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DRG Information ⬇

DRG Category: 674

Mean LOS: 7.4 days

Description: Surgical: Other Kidney and Urinary Tract Procedures With Complication or Comorbidity

DRG Category: 683

Mean LOS: 3.9 days

Description: Medical: Renal Failure With Complication or Comorbidity

Introduction ⬆ ⬇

Chronic kidney disease (CKD), formerly known as chronic renal failure, refers to decreased renal function across a continuum of severity from mild to moderate to severe chronic kidney failure. The Centers for Disease Control and Prevention (CDC, 2021) note that more than 7 in 10 Americans have CKD, and as many as 90% of those with CKD do not know that they have the condition. It is the eighth leading cause of death in the United States. Severe CKD is fatal if it is not treated. One classification of renal failure from the Kidney Disease Outcomes Quality Initiative, based on glomerular filtration rate (GFR; the flow rate of filtered fluid through the kidney), is as follows:

The kidney has many compensatory mechanisms to support its function as it becomes diseased. Each kidney contains approximately 1 million nephrons, the functional unit of the kidney that is responsible for glomerular filtration and reabsorption of solutes and solvents. When nephrons are injured, the kidneys maintain GFR by increasing filtration and reabsorption by hypertrophy of the healthy nephrons. Waste products such as urea and creatinine begin to accumulate in the body only when the GFR drops by 50%. The ability of the kidney to compensate for early disease gives rise to the continuum of severity; many patients can maintain borderline renal function with a mild or moderate reduction in GFR for years.

All individuals with stage 5 kidney failure experience similar physiological changes, regardless of the initial cause of the disease. The kidneys are unable to perform their normal functions of excretion of wastes, concentration of urine, regulation of blood pressure, regulation of acid-base balance, and production of erythropoietin (the hormone needed for red blood cell [RBC] production and survival). Complications of CKD include uremia (accumulation of metabolic waste products in the blood and body tissues), anemia, peripheral neuropathy, sexual dysfunction, osteopenia (reduction of bone tissue), pathological fractures, fluid overload, congestive heart failure, hypertension, pericarditis, electrolyte imbalances (hypocalcemia, hyperkalemia, hyperphosphatemia), metabolic acidosis, esophagitis, and gastritis.

Causes ⬆ ⬇

CKD may be caused by either kidney disease or diseases of other systems (Table 1).

Table 1 Causes of Chronic Kidney Disease

CATEGORYDISEASES
Congenital/hereditary disordersPolycystic kidney disease, renal tubular acidosis
Connective tissue disordersProgressive systemic sclerosis, systemic lupus erythematosus
Infections/inflammatory conditionsChronic pyelonephritis, glomerulonephritis, tuberculosis
Vascular diseaseHypertension, renal nephrosclerosis, renal artery stenosis
Metabolic/endocrine diseasesDiabetes mellitus, gout, amyloidosis, hyperparathyroidism
Obstructive diseasesRenal calculi
Nephrotoxic conditionsMedication therapy, drug overdose
Risk factors for CKD include diabetes mellitus, hypertension, medications that are toxic to the kidney (NSAIDs, some antibiotics, contrast media), smoking, hyperlipidemia, hyperphosphatemia, infections, and shock.

Genetic Considerations ⬆ ⬇

Several heritable diseases can lead to CKD, including the autosomal recessive condition Alport syndrome, which causes nephropathy that is often associated with sensorineural deafness and can be transmitted as X-linked recessive, autosomal recessive, and autosomal dominant forms. Mutations in atrial natriuretic peptide receptor-1 (NPR1) may also contribute to nephropathy and renal failure.

Sex and Life Span Considerations ⬆ ⬇

Both males and females are at risk for CKD. Because of anatomical differences in urethral valves, CKD is more common in boys than girls. Experts suggest that men progress to end-stage kidney disease (ESKD) more rapidly than women. Older patients are more susceptible to some of the causes of acute kidney injury (AKI) and may therefore experience CKD more frequently. CKD as a result of other diseases (diabetes mellitus or uncontrolled hypertension) is more common in older adults simply because they have had the disease longer. It is most typically diagnosed in people who are older than 60 years.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

