Chronic kidney disease

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis. Chronic kidney disease is identified by a blood test for creatinine. Higher levels of creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products. Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).

Stage 1: normal; eGFR>90 ml/min/1.73 m with other evidence of chronic kidney damage (see below) 2 Stage 2: mild impairment; eGFR 60-89 ml/min/1.73 m with other evidence of chronic kidney damage 2 Stage 3a: moderate impairment; eGFR 45-59 ml/min/1.73 m 2 Stage 3b: moderate impairment; eGFR 30-44 ml/min/1.73 m 2 Stage 4: severe impairment; eGFR 15-29 ml/min/1.73 m 2 Stage 5: established renal failure (ERF); eGFR less than 15 ml/min/1.73 m or on dialysis

INCIDENCE
Do you know that End Stage Renal Disease is already the 7th leading cause of death among Filipinos? It is said that a Filipino is having the disease hourly or 120 Filipinos per million population per year. This shows that about 10, 000 Filipinos need to replace their kidney function. Unfortunately though only 73% or about 7, 267 patients received treatment. An estimate of about a quarter of the whole population probably just died without receiving any treatment. A large primary care study (practice population 162,113) suggests an age standardised prevalence of stage 3-5 chronic kidney disease (CKD) of 8.5% (10.6% in females and 5.8% in males). The incidence of CKD requiring dialysis varies worldwide: the number of patients per million population starting dialysis each year is 110 in the UK. The prevalence of end-stage renal failure also varies worldwide: the number of patients per million population in the UK is 498.

Etiology
The causes of chronic renal failure: Arteriopathic renal disease and hypertension Glomerulonephritis Diabetes Infective, obstructive and reflux nephropathies Familial or hereditary kidney disease, e.g. polycystic kidneys Hypercalcaemia Connective tissue diseases Neoplasms Myeloma

Pathophysiology
Modifiable Risk Factor -Smoking -Alcohol -Poor dental hygiene -Streptococcus virus -Unhealthy lifestyle(e.g. high salt diet) Non-modifiable Risk Factor -Family history of CKD, HPN, and DM -Age 40 and above -Premature baby -Race -Gender (females)

With loss of nephrons due to kidney damage, renal function is initially close to normal due to increased activity in the living nephrons. With loss of more nephrons, renal function decreases but the living nephrons will still be operating at max speed. This may cause abnormalities in:

Na secretion: impaired due to decreased GFR and leads to Na retention and edema and hypertension due to water retention.

Potassium (K) : similarly results in hyperkalemia.

H : similar mechanism (decreased urine acidification)

Acidosis

Wastes: accumulation of urotoxins

urotoxemia

nausea/vomiting

Stupor

Coma

DEATH

Assessment
Past Medical History
Diabetes Hypertension Over use of pain killers and allergic reaction to antibiotics Drug abuse Infection

Social history
drug abuse unhealthy lifestyle

Family History
Family history of kidney disease Premature birth Age 45 yrs old Trauma or accident Certain disease (e.g. DM,HPN)

History of Present illness

Two hours prior to admission the patient experience unexplained dizziness, sometimes with headache and insomnia three months ago and he also felt fatigue and would not feel better after rest.

Signs and Symptoms

Anemia decreased in erythropoietin and bleeding Hypertension Pruritus accumulation of waste products in the blood excreted in the skin. Neurologic manifestations because of uremic encephalopathy, hypocalcemia and elevated BUN Constipation because of the use of phosphate binders, immobility, fluid restrictions Fatigue because of anemia

Diagnostic Test/Procedure
Urinalysis: Analysis of the urine affords enormous insight into the function of the kidneys. Twentyfourhour urine tests: This test requires you to collect all of your urine for 24 consecutive hours. The urine may be analyzed for protein and waste products (urea nitrogen 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 level of kidney function and the glomerular filtration rate (GFR). Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function. As kidney disease progresses, GFR falls. The normal GFR is about 100140 mL/min in men and 85115 mL/min in women. It decreases in most people with age. The GFR may be calculated from the amount of waste products in the 24hour urine or by using special markers administered intravenously. Patients are divided into five stages of chronic kidney disease based on their GFR. Urine Specific Gravity This is a measure of how concentrated a urine sample is. A concentrated urine sample would have a specific gravity over 1.030 or 1.040

