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KIDNEYThe kidneys are a pair of bean-shaped organs that lie on eitherside of the spine in the lower middle of the back. Each kidneyweighs about ¼ pound and contains approximately onemillion filtering units called nephrons. Each nephron is madeof a glomerulus and a tubule. The glomerulus is a miniaturefiltering or sieving device while the tubule is a tiny tube likestructure attached to the glomerulus.
The kidneys are connected to the urinary bladder by tubes calledureters. Urine is stored in the urinary bladder until the bladder isemptied by urinating. The bladder is connected to the outside of thebody by another tube like structure called the urethra.
The main function of the kidneys is to remove waste products andexcess water from the blood. The kidneys process about 200 liters ofblood every day and produce about two liters of urine. The wasteproducts are generated from normal metabolic processes including thebreakdown of active tissues, ingested foods, and other substances. Thekidneys allow consumption of a variety of foods, drugs, vitamins andsupplements, additives, and excess fluids without worry that toxic by-products will build up to harmful levels. The kidney also plays a majorrole in regulating levels of various minerals such as calcium ,sodiumand potassium in the blood.
DEFINITION Chronic kidney disease involves progressive, irreversible loss ofkidney function .It is defined as either the presence of kidney damageof GFR<60ml/min for 3 months or longer.
INCIDENCE Since 1973 many death have been prevented through the use of maintenance ofdialysis and renal transplantation. most patients are treated with dialysis because:o There is a lack of donated organs.o Some patients are physically or mentally unsuited for transplantation.o Some patients do not want transplants. The incidence of ESRD has increased by almost 8% per year for the past 5 years. In united states ,more than 280,000 patients with chronic renal failure (65%)arereceiving hemodialysis. More than 120,000(28%)have functioning renal transplants. More than 24,000(7%)are receiving peritoneal dialysis.
S TA G E S O F C H R O N I C K I D N E Y D I S E A S E GFR* Stage Description mL/min/1.73m2 Slight kidney damage with 1 More than 90 normal or increased filtration Mild decrease in kidney 2 60-89 function Moderate decrease in kidney 3 30-59 function Severe decrease in kidney 4 15-29 function Less than 15 (or 5 Kidney failure dialysis)
ETIOLOGY Diabetes mellitus: Type 1 and type2 diabetes mellitus cause a conditioncalled diabetic nephropathy, which is the leading cause of kidney disease. Hypertension: If not controlled, can damage the kidneys over time. Chronic glomerulonephritis: A bilateral, non –infectious inflammation ofthe kidneys, which can damage the filtration system of the kidneys. Pyelonephritis(Inflammation of the renal pelvis) Obstruction of the urinary tract by stones ,an enlargedprostate, strictures and cancers. Polycystic kidney(It is a hereditary disease in which where the bothkidneys have multiple cyst)
Medications: Use of analgesics such as acetaminophen and ibuprofen.regularly over long duration of time can cause analgesic nephropathy, which isthe another cause of chronic kidney disease. Atherosclerosis: Clogging and hardening of the arteries leading to akidneys causes a condition called ischemic nephropathy ,which is the anothercause of chronic kidney disease. Environmental and occupational agents: It includes lead, cadmium, mercury and chromium. Other causes: It includes HIV infections, sickle cell disease, heroinabuse, kidney stones, chronic kidney infections and certain cancers.
RISK FACTORS Diabetes mellitus Type1 and 2. High blood pressure. High cholesterol. Heart disease. Liver disease. Sickle cell disease. Vascular disease such as arteritis, vasculitis etc. Regular use of anti-inflammatory medications. Family history of kidney disease. Advanced age. Obese. Smokers.
PATHOPHYSIOLOGYDue to etiological factors renal functions declinesNephron damage is progressive ,damage nephron cannot function and do notrecoverDecreased glomerular filtration rateRemaining nephron undergo changes to compensate for those damagenephronsCompensatory excretion continues as GFR diminishesFiltration of more concentrated blood by the remaining nephrons
Damage of nephrons results in hypertrophy and hyperphosphotemia ofremaining nephronsUrine may contain abnormal amount of protein,RBC’S WBC’S or castsIncreased serum creatine, BUN level and retension of urea and othernitrogenous wasteFurther damage of the nephrons 80-90% damage ,GFR10-20% Chronic renal failure
CLINICAL MANIFESTATIONSNeurologic: Weakness and fatigue Confusion Inability to concentrate Altered level of consciousness Headache Sleep disturbances Lethargy Disorientations Seizures Behaviour changes Muscle twitching
Restlessness of legs Burning of soles of feet Integumentary: Severe pruritis Thin brittle nails Coarse thinning hair Dry ,flaky skin
Grey –bronze skin colour Puffiness around the eyes
Reproductive: Amenorrhea Decreased level of estrogen, progesterone and lutenizing hormones in women. Decreases testosterone level,low sperm count,testicular atropy in men. Infertility and decrease libido (in both sex).Musculoskeletal: Muscle cramps Loss of muscle strength Renal osteodystrophy Bone pain Bone fractures Foot drop
DIAGNOSTIC EVALUATIONS History collection Physical examinations Renal ultrasound: Ultrasound helps to estimate the prognosis of chronic kidneydisease. It also checks whether urine flow from the kidneys is blocked. An ultrasound alsomay help find causes of kidney disease, such as obstruction or polycystic kidneydisease, kidney stones and also to assess the blood flow into the kidneys. CT Scans and MRI Scans: Helps to identify renal masses and cysts. Renal Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in casesin which the cause of the kidney disease is unclear. Serum Creatinine: Creatinine is a waste product in your blood that comes frommuscle activity. It is normally removed from your blood by your kidneys, but when kidneyfunction slows down, the creatinine level rises and the doctor should use the results ofyour serum creatinine test to calculate your GFR.
Glomerular Filtration Rate (GFR):Glomerular filtration rate is the best test tomeasure your level of kidney function and determine your stage of kidney disease. Yourdoctor can calculate it from the results of your blood creatinine test, yourage, race, gender and other factors. Blood Urea Nitrogen (BUN): Urea nitrogen is a normal waste product in yourblood that comes from the breakdown of protein from the foods you eat and from yourbody metabolism. It is normally removed from your blood by your kidneys, but whenkidney function slows down, the BUN level rises. BUN can also rise if you eat moreprotein, and it can fall if you eat less protein. Serum electrolyte level: Kidney dysfunction causes imbalancesin electrolytes, especially potassium, phosphorus, and calcium. High potassium(hyperkalemia) is a particular concern..
Blood cell counts: Because kidney disease disrupts blood cell production andshortens the survival of red cells, the red blood cell count and hemoglobin may be low(anemia). Some patients may also have iron deficiency due to blood loss in theirgastrointestinal system. Other nutritional deficiencies may also impair the production ofred cells. Urine Protein: When your kidneys are damaged, protein leaks into your urine. Asimple test can be done to detect protein in your urine. Persistent protein in the urine isan early sign of chronic kidney disease. Micro albuminuria: This is a sensitive test that can detect a small amount of proteinin the urine. Urine Creatinine: This test estimates the concentration of your urine and helps togive an accurate protein result. Twenty-four hour urine tests: This test requires you to collect all of your urine for24 consecutive hours. The urine may be analyzed for protein and waste products (ureanitrogen, and creatinine). The presence of protein in the urine indicates kidney damage.The amount of creatinine and urea excreted in the urine can be used to calculate the levelof kidney function and the glomerular filtration rate (GFR).
COMPLICATIONS Hyperkalemia- Due to decreased excretion ,metabolic acidosis andexcessive intake ( diet,medication fluids) Pericarditis –Due to pericardial effusion Hyertension-Due to sodium and water retension and malfunction ofthe renin-angiotension-aldosterone system. Anemia-Due to decreased erythropoietin production ,bleeding in theGI tract and blood loss during hemodialysis. Bone Disease-Due to retension of phosphorous ,low serum calciumlevels,abnormal vitamin D metabolism.
MANAGEMENTMedical management: The main goal of management is to maintain kidney function and homeostasisfor as long as possible. The management is accomplished primarily withmedications and diet therapy ,although dialysis may also may needed to decrease thelevel of uremic waste products in the blood and to control electrolyte balance.Pharmacologic Therapy Calcium and phosphorous binders: Hyperphosphatemia and hypocalcemia are treated with medication thatbind dietary phosphorous in the GI tract .binders such as calcium carbonate orcalcium acetate are prescribed,but there is arisk of hypercalcemia .if calcium is highor the calcium-phosphorous products exceeds 55mg/dl ,a polymeric phosphatebinder such as sevelamer hypochloride (Renagel) may be used.all the binding agentsmust be administered with food to be effective.
Antihypertensive and cardiovascular agents Hypertension is managedby intravascular volume control and variety ofantihypertensive agents.heart failure and pulmonary edema may also requiretreatment with fluid retension ,low sodium diets,diuretic agents,inotropic agentssuch as digoxin (lanoxin)or dobutamine . Antiseizure agents If seizure occurs IV diazepam (valium)or phenytoin is usually administeredto control seizures. Erythropoietin Anemia associated with chronic renal failure is treated with recombinanthuman erythropoietin (Epogen). Erythropoietin is administered intravenously orsubcutaneously 3 times a week in ESRD.it may take 2-6 weeks for the hematocrit toincrease.
Diet Therapy Protein restriction: Decreasing protein intake may slow the progression of chronickidney disease. A dietitian can help you determine the appropriate amount of protein foryou. Salt restriction: Limit to 4-6 grams a day to avoid fluid retention and help controlhigh blood pressure. Fluid intake: Excessive water intake does not help prevent kidney disease. Infact, your doctor may recommend restriction of water intake. Potassium restriction: This is necessary in advanced kidney disease because thekidneys are unable to remove potassium. High levels of potassium can cause abnormalheart rhythms. Examples of foods high in potassium include bananas, oranges, nuts, andpotatoes. Phosphorus restriction: Decreasing phosphorus intake is recommended to protectbones. Eggs, beans, cola drinks, and dairy products are examples of foods high inphosphorus.