CKD affects all groups of people, and the prevalence in various populations depends on predisposing conditions such as diabetes and hypertension. The CDC (2021) report in the United States that 16.3% of Black adults over the age of 18 years have CKD, as well as 13.6% of Hispanic persons, 12.9% of Asian persons, and 12.7% of White persons. Early stage CKD is distributed evenly across racial and ethnic groups, but the burden of ESKD is highest in Black and Hispanic persons, possibly because of high rates of diabetes mellitus and hypertension in those groups. People with low incomes have an increased risk of progressive CKD as compared to people with middle- or upper-level incomes (Nelson et al., 2020). Transgender is a term used to describe persons whose gender identity is different from their sex assigned at birth. Approximately 1% of the U.S. population identify themselves as transgender. Sexual and gender minority persons have higher odds for multiple chronic conditions, cancer, and poor quality of life, and are more apt to have disabilities than cisgender males and females. (Cisgender is a term used to describe persons whose gender identity and gender expression are aligned with their assigned sex listed on their birth certificate.) Gender-affirming hormone therapy is the use of hormone therapy for gender transition or gender affirmation and can be masculinizing or feminizing. It may also affect cardiovascular health in transgender females. Current thinking is that kidney transplantation is safe and effective for transgender patients who are on gender-affirming treatments if drug interactions and calculation of renal function are managed carefully with consideration of hormone treatments (Jue et al., 2020). Recent research suggests that transgender people have an increased incidence of hypertension (Connelly et al., 2019), placing them at risk for CKD.

Global Health Considerations ⬆ ⬇

The global incidence of CKD is increasing, with rates highest in the United States and Japan. Worldwide, CKD is a critical public health problem that is acknowledged as a common condition associated with an increased risk of cardiovascular disease. Experts estimate that the global prevalence is 9.1%. Generally, treatments for ESKD are very expensive; developing countries may not have the economic resources to treat patients with renal failure. Few patients with CKD survive in developing countries where treatment is not government sponsored.

Assessment ⬆ ⬇

ASSESSMENT

History

Patients with CKD in stages 1, 2, and 3 are usually asymptomatic because their kidneys are able to compensate for decreasing GFR. Patients may report a history of AKI, which has progressed to a more chronic condition, although usually patients do not become symptomatic until they have a GFR less than 35% of normal. Ask the patient about the color of the urine, whether it is clear or cloudy, and whether it is frothy. The patient may also complain of a metallic taste in the mouth, anorexia, and stomatitis. Determine if the patient experienced weight loss and muscle weakness. Elicit a gastrointestinal (GI) history with particular attention to nausea, vomiting, hematemesis, diarrhea, and constipation.

Elicit the patient's description of any central nervous system (CNS) symptoms. In stages 4 and 5, blurred vision may occur. Patients may have impaired decision making and judgment, irritability, decreased alertness, insomnia, increased extremity weakness, and signs of increasing peripheral neuropathy (decreased sensation in the extremities, hands, and feet; pain; and burning sensations).

Patients often report changes in other body systems as well. Some have idiopathic bone and joint pain in the absence of a diagnosis of arthritis. Others suffer from loss of muscle mass and nocturnal leg cramping. Men may be impotent or notice gynecomastia, and women may mention amenorrhea (absence of menses). Both may have decreased libido.

Physical Examination

All body systems of patients with stage 5 CKD are affected, with significant cardiovascular involvement. Hypertension is usually noted and may indeed be the cause of CKD. Patients often have rapid, irregular heart rates; distended jugular veins; and, if pericarditis is present, a pericardial friction rub and distant heart sounds that may be accompanied by cardiac tamponade. Respiratory symptoms include hyperventilation, Kussmaul breathing, dyspnea, orthopnea, and pulmonary congestion. Rales may signify fluid overload. Frothy sputum combined with shortness of breath may indicate some degree of pulmonary edema.

The renal effects of CKD are pronounced. You may smell a urine-like odor on the breath and notice a yellow-gray cast to the skin. If the patient is producing any urine at all, it may be dilute, with casts or crystals present. The skin is fragile and dry, and there may be uremic frost on the skin or open areas owing to severe scratching (pruritus) by the patient. The patient may have bruising; petechiae; brittle nails; dry, brittle hair; gum ulcerations; or bleeding. The patient may appear malnourished with muscle wasting. If the patient has been followed for CKD, there may already be access sites created in preparation for dialysis. Assess the sites for patency (an arteriovenous fistula should have a palpable thrill and audible bruit) and signs of infection.