Blood tests Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum creatinine are the most commonly used blood tests to screen for, and monitor renal disease. Creatinine is a breakdown product of normal muscle breakdown. Urea is the waste product of breakdown of protein. The level of these substances rises in the blood as kidney function worsens. Electrolyte levels and acidbase balance: Kidney dysfunction causes imbalances in electrolytes, especially potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a particular concern. The acidbase balance of the blood is usually disrupted as well. Decreased production of the active form of vitamin D can cause low levels of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes its levels in the blood to rise. Blood cell counts: Because kidney disease disrupts blood cell production and shortens 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 their gastrointestinal system. Other nutritional deficiencies may also impair the production of red cells.

Other tests Ultrasound: Ultrasound is often used in the diagnosis of kidney disease. An ultrasound is a noninvasive type of test. In general, kidneys are shrunken in size in chronic kidney disease, although they may be normal or even large in size in cases caused by adult polycystic kidney disease, diabetic nephropathy, and amyloidosis. Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in cases in which the cause of the kidney disease is unclear. Usually, a biopsy can be collected with local anesthesia only by introducing a needle through the skin into the kidney.

Medical Management
I. Promote Fluid and Electrolyte and Acid Base Balance
A. Fluid Balance Monitor fluid volume status Weight most accurate indicator (daily) Input and Output monitoring Assessment of skin turgor and mucous membrane Fluid restrictions Amount of fluids to be taken per day (400 ml (insensible fluid loss) + previous days urine output. Moisten the lips, give ice chips Diuretic therapy Furosemide and Mannitol are often use

B. Electrolyte Balance 1. Hyperkalemia impaired potassium excretion; indication for dialysis; result from metabolic acidosis If there is Emergency Hyperkalemia give 50% dextrose and regular insulin Can give sodium bicarbonate for acidosis Client can be given with Sodium Polystyrene Sulfonate (Kayexalate) can be given with Sorbitol to promote evacuation; can be given orally or rectally Avoid salt substitutes

2. Hyponatremia restriction of fluids Fluid restrictions

3. Hypocalcemia decreased activation of Vit. D; hyperphosphatemia Calcium Carbonate, Calcium Lactate and Vitamin D Emergency Hypocalcemia give Calcium Gluconate IV

4. Hyperphosphatemia impaired excretion of Phosphate by the kidneys in the urine Phosphate binders they bind phosphate in the GI tract for excretion Aluminum hydroxide cause constipation so stool softener maybe given Aluminum Carbonate if use for a long period, this can caused dementia Calcium base phosphate binders excrete phosphorus but increased Ca. Calcium Carbonate Calcium Acetate

5. Hypermagnesemia impaired excretion of Magnesium by the kidneys Magnesium mainly excreted in the urine; seen in antacids or enemas Diuretic therapy Avoid magnesium containing antacids or enemas Emergence Hypermagnesemia Give Calcium Gluconate

C. Acid Base Balance Metabolic Acidosis Impaired hydrogen ion excretion Increased excretion of bicarbonate

Accumulation of urea, creatinine and uric acid Hyperkalemia Give Sodium Bicarbonate alkalinic meds Give Sodium Lactate alkalinic meds Give Shohls solution treatment of metabolic acidosis; caused stomatitis

II. Reserve Renal Function

Dopamine Hydrochloride to dilate renal arteries promoting renal perfusion Control of hypertension with the use of ACE inhibitors, diet and weight control

III. Optimal Nutrition

High CHO diet to spare CHON metabolism Low CHON diet but with essential amino acids (50 proteins); 50 mg/day Serve foods in small amount because of nausea, anorexia and stomatitis

IV. Improve Body Chemistry

Dialysis Hemodialysis Peritoneal dialysis Kidney Transplantation

Case Study On Chronic Kidney Disease

By: Lardel B. Laforteza BSN-lll To: Mr. Adonis Ferrer