CHRONIC KIDNEY DISEASE

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CHRONIC KIDNEY DISEASE CKD/END STAGE RENAL DISEASE (ESRD)  
Is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting  in  uremia  and azotemia.
ESRD  Causes: 
1. Diabetes Mellitus, hypertension, chronic glomerulonephritis,     pyelonephritis. Obstruction of the urinary     tract, hereditary lesions as in polycystic     kidney  disease,  vascular  disorders,     infections, medications, or toxic agents.  

2. Environmental and occupational agents  that  have  been  implicated  in  CRF  include lead, mercury and chromium.  Dialysis  or  kidney  transplantation  eventually  becomes  necessary  for  patient’s survival.

PATHOPHYSIOLOGY 
Has renal function deteriorate the end product of CHON metabolism which are excreted in the urine accumulates in the blood. Uremia develops and adversely affect every system in the body.
 

STAGES OF CHRONIC KIDNEY DISEASE 
Stage 1Reduced renal reserve
characterized by a 40% to 75% loss of nephron function. The patient usually does not have symptoms because the remaining nephrons are able to carry out the normal functions of the kidney.

Stage 2Renal insufficiency 
occurs when 75% to 90% of nephron function is lost. At this point, the serum creatinine and blood urea nitrogen rise, the kidney loses its ability to concentrate urine and anemia develops. The patient may report polyuria and nocturia. 

Stage 3End-stage renal disease(ESRD)
 the final stage of chronic renal failure, occurs when there is less than 10% nephron function remaining. All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired. ESRD is evidenced by elevated creatinine and blood urea nitrogen levels as well as electrolyte imbalances. Once the patient reaches this point, dialysis is usually indicated. Many of the symptoms of uremia are reversible with dialysis.


CLINICAL MANIFESTATIONS 
 1. Cardio vascular manifestations:     
a. Hypertension due to Na and H20 retention or from Renin Angiotensin Aldosterone  activation. 
b. heart failure and edema  due to fluid overload       
c. pericarditis  due to irritation of pericardial lining by  uremic toxins 

2. Dermatologic manifestations     
a. severe pruritus is common      
b. uremic frost, the deposit of urea crystals on the skin. 

3 Gastrointestinal manifestations:    
a. anorexia, nausea and vomiting, and hiccups     
b. The patient’s breath may have the odor of urine   (uremic fetor); this may be associated with   inadequate dialysis

 4. Neurologic manifestations    
 a. Inability to concentrate, muscle twitching, agitation, confusion and seizures.     
b. Peripheral neuropathy, a disorder of the peripheral Nervous system , is present in some patients. 

ASSESSMENT AND DIAGNOSTIC  FINDINGS  
1. Glomerular Filtration Rate GRF
Decreased GFR can be detected by obtaining a 24-hour urinalysis for creatinine clearance. As glomerular filtration decreases (due to non-functioning glomeruli), the creatinine clearance value decreases, whereas the serum creatinine and BUN levels increase.
2. Sodium and water retention
The kidney cannot concentrate or dilute the urine normally in ESRD. Appropriate responses by the kidney to changes in the daily intake of water and electrolytes, therefore, do not occur. Some patients retain sodium and water, increasing the risk for edema, heart failure, and hypertension. 
3. acidosis
 due to inability of the kidneys to excrete increased load of acid 
4. Anemia 
Anemia develops as a result of inadequate erythropoietin production
5. calcium and phosphorous imbalance  
 With decreased filtration through the glomerulus of the kidney, there is an increase in the serum phosphate level and a reciprocal or corresponding decrease in the serum calcium level. The decreased serum calcium level causes increased secretion of parathormone from the parathyroid glands.

COMPLICATIONS  
1. Hyperkalemia due to decreased excretion, metabolic   acidosis,   catabolism   and  excessive intake (diet, meds and fluids)  
2. Pericarditis, pericardial effusion and pericardial  tamponade due to retention of uremic waste products and inadequate dialysis.  
3.  Hypertension due to sodium and water retention  and  malfunction  of  the  R-A-A  system 
4. Anemia due to decreased erythropoietin production,  decreased  RBC  life  span,  bleeding in the GIT from irritating toxins and  ulcer Cormation, and blood ross during hemodialysis 
5. Bone disease and metastatic  and vascular  calciflcations due  to  retention    of  phosphorous, low serum calcium levels,  abnormal  vitamin  D metabolism   and  elevated aluminum levels.

MEDICAL MANAGEMENT  
The goal of management is to maintain kidney function and homeostasis for as long as possible. All factors that contribute to ESRD and all factors that are reversible (eg, obstruction) are identified and treated. Management is accomplished primarily with medications and diet therapy, although dialysis may also be needed to decrease the level of uremic waste products in the blood

1. PHARMACOTHERAPY 
 a. Antacids. Hyperphosphatemia and hypocalcemia are treated with aluminum-based antacids that bind dietary phosphorus in the GI tract.

b Antiseizure agents: diazepam (Valium) or    phenytoin (Dilantin) 
 c. Antihypertensive and CV drugs:  digoxin  (Lanoxin) and dobutamine (Dobutrex). 
d.  Erythropoietin (Epogen): to treat anemia. It is initiated to reach a hematocrit of 33% - 38. 5 and a target hemoglobin of 12gdl. 

2. NUTRITIONAL THERAPY 
a. low sodium
b. low CHON 
c. low K diet  
3. Dialysis


NURSING MANAGEMENT :
 1. Assessing fluid status and identifying     potential sources of imbalance. 
 2. Implementing a dietary program to ensure  proper nutritional intake  
3. promoting positive feelings by  encouraging increased self-care and  greater independence.  
4. Provide explanations and information to   the patient and family concerning ESRD,  treatment options and potential  complications. 
5. Provide emotional support to the patient  and family.

NURSING DIAGNOSIS
 •Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water 
• Imbalanced nutrition: less than body requirements related to anorexia, nausea and vomiting, dietary restrictions, and altered oral mucous membranes
 • Deficient knowledge regarding condition and treatment regimen 
• Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure
 • Low self-esteem related to dependency, role changes, changes in body image, and sexual dysfunction

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