DEFINITION AND DESCRIPTION OF CHRONIC KIDNEY DISEASE Chronic kidney disease occurs when one suffers from gradual

and usually permanent loss of kidney function over time. This happens gradually, usually months to years. Chronic kidney disease is divided into five stages of increasing severity The term "renal" refers to the kidney, so another name for kidney failure is "renal failure." Mild kidney disease is often called renal insufficiency. With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney. Loss of kidney function also causes other problems such as anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and fatty acids, and bone disease. Stage 5 chronic kidney disease is also referred to as kidney failure, end-stage kidney disease, or end-stage renal disease, wherein there is total or near-total loss of kidney function. There is dangerous accumulation of water, waste, and toxic substances, and most individuals in this stage of kidney disease need dialysis or transplantation to stay alive. Unlike chronic kidney disease, acute kidney failure develops rapidly, over days or weeks.

Acute kidney failure usually develops in response to a disorder that directly affects the kidney, its blood supply, or urine flow from it. Acute kidney failure is often reversible, with complete recovery of kidney function. Some patients are left with residual damage and can have a progressive decline in kidney function in the future. Others may develop irreversible kidney failure after an acute injury and remain dialysisdependent.

Stages of Chronic Kidney Disease Stage 1 2 3 4 5 Description Slight kidney damage with normal or increased filtration Mild decrease in kidney function Moderate decrease in kidney function Severe decrease in kidney function Kidney failure GFR* mL/min/1.73m2 More than 90 60-89 30-59 15-29 Less than 15 (or dialysis)

*GFR is glomerular filtration rate, a measure of the kidney's function.

Chronic Kidney Disease Symptoms The kidneys are remarkable in their ability to compensate for problems in their function. That is why chronic kidney disease may progress without symptoms for a long time until only very minimal kidney function is left. Because the kidneys perform so many functions for the body, kidney disease can affect the body in a large number of different ways. Symptoms vary greatly. Several different body systems may be affected. Notably, most patients have no decrease in urine output even with very advanced chronic kidney disease. Effects and symptoms of chronic kidney disease include;

need to urinate frequently, especially at night (nocturia); swelling of the legs and puffiness around the eyes (fluid retention); high blood pressure; fatigue and weakness (from anemia or accumulation of waste products in the body); loss of appetite, nausea and vomiting; itching, easy bruising, and pale skin (from anemia); shortness of breath from fluid accumulation in the lungs; headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep, altered mental status (encephalopathy from the accumulation of waste products or uremic poisons), and restless legs syndrome; chest pain due to pericarditis (inflammation around the heart); bleeding (due to poor blood clotting); bone pain and fractures; and decreased sexual interest and erectile dysfunction.

ANATOMY AND PHYSIOLOGY OF KIDNEY The kidneys are a pair of bean-shaped organs that lie on either side of the spine in the lower middle of the back. Each kidney weighs about pound and contains approximately one million filtering units called nephrons. Each nephron is made of a glomerulus and a tubule. The glomerulus is a miniature filtering or sieving device while the tubule is a tiny tube like structure attached to the glomerulus. The kidneys are connected to the urinary bladder by tubes called ureters. Urine is stored in the urinary bladder until the bladder is emptied by urinating. The bladder is connected to the outside of the body by another tube like structure called the urethra.

The main function of the kidneys is to remove waste products and excess water from the blood. The kidneys process about 200 liters of blood every day and produce about two liters of urine. The waste products are generated from normal metabolic processes including the breakdown of active tissues, ingested foods, and other substances. The kidneys allow consumption of a variety of foods, drugs, vitamins and supplements, additives, and excess fluids without worry that toxic by-products will build up to harmful levels. The kidney also plays a major role in regulating levels of various minerals such as calcium, sodium, and potassium in the blood.

As the first step in filtration, blood is delivered into the glomeruli by microscopic leaky blood vessels called capillaries. Here, blood is filtered of waste products and fluid while red blood cells, proteins, and large molecules are retained in the capillaries. In addition to wastes, some useful substances are also filtered out. The filtrate collects in a sac called Bowman's capsule. The tubules are the next step in the filtration process. The tubules are lined with highly functional cells which process the filtrate, reabsorbing water and chemicals useful to the body while secreting some additional waste products into the tubule.

The kidneys also produce certain hormones that have important functions in the body, including the following:

Active form of vitamin D (calcitriol or 1,25 dihydroxy-vitamin D), which regulates absorption of calcium and phosphorus from foods, promoting formation of strong bone. Erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells. Renin, which regulates blood volume and blood pressure.

