Chronic Kidney Diseases

Introduction
The incidence of chronic renal failure (CRF), and its consequence, end
stage renal disease (ESRD), is increasing throughout both the western and
developing worlds. As economies develop there is a corresponding increase in
access to, and demand for, health care and health care technologies. The World
Foundation for Renal Care estimated that by the year 2020 over 1 million people
would be required to provide care for the approximate 1.4 million people receiving
dialysis, and the approximate 1.2 million with functioning transplants. A daunting
proposition! As renal function declines, the person with CRF or ESRD eventually
experiences involvement of all body systems. Quality of life is altered and major
adjustment in physical, social and psychological aspects of life are required.
Nurses face a variety of challenges when caring for these patients whether the
person chooses to undergo treatment or to allow the natural progression of the
disease to cause their death.

Definition

1. CRF is a slow, progressive, irreversible loss in kidney function, with a GFR less
than or equal to 60 mL/min for 3 months or longer.

2. It occurs in stages and results in uremia or end stage renal disease (Table 62-1).

3. Hypervolemia can occur because of the kidneys’ inability to excrete sodium and
water; hypovolemia can occur because of the kidneys’ inability to conserve sodium
and water.

Alert : Chronic renal failure affects all major body systems and requires
dialysis or kidney transplantation to maintain life.
Causes of CRF

1. May follow ARF

2. Diabetes mellitus and other metabolic disorders

3. Hypertension

4. Chronic urinary obstruction

5. Recurrent infections

6. Renal artery occlusion

7. Autoimmune disorders

Clinical Manifestations

1.Assess body systems for the manifestations of CRF.

Neurological Manifestations
Asterixis
Ataxia (alteration in gait)
Coma
Inability to concentrate or decreased attention span
Lethargy and daytime drowsiness
Myoclonus
Paresthesias
Seizures
Slurred speech
Tremors, twitching, or jerky movements

Cardiovascular Manifestations
Cardiac tamponade
Cardiomyopathy
Heart failure
Hypertension
Pericardial effusion
Pericardial friction rub
Peripheral edema
Uremic pericarditis
Respiratory Manifestations
Crackles
Deep sighing, yawning
Depressed cough reflex
Kussmaul’s respirations
Pleural effusion
Pulmonary edema
Shortness of breath
Tachypnea
Uremic halitosis
Uremic pneumonia

Hematological Manifestations
Abnormal bleeding and bruising
Anemia
Gastrointestinal Manifestations
Anorexia ,Changes in taste acuity and sensation

Constipation
Diarrhea
Metallic taste in the mouth
Nausea
Stomatitis
Uremic colitis (diarrhea)
Uremic fetor
Uremic gastritis (possible gastrointestinal bleeding)
Vomiting
Urinary Manifestations
Diluted, straw-colored appearance
Hematuria
Oliguria, anuria (later)
Polyuria, nocturia (early)
Proteinuria

Integumentary Manifestations
Decreased skin turgor
Dry skin
Ecchymosis
Pruritus
Purpura
Soft tissue calcifications
Uremic frost (late, premorbid)
Yellow-gray pallor
Musculoskeletal Manifestations
Bone pain
Muscle weakness and cramping
Pathological fractures
Renal osteodystrophy
Reproductive Manifestations
Decreased fertility
Decreased libido
Impotence
Infrequent or absent menses

2. Assess psychological changes, which could include emotional lability,

withdrawal, depression, anxiety, suicidal behavior, denial, dependence-
independence conflict, and changes in body image.

Interventions

1. Same as the interventions for ARF

2. Administer a prescribed diet, which is usually a moderate-protein (to decrease

the workload on the kidneys) and high-carbohydrate, low potassium, and low-
phosphorus diet.

3. Provide oral care to prevent stomatitis and reduce discomfort from mouth sores.

4. Provide skin care to prevent pruritus.

5. Teach the client about fluid and dietary restrictions and the importance of daily
weights.

6. Provide support to promote acceptance of the chronic illness and prepare the
client for long term dialysis and transplantation, or explain to the client about his or
her choice to decline dialysis or transplantation.
Special problems in renal failure and interventions

Activity intolerance and insomnia Anemia

Gastrointestinal bleeding Hyperkalemia
Hypermagnesemia Hyperphosphatemia
Hypertension Hypervolemia
Hypocalcemia Hypovolemia

Infection Metabolic acidosis

Muscle cramps Neurological changes
Ocular irritation Potential for injury
Pruritus Psychosocial problems

1. Activity intolerance and insomnia

a. Fatigue results from anemia and the buildup

of wastes from the diseased kidneys.

b. Provide adequate rest periods.

c. Teach the client to plan activities to avoid fatigue.

d. Administer mild central nervous system depressants as prescribed to promote

rest.

