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Case Study:

End-Stage Renal Disease


END-STAGE RENAL DISEASE
Definition and Statistics
Kidneys are important parts of the urinary system. They are found at each side of the
spine, below the rib cage. The kidneys perform life-maintaining functions as monitors and
regulators of body fluid. They excrete fluids when the body has an excess of them and
retain the substances necessary for the body’s continuing function. They produce and
release a variety of chemicals to keep the
body healthy and filter the entire blood
supply every two minutes, excreting waste
materials through the urine.
End-stage renal failure, also known as
end-stage renal disease (ESRD), is the
final, permanent stage of chronic kidney disease, where kidney function has declined to
the point that the kidneys can no longer function on their own. A patient with end-stage
renal failure must receive dialysis or kidney transplantation in order to survive for more
than a few weeks.
Kidney diseases, especially End Stage Renal Disease (ESRD), are already the 7th
leading cause of death among the Filipinos. One Filipino develops chronic renal failure
every hour or about 120 Filipinos per million populations per year. More than 5,000
Filipino patients are presently undergoing dialysis and approximately 1.1 million people
worldwide are on renal replacement therapy. Reliable estimates reveal that the number
of these patients will double in 2010.
The Department of Health (DOH) said close to 23,000 Filipinos underwent dialysis due
to kidney failure in 2013, nearly four times higher than the 4,000 cases recorded in 2004,
or a 10 to 15 percent increase a year.
In the past, chronic glomerulonephritis was the most common cause of chronic renal
failure. Today, diabetes mellitus and hypertension have taken center stage as the main
causes of ESRD, which together account for almost 60 percent of dialysis patients.
Affecting 10 percent of the global population and responsible for more than a million
deaths each year, chronic kidney disease (CKD) has become a major public health issue.
In the U.S. alone 30 million people, or 15 percent of adults, are estimated to have chronic
kidney disease. Around the world, the number of people with chronic kidney disease
continues to rise. The impact is immense; patients with CKD face diminished quality of
life, higher risk of other health problems, and significant financial costs or death.

Risk Factors & Symptoms


Risk factors include diabetes, hypertension, heart disease, smoking, obesity, high
cholesterol, family history of kidney disease, and age 65 or older. The most common
causes of kidney disease include diabetes and high blood pressure, but population growth
and aging are other factors driving
higher rates of CKD. CKD may
result due to infections,
inflammation, or urinary system
blockages such as kidney stones.
Painkillers, like analgesics or
antibiotics, also may cause
chronic kidney disease if taken
over a long period of time. Kidney disease affects people of all ages and races. African-
Americans, Hispanics, Native Americans, and people of South Asian origin have a higher
risk of CKD. This risk is due in part to high rates of diabetes and high blood pressure in
these communities. Chronic kidney disease can occur at any age, but becomes more
common with increasing age and is more common in women. Regardless of age or sex
– kidney disease is harmful. Many people die prematurely due to complications of the
disease, such as heart attack or stroke.
Chronic kidney disease (CKD) usually gets worse slowly, and symptoms may not
appear until the kidneys are badly damaged. In the late stages of CKD, as it’s nearing
kidney failure (ESRD), one may notice symptoms that are caused by waste and extra
fluid building up in your body.
The main symptom of kidney disorder is fluid retention or edema. Patients may have
puffiness around the eyes, swelling in the feet and legs and water in the lungs leading to
difficulty of breathing.
Any change in urination may also indicate kidney
problem. This may consist of pain or unusual
sensation during voiding, increased or decreased
frequency of urination, difficulty in initiating urination,
frequent urination at night, change in color of urine,
blood in the urine or bubbly appearance of the urine.
Kidney failure results in the retention of various
body wastes which cause anorexia, vomiting,
difficulty in sleeping and generalized body weakness.
This is often evaluated by measuring serum creatinine and blood urea nitrogen.
The presence of protein and red blood cells in the urine is also an indication of kidney
disorder. In glomerulonephritis, proteinuria and hematuria are commonly seen because
the glomeruli have become inflamed. Proteinuria is also the earliest manifestation of
diabetic nephropathy. Pallor and weakness are also among the indications of kidney
failure due to anemia secondary to low erythropoietin production by the failing kidneys.
Hypertension is also a major consequence of kidney disorder. Initial evaluation of all
newly diagnosed hypertensive patients should include serum creatinine and electrolyte
levels (sodium and potassium) particularly among young hypertensive subgroup.
Repeated urinary tract infections, back pain or pain in the lower abdomen may indicate
the presence of kidney stones and may also cause blood in the urine.

