Towards Global Eminence Chronic Renal Failure Chronic Kidney Disease JIA LEE, RN, PhD College of Nursing Science Kyung Hee University
Definitions Chronic Kidney Disease (CKD): is defined as either kidney damage or GFR < 60 ml/min/1.73m2 for 3 months Chronic Renal Failure (CRF): irreversible kidney dysfunction with azotemia 3 months Azotemia: BUN >28mg/dl & Cr>1.5mg/dl End Stage Renal Disease (ESRD): uremia requiring transplantation or dialysis Glomerular Filtration Rate (GFR): the total rate of filtration of blood by the kidney Creatinine Clearance (CCr): the rate of filtration of creatinine by the kidney (GFR marker)
Stages of CRF (KDOQI Clinical Practice Guidelines) Stage Description GFR Level Normal Healthy kidneys 90 ml/min or more Stage 1 Stage 2 Kidney damage with normal or high GFR Kidney damage and mild decrease in GFR 90 ml/min or more 60 to 89 ml/min Stage 3 Moderate decrease in GFR Stage 4 Severe decrease in GFR Stage 5 Kidney failure 30 to 59 ml/min 15 to 29 ml/min Less than 15 ml/min or on dialysis
Etiology Diabetes mellitus (28%) Hypertension (25%) Glomerulonephritis (21%) Polycystic Kidney Diease (4%) Other (23%): Obstruction, infection, etc.
Uremia Retention of nitrogenous wastes Increased intracellular Na and water GFR below 50% of normal Azotemia Anorexia and lethargy Decreased mental acuity and coma Fatigue, nausea, vomiting, cold, bone pain, itch, shortness of breath and seizures Fibrinous pericarditis
Subjective Symptoms Nausea Loss of appetite Headache Lethargy Tingling in extremities
Renal Symptoms: Objective Hyponatremia Dry mouth Poor skin turgor Confusion, salt overload, accumulation of K with muscle weakness Fluid overload and metabolic acidosis Proteinuria, glycosuria Urine = RBC s, WBC s, and casts
Cardiovascular Symptoms Hypertension Arrythmias Pericardial effusion CHF Peripheral edema
Neurological Symptoms Burning, pain, and itching, paresthesia Motor nerve dysfunction Muscle cramping Shortened memory span Apathy Drowsy, confused, seizures, coma, EEG changes
GI Symptoms Stomatitis Ulcers Pancreatitis Uremic fetor Vomiting Constipation
Respiratory Symptoms Increased chance of infection Pulmonary edema Pleural friction rub and effusion Dyspnea Kussmaul s respirations from acidosis
Endocrine Symptoms Stunted growth in children Amenorrhea( 무월경 ) Male impotence Increased aldosterone secretion Impaired glucose levels R/T impaired carbohydrate(cho) metabolism Thyroid and parathyroid abnormalities
Hemopoietic Symptoms Anemia Decrease in RBC survival time Blood loss from dialysis and GI bleed Platelet deficits Bleeding and clotting disorders purpura and hemorrhage from body orifices, ecchymoses( 반상출혈 )
Skeletal Symptoms Muscle and bone pain Bone demineralization Pathological fractures Blood vessel calcifications in myocardium, joints, eyes, and brain
Skin Symptoms Yellow-bronze skin with pallor Pruritus Purpura Uremic frost Thin, brittle nails Dry, brittle hair, and may have color changes and alopecia
Lab results BUN indicator of glomerular filtration rate and is affected by the breakdown of protein. Normal is 10-20mg/dL. When reaches 70 = dialysis Serum creatinine waste product of skeletal muscle breakdown and is a better indicator of kidney function. Normal is 0.5-1.5 mg/dl. When reaches 10 x normal, it is time for dialysis Creatinine clearance is best determent of kidney function. Must be a 12-24 hour urine collection. Normal is > 100 ml/min
Lab results: Fluid Imbalance Sodium and water retention: CHF, hypertension, ascites, edema Enhanced sensitivity to extra-renal sodium and water loss Vomiting, diarrhea, fever, sweating Symptoms: dry mouth, dizziness, tachycardia, etc. Recommendations Avoid excess salt and water intake Diuretics or dialysis
Lab results: Metabolic Acidosis Decreased acid excretion and ability to maintain physiologic buffering capacity: GFR > 20 ml/min: transient moderate acidosis Treat with oral sodium bicarbonate Increased susceptibility to acidosis
Lab results: Hyperkalemia The kidneys are means which K+ is excreted. Normal is 3.5-5.0mEq/L, maintains muscle contraction and is essential for cardiac function. Both elevated and decreased can cause problems with cardiac rhythm Hyperkalemia is treated with IV glucose and Na Bicarb which pushes K+ back into the cell Kayexalate is also used
Lab results: Hypocalcemia With disease in the kidney, the enzyme for utilization of Vit D is absent Ca absorption depends upon Vit D Body moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it. Normal Ca level is 4.5-5.5 meq/l Hypocalcemia = tetany Treat with calcium with Vit D and phosphate Avoid antacids with magnesium
Lab results: Anemia Lack of erythropoietin production Bone marrow suppression: uremic poisons: leukocyte suppression - infection bone marrow fibrosis: elevated parathyroid hormone(pth) and aluminum toxicity from dialysis Increased bruising, blood loss (surgery) and hemorrhage Lab Abnormalities: Prolonged bleeding time, abnormal platelet aggregation
Treatment for CKD Lose weight (if overweight), and take regular exercise Stop smoking Reduce the amount of salt in the diet in order to help control the blood pressure Eat a healthy balanced diet Drink about 2 litres of fluid a day (2-litre is about 10 cups or 6 mugs). There is no benefit in drinking large amounts of fluid, except in people who get lots of urine infections, or in a few other special cases Consider buying an automatic blood pressure monitor to check the blood pressure at home Have an annual flu jab (influenza vaccination), and have the pneumonia (pneumococcal) vaccine once (talk to your GP about this)
Treatment for CKD Stage 1 & 2 BP should be treated carefully. If it is above 140/85, tablets are usually needed, and the aim is to get the blood pressure down to 130/80 or lower. Cholesterol should be checked, and some people will be advised to take a daily aspirin tablet. Blood test to check egfr should be performed once a year. If the urine tests show a lot of protein in the urine, or the kidney function is declining over time, the case will be discussed with a kidney specialist, or a referral may be made to a kidney specialist.
