Chronic Renal Failure
Description: CKD is a progressive, irreversible kidney disease. Because the kidneys are highly adaptive, CKD
is not often recognized until there has been considerable loss of nephrons. Individuals w kidney disease are
frequently asymptomatic, resulting in CKD being underdiagnosed and untreated.
Risk Factors Symptoms/Manifestations:
- CKD has many leading causes; the leading causes - All body systems are affected as kidney
are diabetes (50%) and HTN (25%). functions deteriorates.
- Less common include glomerulonephritis, cystic - Clinical manifestations are a result of retained
diseases, and urological diseases. urea, creatinine, phenols, hormones, electrolytes,
- HTN, especially in African Americans and water.
- Chronic glomerulonephritis - Client with CKD can be free from manifestation
- Polycystic kidney disease/Cystic diseases except during periods of stress (infections, stress,
- Acute kidney injury trauma)
- Nephrotoxic medications (gentamicin, NSAIDs) or Stages of Chronic Kidney Disease
chemicals - Stage 1: kidney damage with normal or increase
- Autoimmune disorders (systemic lupus GFR
erythematosus) o >/= 90
- Pyelonephrosis o Diagnosis and treatment, CVD risk
- Renal artery stenosis reduction, slow progression
- Recurrent severe infections - Stage 2: kidney damage with mild decrease GFR
- Obesity o GFR 60-89
- Older clients are at increased risk for CKD related to o Estimation of progress
aging process (decreased number of functioning of - Stage 3A: Moderate decrease in GFR
nephrons, decreased GFR) o GFR 45-59
Symptoms/Manifestations Pt. 1: o Evaluation and treatment of
- Urinary System complications
o Early stages of CKD, no change in urine output. - Stage 3B: Moderate decrease in GFR
o Since Diabetes is the main cause of CKD, o GFR 30-44
polyuria may be present o More aggressive treatment of
o As CKD progresses, fluid retention will occur, complications
and diuretic therapy is needed. - Stage 4: Severe decrease in GFR
o After dialysis, anuria may occur. o GFR 15-29
- Metabolic Disturbances
o Waste Product Accumulation: as GFR decreases,
o Preparation for renal replacement
BUN and creatinine levels increase. Polyuria therapy (dialysis, kidney transplant)
may be present and as CKD progresses fluid - Stage 5: End Stage Kidney Failure (ESRD – End
retention may occur. Anuria may occur post Stage Renal Disease)
dialysis. o GFR <15
o Altered Carb Metabolism: mild to moderate o Renal replacement therapy (if uremia
hyperglycemia and hyperinsulinemia may occur.
o Elevated Triglycerides: increased VLDLs,
increased HDLs. Most CKD pts die from CV Interprofessional Care
disease. - Nephrologist
- Electrolyte and Acid-Base Imbalances - Cardiovascular: to treat CV disease or CVD
o Potassium: hyperkalemia due to decreased management
excretion of potassium by the kidneys
o Sodium: diluted hyponatremia occurs when large
amounts of water is retained
o Calcium and Phosphate:
o Magnesium: hypermagnesemia (generally not a
problem unless pt is consuming magnesium) and
manifestation can include absence of reflexes,
decreased mental status, cardiac dysrhythmias,
hypotension, and respiratory failure.
o Metabolic Acidosis: average adult produces 80-
, Symptoms/Manifestations Pt. 2:
- Hematologic System
o Anemia: normocytic, normochromic anemia due to decreased production of erythropoietin by the kidneys
o Bleeding Tendencies: bleeding in uremia caused by qualitative defect in platelet function, hemorrhagic tendencies and GI bleeds
o Infection: increased susceptibility to infection caused by changes in WBC function and altered immune response and function
- Cardiovascular System
o Most common cause of death in CKD pts is CV disease
o HTN and elevated lipids are common in CKD pts
o Uremic pericarditis can develop and occasionally progress to pericardial effusion and cardiac tompanade
o Manifestations are typically friction rub, chest pain, and low-grade fever
- Respiratory System
o With severe acidosis, respiratory system may compensate with Kussmaul breathing which leads to increased CO2 removal by
exhalation
o Dyspnea may occur, manifestations of fluid overload, pulmonary edema, uremic pleuritis, pleural effusions, and respiratory
infections (pneumonia)
- GI System
o Stomatitis with exudates and ulcerations, metallic taste in mouth, uremic fetor (urinous odor of mouth)
o Anorexia and N/V may develop of CKD becomes ESRD (end stage renal disease)
o Weight loss and malnutrition may occur
o Diabetic gastroparesis (delayed gastric emptying)
o Constipation due to limited fluid and nutritional intake
- Neurological System
o CNS depression
Lethargy, apathy, decreased ability to concentrate, fatigue, irritability, and altered mental status
Seizures and coma may result from increased BUN and hypertensive encephalopathy
o Peripheral neuropathy – Stage 5 CKD pts complain about restless leg syndrome
o Motor involvement leads to bilateral foot drop, muscular weakness and atrophy, and loss of deep tendon refelexes
o Muscle twitching, jerking, asterixis (hand-flapping tremor), and nocturnal leg cramps
o Diabetic neuropathy can be compounded by uremic neuropathy
- Musculoskeletal System
o CKD mineral and bone disorder (CKD-MBD)
o Accelerated rate of bone remodeling causes a weakened bone matrix which places the pt at a higher risk of fractures
o Osteomalacia (disease that weakens bones) and osteitis fibrosa (certain bones become weak and deformed)
- Integumentary, Reproductive and Psychological
o Int: refractory pruritis, dry skin, calcium-phosphate deposition on skin, sensory neuropathy
Uremic frost is a rare condition when BUN levels are extremely elevated
o Repr: infertility and decreased libido (both males and females)
Women: decreased estrogen, progesterone, and luteinizing hormone
Men: loss of testicular consistency, decreased testosterone, low sperm count
Sexual dysfunction, anorgasmy
o Psych: personality and behavioral changes, emotional liability, withdrawal, depression
Diagnosis/Labs:
- Dipstick test: evaluation of protein in the urine bc persistent proteinuria is usually the first indication of kidney damage
o For pts with diabetes, if no protein were present, then evaluate for albuminuria
o Dipstick evaluation for persistent proteinuria would be indicated by 1+ protein on standard dipstick testing two or
more times over a 3-month period.