Diagnosis and Treatment


There is no cure for chronic kidney disease. However, if detected early, treatment can
help slow or halt the progression of the disease and can help prevent other serious
complications. Simple laboratory can detect chronic kidney disease. These include a
blood test to measure creatinine content and estimate Glomerular Filtration Rate (GFR),
or kidney function, and a urine test (ACR for Albumin to Creatinine Ratio), which
measures albumin, a type of protein in the urine. Elevated albumin is one of the earliest
signs of kidney disease. Early detection of failing kidney function is critical to allow
treatment before irreversible damage or other complications occur. The best hope for
reducing the human and economic costs of CKD lies in awareness, and prevention
through management of risk factors and early detection.
Because kidney failure is already irreversible at later stages, treatment focuses on
controlling the symptoms, minimizing complications and slowing the progression of the
disease. Associated diseases that cause or result from chronic renal failure must be
controlled. Hypertension, diabetes, congestive heart failure, UTI, kidney stones,
obstructions of the urinary tract, glomerulonephritis, and other disorders should be treated
appropriately. Medications such as iron supplements and erythropoietin injections may
be needed to control anemia. Blood transfusion may be given but they are less preferred.
Fluid intake may be restricted, often to an amount equal to the volume of urine
produced. Dietary protein restriction may slow the build-up of wastes in the bloodstream
and control associated symptoms such as nausea and vomiting. Salt, potassium,
phosphorus and other electrolytes may be restricted.
However, Dialysis and kidney transplantation may be required eventually when end stage
renal disease ensues or when 85-90 percent of kidney function is lost.
Hemodialysis uses a special filter called a
dialyzer that functions as an artificial kidney to
clean the blood. During treatment, blood
travels through the tubes into the dialyzer
which filters out wastes and extra water. Then
the cleaned blood flows through another set of
tubes back into the body. The dialyzer is
connected to the machine that monitors blood
flow and removes wastes from the blood.
Hemodialysis is usually performed 2 to 3 times
a week. Each treatment last for 4 hours.
Peritoneal dialysis is another procedure that removes extra water and wastes from the
body. This type of dialysis uses the lining of the abdomen to filter the blood. This lining is
called the peritoneal membrane and acts as the artificial kidney. A mixture of minerals
and sugar dissolved in water called dialysis
solution travels through a soft tube into the
abdomen. The sugar, called dextrose,
draws wastes, chemical and extra water
from the tiny blood vessels in the peritoneal
membrane into the dialysis solution. After
several hours, the used solution is drained
from the abdomen through the tube, taking
the wastes from the blood with it. Then the
patient fills his abdomen with fresh dialysis
solution and the cycle is repeated usually 3 to 4 times a day. Each cycle is called an
exchange.
Kidney transplantation surgically places a healthy kidney from another person into
the body of the patient with end stage renal disease. The donated kidney does the work
that the 2 failed kidneys used to do. It is generally not necessary to remove the diseased
kidneys. A donated kidney may come from an anonymous donor who has recently died
or from a living person usually relative. The kidney that the patient receives must be a
good match for his body. The more the new kidney is like his own, the less likely will his
immune system reject it. The patient will be made to take special drugs called
immunosuppressive to help trick his immune system so it would not reject the
transplanted kidney.

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