8.6 Chronic Kidney Disease

Chronic kidney disease (CKD) refers to the gradual, progressive loss of kidney function over time. As kidney function declines, the ability to remove excess fluids and filter wastes from the blood becomes impaired. Additionally, electrolyte imbalance and hormone production may also be compromised.

CKD typically progresses slowly over months or years and is asymptomatic in the early stages. As kidney function continues to decline, symptoms like fatigue, swelling in the legs and ankles, difficulty concentrating, decreased appetite, and changes in urination patterns may begin to emerge.

Pathophysiology and Risk Factors

There are many potential risk factors for developing CKD. Older adults, individuals with a family history of CKD, and certain ethnic groups such as African Americans, Hispanics, and Native Americans have an increased risk of developing CKD. Factors that decrease blood flow to the kidneys, such as atherosclerosis, diabetes, and high blood pressure can damage the kidneys. Urinary tract disorders like glomerulonephritis (inflammation of the kidneys’ filtering units), polycystic kidney disease, kidney stones, prolonged urinary tract obstruction, and recurrent urinary tract infections can also cause damage. Other risk factors include autoimmune diseases and chronic long-term use of certain medications such as nonsteroidal anti-inflammatory medications and antibiotics.^[1]

CKD is classified by health care providers by stages according to the individual’s glomerular filtration rate (GFR). The stage of CKD guides medical treatment. See Table 8.6a for an overview of the stages of CKD.^[2]

Table 8.6a. Stages of CKD

Assessment

CKD affects multiple body systems due to the kidneys’ crucial role in regulating fluids, electrolytes, and hormone levels. See Table 8.6b for an overview of clinical manifestations of CKD by body system.

Table 8.6b. Signs and Symptoms of CKD by Body System^[3],[4],[5]

Diagnostic Testing

Diagnostic testing for CKD is performed to assess and monitor kidney function, identify underlying causes, and stage the disease. Common blood tests include serum creatinine, blood urea nitrogen (BUN), glomerular filtration rate (GFR), and electrolyte panels. Typically, the creatinine and BUN results are increased and the GFR is decreased. In the electrolyte panel results, the potassium and phosphorous are typically elevated and the calcium level is decreased. Complete blood counts are also monitored for signs of anemia (decreased red blood cells) due to decreased erythropoietin production. See Appendix A for normal reference ranges of these blood tests.

Urine tests may be performed to examine the urine for blood, protein, or signs of infection. Additional testing may include renal ultrasound, CT scan, or kidney biopsy to look for signs of structural abnormalities, blockage, tumor, and the extent of the kidney damage.^[6],[7]

Nursing Problems and Diagnoses

Nursing problems and diagnoses for clients with CKD can help guide nursing care and address the specific needs of these individuals. Common nursing diagnoses include the following:

• Electrolyte Imbalance
• Fluid Volume Excess
• Risk for Infection
• Imbalanced Nutrition
• Anxiety
• Readiness for Enhanced Knowledge

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. Examples of expected outcomes for clients with chronic kidney disease are as follows:

• The client will verbalize three dietary modifications required to maintain stable electrolyte levels by the end of the teaching session.
• The client will demonstrate a reduction in edema in lower extremities by 50% within three days.
• The client will demonstrate no signs of infection (e.g., fever, elevated WBC count) throughout the hospital stay.
• The client will demonstrate effective relaxation techniques to cope with anxiety related to chronic disease management before discharge from the hospital.
• The client will verbalize the actions and side effects of prescribed medications after the teaching session.

Interventions

Medical Interventions

Medical interventions for CKD aim to slow disease progression, manage symptoms, and prevent complications. Interventions vary depending on the stage of the disease and client condition and may include medication management, dialysis, nutritional support, and surgery.

Medication Management

Controlling hypertension and managing complications are important parts of medical treatment for CKD. Medications such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) can help to control elevated blood pressure and protect the kidneys from additional damage. Erythropoietin-stimulating agents may be prescribed to stimulate red blood cell production. Electrolyte-lowering agents like phosphate binders and electrolyte replacement like calcium may also be prescribed based on the individual’s lab results.

Dialysis

Hemodialysis and peritoneal dialysis are prescribed for individuals with Stage 5 CKD (also called kidney failure or end-stage renal disease). Both types of dialysis remove waste products and excess fluids from the body. The choice between hemodialysis and peritoneal dialysis depends on various factors such as the client’s medical condition, lifestyle, residual kidney function, vascular access, and personal preference. Fluid and electrolyte balances are routinely assessed, and dialysis therapy is tailored to optimize fluid removal and restore electrolyte balance. See Table 8.6c for a comparison of the aspects of hemodialysis and peritoneal dialysis.

Table 8.6c. Types of Dialysis

Access Sites

Access for hemodialysis may be initiated through a temporary access site and then transitioned to a long-term, stable access. Temporary and emergent access may be achieved through insertion of a central venous access device into a large vein in the neck, chest, or groin.

