Republic Of Yemen 3ed level

J. U. For Medical & Health sci.

Faculty Of Nursing Second term

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Chronic kidney disease (CKD):
• Chronic kidney disease (CKD), previously termed chronic renal failure, irreversible
deterioration in renal function ,develop over a period of years .
• Initially, manifest only as a biochemical abnormality, eventually, loss of the
excretory, metabolic and endocrine functions of the kidney leads to the symptoms
and signs of renal failure, collectively referred to as uraemia.
• When death is likely without renal replacement therapy (RRT) (CKD stage 5), it is
called end-stage renal disease or failure (ESRD or ESRF).

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The severity CKD is described by stages,
 first three also depend whether there is evidence of kidney damage, ((markers of
damage, abnormalities in blood , urine test e.g. proteinuria or imaging studies)):
1) Normal kidney function – GFR above 90mL/min/1.73m2 and no proteinuria
2) CKD1 – GFR above 90mL/ min/1.73m2 with evidence of kidney damage
3) CKD2 (Mild) – GFR 60 to 89 mL/ min/1.73 m2 with evidence of kidney damage
4) CKD3 (Moderate) – GFR of 30 to 59 mL/min/1.73m2
5) CKD4 (Severe) – GFR of 15 to 29 mL/ min/1.73m2
6) CKD5 Kidney failure (RRT , dialysis or kidney transplant needed) – GFR < 15
mL/min/1.73m2

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 Common causes of ESRD:

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 Clinical features of CKD:
 The typical presentation is a raised urea and creatinine found during routine tests,
hypertension, proteinuria or anaemia.
1. General symptoms
1) Most are asymptomatic until (stage 4 or 5) , symptoms and signs affect almost all
systems.
2) Nocturia(loss of concentrating ability).
3) Tiredness.
4) breathlessness, related to renal anemia and metabolic acidosis (Kussmaul’s
respiration).
5) Pruritus.
6) anorexia, nausea , vomiting , hiccups, weight loss, muscular twitching.
7) fits, drowsiness and coma.
2. Electrolyte abnormalities
1) Hyperkalaemia
2) Metabolic acidosis .
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3) Fluid retention is common in advanced CKD sometimes leading to pulmonary oedema.
2. Electrolyte abnormalities:
1) Hyperkalaemia
2) Metabolic acidosis .
3) Fluid retention is common in advanced CKD sometimes leading to pulmonary
oedema.

3. Immune dysfunction:
 Cellular and humoral immunity is impaired , increased susceptibility to
infections
4. Haematological:
• Increased bleeding tendency in advanced CKD, ecchymoses and mucosal bleeds.
• Platelet function is impaired.
• Anaemia is common. Haemoglobin can be as low as 50–70 g/L in CKD stage 5,
although it is often less severe or absent in patients with polycystic kidney
disease.
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5. Endocrine function:
 in both genders, there is loss of libido related, in part, to hypogonadism due
to hyperprolactinaemia
 Insulin resistance.
6. Neurological and muscle function:
 Myopathy occur due to poor nutrition, vitamin D deficiency
hyperparathyroidism, and electrolyte abnormalities.
 Muscle cramps are common. Clinical features of CKD (continued)
7. Cardiovascular disease:
 Left ventricular hypertrophy, secondary to hypertension.
 Pericarditis complicate untreated or inadequately treated ESRD ,cause
pericardial tamponade or constrictive pericarditis.
 Hyperphosphataemia contribute to the increased risk of CVD and itching.

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8. Metabolic bone disease:
 Disturbances of calcium and phosphate metabolism are almost universal in
advanced CKD, there is impaired conversion of 25- hydroxyvitamin D to its active
metabolite, 1, 25(OH)2D, due in part to tubular cell damage.
 The reduced 1,25(OH)2D levels impair intestinal absorption of calcium, causing
hypocalcaemia.

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 Causes of anaemia in CKD:

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 Physical signs in advanced chronic kidney disease. (*Features of renal
replacement therapy)

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 CKD investigations : to
A. Identify the underlying cause.
B. Identify reversible factors that may worsen renal function, such as hypertension, urinary
tract obstruction, nephrotoxic drugs, and salt and water depletion
C. Screen for complications, as anaemia and renal osteodystrophy
D. Screen for CV risk factors.

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 Management of CKD:
1. Dietary and lifestyle interventions:
 Protein 1.2-0.8( gm/kg/day)
 Salt 5<( gm/day)
 Fluid :According to urine output
 Fruit and juice restriction
 All patients should be advised to stop smoking , since there is evidence that this slows
the decline in renal function in addition to reducing cardiovascular risk.
 Exercise and weight loss may also reduce proteinuria and have beneficial effects on
cardiovascular risk profile.

