 1st Test measures the amount of protein or albuminuria in the urine. (1+ protein on standard dipstick 2 or more times over a 3 month period)
   5. GFR

      Nota:

      • MDRD equation (Modification of diet renal disease) or Cockcroft Gualt Formula. Normal GFR is 125ml/min. 
   6. Albumin to Creatine (First Morning)

      Nota:

      • 300mg Albumin to 1g of Creatinine signals CKD. Needs to be 1st voided 
   7. Blood & Urine Test
   8. Ultrasound

      Nota:

      • This checks if there is an obstruction and the Size of the Kidneys.
2. 5 stages

   Nota:

   • Stage 1: >90  Stage 2: 60-90 Stage 3: 30-59 Stage 4: 15-29 Stage 5:  <15
3. Polyuria, Oliguria, Anuria

   Nota:

   • Polyuria initially and as the disease progresses symptoms will appear as oliguria/anuria. Anuria usually when on dialysis 40ml per 24hrs. 
4. Integument
   1. Pruritis
5. Lab Values
   1. Potassium

      Nota:

      • Muscle Weakness, Parasthesias & ECG changes
      1. Hyperkalemia
         1. Peak T wave & Widened QRS waves
   2. BUN/Creatine

      Nota:

      • Increased contributes to N&V, Lethargy, Fatigue, ImpairedThough Processes and headache. 
   3. High Blood Sugar

      Nota:

      • Hyperglycemia- The body cannot metabolize Carbohydrates. 
   4. GFR >60ml/min

      Nota:

      • The lower the % of the GFR value the more progressive the disease
   5. HDL/LDL

      Nota:

      • Increased LDL  & Decreased HDL. Elevated Triglycerides. Most CKD patient die from CV disease. 
   6. Calcium

      Nota:

      • Hypocalcemia- Bones fragile
   7. Metabolic Acidosis

      Nota:

      • Impaired ability to excrete acid and defective reabsorption & Regeneration of Bicarbonate. 
   8. Anemia

      Nota:

      • This is due to decreased EPO Production
   9. Hyperphosphatemia & Hypocalcemia
   10. Hypermagnesia
       1. AVoid Mg containing Antacids
   11. Salt & water Rention
6. Cardiovascular
   1. Calcification
   2. Cardiac Dysrthmias
7. Gastronintestinal
   1. Uremic Fetor
   2. Metallic taste in Mouth
8. Respiratory
   1. Kassmaul Breathing

      Nota:

      • This type of breathing is attempt for the body to compensate for metabolic acidosis by breathing off CO2. 
   2. Pulmonary Edema (Dyspnea)

      Nota:

      • This is a result of fluid overload
9. Musculoskeletal
   1. CKD Bone Mineral Disorder

      Nota:

      • Disease process prevents body from converting the Vitamin D to the active form. Calcium is therefore not being Absorbed. When calcium is Low in the Blood stream the body Releases PTH! This causes bone demineralization
   2. Vacular Calcification
10. Reproductive
    1. Can Experience Infertility
    2. Decreased Libido
11. Psychological
    1. Grieve
    2. Fatigue, Lethargy
12. Uremia

1. Teaching

   Nota:

   • Teach the Patient to Check daily weights & Report Weight Gain greater than 4 pounds. 
   1. Nephrollogist
   2. Nutrition

      Nota:

      • water, Phosphate, Potassium & Sodium Restricitions
   3. Check Weight Daily & Report greater than 4lbs
2. Dialysis
   1. Complications

      Nota:

      • Hypotension & Muscle Cramps (when taken out to quickly), Loss of Blood, Pt. gets Cold, Infection. 
   2. Dialyzed Out medications?
   3. Periotneal Dialysis

      Nota:

      • Warm  (Do NOT want to Cause Hypothermia) . 3-7day training
      1. Exchange
         1. Drain

            Nota:

            • 15-30min. Massage abdomen or change Position. (Glucose used as osmotic force) 
         2. Inflow

            Nota:

            • Inflow of about 10min after done clamp is closed. The amount is 2L and if patient is in Pain  it will be decreased. 
         3. Dwell

            Nota:

            • 20-30min to 8hrs. This is where osmosis &n DIffusion happen 
      2. Complications
         1. Peritonitis

            Nota:

            • Treat with Antibiotics. Usually caused by the exchange making or breaking. 
         2. Protein

            Nota:

            • Loss through dialysis 
         3. Exit site infections
         4. Hernias & Lower back Problems

            Nota:

            • Increased Intraadbominal Pressure. 
         5. Pulmonary

            Nota:

            • Repeated upward displacement of the diaphragm, decreases lungs exapansion. 
         6. Bleeding
   4. Hemodialysis
      1. "Hear the Thrilll & Feel the Bruit"
      2. AVF/AVG

         Nota:

         • Least Complication of Thrombosis & Infections. Thrill can be palpated & Bruit can be heared.  Maturation takes 6w to a month & should be placed 3m before intiating HD. 
         1. Fistula "Gold Standard"

            Nota:

            • Feel a thrill & Hear a Bruit. The Needles 15 or 14 gauge needles. 
         2. Steal Syndrome
      3. Temporary Vascular ACCESS

         Nota:

         • Internal Jugular or Femoral Vein. Soft flexible double lumen tube attach to a Y Hub. Recirculation rate takes about 5%
      4. Complications
         1. Loss of Blood
         2. Hepatitis
         3. Muscle Cramps

            Nota:

            • Rapid removal of water & sodium may cause cramps. NS is the treatment of choice. 
         4. Hypotension
   5. Increase Protein due to being able to dialyze nitrogenous waste
3. Kidney Transplant
   1. Compatible
   2. Rejection

      Nota:

      • Hyperacute (Minutes) Acute (Days to Months) Chronic Rejection (Months-Years)
      1. Immunosuppressives

         Nota:

         • Teach about signs & Symptoms of Infection. Worsen Hypertension & Hyperlispedemia!!!
         1. Tachrolimus
   3. Surgery label arm "Dialysis, no procedures"
   4. Empty Peritoneal cavity
   5. Fluid & Electrolytes post-op 1st priority

      Nota:

      • will have high urine output up to 1L
   6. watch out for Acute Tubuler Necrosis
   7. Acute Tubular Necrosis

      Nota:

      • Decrease in CVP suggest hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion. 
   8. Fluid Volume replaced based on Urine Output
4. CKMD

   Nota:

   • Biopsy is the GOLD STANDARD
   1. Limit Dietary Phosphorus

      Nota:

      • NOT restricted usually until the patient requires RRT (limit 1g/day)
   2. Administer phosphate binders

      Nota:

      • Calcium Acetate, Calcium Carbonate, They bind to the phosphate in the bowel and are excreted in the stool.  *Administer Non-Calcium Binders Lanthanum Carbonate & Salvelamor Carbonate if Calcification is evident!!! (Most effective with Meals) 
      1. Constipation Side effect (may need stool softener)
   3. Parathyroidectomy

      Nota:

      • If there is excessive release of parathyroid surgery may be an option and a small portion can be implanted into the forearm. 
   4. Calcium & Supplement Vitamin D (cholecalciferol)

      Nota:

      • Oral or IV Calcitriol, IV paricalcitol, Oral or IV Doxercalciferol (Active form) Can reduce PTH. If Hypercalcemia occurs reduce Phosphate Binders and d/c Supplementation. 
   5. Cinacalcate

      Nota:

      • Mimic Calcium & increase sensitivity of calcium receptors in the parathyroid gland. 
5. Hyperkalemia
   1. Restrict High k+ Foods & Drugs
   2. (Acute) IV glucose & Insulin
   3. iv Calcium Gluconate
   4. Kayexalate (Sodium Polystyrene

      Nota:

      • Commonly used with patient on stage 4 CDK
      1. Never give to patient that have Hypoactive bowel (Paralytic ileus)

         Nota:

         • Could lead to Necrotic Bowels
      2. Montior for sodium & Water Retention
      3. Diarrhea

         Nota:

         • Contains sorbitol a sugar alcohol  that has an osmotic laxative action
6. Anemia
   1. Erythropoietin Replacement

      Nota:

      • Eopoietin Alfa (IV or SC) 2-3w  Darbepoetin alfa (longerlasting weekly or biweekly) effects dont kick in until 2-3w
      1. Thromboemobolitic

         Nota:

         • Teach about Risk & Benefits. Start LOW 
         1. check Hgb!!! higher than 12g/dL
      2. Iron Supplements
         1. Do not take at same time as Phosphate BINDERS

            Nota:

            • Adherence may not be good because of stomach upset & Constipation. Teach that darker stool is Normal. Calcium binds to Iron 
         2. Folic Acid needed for RBC formation

            Nota:

            • Removed by dialysis
7. Hypertension
   1. Weight loss, excercise, cessation of Smoking
   2. ACE/ARB

      Nota:

      • Use with diabetics and with nondiabetics w/ proteinuria *Must used Cautiously because can further decrease GFR & Increase K+ 
   3. Diuretcs
   4. Calcium Channel Blockers
   5. BP

      Nota:

      • Monitor Blood Pressure in supine, sitting & standing positions. Evaluate if the medications are working. 
8. Dyslipedemia
   1. Statins

      Nota:

      • Simvastatin is associated with myopathy if this develops transer to myopathy. 
9. Durgs Caution

   Nota:

   • Digoxin, diabetic agents, antibiotics & opioids