Chronic Kidney Disease

Robin E. Roberts, RN BSN CEN LP

Adapted from:
Lewis, S., Dirksen, S., Heikemper, M., & Bucher, L. (2014) Medical-surgical
nursing: Clinical management for positive outcomes (9th ed.) St. Louis, Mosby.
pp. 1107-1129.

1. Chronic Kidney Disease:

Chronic Kidney Disease (CKD) involves progressive,
irreversible loss of kidney function.
More common than AKI (Acute Kidney Injury)
CKD is defined by:
Presence of kidney damage
GFR less than 60ml/min/1.75m2 for longer than 3
months
May not be recognized until considerable damage
has occurred
o Due to subtle symptoms of onset
2. CKD is classified by stages of severity: 1-5
(see table 47-6)
Stage V: End-stage kidney disease (ESKD)
Defined by a glomerular filtration rate (GFR) less
than 15ml/min.
Dialysis or transplant required to maintain life
Associated with high mortality rate
o 19%-24% of dialysis patients with ESKD
die/year
3. Causes of CKD
Diabetes (50%)
Hypertension (25%)
Other causes:
o Glomerulonephritis
o Cystic diseases
o Urologic diseases
The increasing prevalence of chronic kidney disease has been partially
attributed to the increase in risk factors: aging population, rise in
obesity, increased incidence of diabetes and hypertension. Ethnic
minorities (African Americans and Native Americans) are at increased
risk.

4. Clinical Manifestations
All body systems are affected
A result of retained substances
o Urea
o Creatinine
o Phenols
o Hormones
o Electrolytes
o Water
Typically occurs when the GFR is 10ml/min or less

5. Possible Clinical Manifestations

(see table 47-2)
Other disease processes may disguise symptoms of CKD causing
difficult early diagnosis.
6. Clinical Manifestations by body system
Urinary System
o May be asymptomatic in early stages or have
polyuria
o Fluid retention requiring diuretics
o Anuria after a period of dialysis
Metabolic Disturbances
o Waste product accumulation
o Altered carbohydrate metabolism
o Elevated triglycerides
Electrolyte and acid-base imbalances
o Potassium (hyperkalemia)
Decreased secretion by kidneys
Fatal Dysrhythmias (levels 7-8 mmol/L)
o Sodium (elevated, normal or low)
Causes: edema, hypertension, and HF
Usually restricted to 2g/day
o Calcium and Phosphate
o Magnesium
Typically not an issue unless patient is
ingesting magnesium
MOM
Magnesium Citrate
Antacids containing magnesium
o Metabolic Acidosis

Inability to excrete acid load

o Ammonia
Defective reabsorption and regeneration of
bicarbonate
Hematologic System
o Anemia
Due to decreased production of erythropoietin
(stimulates precursor cells in bone marrow to
produce RBCs)
Other causes: frequent blood sampling,
bleeding from GI tract, blood loss in dialyzer,
increased production of parathyroid hormone
and iron deficiencies.
o Bleeding Tendencies
Defect in platelet function
o Infection
Cardiovascular System
The most common cause of death in patients
with CKD is CV disease
Even a slight reduction in GFR has been
associated with a higher risk of CAD.
CV disease and CKD are so closely linked that
patients with Cardiac problems should undergo
renal evaluation
Contributing Risk Factors: Hypertension and
Diabetes: Vascular Complications
o Hypertension and elevated lipids are
common in CKD patients
Hypertension is aggravated by
sodium retention and increased
fluid volume
Hypertension may be caused by
increased renin production
o Increased serum calcium caused by CKD
can result in vascular calcifications and
arterial stiffness
Long standing hypertension, extracellular fluid
volume overload, and anemia contribute to
development of LVH that may lead to
cardiomyopathy and heart failure

 Cardiac dysrhythmias may result from

electrolyte imbalances and/or decreased
coronary artery perfusion
Control of Hypertension and Diabetes are key in the
management of CKD

Respiratory System
o Kussmaul Respirations to compensate for acidosis
o Dyspnea related to fluid volume overload
Gastrointestinal System
o Uremic fetor: ruinous odor of breath
o Nausea, Anorexia, stomatitis
o Delayed gastric empting and constipation
o GI bleeding
Neurologic System
o Changes related to increased nitrogenous waste,
electrolyte imbalances, metabolic acidosis and nerve
fiber damage
o Peripheral neuropathy
Musculoskeletal System
o Mineral and bone disorders
(insert table 47-3)
Integumentary System
o Puritis (more prevalent in dialysis patients)
Reproductive System
o Infertility
o Sexual dysfunction
May return after dialysis/transplantation
Psychologic Changes
o Body changes
o Lifestyle changes
o Fatigue/lethargy due to illness

