? Chronic kidney disease (CKD) encompasses a spectrum of different
pathophysiologic processes associated with abnormal kidney function and a
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progressive decline in glomerular filtration rate (GFR), present for >3 months.? PATHOPHYSIOLOGY OF CHRONIC KIDNEY DISEASE ?
? initiating mechanisms specific to the underlying etiology
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? a set of progressive mechanisms, involving hyperfiltration and hypertrophy of
the remaining viable nephrons, that are a common consequence following
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long-term reduction of renal mass, irrespective of underlying etiology? Eventually, these short-term adaptations of hypertrophy and
hyperfiltration become maladaptive leading to sclerosis and dropout
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of the remaining nephrons
RISK FACTORS
? smal for gestation birth weight
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? childhood obesity
? hypertension
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? diabetes mel itus? autoimmune disease
? advanced age
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? African ancestry
? a family history of kidney disease
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? a previous episode of acute kidney injury? presence of proteinuria
? abnormal urinary sediment
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? structural abnormalities of the urinary tract.
? The normal annual mean decline in GFR with age from the peak GFR
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(~120 mL/min per 1.73 m2) attained during the third decade of life is~1 mL/min per year per 1.73 m2, reaching a mean value of 70 mL/min
per 1.73 m2 at age 70.
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Etiology of CKD? Diabetes
? Hypertension
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? Glomerulonephritis
? Hereditary cystic and congenital renal disease
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? Interstitial nephirits and pyelonephritisEvaluation
? estimation of GFR ? only when creatinine levels are steady
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? Measurement of albuminuria ?? 24-h urine collection
? protein-to-creatinine ratio in a spot first-morning urine sample
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Clinical features? Stages 1 and 2 CKD - asymptomatic
? stages 3 and 4- clinical and laboratory complications of CKD
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? most evident complications include? anemia and associated easy fatigability;
? decreased appetite;
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? abnormalities in calcium, phosphorus, and mineral-regulating hormones, such as
1,25(OH)2D3 (calcitriol), parathyroid hormone (PTH), and fibroblast growth factor 23
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(FGF-23);? and abnormalities in sodium, potassium, water, and acid-base homeostasis.
Clinical manifestations
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Uremia
? Syndrome that incorporates all signs and symptoms seen in various
systems throughout the body
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Uremic symptomsUrinary system
? Polyuria
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? Results from inability of kidneys to concentrate urine? Occurs most often at night
? Specific gravity fixed around 1.010
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? Oliguria
? Occurs as CKD worsens
Metabolic disturbance
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? Waste product accumulation
? As GFR , BUN and serum creatinine levels
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? BUN? Not only by kidney failure but by protein intake, fever, corticosteroids, and catabolism
? N/V, lethargy, fatigue, impaired thought processes, and headaches occur
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Electrolyte/acid?base imbalances
? Sodium
? May be normal or low
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? Because of impaired excretion, sodium is retained
? Water is retained
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? Edema? Hypertension
? CHF
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? Potassium
? Hyperkalemia
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? Most serious electrolyte disorder in kidney disease? Fatal dysrhythmias
? Calcium and phosphate alterations
? Magnesium alteration
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? Metabolic acidosis
? Results from -Inability of kidneys to excrete acid load (primary ammonia)
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Hematologic system? Anemia
? Due to production of erythropoietin
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? From of functioning renal tubular cells
? Bleeding tendencies
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? Defect in platelet function? Infection
? Changes in leukocyte function
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? Altered immune response and function
? Diminished inflammatory response
? Anemia treatment
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? Erythropoietin
? Administered IV or subcutaneously
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? Increased hemoglobin and hematocrit in 2 to 3 weeks? Side effect: Hypertension
? Iron supplements
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? If plasma ferritin <100 ng/ml
? Side effect: Gastric irritation, constipation
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? May make stool dark in color? Folic acid supplements
? Needed for RBC formation
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? Removed by dialysis
? Avoid blood transfusions
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Cardiovascular system? Hypertension
? Heart failure
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? Left ventricular hypertrophy
? Peripheral edema
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? Dysrhythmias? Uremic pericarditis