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2. Control of hypertension( Goal – BP 80/120< mm Hg)
 Calcium channel blockers.
 β-blockers.
 α-blockers.
 Diuretics.
3. Control of proteinuria:
 ACE-I/ARB( Goal – proteinuria 0.3 < g 24/hours)
4. Control of diabetes mellitus
5. Treatment of dyslipidemia

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6. Treatment of complications:
1. Fluid overload :Diuretics
2. Hyperkalemia :Diuretics ,nebulization ,Ca ++gluconate
3. Metabolic acidosis :Sodium bicarbonate.
4. Renal osteodystrophy :Vit. D ,calcium carbonate
5. Anemia :Iron ,erythropoietin, blood transfusion.

7. Renal replacement therapy( RRT):

 Hemodialysis
 Peritoneal dialysis
 Kidney transplantationa

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 Management of CKD (continued)

 Haemodialysis (HD):
 Haemodialysis is the most common form of RRT in ESRD and is also used in AKI.
 Haemodialysis involves gaining access to the circulation, either through an arteriovenous
fistula, a central venous catheter or an arteriovenous shunt, (a Scribner shunt).
 The patient’s blood is pumped through a haemodialyser, which allows bidirectional
diffusion of solutes between blood and the dialysate across a semipermeable membrane
down a concentration gradient .
 Haemodialysis is usually carried out for 3–5 hours three times weekly, either at home or in
an outpatient dialysis unit.

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 Haemodialysis in CKD:
 Vascular access for is gained by formation of an AV fistula, usually in the forearm, up to a
year before dialysis is contemplated. After 4–6 weeks, increased pressure transmitted from
the artery to the vein causes distension and thickening of the vessel wall
(arterialisation).Large-bore needles can then be inserted into the vein to provide access for
haemodialysis.
 All patients must be screened for hepatitis B, C and HIV, and vaccinated against hepatitis B
if they are not immune.
 All dialysis units should have segregation facilities for hepatitis B-positive patients, given its
easy transmissibility. Patients with hepatitis C and HIV are less infectious and can be
treated satisfactorily using machine segregation and standard infection control measures.

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CKD- Indications for dialysis:
1. Uremic Pericarditis.

2. Uremic Encephalopathy or Neuropathy.

3. Pulmonary edema (unresponsive to diuretics).
4. Severe Hypertension.
5. Severe hyperkalemia.
6. Intractable acidosis.
7. Severe Bleeding diathesis.
8. Persistent gastrointestinal symptoms.

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Medical Complications during hemodialysis
 Common: hypotension , chest Pain , muscle cramps, nausea ,vomiting, headache,
itching, fever and chills .
 Serious complications:
1. Disequilibrium syndrome, Intracranial bleeding , seizures .
2. Arrhythmia , cardiac tamponade .
3. Hemolysis, air embolism .

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 Peritoneal dialysis
• Principally used in the treatment of CKD.
• It requires the insertion of a permanent Silastic catheter into the peritoneal cavity Two
types are in common use.
1. In continuous ambulatory PD(CAPD), about 2 litres of sterile, isotonic dialysis fluid are
introduced and left in place for approximately 4–6 hours.
• The fluid is then drained and fresh dialysis fluid introduced, in a continuous four-times-daily
cycle.
• Metabolic waste products diffuse from peritoneal capillaries into the dialysis fluid down a
concentration gradient.
• The fluid is then drained and fresh dialysis fluid introduced, in a continuous four-times-daily
cycle.
• The patient is mobile and able to undertake normal daily activities.

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 Peritoneal dialysis (continued)
2. Automated PD (APD) is similar to CAPD but uses amechanical device to perform
the fluid exchanges during the night, leaving the patient free, or with only a single
exchange to perform, during the day.
• is particularly useful in children, as a first treatment in adults with residual renal
function, and as a treatment for elderly patients with CV instability.
• The long-term use of peritoneal dialysis may be limited by episodes of bacterial
peritonitis and damage to the peritoneal membrane

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 Specific indications for peritoneal dialysis:
1. Patients with cardiovascular or hemodynamic instability
2. Vascular access failure or can not be created .
3. High risk of anticoagulation .
4. older age group (over 65) and small children .
5. Severe hemodialysis-related symptoms or disequilibrium .

 Contraindication for Peritoneal dialysis:

1. Pleuroperitoneal leak . Peritoneal fibrosis
2. Recent Abdominal and thoracic surgery .
3. Extensive Abdominal adhesions

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Renal transplantation:
 Offers the best chance of long-term survival in ESRD, and is the most cost-
effective treatment.
 Transplantation can restore normal kidney function and correct all the metabolic
abnormalities . but requires long-term immunosuppression with its attendant
risks .
 All ESRD patients should be considered for transplantation, unless there are
contraindications .Compatibility of ABO blood group between donor and
recipient is usually required and the degree of matching for major
histocompatibility (MHC) antigens, particularly HLA DR, influences the incidence
of rejection.

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