End Stage Renal Disease

From the desk of Santa Claus

Dear UNLV nursing students and staff,

The Elves and I have been busy for I have recently been diagnosed with End Stage Renal Disease. Know that although I am unwell, Christmas will go on! I just need some treatment and a little bit of Christmas cheer to get back to moving!

Best wishes,

Santa Claus

ESRD - What causes it?

Causes

• Poor Perfusion
• Kidney Infections
• Direct Kidney Damage
• Congenital Condition

How does it affect you?

End-Stage Renal Disease affects all body systems

Pathophysiology

The kidneys are responsible for the following:

• Acid-Base Balance
• Fluid Volume Balance
• Electrolyte Balance
• Drug Elimination
• Waste Product Elimination
• Blood Pressure Regulation
• RBC Production Regulation

Diabetes Mellitus

Diabetes

• Most common cause of chronic kidney failure
• High blood sugar can damage blood vessels, as well as the nephrons (CDC, 2021)
• Excess glucose sticks to arterial walls, which disrupts blood flow
• Kidneys are deprived of the nutrients needed to function

Hypertension

HTN

• Second leading cause of kidney failure in the US
• High BP can constrict and narrow the blood vessels in the kidneys, which reduces blood flow (National Kidney Foundation, 2021)
• Constant high pressure hitting the arterial walls
• Kidneys are not able to remove all extra wastes and fluids, which can raise BP even more

Analgesic Overuse

• Include aspirin, acetaminophen, and ibuprofen
• Long-term exposure to certain painkillers can damage the small filtering blood vessels in the kidney, which leads to analgesic nephropathy (Johns Hopkins Medicine, 2021)
• Analgesic nephropathy: damage within internal structures of the kidneys due to prolonged use of analgesics

Kidney Stones

• Formation of hardened minerals in the kidneys or urinary system (Davita Kidney Care, n.d.)
• Dislodgement can block the flow of urine and cause the kidneys to swell

Glomerulonephritis

Glomerulonephritis

• Inflammation of the glomeruli in the kidneys
• Kidneys will have trouble removing waste and fluid from the body, which can lead to kidney failure (Cleveland Clinic, 2020)

Others

• Family history/genetics, including Polycystic Kidney Disease
• Smoking

Others

(Bello, et al., 2017)

(Latif, 2022)

Cardiovascular Complications

Cardiovascular Complications

• Left ventricular hypertrophy
• Valvular disease
• Arterial calcification
• Atherosclerosis

Can manifest as:

• Dysrhythmias
• Heart failure
• Myocardial infarction
• Angina
• Pericardial effusion
• Mortality

RefereRefnces

(Bello, et al., 2017)

Salt and Water Retention

Salt and Water Retention

• Sodium excess with fluid retention
• Edema
• Hypertension
• CVD
• Left ventricular hypertrophy

(Bello, et al., 2017)

Chronic Metabolic Acidosis

Chronic Metabolic Acidosis

• Skeletal muscle catabolism
• Insensitivity to endocrine hormones
• Bone disease

(Cleveland Clinic, 2021)

Uremia

Uremia

• Anorexia
• Fatigue
• Cachexia
• Pruritus
• Nausea
• Restless leg syndrome
• Edema (pulmonary and in extremities)
• Stroke
• Hyperkalemia

Drug Toxicity

Drug Toxicity

• Lower drug doses might be needed
• How the drug is eliminated needs to be considered when new medications are prescribed

(Karch, 2019)

Urine Tests

These tests are pulled from a sample of urine:

• GFR
• Creatinine Clearance
• BUN
• Protein Urine Tests
• Miroalbumin Urine Test

Urine Tests

Blood Tests

The tests are ran from a blood serum sample are:

• ABG's
• Erythrocyte Sedimentation Rate
• Serum Creatinine
• Hbg
• Hct
• Serum sodium
• Serum potassium
• Serum magnesium
• Serum phosphorus

Renal Ultrasound & MRI

Renal Ultrasound & MRI scan

• Ultrasounds use sound waves to study the urinary system (Winchester Hospital, n.d.e).
• Can look for
• Changes in the kidneys, bladder, and ureters (Winchester Hospital, n.d.e).
• Changes in kidney size or structure (Winchester Hospital, n.d.e).
• MRIs use magnetic waves and computers to take pictures of the inside of the body (Winchester Hospital, n.d.d.).
• Used to look for problems or injuries in the body (Winchester Hospital, n.d.d.).