7. Diagnostic Studies
Laboratory Studies
o Urinalysis
Protein (proteinuria is usually first indication of
kidney damage)
Two or more positive tests over 3 month
period indicates need for further work up
Micro albuminuria (additional test for diabetics)
Albumin-to creatinine ratio

Ratio greater than 300mg albumin per 1g

creatinine signals CKD

o Serum
Serum
GFR
Cockcroft-Gault formula
MDRD equation
Ultrasound
o Looks for obstructions
Biopsy
o May provide definitive diagnosis

8. Collaborative Care
Early diagnosis and treatment of risk factors is key
All patients with CV disease should be assessed for CKD
9. Drug Therapy
Hyperkalemia (noted by labs or EKG changes)
o Daily management with restrictions of high
potassium foods and medications
o Acute Hyperkalemia
Dialysis (if dialysis patient)
IV Glucose/Insulin
IV Calcium Gluconate 10%
Sodium polystyrene sulfonate (Kayexalate)
Used in stage 4
Can be used as out-patient
Hypertension
o HTN control can delay progression of CKD
o Target BP is <130/80 for all CKD patients and
<125/75 for those with significant protein urea.
o Non-Pharmacological Treatment:
Weight loss (if obese or overweight)
Therapeutic Lifestyle Changes
Exercise
Avoidance of Alcohol Consumption
Smoking cessation
Self monitoring of BP
Diet recommendations
DASH diet
Protein restrictions (?)
Fluid restrictions (dialysis patients with
anuria)
5

Limiting dietary phosphorous (not usual

done until RRT is required)
Sodium restriction
Potassium restriction (K in salt
substitutes)
o May not be restricted for PD
patients
Do not use magnesium containing antiacids
o Pharmacological Treatment:
Anti-hypertensive (may need combination
therapy)
Diuretics
Calcium Channel Blockers
ACE inhibitors (angiotensin conversion
enzyme)
ARB agents (angiotensin receptor
blockers)
CKD-MBD (Mineral and Bone Disorder) [degree is diagnosed by
bone biopsy]
Phosphate binders-bind phosphate in bowel and
eliminate in stool. May cause constipation with
need for stool softener.
o Phoslo (calcium acetate)-normal calcium
o Caltrate (calcium carbonate)-normal
calcium
o Fosrenol (lanthanum carbonate)-calcium
is elevated
o Renvela (sevelamer carbonate)-calcium
is elevated
o Do not use products containing
magnesium
o Excessive aluminum is associated with
osteomalacia (bone disease)

Supplemental calcium in late stages to combat

hypocalcaemia (GI tract unable to absorb
calcium in absence of Vit. D)
Supplemental Vitamin D to assist in calcium
absorption
o Cholecalciferol
Discontinue in case of
hypercalcemia
6

Treatment of secondary hyperparathyroidism in

ESKD
o Activated Vitamin D
Oral
IV
o Cinacalcet (Sensipar) [calcimimetic]
Mimics calcium and increase the sensitivity of the calcium
receptors in the parathyroid gland, helps parathyroid detect
calcium and limits production of PTH
o Patient may ultimately require Para
thyroidectomy

Anemia- caused by decreased production of erythropoietin.

o Replace with exogenous erythropoietin
IV
SQ
o Side effects include
Increased risk of CV events
Higher hemoglobin levels and higher doses of
EPO are associated with a higher rate of
thrombolitic events and increased risk of death
from serious CV events
Iron deficiency
Iron deficiency due to increased demand from
new RBCs
May need supplements
o Do not administer with phosphate
binders
Dyslipidemia-risk factor for CV disease
o Statins (Lipitor)-used to lower LDL
o Fibrates (Lopid)-used to lower HDL
Complications of drug therapy
o Many drugs are partially or totally excreted in the kidneys
Drug toxicity may occur due to poor excretion

Nursing Management
Assessment:
History
o Existing or family history of
Alport syndrome and polycystic kidney disease

 Diabetes
Hypertension
Lupus erythematous
o Current and past use of medications (prescription,
OTC, herbals)
Decongestants (pseudoephedrine,
phenylephrine)
Use of anti-acids
NSAID use
Analgesics
o Dietary habits
Height and weight
Nursing Diagnoses:
Risk for fluid volume excess
Risk for electrolyte imbalances
Imbalanced nutrition
Planning:
Goals:
Demonstrate knowledge and ability to comply with
therapeutic regimen
o Do they have what they need to facilitate this?
Participate in decision making for the plan of care and future
treatment
o Must be patient centered and not just nurse/doctor
pleasing

