Alteration of the Renal System

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Alteration of the Renal System
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Risk Factors for CKD

• Diabetes
• Hypertension
• Age
• Family history of kidney disease or diabetes
• Male gender

• Racial/Ethnic Background
• African American
• Native American
• Asian-American
• Pacific Islander
• Latin American
• Tobacco Use

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Risk Factors for CKD (Cont.)

• Coexisting kidney disease
• Anemia
• High-protein diet
• Hyperlipidemia

• Atherosclerosis
• Obesity
• Exposure to nephrotoxic drugs
• NSAIDS
• Contrast dye
• Hydrocarbons

McCarthy. Mayo Clin Proc. 199974(3)269.
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Anatomy of the Urinary System
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Renal Anatomy
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Physiology

• Filtration (GFR125 ml/min)
• Reabsorption (Ex. Sodium and water)
• Maintenance Acid-Base Balance
• Excretion
• Renal Control of Cardiac Output and Systemic BP
• Production of active form of Vitamin
  D(Calcitriol)
• Production of Erythropoietin

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Acute vs. Chronic Renal Failure

• Usually sudden onset
• Can be reversible
• Usually lasts short period of time
• Can be oliguric or non-oliguric
• Can progress to CKD / ESRD if not treated
  immediately

• Usually insidious onset
• Progressive destruction of renal structures
• Irreversible

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Assessment

• Blood Tests
• BUN/Cr
• Electrolytes
• Na
• K
• Ca
• Po4
• Uric Acid
• Albumin

• Urine Tests
• Protein
• Creatinine Clearance
• Urea Clearance
• Specific Gravity
• GFR
• Special Procedures
• Review from N2903
• CT / MRI / biopsy / IVP

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Client History

• Recent use of nephrotoxic substances
• Recent exposure to heavy metals or organic
  solvents
• Recent hypotensive episode of gt30 minutes
• Presence of tumor or multiple clots causing
  renovascular or urine outflow obstruction

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Nephrotoxins

• Antibiotics
• Aminoglycosides
• Amphotericin
• Neomycin
• Kanamycin
• PCN

• Chemicals
• Lead
• Arsenic
• Methanol
• Mercuric chloride
• Carbon tetrachloride

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Nephrotoxins

• Contrast Agents
• IVP dye
• Arteriogram dye

• Drug-Induced
• NSAIDS
• Sulfonamides
• Cephlosporins
• Lasix
• Dilantin
• Anesthetics
• Chemotherapy agents

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Other Nephrotoxins

• Hemoglobin - hemolysis of red blood cells
• Rhabdomyolysis - myoglobin from muscle breakdown
  as in a crush injury, heat stroke, seizure
• Street drugs

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Acute Renal Failure (ARF)

• Sudden and complete loss of kidney function
  caused by failure of renal circulation or by
  glomerular or tubular dysfunctions
• Can occur suddenly, within hours, or over a
  period of days
• Delayed treatment or untreated progresses to
  chronic kidney disease

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Acute Renal Failure - Causes

• Prerenal causes interfere with renal perfusion
• Hypovolemia
• Decreased cardiac output
• Decreased renal perfusion

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Acute Renal Failure

• Intrarenal (Intrinsic) causes that damage the
  renal parenchyma (tissue)
• Sequelae to prolonged prerenal disease
• Nephrotoxins
• Intratubular obstruction
• Calculi, hemolytic reactions
• Infections
• Renal injury
• Vascular lesions

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Acute Renal Failure

• Postrenal caused by obstruction to outflow of
  urine from the kidneys
• Can occur in the ureters, bladder, or urethra
• Causes buildup of pressure that unrelieved will
  cause decrease in function and damage to the
  kidney

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Acute Tubular Necrosis

• ATN (intrarenal) - accounts for 75 of ARF
  cases
• Refers to necrosis (death) of renal tissue
• Most frequent causes - surgery, trauma, sepsis,
  C-V collapse, and nephrotoxic injury
• Divided into four stages

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Onset Stage

• Initial insult occurs
• Urine output down to 20 of normal
• Lasts two days
• Ends with Oliguric/Anuric Stage or development of
  azotemia

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Oliguric/Anuric Stage

• Oliguria - Urine output less than 400 ml/24 hr
• Anuria less than 50 ml/24 hr
• Usually occurs 48 hrs post injury
• Persists for 1-2 weeks until early diuresis stage
  begins
• Prognosis worse the longer in this stage

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Diuretic Stage

• Early Diuretic Stage lasts until
• Creatinine stabilizes (stops rising)
• Urine output increase to over 400ml/24 hr
• Lasts 1-2 weeks
• Renal tubules begin to heal
• Output 1-2 L/24 hr dilute
• Fluids /lytes difficult to manage