When you assess the CNS, you may find that the patient has difficulty with ambulation because of altered motor function, gait abnormalities, bone and joint pain, and peripheral neuropathy. The patient's mental status may range from mild behavioral changes to profound loss of consciousness and seizures. Electrolyte imbalances may result in signs of hypocalcemia (see Hypocalcemia), muscle cramps, and twitching.

Psychosocial

Patients with CKD present complex and difficult challenges to caregivers. Many have personality and cognitive changes. Apathy, irritability, and fatigue, which are part of the disease process, are common and interfere with interpersonal relationships. Sexual dysfunction is common. A careful assessment of the patient's capabilities, home situation, available support systems, financial resources, and coping abilities is important before any nursing interventions can be planned.

Diagnostic Highlights

TestNormal ResultAbnormality With ConditionExplanation
Blood urea nitrogen8–21 mg/dLElevatedKidneys cannot excrete wastes
Serum creatinine0.5–1.2 mg/dL>3 mg/dLKidneys cannot excrete wastes
Creatine clearanceFemales: 75–115 mL/min/1.73 m2; males: 85–125 mL/min/1.73 m2<95% decreaseAcute damage to the kidney limits ability to clear creatinine

Other Tests: Urinalysis; complete blood count; erythrocyte sedimentation rate; hemodynamic monitoring; renal ultrasound; radionuclide scanning; magnetic resonance angiography; renal biopsy; serum levels of sodium, potassium, magnesium, and phosphorus; arterial blood gases

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisExcess fluid volume related to compromised regulatory mechanisms as evidenced by elevated heart rate, distended jugular veins, and/or hyperventilation

Outcomes

OutcomesFluid balance; Hydration; Circulation status; Cardiac pump effectiveness; Urinary elimination; Vital signs

Interventions

InterventionsFluid monitoring; Fluid/electrolyte management; IV therapy; Medication management; Hemodialysis therapy; Vital signs monitoring

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Aggressive blood pressure control is important through all the stages of CKD to promote kidney function and slow the progression to CKD. In the early stages of CKD, the goals are to delay or halt the progression of the disease, treat the manifestations of CKD, and plan for renal replacement therapy. Patients who have progressed to stage 5 CKD, or ESKD, require either dialysis or renal transplantation. Renal transplantation is the treatment of choice for many patients; more than 375,000 kidney transplants have been performed in the United States, with 110,000 people on the kidney transplant waiting list. The transplanted kidney may come from a living donor or a cadaver. One-year survival rates are currently 90% to 95%. The new organ is placed in the iliac fossa. The original kidneys are not generally removed unless there is an indication, such as infection, for removing them. The greatest postoperative problem is transplant rejection. If kidney transplantation is not chosen, the patient will need lifelong dialysis. The three basic types of dialysis are peritoneal dialysis, hemodialysis, and continuous hemofiltration. Peritoneal dialysis uses the peritoneum as the semipermeable membrane. Access is achieved with the surgical placement of a catheter into the peritoneal cavity. Approximately 2 L of sterile dialysate is infused into the cavity and left for a variable period of time (usually 4 to 8 hr). At the end of the cycle, the dialysate is removed and discarded. A fresh amount of sterile dialysate is infused, and the cycle is continued.

Hemodialysis uses a surgically inserted vascular access, such as a shunt, or vascular access into an arterialized vein that was created by an arteriovenous fistula. In emergencies, vascular access through a large artery may be used. The blood is removed through one end of the vascular access and is passed through a machine (dialyzer). The dialyzer contains areas for the dialysate and the blood, separated by a semipermeable membrane. The fluid and waste products move quickly through the membrane because the pressure on the blood side is higher than that on the dialysate side. The blood is returned to a venous access site.

Continuous hemofiltration uses vascular access in the same manner as hemodialysis. The patient's heparinized blood goes from an arterial access, through the hemofilter (the semipermeable membrane), and back to the patient through venous access. No dialysate is used. The hemofilter uses the patient's own blood pressure as the source of pressure. One disadvantage is that frequently too much fluid is filtered, resulting in the need for IV fluid replacement. Other procedures, such as venovenous dialysis, are also used in some institutions. Glycemic control, control of blood pressure, dietary protein restrictions, smoking cessation, calcium supplementation, management of anemia, and control of hyperlipidemia are all components of collaborative management.