CT Scan of Abdomen

• Type of X-ray that takes picutes inside the body of the area between the chest and hips (Winchester Hospital, n.d.a).
• Used when pt. has symptoms of
• Abdominal pain
• Bowel changes or blockages
• Problems passing urine
• Fluid buildup in the abdomen
• (Winchester Hospital, n.d.a).

MRA Scan

MRA Scan

• Type of MRI that focuses on the blood flow and blood vessels of the organ being examined (Van Leeuwen & Bladh, 2021).
• Used for detecting abnormalities and diseases within the blood vessels (Radiologyinfo.org for patients, 2021).

Kidney Biopsy

• Tissue samples are taken and looked at in the lab (Winchester Hospital, n.d.c).
• Helps to see how much kidney damage a person has (Winchester Hospital, n.d.c).
• Used when
• Kidneys don't work the way as they should (Winchester Hospital, n.d.c).
• High levels of protein in the urine (Winchester Hospital, n.d.c).

Dialysis

Dialysis

Hemodialysis

• Blood based
• Vitamin E*

Peritoneal Dialysis

• "Belly Dialysis"
• CAPD, CCPD, IPD

Kidney Transplant

(Johns Hopkins Medicine, n.d.)

Fluid & Blood Pressure Control

Fluid & BP Control

Antihypertensives

• ACE Inhibitors: -pril (lisinopril)
• ARBs: -sartan (losartan)

Diuretics

• furosemide (loop diuretic)

(Sarah, 2017)

Anticoagulants

• warfarin
• Unfractionated heparin

(Smyth et al, 2016)

Electrolyte Control & Erythropoietin

Electrolyte Control & EPO

Erythropoietin

• Subcutaneous injection
• Blood transfusion

(Sarah, 2017)

Electrolyte Balance

• Insulin/glucose control
• Iron, Folic Acid, B-Complex Vitamins
• Bicarbonate Buffers
• kayexalate
• IV calcium gluconate
• Active Vitamin D
• Phosphorous Binders
• calcium carbonate
• calcium acetate (PhosLo)

(Lynn, R, n.d.)

Pain Medications & Contraindications for ESRD

Pain & Contraindications

Pain Medications

• paracetamol (simple analgesic)
• hydromorphone (opioid)
• Stool softener

Contraindications & Considerations

• Increased risk for CVD, nephrotoxicity, neurotoxicity, sodium retention, HTN, Diabetes Mellitus (type 2)
• "Start low and slow;" increased half life of certain drugs
• Some other opioids such as morphine & codeine
• cyclo-oxygenate-2 inhibitors
• Certain insulins
• Sulfonylureas
• Magnesium/magnesium-based antacids/laxatives
• NSAIDs (*aspirin)
• metformin

(Smyth et al, 2016)

SMART Goal: Excessive Fluid Volume

SMART Goal #1

Patient will list at least 3 actions that are needed to treat or prevent excessive fluid volume such as fluid and dietary restrictions by the end of my shift.

(Ackley, 2023)

Nursing Actions

- Monitor the client’s behavior for restlessness, anxiety, or confusion; use safety precautions if symptoms are present.

- Administer prescribed diuretics as appropriate; ensure adequate blood pressure before administration. If diuretic is administered intravenously, note and record the blood pressure and urine output after the dose. Monitor serum sodium for hyponatremia.

- Monitor for side effects of diuretic therapy, including orthostatic hypotension (especially if the client is also receiving angiotensin-converting enzyme [ACE] inhibitors), hypovolemia, and electrolyte imbalances (hypokalemia and hyponatremia).

- Monitor intake and output; note trends reflecting decreasing urine output in relation to fluid intake

- Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast.

(Ackley, 2023)

SMART Goal: Decreased Cardiac Output

SMART Goal #2

Patient will explain at least 3 actions and 3 precautions to prevent primary or secondary cardiac disease by the end of my shift.

(Ackley,2023)

Nursing Actions

- Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Reducing stressors decreases cardiac workload and oxygen demand.

- Apply graduated compression stockings or intermittent pneumatic compression (IPC) leg sleeves as ordered. Ensure proper fit by measuring accurately. Remove stockings at least twice a day, and then reapply. Assess the condition of the extremities frequently.

- Encourage a diet that promotes cardiovascular health and reduces risk of hypertension, atherosclerotic disease, renal impairment, insulin resistance, and hypervolemia, within the context of an individual’s cultural preferences.

- Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating, as this may cause vasovagal syncope. Decreased activity, pain medication, and diuretics can cause constipation.

- Refer to a cardiac rehabilitation program for education and monitored exercise. Exercise training or regular physical activity is recommended. Cardiac rehabilitation can improve quality of life and functional capacity.

(Ackley, 2023)