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Acute Renal Failure

• Late (Recovery) Diuretic Stage
• BUN/Cr begin to decrease
• Lasts until levels normal
• Lasts approximately 10 days
• Nephrons healing function improving
• Kidneys very vulnerable avoid nephrotoxic agent
  
• Output high
• Need to control fluids/lytes

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Convalescent Stage

• Lab values normal
• Renal function returns
• Lasts 6-12 months
• Output returns to normal
• Concentration of urine returns to normal
• Kidneys extremely vulnerable

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Clinical Manifestations of ARF

• Urine output decreases
• Decreased specific gravity
• Increased BUN and Creatinine levels
• Elevated BP
• Hyperkalemia
• Metabolic acidosis
• Hypo-or hypernatremia
• Altered Calcium/Phosporus levels

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Clinical Manifestations

• Anemia
• Appears critically ill
• Lethargy
• Possible GI problems/bleeding
• Skin - dry, yellow cast, bruising
• Pruritis
• Peripheral neuropathy

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Clinical Manifestations

• Cerebral edema and decreased LOC
• High risk for pneumonia
• R/T decreased LOC, weakness, thickened
  secretions, decreased cough reflex, and decreased
  pulmonary macrophage activity

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Children and ARF

• Lethargy
• Decreased LOC
• Decreased urine output
• History of dehydration
• Shock
• Recent post-op

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Treatment of ARF

• Emergent dialysis
• Treatment of hyperkalemia
• Monitor labs and clinical changes
• Kayexalate (po or pr)
• Sorbitol
• IV Glucose and Insulin or Calcium Gluconate
• Sodium Bicarb

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Treatment of ARF

• Maintain fluid balance
• Monitor daily body wt., serial CVP measurements,
  serum/urine concentrations, fluid losses, BP,
  clinical status
• Strict I O - includes insensible losses - used
  to calculate fluid replacement

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Treatment of ARF

• Nutrition
• Hypermetabolic state
• Severe nutritional imbalances
• Proteins limited to 1gm/kg during oliguric
  phase to minimize protein breakdown - prevents
  accumulation of toxic end products
• Increase CHO, fats, essential amino acids to
  spare proteins
• Na/K/Phos - restricted

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Treatment of ARF

• IV fluids and diuretics
• Mannitol, Lasix, Bumex - may not work
• Treat shock and infection
• Albumin IV to increase protein in blood - aids in
  decreasing hypovolemia

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Treatment of ARF

• Correct acidosis and phosphatemia
• Monitor ABGs - may need vent
• May need NaHCO3 or dialysis
• Phosphate-binding agents
• Calcitriol IV
• Calcium supplements

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Treatment of ARF

• Need to monitor labs throughout all phases
  including convalescent phase
• Dietary changes/fluid restrictions based on labs
  and output

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Nursing Interventions

• Monitor fluid and electrolytes
• Reduce metabolic rate
• Promote pulmonary function
• Avoid infection
• Provide skin care
• Dialysis support as needed
• Family support
• Spiritual support
• Economic concerns

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Chronic Kidney Disease

• Progressive, irreversible deterioration in renal
  function
• Causes the bodys ability to maintain metabolic,
  fluid, and electrolyte balance to fail
• Results in uremia

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End-Stage Renal Disease

• Results from CKD
• Most or all of kidneys ability to produce urine
  and regulate blood chemistries is severely
  compromised
• Renal function falls to 10-15 of normal
• Increasing at rate of 10/yr

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Causes of CKD

• Diabetes Mellitus - No.1
• Hypertension - No. 2
• Chronic glomerulonephritis
• Pyelonephritis
• Obstruction of urinary tract
• Hereditary lesions (polycystic kidney disease)

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Polycystic Kidney Disease
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Causes of CKD

• Vascular disorders
• Infections
• Medications
• Toxic agents
• Drug addiction

• Neoplasms
• Congenital anomalies
• SLE
• Calculi
• Renal artery stenosis

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Stages of CKD

• Stage 1
• 9 million people persistent albuminuria
• Stage 2
• 5.3 million people GFR 60-89
• Stage 3
• 7.6 million people GFR 30-59
• Stage 4
• 400,000 people GFR 15-29
• Stage 5
• 300,000 people GFR lt15

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Pathophysiology of CKD

• R/T accumulation of end products of metabolism in
  the blood
• Affects every system in the body
• Progression of CKD r/t underlying cause, to
  urinary excretion of protein, presence of
  hypertension
• Metabolic acidosis results

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CV Manifestations

• Hypertension
• CHF and Pulmonary Edema
• Arrhythmias
• Chest pain
• Pitting edema, periorbital edema
• Engorged neck veins
• Hyperkalemia/hyperlipidemia