Demonstrate effective coping strategies

Continue with ADLs within physiologic limitations

Implementation:
Health Promotion
o Identification of CKD
Acute Intervention
Ambulatory and home care
(see table 47-12)
Facilitating behavioral change and management of CKD:
The role of nurses:
According to Dean and Low (2012), Psychological models can help us
to understand how to support behavior change in renal patients.
8

Behavior change is an important and necessary part of the treatment

of kidney failure and only by understanding the psychological process
involved, can nurses hope to properly support patients with difficult
behavioral changes they face.
Attitude, subjective norms and perceived behavioral control all
influence behaviors
Learned helplessness (a passive state of being that occurs when a
person learns that their environment is uncontrollable) is a common
occurrence in renal populations due to constant exposure to painful or
unpleasant procedures and stimuli associated with treatments for CKD
Renal patients (like most patients) are often at different stages of
readiness to change
Choi and Lee studied the impact of a face-to-face self management
educational program on knowledge, self-care practice and kidney
function in patients with CKD. Their findings suggested that health
care providers can identify various and individualized needs, and
provide effective education and consultation through face to face selfmanagement for patients with chronic irreversible illnesses. These
efforts can be coordinated and designed by nurses.
Evaluation: The expected outcomes that the patient with CKD will
maintain
Treatment/Adjunct Therapy
Dialysis: A technique in which substances move from the blood
through a semipermeable membrane and into a dialysis solution
(dialysate).
o To correct fluid and electrolyte imbalances
o To remove waste products in kidney failure
o To treat drug overdose (medication specific)
Two Methods:
Peritoneal dialysis (PD)
Hemodialysis (HD)
Peritoneal Dialysis
Catheter placement
Dialysis Solution Cycles
o Inflow (fill)
Takes about 10 min and aprox. 2L is used
(determined by size of peritoneal cavity)
Catheter is clamped after inflow
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o Dwell (equilibration)
May take 20-30min or up to 8+ hours
Diffusion and osmosis occurs between patients
blood and the peritoneal cavity
o Drain
15-30 min. gentle massage may facilitate
Dialysis solutions
o Glucose
Hyperglycemia
Hypertriglyceridemia
Long-term peritoneal membrane dysfunction
o Icodextrin
o Amino acid
Dialysis Systems
o Automated Peritoneal Dialysis (APD)
Most popular form (done during sleep)
Four or more cycles (1-2 hours/cycle)
Usually need 1-2 additional daytime cycles
o Continuous Ambulatory Peritoneal Dialysis (CAPD)
Done during the day
Four cycles (5ish hours/cycle)
Connected during inflow and drain but
disconnected during dwell
Complications
o Infection
Catheter exit (Staphylococcus aureus or
Staphylococcus epidermidid)
Redness at site
Tenderness
Drainage
Treatment is ABX therapy
o Peritonitis
o Hernias
o Low Back Problems
o Bleeding
o Pulmonary Complications
o Protein Loss
Effectiveness
o Mortality rates are same for PD and HD for first two
years
o Higher than HD after two years
o Indicated for patients
Who prefer and OP setting

10

With vascular access problems

Hemodialysis
Vascular Access: Rapid blood flow is required
o Arteriovenous Fistulas (anastomosis)
Allows arterial blood flow through a vein
Not compatible with PVD, IV drug use, obese
women
Placed at least 3 months prior to HD
Thrill-felt
Bruit-heard
o Arteriovenous Grafts (synthetic anastomosis)
2-4 weeks till use
may impede distal circulation
Do not perform BP measurement, IV access or
venipuncture in extremity with VA
o Temporary Vascular Access
Catheterization of internal jugular or femoral
vein.
For Acute Hemodialysis
o Dialyzers
Long plastic cartridge that contains thousands
of parallel hollow tubes or fibers.
Fibers are semipermeable membranes
Procedure for Hemodialysis:
(see 47-12)
o Prior to dialysis fluid status assessment is needed
Weight
BP
Peripheral edema
Lung/heart sounds
o Compare last post dialysis weight with pre-dialysis
weight
Settings and schedules
o 3 days/wk (3-4 hrs)
Complications
o Hypotension
o Muscle cramps
o Loss of blood
o Hepatitis
o Infection (second leading cause of death by HD)
Effectiveness
o 19-24% of deaths per year