Dialysis Dialysis is an artificial means of removing waste products and extra fluid from yourblood when your kidneys arent able to perform these functions. There are two types of dialysis.In hemodialysis, blood is pumped out of your body to a machine that works like an artificialkidney, filtering waste out of your blood. The blood is then pumped back into your body.Another type of dialysis, called peritoneal dialysis, involves pumping a dialysis solution into yourabdominal cavity. Peritoneal dialysis relies on your bodys network of tiny blood vessels to carrywaste products and excess fluids to your abdominal cavity where the dialysis solution absorbsthem. The dialysis solution is then pumped out of your body with carrying the waste and excessfluids .Surgical Management: Kidney Transplant If you have no life-threatening medical conditions other than kidney failure, a kidneytransplant may be an option for you. Kidney transplant involves surgically placing a healthykidney from a donor inside your body. Transplanted kidneys can come from deceased donors orfrom living donors.
Nursing Management: Excess fluid volume related to decreased urine output, dietary excesses and retension of sodium and water. Monitor respiratory pattern for symptoms of respiratory difficulty (eg:dyspnea, tachycardia, shortness of breath etc )that are indicators of fluid excess. weigh patient daily. Maintain Intake and output chart. Assess for Skin turgor . Check for the presence of edema . Limit fluid intake to prescribed volume. Provide or encourage frequent oral hygiene. Assist patient to cope with the discomforts resulting from fluid restriction. Explain to patient and family rationale for fluid restriction.
Imbalanced nutrition ;less than body requirement related to anorexia ,nausea,vomiting ,dietary restriction and altered oral mucous membranes. Assess for factors(anorexia,nausea,vomiting,stomatitis)contributing toaltered nutritional intake. weigh patient daily. Provide oral care before meals to prevent stomatitis,remove bad tasteand increase patients appetite. Provide pleasant surroundings at meal-times. Encourage for high-calorie,low-protein,low-sodium,low potassiumdiet. Explain to the patient and family about dietary intake.
Risk for infection related to suppressed immune system, malnutrition secondary to dialysis and uremia. Monitor for systemic and localized signs and symptoms ofinfection(eg:pain on urination,hematuria,chills,fever) Limit number of visitors to decrease risk of infection. Ensure aseptic handling of all IV lines to prevent the introduction oforganisms. Wash hands before and after patient care activity to preventtransmission of pathogens. Teach patient and family about signs and symptoms of infection andwhen to report them to the health care provider to obtain early treatment.
Risk for injury related to alterations in bone structure due to decreased calcium absorption,retension of phosphate and altered vitamin D metabolism. Monitor trends in serum level of calcium. Administer appropriate prescribed calcium salt (eg:calciumcarbonate,calciumchloride,calcium gluconate) Provide adequate intake of vitamin D to facilitate GI absorption of calcium to prevent andtreat the bone demineralization. Instruct patient on measures to control /minimize symptoms(eg:taking calcim and vitaminD suppliments) Activity intolerance related to fatigue ,anemia,retension of waste products and dialysis procedure. Assess factors contributing to activity intolerance (eg: fatigue,anemia,fluid and electrolyteimbalance, retension of waste products,depression) Promote independence in self care activities as tolerated ;assist if fatigued. Encourage alternating activity with rest. Encorage patient to rest after dialysis treatment.
Deficient knowledge regarding condition and treatment Assess understanding of cause of renal failure ,consequences of renal failure,and its treatment. Cause of patients renal failure. Meaning of renal failure. Understanding of renal function. Relationship of fluid and dietary restriction to renal failure. Rationale for treatment. Provide explanation of renal function and consequences of renal failure at patients level ofunderstanding and guided by patients readiness to learn. Provide oral and written information as appropriate about: Renal function and failure. Fluid and dietary restriction . Medications. Reportable problems,signs and symptoms. Follow -up schedule. Treatment options.
PATIENT AND FAMILY TEACHING GUIDE Explain dietary (protein,sodium,potassium,phosphate)and fluid restrictions. Explain signs and symptoms of electrolye imbalance ,especially high potassium. Explain the importance of reporting any of the following:1. Weight gain greater than 2 kg.2. Increasing BP.3. Shortness of breath.4. Edema.5. Increase fatigue and weakness.6. Confussion and lethargy. Explain the rationale for prescribed drugs and common side effects.1. Phosphate binders should be taken with meals.2. Calcium suppliments should be taken on an empty stomach.3. Iron suppliments should be taken between meals. Encourage patient and family to share concern about lifestyle changes,living with chronic illness,and decisions about type of dialysis or transplantations.