PATHOPHYSIOLOGY: CHRONIC KIDNEY DISEASE SECONDARY TO DIABETES MELLITUS NEPHROPATHY

Insulin resistance

Polyphagia Polydipsia

Diabetes Mellitus Type 2 Blood Viscosity

Polyuria

Blood vessel walls thicken, sclerose and become occluded by plaque that adheres to blood vessel walls (Atherosclerosis) Hypertension Blockage in blood flow Bilateral obstruction of renal arteries or veins Untreated disease Nephropathy Chronic Kidney Disease Glomerular Filtration Rate: > 15 mL/min/1.73m2

Non-functioning glomeruli Increased BUN and Creatinine Levels Accumulation of nitrogenous wastes in the blood (Uremia) Inability of kidney tubules to excrete ammonia and reabsorb bicarbonate Decreased acid secretion Metabolic Acidosis Decreased Erythropoietin

Profound Anemia Decreased oxygen supply Fatigue

MEDICAL & SURGICAL TREATMENT Medical Treatment There is no cure for chronic kidney disease. The four goals of therapy are to: 1. slow the progression of disease; 2. treat underlying causes and contributing factors; 3. treat complications of disease; and 4. replace lost kidney function. Strategies for slowing progression and treating conditions underlying chronic kidney disease include the following:

Control of blood glucose: Maintaining good control of diabetes is critical. People with diabetes who do not control their blood glucose have a much higher risk of all complications of diabetes, including chronic kidney disease. Control of high blood pressure: This also slows progression of chronic kidney disease. It is recommended to keep your blood pressure below 130/80 mm Hg if you have kidney disease. It is often useful to monitor blood pressure at home. Blood pressure medications known as angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) have special benefit in protecting the kidneys. Diet: Diet control is essential to slowing progression of chronic kidney disease and should be done in close consultation with your health care practitioner and a dietitian. For some general guidelines, see the Self-Care at Home section of this article.

The complications of chronic kidney disease require medical treatment.

Anemia can be treated with erythropoiesis stimulating agents such as erythropoietin. Erythropoiesis stimulating agents are a group of drugs that replace the deficiency of erythropoietin, which is normally produced by healthy kidneys. Often, patients treated with such drugs require iron supplements (FeSO4) by mouth. Acidosis develops with kidney disease. The acidosis may cause breakdown of proteins, inflammation, and bone disease. If the acidosis is significant, doctor prescribes drugs such as sodium bicarbonate (NaHCO3 or baking soda) to correct the problem. Hypertension is one of the main causes of kidney disease that is usually developed with Diabetes Mellitus. Patient was prescribed with antihypertensive drugs such as Amlodipine and Clonidine to control the blood pressure as well as to promote vasodilation thus, increasing blood flow to the body.

Hypercholesterolemia or increase in cholesterol level in the body frequently cases the blood vessels to block due to its accumulation in arteries or veins. For this condition, the patient is given Simvastatin to control high level of cholesterol and to prevent further blockage and sclerosis of blood vessels that may lead to damage of vital organs. Pain and inflammation is associated w/ kidney disorder. Patient may usually report pain that disrupts the normal functioning. For this, the patient is given Aspirin to alleviate pain and discomfort. Gastrointestinal irritability frequently occurs due to the adverse effects of other medications that is taken by the patient. To prevent this from recurring that leads to poor compliance, the patient is prescribed Ranitidine that reduces acid secretion.

Surgical Treatment A vascular access is required for hemodialysis so that blood can be moved through the dialysis filter at rapid speeds to allow clearing of the wastes, toxins, and excess fluid. There are three different types of vascular accesses: arteriovenous fistula (AVF), arteriovenous graft, and central venous catheters. First, the patient has undergone the insertion of Central venous catheter: A catheter may be that is temporary. These catheters are either placed in the patients neck into a large blood vessel. While these catheters provide an immediate access for dialysis, they are prone to infection and may also cause blood vessels to clot or narrow. Ideally, while the patient is having a central venous catheter, he must undergo surgery fro the creation of Arteriovenous fistula (AVF): The preferred access for hemodialysis, wherein an artery is directly joined to a vein. The vein takes two to four months to enlarge and mature before it can be used for dialysis. Once matured, two needles are placed into the vein for dialysis. One needle is used to draw blood and run through the dialysis machine. The second needle is to return the cleansed blood. AVFs are less likely to get infected or develop clots than any other types of dialysis access. Renal Replacement Therapies In end-stage kidney disease, kidney functions can be replaced only by dialysis or by kidney transplantation. The planning for dialysis and transplantation is usually started in Stage 4 of chronic kidney disease. The physician considered multiple factors when recommending the appropriate point to start dialysis, including laboratory work and actual or estimated glomerular filtration rate, nutritional status, fluid volume status, the presence of symptoms compatible with advanced kidney failure, and risk of future complications. Dialysis is usually started before individuals are very symptomatic or at risk for life-threatening complications.

Since the patient is diagnosed with Chronic Kidney Disease Stage 5, the patient is subject for kidney transplantation. But due to the high incidence of organ rejection and high cost of kidney transplantation, the patient decided to have hemodialysis. Hemodialysis Hemodialysis involves circulation of blood through a filter or dialyzer on a dialysis machine.