2. Anemia

a. Anemia results from the decreased secretion of erythropoietin by damaged

nephrons resulting in decreased production of red blood cells.

b. Monitor for decreased hemoglobin and hematocrit levels.

c. Administer epoetin alfa (Epogen, Procrit) or darbepoetin alfa (Aranesp),
hematopoietics, as prescribed to promote maturity of the red blood cells.

d. Administer folic acid (vitamin B9) as prescribed.

e. Administer iron orally as prescribed, but not at the same time as phosphate
binders.

f. Administer stool softeners as prescribed because of the constipating effects of

iron.

g. Note that oral iron is notwell absorbed by the gastrointestinal tract in CRF and
causes nausea and vomiting; parenteral iron (iron sucrose [Venofer] or sodium
ferric gluconate complex [Ferrlecit]) may be used if iron deficiencies persist
despite folic acid or oral iron administration.

h. Administer blood transfusions if prescribed; blood transfusions are prescribed

only when necessary (acute blood loss, symptomatic anemia) because they
decrease the stimulus to produce red blood cells; note that certain clients’ religious
beliefs (e.g., Jehovah’s Witness) may refuse blood and blood products.

i. Blood transfusions also cause the development of antibodies against human

tissues, which can make matching for organ transplantation difficult.

3. Gastrointestinal bleeding

a. Urea is broken down by the intestinal bacteria to ammonia; ammonia irritates the
gastrointestinal mucosa, causing ulceration and bleeding.

b. Monitor for decreasing hemoglobin and hematocrit levels.