The diet for the CKD patient on dialysis is generally restricted in fluids, protein, sodium, and potassium. It is usually high in calories, particularly carbohydrates. The fluid restriction is generally the amount of the previous day's urine plus 500 to 600 mL. The patient with CKD is frequently taking many medications. A significant concern is that the patient's altered renal function also alters the action and the excretion of medications; toxicity, therefore, is always considered a possibility, and dosages are altered accordingly. Manifestations of CKD, such as anemia, electrolyte imbalances (hyperphosphatemia, hypocalcemia, hyperkalemia), hyperparathyroidism, fluid overload, and metabolic acidosis need treatment as well.

Pharmacologic Highlights

Medication or Drug ClassDosageDescriptionRationale
AntihypertensivesVaries by drugAngiotensin-converting enzyme (ACE) inhibitors; beta-adrenergic antagonistsTreat the underlying hypertension
DiureticsVaries by drugLoop and thiazide diureticsControl fluid overload early in the disease if the patient is not anuric (total absence of urinary output)
Hematopoietic growth factorsVaries by drugEpoetin alfa, darbepoetinStimulates RBC production to treat anemia
Sodium polystyrene sulfonate (Kayexalate)Orally or by enema: 15 g/60 mL in 20–100 mL sorbitol to facilitate passage of resin through the intestinal tractCation exchange resin; 0.5–1 mEq/L of potassium is removed with each enema, but an equivalent amount of sodium is retainedExchanges sodium for potassium in the GI tract, leading to the elimination of potassium

Other Drugs: Hypocalcemia and hyperphosphatemia may be treated with lanthanum carbonate; sevelamer; and sucroferric oxyhydroxide or phosphorus-lowering agents such as calcium acetate, calcium carbonate, calcitriol, or doxercalciferol. If long-term effects of aluminum hydroxide are a concern, an oral calcium (with vitamin D) preparation may be given. Anemia may be treated with iron salts such as ferrous sulfate. If the patient undergoes renal transplantations, immunosuppressives such as tacrolimus, azathioprine, mycophenolate mofetil, or cyclosporine are prescribed. Corticosteroids may also be given at this time to decrease antibody formation.

Independent

To help the patient deal with fluid restrictions, use creative strategies to increase the patient's comfort and compliance. Use ice chips, frozen lemon swabs, hard candy, and diversionary activities. Give medications with meals or with minimal fluids to maximize the amount of fluid that is available for patient use. Skin care is important because of the effects of uremia. Uremia results in itching and dryness of the skin. If the patient experiences pruritus, help the patient clip the fingernails short and keep the nail tips smooth. Teach the patient to use skin emollients liberally, to avoid harsh soaps, and to bathe only when necessary. You may need to speak to the physician to request an as-needed dose of an oral antihistamine such as diphenhydramine (Benadryl). If the patient is hospitalized, frequent turning and range-of-motion exercises assist in preventing skin breakdown. If the patient is taking medications that cause frequent stools, teach the patient to clean the perineum and buttocks frequently to maintain skin integrity.

The patient needs to plan the week's activities to incorporate the level of fatigue, the dialysis routine, and any desired activities. The patient may also find that cognitive activities are more easily accomplished on certain days in relationship to dialysis treatments. Reassure the patient that this is not unusual but is caused by the shift of fluid and waste products. Counseling relative to role function, family processes, and changes in body image is important. Sexuality counseling may be required. Reassure the patient that adaptation to a chronic illness with an uncertain future is not easy for either the patient or the significant others. Participate when asked in discussions related to feasibility of home dialysis, placement on the transplant list, and decisions related to acceptance or refusal of dialysis treatment. Encourage decisions that increase feelings of control for the patient.

If the patient undergoes a kidney transplantation, provide preoperative and postoperative care as for any patient with abdominal surgery. Monitoring of fluids is more important for these patients than for other surgical patients because a decrease in output may be an early sign of rejection. Other signs include weight gain, edema, fever, pain over the site, hypertension, and increased white blood cell count. Emotional support is important for the patient and family, both preoperatively and postoperatively, because both positive and negative outcomes produce emotional turmoil. Teaching about immunosuppressive drugs is essential before discharge.

