CKD

Question 1

How does filtration of electrolytes and waste products change in CKD? Why?

Answer 1

substances aren’t being filtered by the glomerulus and excreted in the urine leading to:

accumulation in the blood (serum)
- Na (hypernatremia)
- Potassium (Hyperkalemia)
- Phosphorus (Hyperphosphatemia)
- Glucose (Hyperglycemia)
- Urea (Uremia)
- Creatinine (Elevated serum levels)

Question 2

How does filtration of blood cells change in CKD? Why?

Answer 2

larger molecules are able to pass through the glomerulus leading to:

loss of protein, red blood cells, white blood cells, and platelets in the urine

• Proteinuria
• Hematuria
• Leukocyturia
• Thrombocytosis in the urine

Question 3

How does pH change in CKD? Why?

Answer 3

Kidneys no longer excrete excess hydrogen leading to an increase in hydrogen ions
- decrease in serum pH levels and subsequent metabolic acidosis.

Question 4

What are the clinical manifestations to metabolic acidosis?

Answer 4

• Tachycardia
• Confusion
• Fatigue
• Headache
• Tachypnea
• Nausea and/or vomiting
• Weakness

Question 5

How does fluid balance change in CKD? Why?

Answer 5

Kidneys no longer excrete excess fluid leading to an increase in fluid levels throughout the body
- GFR < 4-5 ml/min = significant amounts of water are retained in the blood = volume overload (hypervolemia)
- an accumulation of fluid in the interstitial space (edema)

Question 6

What are the clinical manifestations of fluid imbalance?

Answer 6

• Hypertension
• Pulmonary edema, Rales
• Dyspnea
• Distended neck veins
• Liver congestion
• Congestive heart failure

Question 7

How to treat/manage fluid imbalance?

Answer 7

Diuretics
- potassium-sparing diuretics will not be given to patients with CKD
- loop diuretics, stronger that other diuretics.
- Furosemide (Lasix)
- Bumetamide (Bumex)
Albumin
- intravenous
- will pull water from the interstitial spaces into the vasculature

Question 8

How do potassium levels change in CKD? Why?

Answer 8

Kidneys no longer excrete excess potassium ions leading to an increase in serum potassium (hyperkalemia)
- Elevated serum potassium can result in myocardial depression

Question 9

What are the clinical manifestations to hyperkalemia?

Answer 9

• Myocardial depression
  
  • Bradycardia
  • Hypotension
• Muscle weakness
  
  • when potassium > 8 mEq/L
  • begins in the lower extremities (trunk) -> upper extremities

Question 10

How to treat/manage hyperkalemia?

Answer 10

• monitor intake of potassium in foods, medications and IV fluids.
• teach about salt substitutes that contain potassium.
• if the patient requires a blood transfusion, administer during the dialysis treatment so excess potassium can be removed during dialysis.

Question 11

How does red blood cell count change in CKD? Why?

Answer 11

Kidneys no longer produce and secrete erythropoietin leading to a decrease in the production of red blood cells

Question 12

What is a treatment for anemia? List some side effects.

Answer 12

• Recombinant human erythropoetin (EPO)- IV or SQ
• Monitor side effects of Epo
  ~ Hypertension, Seizures

Question 13

How does renal clearance change in CKD? Why?

Answer 13

Kidneys no longer excrete waste products of protein leading to an increase in sCr and serum urea levels
- uremia causes a vast array of problems that affect many body systems

Question 14

How does vitamin D activation change in CKD? Why?

Answer 14

Kidneys no longer convert vitamin D to the activated form, which is needed to absorb calcium, leading to a decrease in calcium absorption (hypocalcemia)

Question 15

What are the clinical manifestations of hypocalcemia?

Answer 15

• bone fractures
• slipped epiphyses (damaged growth plate)
• mobility changes
• pain
• can lead to hyperparathyroidism
• s/s of hypocalcemia

Question 16

How do we treat hyperkalemia / hypercalcium? List some side effects.

Answer 16

• Use extreme caution when giving calcium to a patient receiving digitalis preparations because hypercalcemia and hypokalemia can precipitate digitalis toxicity (makes the heart more sensitive to digitalis)
• Intravenous calcium can cause extravasation.
  ~ Monitor the IV site closely!!!!

Question 17

What fluid limitation does a renal patient usually have?

Answer 17

The renal client usually has a fluid limitation of 1000cc/24 hours/

Question 18

What are fluids? List some examples of acceptable fluids.

Answer 18

• Fluids are any substances that are liquid at room temperature
  ~ Gravies, Ice cream
  ~ Jello, Water, Juices,
  ~ Ice, sodas, soup and broth

Question 19

List the clinical manifestations of uremia.

Answer 19

• Platelet defects
• Integument changes
• Uremic Frost
• Infection
• Hyperlipidemia / Dyslipidemia

Question 20

Describe platelet defects resulting from uremia.

Answer 20

• Blood will not clot efficiently
• Ecchymoses and purpura related to abnormal blood clotting and capillary fragility in uremia (Assess)
• Monitor platelet level (normal 150,000-350,000 mm)

Question 21

Describe integument changes resulting from uremia.

Answer 21

• Discoloration secondary to urochromes in the skin
• Dry skin secondary to decreased sweat and sebaceous gland activity

Question 22

Describe uremic frost resulting from uremia.

Answer 22

• Uremic Frost- white powdery substance composed of urates that are deposited onto the skin surface with perspiration.
  ~ When perspiration dries, the frost is left behind

Question 23

Describe infection resulting from uremia.

Answer 23

• There is a diminished inflammatory response due to uremia
  ~ Decreased white blood cells at the site if injury or infection.
  ~ Decreased antibody production

Question 24

Describe hyperlipidemia / dyslipidemia resulting from uremia.

Answer 24

• With CKD, the patient will experience hyperinsulinemia because insulin is excreted through the kidneys (in the normal kidney).
• Uremia and Hyperinsulinemia leads to elevated liver production of lipids (VLDL and LDL)
• This leads to an increased risk in the development of artherosclerosis