- Urinalysis: to detect RBCs, WBCs, protein, casts, and glucose. Hematuria, proteinuria, and decrease in specific gravity.
- Ultrasound: to detect nay obstruction and to determine the size of the kidneys
- Biopsy: may be necessary to provide definite diagnosis
- BUN: gradual increase w elevated blood creatinine over months to years for CKD; can increase 10-20 times the creatinine
finding
- CBC: decreased hemoglobin and hematocrit from anemia secondary to loss of erythropoietin
- Blood Creatinine: gradual increase over months to years for CKD exceeding 4mg/dL; can increase to 15-30 mg/dL
- Blood Electrolyte: decreased sodium (dilutional) and calcium; increased potassium, phosphorus, and magnesium
- Other diagnostic methods:
o Hx and physical examination
o Identification of reversible kidney disease
o Renal scan, CT scan
o BUN, serum creatinine and creatinine clearance levels
o Serum electrolytes
o Lipid profile
o Protein-to-creatinine ratio in first morning voided specimen
o Cystoscopy
o Retrograde pyelography
o KUB (kidney, ureter, and bladder)
o MRI
Description: CKD is a progressive, irreversible kidney disease. Because the kidneys are highly adaptive, CKD
is not often recognized until there has been considerable loss of nephrons. Individuals w kidney disease are
frequently asymptomatic, resulting in CKD being underdiagnosed and untreated.
Risk Factors Symptoms/Manifestations:
- CKD has many leading causes; the leading causes - All body systems are affected as kidney
are diabetes (50%) and HTN (25%). functions deteriorates.
- Less common include glomerulonephritis, cystic - Clinical manifestations are a result of retained
diseases, and urological diseases. urea, creatinine, phenols, hormones, electrolytes,
- HTN, especially in African Americans and water.
- Chronic glomerulonephritis - Client with CKD can be free from manifestation
- Polycystic kidney disease/Cystic diseases except during periods of stress (infections, stress,
- Acute kidney injury trauma)
- Nephrotoxic medications (gentamicin, NSAIDs) or Stages of Chronic Kidney Disease
chemicals - Stage 1: kidney damage with normal or increase
- Autoimmune disorders (systemic lupus GFR
erythematosus) o >/= 90
- Pyelonephrosis o Diagnosis and treatment, CVD risk
- Renal artery stenosis reduction, slow progression
- Recurrent severe infections - Stage 2: kidney damage with mild decrease GFR
- Obesity o GFR 60-89
- Older clients are at increased risk for CKD related to o Estimation of progress
aging process (decreased number of functioning of - Stage 3A: Moderate decrease in GFR
nephrons, decreased GFR) o GFR 45-59
Symptoms/Manifestations Pt. 1: o Evaluation and treatment of
- Urinary System complications
o Early stages of CKD, no change in urine output. - Stage 3B: Moderate decrease in GFR
o Since Diabetes is the main cause of CKD, o GFR 30-44
polyuria may be present o More aggressive treatment of
o As CKD progresses, fluid retention will occur, complications
and diuretic therapy is needed. - Stage 4: Severe decrease in GFR
o After dialysis, anuria may occur. o GFR 15-29
- Metabolic Disturbances
o Waste Product Accumulation: as GFR decreases,
o Preparation for renal replacement
BUN and creatinine levels increase. Polyuria therapy (dialysis, kidney transplant)
may be present and as CKD progresses fluid - Stage 5: End Stage Kidney Failure (ESRD – End
retention may occur. Anuria may occur post Stage Renal Disease)
dialysis. o GFR <15
o Altered Carb Metabolism: mild to moderate o Renal replacement therapy (if uremia
hyperglycemia and hyperinsulinemia may occur.