Evidence-Based Practice and Health Policy

Novick, T., Rizzolo, K., & Cervantes, L. (2020). COVID-19 and kidney disease disparities in the United States. Advances in Chronic Kidney Disease, 27, 427–433.

  • The authors note that the coronavirus disease 2019 (COVID-19) disproportionately affected older adults, people who were not housed, underrepresented minorities, and immigrants. Not only were these groups affected by the societal aspects of the pandemic, but they were at an increased risk for infection and may have experienced more severe complications than other groups. Many people in those groups with underlying kidney disease had difficulties managing their kidney disease and had progression of their illness.
  • For older adults, worsening of frailty and depression due to sheltering in place increased the risk of hospitalization for renal complications. For people without housing, limited computer and Internet access led to less healthcare contact, worsened chronic conditions, and more dependence on acute care settings and hospitalization. They also noted that minorities were disproportionately affected by COVID-19 which may have worsened kidney disease. They conclude that the pandemic may have exacerbated existing disparities in kidney disease.

Documentation Guidelines ⬆ ⬇

Discharge and Home Healthcare Guidelines ⬆

CKD and ESKD are disorders that affect the patient's total lifestyle and the whole family. Patient teaching is essential and should be understood by the patient and significant others. Note that you may need to work collaboratively with social services to arrange for the patient's dialysis treatments. Issues such as the location for outpatient dialysis and follow-up, home health referrals, and the purchasing of home equipment are important. All teaching should be reinforced at intervals during the patient's lifetime.

Care of Peritoneal Catheter for Dialysis

The access site is a sterile area that requires a sterile dressing except when the site is being accessed. Teach the patient or significant others the dressing technique recommended by your institution. In addition, the patient needs to learn the signs of an infected access site, such as swelling, redness, drainage, and odor. In addition, teach the patient to avoid restrictive clothing around the waist and to avoid external abdominal pressure.

Care of External Arteriovenous Dialysis Access (Shunt)

A shunt can be surgically inserted on any limb, but the dominant arm is usually avoided. The access site is considered sterile and is covered with a sterile dressing at all times. Teach the patient to cover the access site between dialysis treatments with a dressing and further support, such as a nonelastic tensor bandage. Because one end of the shunt is inserted directly into an artery, care must be taken to ensure that the shunt does not accidentally come apart, which would lead to immediate hemorrhage. Teach the patient to carry a clamp to use if the shunt becomes disconnected. Teach the patient to feel for the “thrill” of blood moving through the shunt when it is touched (except during dialysis). The presence of darker blood within the shunt may indicate clotting; if this condition occurs, the patient needs to notify the dialysis staff or physician immediately. Any pressure on that limb—such as blood pressure readings, sleeping with the affected limb under the body, carrying boxes or groceries with that arm, or tight clothing—is contraindicated. Tell the patient not to use creams or lotions on the access site and to protect the site during bathing.

Care of the Arteriovenous Fistula

The increased pressure in the arterialized vein creates a large and sometimes unsightly vessel but also creates an access site with enough pressure to complete hemodialysis. Teach the patient to palpate a thrill over the anastomosis or graft site every day. Postoperatively, the patient may be asked to do strengthening exercises (grasping ball) to increase the size of the arterialized vein. After hemodialysis, the nursing staff applies pressure for a lengthy period of time to ensure clotting of the patient's blood. If the patient notices excessive bleeding after a dialysis treatment, the patient must notify the dialysis unit. Teach the patient that the site does not need to be protected during bathing. Tell the patient to remind all healthcare personnel that the involved arm should not be used for blood pressure measurements and phlebotomy.

Posttransplantation Teaching

Discharge teaching for the patient with a renal transplant includes information about medications and the signs of rejection. The immunosuppressive drugs place the patient at greater risk for infection and skin cancer. Teach the patient to avoid large groups of people in the first 3 to 4 months and strong sunlight for the duration of the transplant. Although most forms of daily activity are restricted only by how the patient is feeling, contact sports and heavy lifting are contraindicated because of the placement of the transplant. Teach the patient to report signs of infection, rejection, and skin changes immediately to the physician. Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions.