CKD

 Involves progressive, irreversible loss of
kidney function
 Defined as either presence of
• Kidney damage
 Pathological abnormalities
• Glomerular filtration rate (GFR)
 <60 ml/min for 3 months or longer
Complications
Increased Kidney CKD

Normal Damage  GFR
risk failure death
Screening CKD risk Diagnosis Estimate Replacement

for CKD reduction; & treatment; progression; by dialysis
risk factors Screening for Treat Treat & transplant
CKD comorbid complications;
conditions; Prepare for
Slow replacement
progression
Prevalence*
GFR
Stage Description N
(ml/min/1.73 m2) %
(1000s)
Kidney Damage with
1  90 5,900 3.3
Normal or  GFR
Kidney Damage with
2 60-89 5,300 3.0
Mild  GFR
3 Moderate  GFR 30-59 7,600 4.3
4 Severe  GFR 15-29 400 0.2
5 Kidney Failure < 15 or Dialysis 300 0.1
*Stages 1-4 from NHANES III (1988-1994). Population of 177 million with age 20. Stage 5 from USRDS (1998), includes
approximately 230,000 patients treated by dialysis, and assuming 70,000 additional patients not on dialysis. GFR estimated
from serum creatinine using MDRD Study equation based on age, gender, race and calibration for serum creatinine. For
Stage 1 and 2, kidney damage estimated by spot albumin-to-creatinine ratio 17 mg/g in men or 25 mg/g in women in two
measurements.
 Leading causes of ESRD
• Diabetes
• Hypertension
• Last stage of kidney failure