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Neurologic Manifestations

• Weakness and fatigue
• Confusion, disorientation
• Inability to concentrate
• Tremors, seizures, restless legs
• Burning of soles of feet
• Behavior changes
• Asterixis

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Integumentary Manifestations

• Pruritus
• Dry, flaky skin
• Gray-bronze skin color
• Uremic frost - uncommon
• Ecchymosis
• Purpura
• Thin, brittle nails
• Coarse, thinning hair

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Pulmonary Manifestations

• Crackles
• Thick, tenacious sputum
• Depressed cough reflex
• Dyspnea, tachypnea
• Uremic pneumonitis
• Kussmaul-type respirations

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GI Manifestations

• Ammonia odor to breath
• Metallic taste
• Mouth ulceration and bleeding
• Anorexia
• Nausea/vomiting
• Hiccups
• Constipation or diarrhea
• GI bleeding

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Hematoligic Manifestations

• Anemia
• Thrombocytopenia
• Easy bruising
• Bleeding tendency

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Erythropoiesis in CKD
Adapted from Fauci.Harrisons Principles of
Internal Medicine. 1998334.
REreticuloendothelial
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Reproductive Manifestations

• Amenorrhea
• Testicular atrophy
• Infertility
• Decreased libido

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Musculoskeletal Manifestations

• Muscle cramps
• Loss of muscle strength
• Renal osteodystrophy
• Bone pain
• Bone fractures
• Foot drop

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Vitamin D Deficiency and Phosphate Retention
CKD
Vitamin D Deficiency
Phosphate Retention
Hypocalcemia
Hyperparathyroidism
Osteodystrophy
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Management of Vitamin D Deficiency and Phosphate
Retention

• Vitamin D analogs
• Calcitriol ? 0.25 mg/day
• Low phosphate diet
• Phosphate binders
• Calcium-containing
• Calcium-free (eg, sevelamer hydrochloride)
• Calcium

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Treatment of Metabolic Acidosis in CKD

• Goal
• Serum HCO3- gt 20 mEq/L
• pH gt 7.35
• Agents
• Sodium bicarbonate tablets
• (650 mg 8 mEq HCO3-)
• Sodium citrate (Shohls solution)
• Dose of HCO3-
• 1.0-1.5 mEq/kg/day
• Dependent upon initial serum HCO3- and degree of
  renal insufficiency

Dubose TD. Harrisons Principles of Internal
Medicine. 1998277. Facts and Comparisons. 1977
726-727.
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Immunologic Manifestations

• Decreased resistance to infection
• Failure to respond to certain vaccines
• Increased risk of cancer

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Metabolic Disturbances

• Abnormal glucose metabolism in nondiabetics
• Resistance to insulin in diabetic patients
• Wide swings in glucose levels and problems with
  insulin dosage in diabetics - decreased ability
  of kidney to metabolize insulin and increased
  half-life of insulin

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Pediatric Problems

• Growth failure (esp. preadolescent)
• Lack of sexual maturation
• Osseous deformities
• Alteration in size/shape of teeth and
  discoloration of teeth
• Ulcerative stomatitis

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Gerontologic Considerations

• Kidney function normally changes with age
• Use caution with medications (prescribed and OTC)
• Increased incidence of systemic disease
• Decreased ability of kidney to handle
  fluid/electrolyte imbalances
• Misinterpretation of atypical and nonspecific
  signs of impaired renal function

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Management of CKD

• Goal Maintain kidney function / homeostasis
• Fluid volume control
• Antihypertensives
• Bone Protection Potassium restricted diet
• Electrolyte balance

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Nutrition and CKD

• Dietary Interventions
• Protein restriction
• Fluid restriction
• Calories from CHO and fat
• Water-soluble vitamin replacement (B and C)
• Vitamin D supplement
• Restricted Potassium
• Restricted phosphorus
• Low sodium
• Calcium supplementation or calcium analogs

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Transplantation

• Treatment, not a cure
• Cost of maintaining transplant approximately 1/3
  cost of treating dialysis patient
• Donor - living or cadaver
• Compatible ABO and HLA antigen
• Native kidneys not always removed

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Transplant Evaluation

• Psychosocial evaluation
• Assess ability to adjust/coping styles
• Assess support system
• Assess social history
• Assess financial resources
• Assess insurance

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Placement of Transplanted Kidney
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Pre-op Management

• Bring metabolic state as close to normal as
  possible
• Complete physical exam
• Varied diagnostic testing
• Tissue and blood typing, and antibody screening
• Lower urinary tract assessed
• Free of infection

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Pre Op Care of Transplant Candidate

• Dental exam and needed care
• Dialysis prior to surgery
• Similar nursing interventions to any major
  abdominal surgery
• Post-op pulmonary hygiene
• Pain management
• Dietary restrictions
• Lines/tubes
• Early ambulation