The dialyzer has two fluid compartments and is configured with bundles of hollow fiber capillary tubes. Blood in the first compartment is pumped along one side of a semipermeable membrane, while dialysate (the fluid that is used to cleanse the blood) is pumped along the other side, in a separate compartment, in the opposite direction. Concentration gradients of substances between blood and dialysate lead to desired changes in the blood composition, such as a reduction in waste products (urea nitrogen and creatinine); a correction of acid levels; and equilibration of various mineral levels. Excess water is also removed. The blood is then returned to the body.

Drug Name & Classification FOLIC ACID Classification: Hemopoetic vitamin

Indication & Dosage Folate deficiency due to inadequate intake, absorption or utilization, or increased excretion Kidney disease Dosage: 0.8mg/ tab OD

Therapeutic Action Stimulates normal erythropoiesis and nucleoprotein synthesis.

Adverse Reaction CNS: altered sleep pattern, general malaise, difficulty concentrating, confusion, irritability GI: anorexia, bitter taste, flatulence Skin: allergic reactions including rash, pruritus and eryhthema.

Contraindication Contraindicated in patients undiagnosed with anemia (it may mask pernicious anemia) and in those with vitamin B12 deficiency.

Nursing Consideration Protest drug from light and heat; store at room temperature.

Patient Teaching Teach patient about proper nutrition to prevent severity of anemia Stress importance of follow- up visits and laboratory studies Teach patient about foods that contain folic acid: liver, oranges, whole meat, and broccoli.

Drug Name & Classification

Indication & Dosage

Therapeutic Action Competitively inhibits action of histamine on the H2 receptor sites of parietal cells, decreasing gastric acid secretion.

Adverse Reaction CNS: vertigo, malaise, headache EENT: blurred vision Other: burning and itching, anaphylaxis

Contraindication

Nursing Consideration

Patient Teaching Instruct patient to take drug without regard to meals because absorption is not affected by food. Advise patient to report abdominal pain and blood in stool or emesis.

RANITIDINE For HYDROCHOLORIDE prophylaxis of GI hemorrhage Classification: from stress Hstamine H2 Receptor ulcer and in patients at risk Antagonist of acid aspiration. Dosage: 150mg/ tab TID

Adjust dosage in Assess for patient with renal abdominal pain. dysfunction. Note presence of blood in emesis, stool or gastric aspirate.

Drug Name & Classification CLONIDINE Classification: Antihypertensive drug

Indication & Dosage Hypertension

Therapeutic Action Unknown. Thought to stimulate alpha 2 receptors and inhibit central vasomotor centers, decreasing sympathetic out flow to the heart and peripheral vasculature and lowering peripheral vascular resistance, blood pressure and heart rate.

Adverse Reaction CNS: fatigue, weakness, agitation CV: orthostatic hypotension GI: dry mouth, nausea, vomiting Skin: dry skin, rash

Contraindication Use cautiously in patients with severe vascular disease and chronic renal failure.

Nursing Consideration Drug may be given to lower blood pressure rapidly in some hypertensive emergencies. Monitor blood pressure and pulse rate frequently. Dosage is usually adjusted to patients BP and tolerance.

Patient Teaching Instruct patient to take drug exactly as prescribed. Advise patient that stopping drug may cause severe rebound high blood pressure. Tell patient to take last dose immediately before bedtime Advise patient to avoid sudden position changes.

Drug Name &

Indication &

Therapeutic

Adverse

Contraindication

Nursing

Patient

Classification AMLODIPINE

Dosage Hypertension

Action Inhibits calcium ion influx across cardiac and smooth- muscle contractility and oxygen demand; also dilates coronary arteries and arterioles.

Reaction CNS: headache, fatigue, dizziness CV: flushing, palpitation GI: nausea, abdominal pain Musculoskeletal: muscle pain Skin: rash, pruritus Contraindicated to patients hypersensitive to drug.

Consideration Monitor patient carefully. Monitor blood pressure frequently during initiation of therapy. Notify prescriber if signs of heart failure occur, such as hand or feet swelling and shortness of breath.

Teaching Caution patient to continue taking drug even after feeling well.

Classification: Dosage: 80 mg/ Antihypertensive tab TID drug

Assessment

Nursing Diagnosis

Planning

Nursing

Rationale

Evaluation

Intervention Subjective Data: Nilalamig ako. Pahingi ng kumot. As verbalized by the patient. Objective Data: Temp: 35.1 C PR:82 bpm RR: 30 bpm BP: 120/ 80 mmHg Patient is currently on hemodialysis Patient presents chilling Ineffective thermoregulation related to effect of hemodialysis as manifested by temperature of 35.1 C and chilling Af