 End-stage renal disease (ESRD) occurs when GFR <15
ml/min
 Diabetes Mellitus  Family history of CKD
 Hypertension  Kidney Stones
 Cardiovascular  Infections like Hep C
Disease and HIV
 Obesity  Autoimmune diseases
 Metabolic Syndrome  Nephrotoxics like
 Age and Race NSAIDS
 Acute Kidney Injury
 Malignancy
 Uremia
• Syndrome that incorporates all signs and symptoms seen in various
systems throughout the body
Fig. 47-5
Urinary system
 Polyuria
• Results from inability of kidneys to
concentrate urine
• Occurs most often at night
• Specific gravity fixed around 1.010
 Oliguria
• Occurs as CKD worsens
 Anuria
• Urine output <40 ml per 24 hours
Metabolic disturbances
 Waste product accumulation
• As GFR ↓, BUN ↑ and serum creatinine levels ↑
 BUN ↑
 Not only by kidney failure but by protein intake, fever,
corticosteroids, and catabolism
 N/V, lethargy, fatigue, impaired thought processes, and
headaches occur
Electrolyte/acid–base imbalances
 Sodium
• May be normal or low
• Because of impaired excretion, sodium is retained
 Water is retained
 Edema
 Hypertension
 CHF
 Potassium
• Hyperkalemia
 Most serious electrolyte disorder in kidney disease
 Fatal dysrhythmias
Electrolyte/acid–base imbalances
 Calcium and phosphate alterations
 Magnesium alterations
 Metabolic acidosis
• Results from
 Inability of kidneys to excrete acid load (primary ammonia)
Hematologic system
 Anemia
• Due to ↓ production of erythropoietin
 From ↓ of functioning renal tubular cells
 Bleeding tendencies
• Defect in platelet function
 Infection
• Changes in leukocyte function
• Altered immune response and function
• Diminished inflammatory response
Cardiovascular system
 Hypertension
 Heart failure
 Left ventricular hypertrophy
 Peripheral edema
 Dysrhythmias
 Uremic pericarditis
Respiratory system
 Kussmaul respiration
 Dyspnea
 Pulmonary edema
 Uremic pleuritis
 Pleural effusion
 Predisposition to respiratory infections
 Depressed cough reflex
 “Uremic lung”
Gastrointestinal system
 Every part of GI is affected
• Due to excessive urea
 Mucosal ulcerations
 Stomatitis
 Uremic fetor (urinous odor of the breath)
 GI bleeding
 Anorexia
 N/V
Neurologic system
 Expected as renal failure progresses
• Attributed to
 Increased nitrogenous waste products
 Electrolyte imbalances
 Metabolic acidosis
 Demyelination of nerve fibers
 Altered mental ability
 Seizures and Coma
 Dialysis encephalopathy
 Peripheral neuropathy
Neurologic system
 Restless leg syndrome
 Muscle twitching
 Irritability
 Decreased ability to concentrate
Reproductive system
 Infertility
• Experienced by both sexes
 Decreased libido
 Low sperm counts
 Sexual dysfunction
Musculoskeletal system
 Renal osteodystrophy
• Syndrome of skeletal changes
• Result of alterations in calcium and phosphate
metabolism
 Weaken bones, increase fracture risk
• Two types associated with ESRD:
 Osteomalacia
 Osteitis fibrosa
Integumentary system
 Most noticeable change
• Yellow-gray discoloration of the skin
 Due to absorption/retention of urinary pigments
 Pruritus
 Uremic frost
 Dry, pale skin
 Dry, brittle hair
 Thin nails
 Petechiae
 Ecchymoses
Laboratory tests (cont’d)
• Urinalysis
• Urine culture
• Hematocrit
• Hemoglobin
• Urea
• Creatinine
 Renal ultrasound
 Renal scan
Drug therapy
• Hyperkalemia
 IV insulin and glucose
• IV 10% calcium gluconate
 Raises threshold for excitation
 Sodium bicarbonate
 Shift potassium into cells
 Correct acidosis
 Sodium polystyrene sulfonate (Kayexalate)
 Cation-exchange resin
 Resin in bowel exchanges potassium for sodium
 Evacuates potassium-rich stool from body
 Educate patient that diarrhea may occur due to
laxative in preparation
Drug therapy
 Hypertension (cont’d)
• Antihypertensive drugs
 Diuretics
 β-Adrenergic blockers
 Calcium channel blockers
 Angiotensin-converting enzyme (ACE)
inhibitors
 Angiotensin receptor blocker agents
Drug therapy
 Renal osteodystrophy
• Phosphate intake restricted to
<1000 mg/day
• Phosphate binders
 Calcium carbonate (Tums)
Bind phosphate in bowel and excreted
 Sevelamer hydrochloride (Renagel)
Lowers cholesterol and LDLs
Drug therapy
 Renal osteodystrophy (cont’d)
• Phosphate binders (cont’d)
 Should be administered with each meal
 Side effect: Constipation
• Supplementing vitamin D
 Calcitriol (Rocaltrol)
 Serum phosphate level must be lowered
before administering calcium or vitamin D
Drug therapy
 Renal osteodystrophy (cont’d)
• Controlling secondary hyperparathyroidism
 Calcimimetic agents
 Cinacalcet (Sensipar)
 ↑ Sensitivity of calcium receptors in parathyroid
glands
 Subtotal parathyroidectomy
Drug therapy
 Anemia
• Erythropoietin
 Epoetin alfa (Epogen, Procrit)
 Administered IV or subcutaneously
 Increased hemoglobin and hematocrit in
2 to 3 weeks
 Side effect: Hypertension
Drug therapy
 Anemia (cont’d)
• Iron supplements
 If plasma ferritin <100 ng/ml
 Side effect: Gastric irritation, constipation
 May make stool dark in color
• Folic acid supplements
 Needed for RBC formation
 Removed by dialysis
• Avoid blood transfusions
Drug therapy
 Complications
• Drug toxicity
 Digitalis
 Antibiotics
 Pain medication (Demerol, NSAIDs)
Nutritional therapy
 Protein restriction
• 0.6 to 0.8 g/kg body weight/day
 Water restriction
• Intake depends on daily urine output
Nutritional therapy
 Sodium restriction
• Diets vary from 2 to 4 g depending on
degree of edema and hypertension
• Sodium and salt should not be equated
• Patient should be instructed to avoid
high-sodium foods
• Salt substitutes should not be used because
they contain potassium chloride
Nutritional therapy
 Potassium restriction
• 2 to 4 g
• High-potassium foods should be
avoided
 Oranges
 Bananas
 Tomatoes
 Green vegetables
 Phosphate restriction
• 1000 mg/day
• Foods high in phosphate
 Dairy products
• Most foods high in phosphate are also high in
calcium
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CKD

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 Involves progressive, irreversible loss of

Increased Kidney CKD

Screening CKD risk Diagnosis Estimate Replacement

3 Moderate  GFR 30-59 7,600 4.3

4 Severe  GFR 15-29 400 0.2

5 Kidney Failure < 15 or Dialysis 300 0.1

• Last stage of kidney failure

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