ORGANISE FOR MEDICAL STUDENT

1. Prepared by D. Chaplin
Chronic Kidney
Disease

2. Prepared by D. Chaplin
Chronic Kidney Disease
Progressive, irreversible damage to the nephrons
and glomeruli

3. Prepared by D. Chaplin
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.

4. Prepared by D. Chaplin
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

5. Prepared by D. Chaplin
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

6. Prepared by D. Chaplin
Stage Description
GFR*
mL/min/1.73m2
1
Slight kidney damage with normal
or increased filtration
More than 90
2 Mild decrease in kidney function 60-89
3
Moderate decrease in kidney
function
30-59
4
Severe decrease in kidney
function
15-29
5 Kidney failure
Less than 15 (or
dialysis)
Table 1. Stages of Chronic Kidney Disease
*GFR is glomerular filtration rate, a measure of the kidney's function.

7. Prepared by D. Chaplin
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
Decreased
glomerular
filtration
Serum
Creatinine
BUN
Hypertrophy of
remaining
nephrons
Inability to
concentrate urine
Dilute
Polyuria
Dehydration
Further loss of
nephron function
Loss of
nonexcretory renal
function
Failure to convert
inactive forms of
calcium
Calcium
absorption
1
Failure to
produce
eryhtropoietin
Anemia
Pallor
Impaired
insulin action
Erratic blood
glucose
levels
Production of
lipids
Advanced
atherosclerosis
Immune
disturbance
s
Delayed
wound
healing
Infection
Disturbances in
reproduction
Libido Infertility
2
a
Loss of Sodium
in Urine
Hyponatremia

8. Prepared by D. Chaplin
Hypocalcemia
Osteodystrophy
Excretion of
nitrogenous
waste
Uremia
BUN,
Creatinine
Uric Acid
Proteniuria
Peripheral
nerve
changes
Pericarditis
CNS
changes
Altered
Taste
Bleeding
Tendencie
Decreased
sodium
reabsorption in
tubule
Water
Retention
Hypertension
Heart Failure
Edema
Decreased
potassium
excretion
Hyperkalemia
Decreased
phosphate
excretion
Hyperphosphate
mia
Decreased
calcium
absorption
Hypocalcemia
Hyperparathyroidis
m
Decreased
potassium
excretion
Increased
potassium
Decreased
hydrogen
excretion
Metabolic
acidosis
1
2
a
Loss of excretory
renal function
Pruritus

9. Prepared by D. Chaplin
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

10. Prepared by D. Chaplin
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

11. Prepared by D. Chaplin
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)

12. Prepared by D. Chaplin
 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 be:

13. Prepared by D. Chaplin
 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 be:

14. Prepared by D. Chaplin
 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 be:

15. Prepared by D. Chaplin
 Metabolic dysfunction - involving lipids, insulin
and uric acid (gout). Metabolic acidosis is also
associated
Associated complications of chronic
Kidney Disease would be:

16. Prepared by D. Chaplin

17. Prepared by D. Chaplin
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

18. Prepared by D. Chaplin
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.

19. Prepared by D. Chaplin
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

20. Prepared by D. Chaplin
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 - movement fluid from an area of < to >
concentration of solutes (particles)
Osmosis-Diffusion-Ultrafiltration

21. Prepared by D. Chaplin
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

22. Prepared by D. Chaplin
Peritoneal Dialysis

23. Prepared by D. Chaplin
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

24. Prepared by D. Chaplin
Hemodialysis
AV Fistula Communication
AV Graph Access

25. Prepared by D. Chaplin
Hemodialysis
Hemodialysis Machine
Hemodialysis Circuit

26. Prepared by D. Chaplin
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
Advantages Disadvantages

27. Prepared by D. Chaplin
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
Advantages Disadvantages

28. Prepared by D. Chaplin
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

29. Prepared by D. Chaplin
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

30. Prepared by D. Chaplin
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

31. Prepared by D. Chaplin
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.

32. Prepared by D. Chaplin
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)

33. Prepared by D. Chaplin
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

34. Prepared by D. Chaplin
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.

35. Prepared by D. Chaplin
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

36. Prepared by D. Chaplin
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

37. Prepared by D. Chaplin
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.

38. Prepared by D. Chaplin
Complications Post Transplant
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

39. Prepared by D. Chaplin
Complications Post Transplant
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

40. Prepared by D. Chaplin
Complications Post Transplant
Infection
Hypertension
Malignancies (lip, skin,
lymphomas, cervical)
Recurrence of renal disease
Retroperiotneal bleed
Arterial stenosis
Urine leakage

41. Prepared by D. Chaplin
100 patients with eGFR < 60
(Tuesday morning in Outpatients)

42. Prepared by D. Chaplin
Tuesday morning 1 year later: 1 patient needs RRT, 10
patients have died (> 50% CV death)

43. Prepared by D. Chaplin
Tuesday morning 10 years later: 8 patients need RRT, 65 patients have
died, 27 have ongoing CKD

44. Prepared by D. Chaplin
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.

45. Prepared by D. Chaplin
Optimise risk factors
 Cardiovascular disease
 Proteinuria
 Hypertension
 Diabetes
 Smoking
 Obesity
 Exercise tolerance
TAKE HOME MESSAGE

46. Prepared by D. Chaplin
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.
46

47. Prepared by D. Chaplin
 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.

48. Prepared by D. Chaplin
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.
48

49. Prepared by D. Chaplin
• 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

50. Prepared by D. Chaplin
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.
50

51. Prepared by D. Chaplin
• 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.

52. Prepared by D. Chaplin
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.
52
TAKE HOME MESSAGE

53. Prepared by D. Chaplin
THANK YOU
Have a check on
your blood pressure
Sugar & Salt / year