For long-term dialysis, an arteriovenous fistula is established where a surgical connection is made between an artery and vein that can withstand repeated access for multiple weekly treatments. The AV fistula is typically inserted into the arm. Special care measures must be taken to preserve the integrity of the fistula, such as avoidance of blood pressure measurements, blood draws, or other procedures that constrict blood flow in the AV extremity. Additionally, fistulas are only used for dialysis; they are not used for blood draws, and they are not flushed between dialysis treatments. Cleanliness of the fistula site is also important. The client is taught to gently wash the area with soap and water, allowing it to adequately dry, and to monitor the site daily for signs of redness and infection. The patency of the fistula site can be monitored by assessing for a thrill (vibration) and bruit (whooshing) sound. The presence of thrill and bruit indicates the fistula has adequate blood flood and is functioning.

An arteriovenous graft may also be created for long-term access. An arteriovenous graft is similar to a fistula but uses a synthetic tube to create a conduit between the artery and vein. An AV graft is a preferable long-term access when a client’s blood vessels are unsuitable for a fistula.

Nutritional Support

Nutrition plays a crucial role in managing CKD, particularly in terms of controlling fluid and electrolytes balances. With the complexity of dietary modifications that are often required for individuals with CKD, it is often helpful for a referral to a registered dietician who specializes in renal nutrition. Common dietary restrictions include the following:

• Sodium Restriction: Limiting sodium helps manage fluid balance and blood pressure. Typical recommended sodium intake for clients with CKD is 1,500-2,300 mg per day. Health teaching is provided to avoid processed foods, canned goods, and use of salt when preparing meals.
• Potassium Restriction: For individuals with CKD with high potassium levels, limiting intake of potassium-rich foods like bananas, oranges, potatoes, tomatoes, and dried fruits is advised. Recommended intake may vary based on potassium blood levels and the individual’s stage of CKD.
• Phosphorus Restriction: Foods high in phosphorus (dairy, nuts, seeds, colas) should be limited because damaged kidneys have difficulty removing excess phosphorus. Medications called phosphate binders may be prescribed to limit the absorption of phosphate in the digestive tract.
• Protein Restriction: Reducing the amount of protein consumed can lessen the workload on the kidneys. A moderate amount of high-quality protein is often recommended for individuals with CKD to maintain muscle mass without taxing the kidneys. Intake is personalized based on the individual’s stage of CKD and their dietary needs.
• Fluid Restriction: In later stages of CKD, fluid intake may be restricted to avoid fluid overload and prevent complications like edema and high blood pressure. The amount of fluid permitted is individualized based on their urine output and residual kidney function.
• Vitamin & Mineral Supplementation: CKD may cause deficiencies in certain vitamins and minerals (like vitamin D, iron, and B vitamins). Supplements may be prescribed to manage deficiencies.

Kidney Transplantation

Kidney transplantation may be an option for eligible clients with end-stage renal disease (ESRD). A kidney transplant involves surgically implanting a healthy kidney from a living or deceased donor to restore kidney function. A transplant offers beneficial outcomes compared to long-term dialysis. Clients undergo a thorough evaluation to determine if they are suitable candidates for transplantation. If eligible, they are placed on a waiting list for a donated kidney. After receiving a kidney transplant, the client is on life-long immunosuppressant medications.^{[9],[10],[11],[12]}

Nursing Interventions

Nursing interventions for individuals with CKD aim to manage symptoms, slow disease progression, prevent complications, and support the client’s overall well-being. Interventions include routine monitoring, medication management, fluid and electrolyte management, and health teaching.

Routine Monitoring

Routine monitoring for clients with CKD includes blood pressure (compared to their baseline), fluid intake/output, and signs of fluid overload or dehydration. Nurses also monitor the results of lab tests like kidney function tests (serum creatinine, BUN, GFR), electrolyte levels, and red blood cells/hemoglobin.

Medication Management

During inpatient care, nurses administer prescribed medications for managing blood pressure and fluid retention, treating anemia, promoting bone health, and preventing complications associated with CKD. Health teaching is provided regarding the actions of prescribed medications, their potential side effects, and when to notify the health care provider.

Nutritional Support/Fluid and Electrolyte Management

Nurses monitor for symptoms of electrolyte imbalances (sodium, potassium, phosphorus) and assist in maintaining balanced electrolyte levels through dietary modifications and medications. Nutritional intake is assessed, and deficiencies or malnutrition is addressed through dietary modifications or supplements. Prescribed fluid restrictions are implemented to prevent fluid overload. Referrals may be encouraged to dieticians to educate clients about a kidney-friendly diet, including restrictions on protein, sodium, potassium, and phosphorus.

Health Teaching and Psychosocial Support

Nurses provide health teaching about CKD, its progression, prescribed treatments, and the importance of self-management and not missing their dialysis appointments. Clients are also taught to monitor their daily weights or their weight before/after dialysis and to avoid medications that are nephrotoxic. Lifestyle modifications like exercise, smoking cessation, and stress management are encouraged to improve overall health and slow disease progression.

Nurses use active listening and therapeutic communication to help clients cope with the challenges, anxiety, and lifestyle changes associated with chronic disease and self-management. Clients are encouraged to participate in support groups to connect with others facing similar challenges.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.