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CV disease
Stroke and MI
Continuous Renal Replacement Therapy (CRRT): To dialyze patients in
a more physiologic way over 24 hours, like kidneys.
(see 47-14)
May be used alone or in conjunction with HD
Used for AKI
Typically done in ICU by trained nurse

Kidney Transplantation
Best treatment option for ESKD (fewer than 4% receive)
o Supply/demand
93,000 currently on list
Cadaveric kidney wait is usually 2-5 years
o 90% success rate after 1 year
Recipient Selection
o Varies by transplant center
o CV disease patients are high risk
o May be excluded for health factors such as obesity
and smoking
o Must be histocompatable
Donor Sources
o Live Donors
Extensive evaluation to ensure minimized risks
Physical
Emotional
Better patient and graft survival rates
Immediate availability
Minimized out of body time
o Deceased Donors
Donor Networks may be used
Usually Head Trauma Death
Permission from legal next of kin
May be preserved up to 72 hours
Less is better to avoid ATN.
Surgical Procedure
o Live Donor
27% of all transplants in US.
Usually removed via laparoscopic technique
Open nephrectomy may require removal of 11th
rib
o Kidney Transplant Recipient
Transplanted kidney placed in right iliac fossa
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Facilitates anastomoses of blood vessels

Decreased occurrence of paralytic ileus.

(insert 47-15)

Nursing Management
Transplant Recipient
Pre-op care:
o EKG, CXR, labs
o Label vascular access no procedures
May be needed post op
Post-op care
o ICU care for close monitoring of fluid and electrolyte
balance
o Large volumes of urine expected
New kidneys ability to filter BUN which acts as
a diuretic
Abundance of fluids received during surgery
Initial renal tubular dysfunction which inhibits
normal concentration of urine
o Sudden decrease in u/o is concerning in early post-op
period
Dehydration
Rejection
Leak
Obstruction (blood clot or catheter)
Maintain catheter patency and
Gentle irrigation to remove clots
Immunosuppressive Therapy
o Prevent rejection
o Maintain immunity
Complications of Transplantation
o Rejection
o Infection
o CV disease
o Malignancies
o Recurrence of Original Kidney Disease
o Corticosteroid-Related Complications
Aseptic necrosis of joints
PUD
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Glucose intolerance
Diabetes
Cataracts
Dyslipidemia
Malignancies
Infections
Decrease or eliminate use
Monitor for side effects
Gerontologic Considerations
o Increased incidence
o Diabetes/hypertension
o Increased number of comorbidities
o May have increased issues with assistance or
transportation
o May choose to withdraw from treatment
o Raises Ethical concerns

Hussain, Mooney and Russon (2013) studied outcomes of elderly CKD

patients undergoing RRT. Their findings suggest no benefit for patients
over the age of 80 with poor performance status or high comorbidity.
In a nutshell, those choosing conservative management were less
likely to be admitted to or die in the hospital.

Reference:
Lewis, S., Dirksen, S., Heikemper, M., & Bucher, L. (2014) Medical-surgical
nursing: Clinical management for positive outcomes (9th ed.) St. Louis, Mosby.
ISBN 978-0-323-08678-3

Dean, J. & Low, S. (2012) Facilitating behavior change in renal patients.

Journal of
Renal Nursing, 4(6) 284-288.
https://ezproxy.uttyler.edu/login?url=http://search.ebscohost.com/login.aspx?
direct=true&db=ccm&AN=2011936464&site=ehost-live&scope=site
Hussain, J., Mooney, A., & Russon, L. (2013) Comparison of survival analysis and
palliative care involvement in patients aged over 70 years choosing conservative
management or renal replacement therapy in advanced chronic kidney disease.
Pallative Medicine, 27(9) 829-839.
https://ezproxy.uttyler.edu/login?url=http://search.ebscohost.com/login.aspx?
direct=true&db=ccm&AN=2012306300&site=ehost-live&scope=site

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Choi, E. S. & Lee, J. (2012) Effects of a face-to-face self-management program on

knowledge, self-care practice and kidney function in patients with chronic kidney
disease before the renal replacement therapy. Journal of Korean Academic Nursing,
42(7) 1076-1078.
https://ezproxy.uttyler.edu/login?url=http://search.ebscohost.com/login.aspx?
direct=true&db=ccm&AN=2012171887&site=ehost-live&scope=site

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