Chronic Kidney Disease

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Chronic Kidney Disease:

Chronic Kidney Disease

Anatomy:

Anatomy 2 Kidneys 2 Ureters Bladder Urethra

Kidney Function:

Kidney Function Detoxify blood Increase calcium absorption calcitriol Stimulate RBC production erythropoietin Regulate blood pressure and electrolyte balance renin

Classifications:

Classifications Acute versus chronic Pre-renal, renal, post-renal Anuric, oliguric, polyuric

Acute Versus Chronic:

Acute Versus Chronic Acute sudden onset rapid reduction in urine output Usually reversible Tubular cell death and regeneration Chronic Progressive Not reversible Nephron loss 75% of function can be lost before its noticeable

Acute Renal Failure:

Acute Renal Failure Pre-renal = 55% Renal parenchymal (intrinsic)= 40% Post-renal = 5-15%

Causes of ARF:

Causes of ARF Pre-renal = vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure cardiac failure, liver dysfunction, or septic shock Intrinsic Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins Post-renal = prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders neurogenic bladder bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus

Symptoms of ARF:

Symptoms of ARF Decrease urine output (70%) Edema, esp. lower extremity Mental changes Heart failure Nausea, vomiting Pruritus Anemia Tachypenic Cool, pale, moist skin

Acute Renal Failure Management:

Acute Renal Failure Management Make/think about the diagnosis Treat life threatening conditions Identify the cause if possible Hypovolemia Toxic agents (drugs, myoglobin) Obstruction Treat reversible elements Hydrate Remove drug Relieve obstruction

Hyperkalemia Symptoms:

Hyperkalemia Symptoms Weakness Lethargy Muscle cramps Paresthesias Hypoactive DTRs Dysrhythmias EKG?

Hyperkalemia & EKG:

Hyperkalemia & EKG K > 5.5 -6 Tall, peaked T’s Wide QRS Prolong PR Diminished P Prolonged QT QRS-T merge – sine wave

Hyperkalemia Treatment:

Hyperkalemia Treatment Calcium gluconate (carbonate) Sodium Bicarbonate Insulin/glucose Kayexalate Lasix Albuterol Hemodialysis

Chronic Kidney Disease:

Chronic Kidney Disease Chronic kidney disease (CKD) encompasses a spectrum of different pathophysiologic processes associated with abnormal kidney function and a progressive decline in glomerular filtration rate (GFR).

Recommended Equations for Estimation of Glomerular Filtration Rate (GFR) Using Serum Creatinine Concentration (PCr), Age, Sex, Race, and Body Weight:

Recommended Equations for Estimation of Glomerular Filtration Rate (GFR) Using Serum Creatinine Concentration ( P Cr ), Age, Sex, Race, and Body Weight 1. Equation from the Modification of Diet in Renal Disease study * Estimated GFR (mL/min per 1.73 m 2 ) = 1.86 x ( P Cr ) –1.154 x (age) –0. 203 Multiply by 0.742 for women Multiply by 1.21 for African Americans 2. Cockcroft- Gault equation Estimated creatinine clearance (mL/min) = (140–age) x body weight (kg) 72 x P Cr (mg/ dL ) Multiply by 0.85 for women

Leading Categories of Etiologies of CKD:

Leading Categories of Etiologies of CKD Diabetic glomerular disease Glomerulonephritis Hypertensive nephropathy Primary glomerulopathy with hypertension Vascular and ischemic renal disease Autosomal dominant polycystic kidney disease Other cystic and tubulointerstitial nephropathy

CRF Symptoms:

CRF Symptoms Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal hemostasis

Causes of Anemia in CKD:

Causes of Anemia in CKD Relative deficiency of erythropoietin Diminished red blood cell survival Bleeding diathesis Iron deficiency Hyperparathyroidism/bone marrow fibrosis "Chronic inflammation" Folate or vitamin B12 deficiency Hemoglobinopathy Comorbid conditions: hypo/hyperthyroidism, pregnancy, HIV-associated disease , autoimmune disease, immunosuppressive drugs

Problems Related to ESRD:

Problems Related to ESRD Metabolic – K/Ca Volume overload Anemia, platelet disorder, GI bleed HTN, pericarditis Peripheral neuropathy, dialysis dementia Abnormal immune function

Dialysis:

Dialysis ½ of patients with CRF eventually require dialysis Diffuse harmful waste out of body Control BP Keep safe level of chemicals in body 2 types Hemodialysis Peritoneal dialysis

Hemodialysis:

Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters blood and returns it to body

Types of Access:

Types of Access Temporary site AV fistula Surgeon constructs by combining an artery and a vein 3 to 6 months to mature AV graft Man-made tube inserted by a surgeon to connect artery and vein 2 to 6 weeks to mature

Access Problems:

Access Problems AV graft thrombosis AV fistula or graft bleeding AV graft infection Steal Phenomenon Early post-op Ischemic distally Apply small amount of pressure to reverse symptoms

Peritoneal Dialysis:

Peritoneal Dialysis Abdominal lining filters blood 3 types Continuous ambulatory Continuous cyclical Intermittent

EMS Considerations:

EMS Considerations Make sure the dressing remains intact Do not push or pull on the catheter Do not disconnect any of the catheters Always transport the patient and bags/catheters as one piece Never inject anything into catheter

Dialysis Related Problems:

Dialysis Related Problems Lightheaded –give fluids Hypotension Dysrhythmias Disequilibration Syndrome At end of early sessions Confusion, tremor, seizure Due to decrease concentration of blood versus brain leading to cerebral edema

Patient Education:

Patient Education Social, psychological, and physical preparation for the transition to renal replacement therapy and the choice of the optimal initial modality are best accomplished with a gradual approach involving a multidisciplinary team. Along with conservative measures discussed in the sections above, it is important to prepare patients with an intensive educational program, explaining the likelihood and timing of initiation of renal replacement therapy and the various forms of therapy available. The more knowledgeable that patients are about hemodialysis (both in-center and home-based), peritoneal dialysis, and kidney transplantation, the easier and more appropriate will be their decisions. Patients who are provided with educational programs are more likely to choose home-based dialysis therapy. This approach is of societal benefit because home-based therapy is less expensive and is associated with improved quality of life. The educational programs should be commenced no later than stage 4 CKD so that the patient has sufficient time and cognitive function to learn the important concepts, to make informed choices, and implement preparatory measures for renal replacement therapy .

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