Treatment for CKD Stage 3 Treatment as in CKD stages 1 and 2, but with more careful monitoring for declining kidney function
Treatment for CKD Stage 4 & 5 Treatment as for CKD stages 1-3. Additionally, any medications should be reviewed, as the dose may need to be altered and some drugs may need to be avoided as they could damage the kidneys further. This should include prescribed drugs and any drugs bought at the chemist and complementary therapies. In CKD stages 4 and 5 it is usually necessary to get advice from a kidney specialist, especially in stage 5 because kidney failure may become life threatening
Treatment: Hemodialysis Vascular access Temporary subclavian or femoral Permanent shunt, in arm Care post insertion Can be done rapidly Takes about 4 hours Done 3 x a week
Treatment: Peritoneal dialysis Semipermeable membrane Catheter inserted through abdominal wall into peritoneal cavity Cost less Fewer restrictions Can be done at home Risk of peritonitis 3 phases inflow, dwell and outflow
Treatment: Transplant Must find donor Waiting period long Good survival rate 1 year 95-97% Must take immunosuppressant s for life Rejection Watch for fever, elevated B/P, and pain over site of new kidney
Nursing Diagnosis Excess fluid volume Imbalanced nutrition Ineffective coping Risk for infection
1. 적당량의단백질섭취 너무많이섭취하면 피로, 오심, 식욕부진등의요독증유발 너무적게섭취하면 근육이분해되어영양결핍초래 이하의한글가이드라인은경희의료원이지은수간호사의허락을받아기재함 30
2. 충분한열량섭취 체중감소를막고적절한영양상태를유지 열량을보충하려면 - 조리시설탕, 물엿을적절히사용 - 식물성기름을이용하여섭취 - 간식으로꿀, 젤리, 사탕을적절히이용 - 당면, 녹말가루를이용한메뉴를선택 31
3. 수분제한 소변량감소 체내수분제거불가능 체중증가 혈압상승 수분 : 물, 얼음, 아이스크림, 주스, 우유, 국등 바람직한투석간체중증가량 : 체중의 3-4% 예 ) 60kg 의경우 :60x0.04=2.4kg 32
4. 염분 (Na) 제한 소금, 된장, 간장등의양을반으로줄여사용한다. 식초, 레몬, 오렌지즙등의신맛을내는소스와향신료를사용한다. 젓갈, 짱아찌, 김치, 햄, 소시지, 인스턴트식품은피한다. 국이나찌개대신숭늉이나보리차를이용한다. 조리할때염분을사용하지말고따로양념장을만들어서식사할때같이먹는다. 소금이발라져있는크래커등의군것질은피한다. 주의! 소금대용식품에는칼륨이들어있으므로주위 33
5. 칼륨 (K) 제한 몸근육의정상기능유지에필요 모든자연식품중에함유 혈액내칼륨이상승 : 근육마비, 심장마비초래 혈액내허용치 : 3.5-5.5 meq/l 34
5. 칼륨 (K) 제한 곡류군어육류군우유군채소군과일군기타 고구마, 감자, 토란, 옥수수, 검정쌀, 현미쌀, 율무, 콩종류, 밤, 명태, 땅콩버터, 은행, 잣, 견과류 명태, 미꾸라지, 방어, 삼치, 우럭, 잉어, 대하새우, 굴, 참치살 ( 냉동 ), 생오징어, 갑오징어 우유, 치즈, 유제품 ( 아이스크림, 요구르트 ), 두유 고추잎, 아욱, 근대, 머위, 미나리, 부추, 쑥, 시금치, 쑥갓죽순, 취, 물미역, 늙은호박 곶감, 멜론, 바나나, 앵두, 참외, 천도복숭아, 토마토, 키위 커피, 초코렛, 코코아, 포테이토칩, 흑설탕 35
6. 인제한 콩팥기능의감소 혈액속의인이축적 칼슘은감소 뼈속의칼슘을빼내려고함 칼슘인의농도유지 단백질적당히섭취 약으로캄슘과인의균형유지 예 : CAOD, vit D 뼈가약해짐 36
7. 비타민보충 영양소 B1(Thiamine) B2(Riboflavin) B3(Niacin) B6(Pyridoxin) B12(Cobalamin) B9(Folic acid) B5(Pantothenic acid) C(L-Ascorbic acid) 함유식품 돼지고기, 간, 해바라기씨, 두류, 밀배아, 땅콩 간, 달걀, 치즈, 우유, 녹색채소 간, 땅콩, 표고버섯, 정어리, 가다랭이 쌀겨, 효모, 난황, 간, 옥수수, 어육류 간, 굴 간, 효모, 난황, 우유 간, 고기, 어육, 우유, 분유 녹색채소, 감귤, 딸기, 녹차 37
8. 변비예방 원인 : 수분과섬유질식품의섭취제한당뇨나요독에의한자율신경의기능이상 조절방법 : 처방받은수분, 채소, 과일은모두섭취 변비는 hyperkalemia의원인이되므로변비약을처방 38
문제 1. 만성신부전대상자의증상으로옳은것은? 1) 빈혈이발생한다. 2) 저혈압이발생한다. 3) 대사성알칼리혈증이발생한다. 4) 생화학검사시 BUN/Cr이감소한다. 5) Renal angiography 상에서혈관분포가증가한다. 39
문제 2. 만성신부전대상자에대한교육내용중틀린것은? 1) 수분섭취를제한한다. 2) 저칼륨식이를권장한다. 3) 저염분식이를권장한다. 4) 비타민보충을권장한다. 5) 고단백질식이를권장한다. 40