o Elevated Triglycerides: increased VLDLs,
increased HDLs. Most CKD pts die from CV Interprofessional Care
disease. - Nephrologist
- Electrolyte and Acid-Base Imbalances - Cardiovascular: to treat CV disease or CVD
o Potassium: hyperkalemia due to decreased management
excretion of potassium by the kidneys
o Sodium: diluted hyponatremia occurs when large
amounts of water is retained
o Calcium and Phosphate:
o Magnesium: hypermagnesemia (generally not a
problem unless pt is consuming magnesium) and
manifestation can include absence of reflexes,
decreased mental status, cardiac dysrhythmias,
hypotension, and respiratory failure.
o Metabolic Acidosis: average adult produces 80-
, Symptoms/Manifestations Pt. 2:
- Hematologic System
o Anemia: normocytic, normochromic anemia due to decreased production of erythropoietin by the kidneys
o Bleeding Tendencies: bleeding in uremia caused by qualitative defect in platelet function, hemorrhagic tendencies and GI bleeds
o Infection: increased susceptibility to infection caused by changes in WBC function and altered immune response and function
- Cardiovascular System
o Most common cause of death in CKD pts is CV disease
o HTN and elevated lipids are common in CKD pts
o Uremic pericarditis can develop and occasionally progress to pericardial effusion and cardiac tompanade
o Manifestations are typically friction rub, chest pain, and low-grade fever
- Respiratory System
o With severe acidosis, respiratory system may compensate with Kussmaul breathing which leads to increased CO2 removal by
exhalation
o Dyspnea may occur, manifestations of fluid overload, pulmonary edema, uremic pleuritis, pleural effusions, and respiratory
infections (pneumonia)
- GI System
o Stomatitis with exudates and ulcerations, metallic taste in mouth, uremic fetor (urinous odor of mouth)
o Anorexia and N/V may develop of CKD becomes ESRD (end stage renal disease)
o Weight loss and malnutrition may occur
o Diabetic gastroparesis (delayed gastric emptying)
o Constipation due to limited fluid and nutritional intake
- Neurological System
o CNS depression
Lethargy, apathy, decreased ability to concentrate, fatigue, irritability, and altered mental status
Seizures and coma may result from increased BUN and hypertensive encephalopathy
o Peripheral neuropathy – Stage 5 CKD pts complain about restless leg syndrome
o Motor involvement leads to bilateral foot drop, muscular weakness and atrophy, and loss of deep tendon refelexes
o Muscle twitching, jerking, asterixis (hand-flapping tremor), and nocturnal leg cramps
o Diabetic neuropathy can be compounded by uremic neuropathy
- Musculoskeletal System
o CKD mineral and bone disorder (CKD-MBD)
o Accelerated rate of bone remodeling causes a weakened bone matrix which places the pt at a higher risk of fractures
o Osteomalacia (disease that weakens bones) and osteitis fibrosa (certain bones become weak and deformed)
- Integumentary, Reproductive and Psychological
o Int: refractory pruritis, dry skin, calcium-phosphate deposition on skin, sensory neuropathy
Uremic frost is a rare condition when BUN levels are extremely elevated
o Repr: infertility and decreased libido (both males and females)
Women: decreased estrogen, progesterone, and luteinizing hormone
Men: loss of testicular consistency, decreased testosterone, low sperm count
Sexual dysfunction, anorgasmy
o Psych: personality and behavioral changes, emotional liability, withdrawal, depression
Diagnosis/Labs:
- Dipstick test: evaluation of protein in the urine bc persistent proteinuria is usually the first indication of kidney damage
o For pts with diabetes, if no protein were present, then evaluate for albuminuria
o Dipstick evaluation for persistent proteinuria would be indicated by 1+ protein on standard dipstick testing two or
more times over a 3-month period.
- Urinalysis: to detect RBCs, WBCs, protein, casts, and glucose. Hematuria, proteinuria, and decrease in specific gravity.
- Ultrasound: to detect nay obstruction and to determine the size of the kidneys
- Biopsy: may be necessary to provide definite diagnosis
- BUN: gradual increase w elevated blood creatinine over months to years for CKD; can increase 10-20 times the creatinine
finding
- CBC: decreased hemoglobin and hematocrit from anemia secondary to loss of erythropoietin
- Blood Creatinine: gradual increase over months to years for CKD exceeding 4mg/dL; can increase to 15-30 mg/dL
- Blood Electrolyte: decreased sodium (dilutional) and calcium; increased potassium, phosphorus, and magnesium
- Other diagnostic methods:
o Hx and physical examination
o Identification of reversible kidney disease
o Renal scan, CT scan
o BUN, serum creatinine and creatinine clearance levels
o Serum electrolytes
o Lipid profile
o Protein-to-creatinine ratio in first morning voided specimen
o Cystoscopy
o Retrograde pyelography
o KUB (kidney, ureter, and bladder)
o MRI