c. Monitor stools for occult blood.
d. Instruct the client to use a soft toothbrush.
e. Avoid the administration of acetylsalicylic acid (aspirin) because it is excreted
by the kidneys; if administered, aspirin toxicity can occur and prolong the bleeding
time.
4. Hyperkalemia
a. Monitor vital signs for hypertension or hypotension and the apical heart rate; an
irregular heart rate could indicate dysrhythmias.
b. Monitor the serum potassium level; an elevated serum potassium level can cause
tall, peaked T waves, flat P waves, a widened QRS complex, and a prolonged PR
interval; decreased cardiac output; heart blocks; fibrillation; or a systole .
c. Provide a low-potassium diet, avoiding foods high in potassium .
d. Administer electrolyte-binding and electrolyte excreting medications such as
oral or rectal sodium polystyrene sulfonate (Kayexalate) as prescribed to lower the
serum potassium level.
e. Administer prescribed medications: 50% dextrose and insulin may be prescribed
to shift potassium into the cell; calcium gluconate IV may be prescribed to reduce
myocardial irritability from hyperkalemia; and sodium bicarbonate IV may be
prescribed to correct acidosis.
f. Administer prescribed loop diuretics to excrete potassium.
g. Avoid potassium-sparing medications such as spironolactone (Aldactone) and
triamterene (Dyrenium) because these medications will increase the potassium
level.
h. Prepare the client for peritoneal dialysis or hemodialysis as prescribed.
5. Hypermagnesemia
a. Results from decreased renal excretion of magnesium.
b. Monitor for cardiac manifestations such as bradycardia, peripheral vasodilation,
and hypotension.
c. Monitor central nervous system (CNS) manifestations of decreased nerve
impulse transmission, such as drowsiness or lethargy.
d. Monitor neuromuscular manifestations, such as reduced or absent deep tendon
reflexes or weak or absent voluntary skeletal muscle contractions.
e. Administer loop diuretics as prescribed, such as furosemide (Lasix).
f. Administer calcium as prescribed for resulting cardiac problems.
g. Avoid medications that contain magnesium, such as antacids, laxatives, or
enemas.
h. During severe elevations, avoid foods that increase magnesium levels.
6. Hyperphosphatemia
a. As the phosphorus level rises, the calcium level drops; this leads to the
stimulation of parathyroid hormone, causing bone demineralization.
b. Treatment is aimed at lowering the serum phosphorus level.
c. Administer phosphate binders such as calcium carbonate (TUMS), calcium
acetate (PhosLo), or sevelamer (Renagel) as prescribed with meals to lower serum
phosphate levels.
d. Avoid the use of aluminum hydroxide preparations to bind phosphates because
they are associated with dementia and osteomalacia.
e. Administer stool softeners and laxatives as prescribed because phosphate binders
are constipating.
f. Teach the client about the need to limit the intake of foods high in phosphorus
7. Hypertension
a. Caused by failure of the kidneys to maintain BP homeostasis
b. Monitor vital signs for elevated blood pressure.
c. Maintain fluid and sodium restrictions as prescribed.
d. Administer diuretics and antihypertensives as prescribed.
e. Administer propranolol (Inderal), a bblocker, as prescribed; propranolol
decreases renin release (renin causes vasoconstriction and subsequent
hypertension).
8. Hypervolemia
a. Monitor vital signs for an elevated blood pressure.
b. Monitor intake and output and daily weight for indications of fluid retention.
c. Monitor for periorbital, sacral, and peripheral edema.
d. Monitor the serum electrolyte levels.
e. Monitor for hypertension and notify the health care provider for sustained
elevations.
f. Monitor for signs of CHF and pulmonary edema, such as restlessness,
heightened anxiety, tachycardia, dyspnea, basilar lung crackles, and blood-tinged
sputum; notify the physician immediately if signs occur.
g. Maintain fluid restriction.
h. Avoid the administration of large amounts of IV fluids.
i. Administer diuretics such as furosemide (Lasix) as prescribed.
j. Teach the client to maintain a low-sodium diet.
k. Teach the client to avoid antacids, cold remedies, or other products containing
sodium bicarbonate.
9. Hypocalcemia
a. Results from the high phosphorus level and the inability of the diseased kidney
to activate vitamin D
b. The absence of vitamin D causes poor calcium absorption from the intestinal
tract.
c. Monitor the serum calcium level.
d. Administer calcium supplements as prescribed.
e. Administer activated vitamin D as prescribed.
10. Hypovolemia
a. Monitor the vital signs for hypotension and tachycardia.
b. Monitor for decreasing intake and output and a reduction in the daily weight.
c. Monitor for dehydration.
d. Monitor electrolyte levels.
e. Provide replacement therapy based on the serum electrolyte level values.
f. Provide sodium supplements as prescribed, based on the serum electrolyte level.
11. Infection
a. The client is at risk for infection caused by a suppressed immune system,
dialysis access site, and possible malnutrition.
b. Monitor for signs of infection.
c. Avoid urinary catheters when possible; if used, provide catheter care.
d. Provide strict asepsis during urinary catheter insertion and other invasive
procedures.
e. Instruct the client to avoid fatigue, which decreases body resistance.
f. Instruct the client to avoid persons with infections.
g. Administer antibiotics as prescribed, monitoring for nephrotoxic effects.
12. Metabolic acidosis
a. The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate,
resulting in acidosis.
b. Administer alkalizers such as sodium bicarbonate as prescribed.
c. Note that clients with CRF adjust to low bicarbonate levels and as a result do not
become acutely ill.
13. Muscle cramps
a. Occur from electrolyte imbalances and the effects of uremia on peripheral nerves
b. Monitor serum electrolyte levels.
c. Administer electrolyte replacements and medications to control muscle cramps
as prescribed.
d. Administer heat and massage as prescribed.
14. Neurological changes
a. The buildup of active particles and fluids causes changes in the brain cells and
leads to confusion and impairment in decision making ability.
b. Peripheral neuropathy results from the effects of uremia on peripheral nerves.
c. Monitor the level of consciousness and for confusion.
d. Monitor for restless leg syndrome, which is also common during dialysis
treatments.
e. Teach the client to examine areas of decreased sensation for signs of injury.
15. Ocular irritation
a. Calcium deposits in the conjunctivae cause burning and watering of the eyes.
b. Administer medications to control the calcium and phosphate levels as
prescribed.
c. Administer lubricating eye drops.
d. Protect the client from injury.
e. Provide a safe and hazard-free environment.
f. Use side rails as needed.
16. Potential for injury
a. The client is at risk for fractures caused by alterations in the absorption of
calcium, excretion of phosphate, and vitamin D metabolism.
b. Provide for a safe environment.
c. Avoid injury; tissue breakdown causes increased serum potassium levels.
17. Pruritus
a. To rid the body of excess wastes, urate crystals are excreted through the skin,
causing pruritus.
b. The deposit of urate crystals (uremic frost) occurs in advanced stages of renal
failure.
c. Monitor for skin breakdown, rash, and uremic frost.
d. Provide meticulous skin care and oral hygiene.
e. Avoid the use of soaps.
f. Administer antihistamines and anti pruritics as prescribed to relieve itching.
g. Teach the client to keep the nails trimmed to prevent local infection from
scratching.
18. Psychosocial problems
a. Listen to the client’s concerns to determine how the client is handling the
situation.
b. Allow the client time to mourn the loss of kidney function.
c. With client permission, include the family members in discussions of the client’s
concerns.
d. Provide education about treatment options and support their decision.
e. Offer information about support groups.
f. Provide end-of-life care for the client with end-stage renal disease.

Alert: Place the client with renal failure on continuous cardiac monitoring.
The client can develop hyperkalemia resulting in the risk for dysrhythmias.
Dr. Adel H. Midhin