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Post-op Management

• Maintain homeostasis until kidney functioning
• Immunosuppressive therapy to prevent rejection -
  life-long therapy
• Diet more liberal
• Fluids pushed

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Rejection

• Hyperacute - within 24 hours
• Acute - within 3-14 days
• Chronic - after many years
• Kidney may or may not be removed
• Evaluated by percutaneous renal biopsy and x-ray
• Return to dialysis

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Post-op Assessment

• Signs/symptoms of rejection
• Oliguria
• Edema
• Fever
• Increasing BP
• Weight gain
• Swelling over transplant site
• Asymptomatic rise in Creatinine level if
  receiving Cyclosporin (may be only sign)

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Post-op Nursing Interventions

• Monitor serum electrolytes
• Monitor for and protect from infection
• Monitor VS
• Cultures as indicated
• Urine
• Wound drainage
• Catheter and drain tips
• Monitor urinary output
• Monitor fluid/electrolyte status
• Monitor vascular access

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Psychological Considerations

• Fear of rejection
• Concern re complications of immunosuppressive
  therapy
• Anxiety and uncertainty about future and
  adjustment
• Weight gain R/T medication regime

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Potential Complications

• Rejection
• GI ulceration and steroid-induced bleeding
• Fungal colonization of GI tract especially of the
  mouth
• Fungal colonization of bladder
• Increased risk for cancers

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Hemodialysis

• Used to combat ARF - short-term therapy
• Used for ESRD - life-long therapy
• Does not cure or reverse renal failure
• Removes fluids and toxic wastes

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Hemodialysis

• Uses bicarb/acid bath
• Requires an access
• Fistula, graft, or catheter
• Requires water system
• Utilizes an arterial and a venous line connected
  to a dialyzer
• Treatment - program wt to be removed and desired
  length of time

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Medical Management

• Diet - restricts protein, sodium, potassium, and
  phosphorus
• Fluid restriction - usually a liter/day
• Medications
• Possible drug toxicity
• Possible removal by dialysis
• Possible withholding of certain medication
  pre-dialysis

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Associated Dialysis Complications

• Hypotension
• Nausea/vomiting
• Seizures
• Muscle cramping
• Chest pain
• Cardiac arrest
• Air embolism
• Renal osteodystrophy
• Gastric ulcers

• Disequilibrium
• Blood loss
• Hypoxia
• Hypoglycemia
• Hemolysis
• Sepsis
• CVD
• Anemia
• Fatigue

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Patient Education

• Small increments
• Good communication
• Nonjudgmental
• Team effort
• Consider psycho-social ramifications

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Peritoneal Dialysis (PD)

• Two Types of PD
• CAPD - Continuous Ambulatory PD
• CCPD - Continuous Cycling PD
• Surface of peritoneum
• Acts as agent for diffusion / osmosis
• Reasons for choice
• CV status
• Home concerns

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Peritoneal Dialysis

• Appropriate dialysate
• Glucose concentration varies
• Medications nay be added
• Solution warm
• Flows by gravity
• Dwell time
• Drained by gravity
• Number of exchanges/frequency prescribed

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Contraindications for PD

• Medical
• Adhesions
• Immunosuppressive medications
• Opening between peritoneal and pleural cavities
• Concurrent abdominal disease
• HX recurrent hernias or ruptured diverticulum
• Weighing gt70 Kg w/no renal function
• Psychosocial issues
• Physical limitations

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Complications of PD

• Peritonitis
• Exit site infection
• Tunnel infection
• Fibrin formation
• Inflow/Outflow problems
• Position
• Constipation
• Catheter migration

• Air in peritoneum
• Dialysate leak
• Hernias
• Initial treatments - leakage or bleeding
• Constipation
• Low back pain
• Anorexia
• Weight gain

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Continuous Renal Replacement Therapy (CRRT)

• SCUF - slow continuous ultrafiltration
• CAVH - continuous arteriovenous hemofiltration
• CAVHD - continuous arteriovenous hemodialysis
• CVVH - continuous venovenous hemofiltration
• CVVHD - continuous venovenous hemodialysis

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Pediatric Considerations

• Children - can use femoral artery and vein with
  smaller gauge catheter
• Neonates - usually utilize umbilical artery/vein

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Nursing Management with CRRT

• Monitor VS and hemodynamic measurements
• Monitor strict I O
• Observe for bleeding/clotting
• Monitor connections
• Site care
• Lower extremity observation when femoral accesses
  used
• Assess for local/systemic infections

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Questions / Concerns?

• The END!!
• Exam
• 2/23
• 21 renal
• 21 fluid / electrolyte
• Focus on nursing interventions
• Case studies on web for review