Respiratory system
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? Kussmaul respiration? Dyspnea
? Pulmonary edema
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? Uremic pleuritis
? Pleural effusion
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? Predisposition to respiratory infections? Depressed cough reflex
? "Uremic lung"
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Gastrointestinal system
? Mucosal ulcerations
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? Stomatitis? Uremic fetor (urinous odor of the breath)
? GI bleeding
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? Anorexia
? N/V
Neurologic system
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? Expected as renal failure progresses
? Attributed to
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? Increased nitrogenous waste products? Electrolyte imbalances
? Metabolic acidosis
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? Demyelination of nerve fibers
? Altered mental ability
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? Seizures and Coma? Dialysis encephalopathy
? Peripheral neuropathy
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Restless leg syndrome
? Muscle twitching
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? Irritability? Decreased ability to concentrate
Reproductive system
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? Infertility
? Experienced by both sexes
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? Decreased libido? Low sperm counts
? Sexual dysfunction
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Musculoskeletal system
? Renal osteodystrophy
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? Syndrome of skeletal changes
? Result of alterations in calcium and phosphate metabolism
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? Weaken bones, increase fracture risk? Two types associated with ESRD:
? Osteomalacia
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? Osteitis fibrosa
? Phosphate intake restricted to <1000 mg/day
? Phosphate binders
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? Calcium carbonate
? Bind phosphate in bowel and excreted
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? Sevelamer hydrochloride? Should be administered with each meal
? Side effect: Constipation
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? Supplementing vitamin D
? Calcitriol l)
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? Serum phosphate level must be lowered before administering calcium orvitamin D
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? Controlling secondary hyperparathyroidism
? Calcimimetic agents
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? Sensitivity of calcium receptors in parathyroid glands? Subtotal parathyroidectomy
Integumentary system
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? Most noticeable change? Yellow-gray discoloration of the skin
? Due to absorption/retention of urinary pigments
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? Pruritus
? Uremic frost
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? Dry, pale skin? Dry, brittle hair
? Thin nails
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? Petechiae
? Ecchymoses
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Nutritional therapy? Protein restriction
? 0.6 to 0.8 g/kg body weight/day
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? Water restriction
? Intake depends on daily urine output
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? Sodium restriction? Diets vary from 2 to 4 g depending on degree of edema and hypertension
? Potassium restriction up to 2 to 4 g
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? Phosphate restriction up to 1000 mg/dayHemodialysis
? Artificial replacement in case of renal failure for removing excess
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waste in form of solutes like urea and creatinine and water from theblood.
GOALS
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? Solute clearance
? Diffusive transport(countercurrent mechanism between blood flow
and diasylate)
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? Convective transport (solvent drag and ultrafiltration)
? Fluid removal
Types of Dialysis
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? continuous renal replacement therapies (CRRTs)? slow low-efficiency dialysis (SLED)
? intermittent hemodialysis session
? Peritoneal dialysis
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? continuous ambulatory peritoneal dialysis (CAPD)? continuous cyclic peritoneal dialysis (CCPD)
ACCESS
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? ARTERIOVENOUS FISTULA
? ARTERIOVENOUS GRAFT
? CENTRAL VENOUS CATHETER
COMPLICATIONS DURING HEMODIALYSIS
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? Hypotension
? Increase the risk of hypotension,
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? Including excessive ultrafiltration with inadequate compensatory vascularfilling,
? Impaired vasoactive or autonomic responses,
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? Osmolar shifts,
? Overzealous use of antihypertensive agents,
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? Reduced cardiac reserve.? high-output cardiac failure due to shunting of blood through the dialysis
access in AVF patients
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? Muscle cramps during dialysis are also a common complication? excessively rapid volume removal (e.g., >10?12 mL/kg per hour)
? Anaphylactoid reactions to the dialyzer
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? Type A reactions - IgE mediated intermediate hypersensitivity
reaction to ethylene oxide ,
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? within minutes? The type B reactions- complement activation and cytokine release
? symptom complex of nonspecific chest and back pain typically
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occur several minutes into the dialysis run