Hemodialysis

IntroductiontotheManitobaRenalProgram...............................................
3
TheRenalEducationDepartment..................................................................6
WRHARenalEducationDepartment..........................................................6
SiteEducators:............................................................................................7
CourseStructureandDesign..........................................................................8
MNNCCourseTuition.................................................................................8
AcronymsandAbbreviations.......................................................................11
WebAddresses.............................................................................................15
RecommendedNephrologyJournals...........................................................15
ManitobaNephrologyNursingCourseSelfLearningPackageLearning
Objectives.....................................................................................................16
I.Introduction:.........................................................................................16
II.NormalKidneyFunction......................................................................16
III.MeasuringKidneyFunction................................................................16
IV.RenalAnatomyandPhysiology..........................................................17
V.RenalCirculation.................................................................................17
VI.TheNephron......................................................................................17
VII.CausesofChronicKidneyDisease.....................................................18
VIII.ChronicKidneyDisease(CKD)..........................................................18
IX.AcuteRenalFailure(ARF)...................................................................19
X.CKDinManitoba..................................................................................19
I.SLPIntroduction:......................................................................................21
IntroductiontotheManitobaRenalProgram...............................................3
TheRenalEducationDepartment..................................................................6
WRHARenalEducationDepartment..........................................................6
SiteEducators:............................................................................................7
CourseStructureandDesign..........................................................................8
MNNCCourseTuition.................................................................................8
AcronymsandAbbreviations.......................................................................11
WebAddresses.............................................................................................15
RecommendedNephrologyJournals...........................................................15
ManitobaNephrologyNursingCourseSelfLearningPackageLearning
Objectives.....................................................................................................16
I.Introduction:.........................................................................................16
II.NormalKidneyFunction......................................................................16
III.MeasuringKidneyFunction................................................................16
IV.RenalAnatomyandPhysiology..........................................................17
V.RenalCirculation.................................................................................17
VI.TheNephron......................................................................................17
VII.CausesofChronicKidneyDisease.....................................................18
VIII.ChronicKidneyDisease(CKD)..........................................................18
IX.AcuteRenalFailure(ARF).......................................................................19
II.Normalkidneyfunction...........................................................................21
III.Measuringkidneyfunction.....................................................................26
IV.RenalAnatomyandPhysiology..............................................................28
MANITOBA NEPHROLOGY NURSING COURSE
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V.RenalCirculation.....................................................................................29
VI.TheNephron..........................................................................................32
VII.CausesofChronicKidneyDisease(CKD)...............................................35
VIII.ChronicKidneyDisease(CKD)..............................................................43
IX.AcuteRenalFailure(ARF).......................................................................49
X.CKDinManitoba......................................................................................52
Conclusion....................................................................................................55
ThisSelfLearningPackagehasbeencreatedbytheManitobaRenal
ProgramRenalEducationDepartment.
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INTRODUCTIONTOTHEMANITOBARENALPROGRAM
TheManitobaRenalProgram(MRP),establishedinOctober1997,isoneof
theclinicalprogramswithintheWinnipegRegionalHealthAuthority(WRHA).
TheprogramoperatesthroughaMemorandumofUnderstandingwiththe
Government of Manitoba, which indicates that under the auspices of the
WRHA, the MRP is to oversee the management and delivery of renal
services including hemodialysis, peritoneal dialysis,renal health clinics and
renalhealthoutreachinManitoba.ManitobaistheonlyprovinceinCanada
that has a single provincial renal program, and all dialysis services are
fundeddirectlythroughtheprovincialprogram.
Currently in Manitoba, there are approximately 1300+ people receiving

dialysis services. Almost 1100 are receiving hemodialysis services, while
approximately260patientsreceiveperitonealdialysisand45areonHome
Hemodialysis.Eachyearthereisanaverageof3545netnewpatientswho
begin a dialysis therapy. In addition to these patients, there are
approximately4000patientswhoarefollowedbytheRenalHealthClinics.
The 2010 MRP annual budget to manage this care service was
approximately$54million.
HemodialysisServices:HemodialysisisofferedinWinnipeg,Brandon,and
seventeen rural locations throughout the province spanning over five
RegionalHealthAuthorities.WinnipeghemodialysissitesincludetheHealth
SciencesCentre,St.BonifaceHospitalandSevenOaksHospital.Thecurrent
ruralhemodialysislocationsare:
LakeshoreGeneralHospital(Ashern,MB)
DauphinHealthCentre(Dauphin,MB)
FlinFlonGeneralHospital(FlinFlon,MB)
LakeoftheWoodsHospital(Kenora,ON)
BoundaryTrailsHealthComplex(Morden,MB)
NorwayHouseHospital(NorwayHouse,MB)
ThePasHealthComplex(ThePas,MB)
PortageGeneralHospital(Portage,MB)
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PineFallsHealthComplex(PineFalls,MB)
SelkirkGeneralHospital(Selkirk,MB)
SwanRiverValleyHospital(SwanRiver,MB)
ThompsonGeneralHospital(Thompson,MB)
J.A.HildesNorthernMedicalUnit(IslandLakes,MB)
BerensRiverRenalHealthUnit(BerensRiver,MB)
GimliCommunityHealthCentre(Gimli,MB)
PercyE.MooreHospital(Hodgson,MB)
RussellDistrictHealthCentre(Russell,MB)
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PeritonealDialysisServices:Peritonealdialysisteachingandfollowupcare
is currently offered at the St. Boniface Hospital and Seven Oaks Hospital.
Mostpatientsareabletoreturntotheirhomecommunitiesoncetheyhave
learnedtheirtreatmentregimen,astheyusuallyselfmanagetheircare.
Home Hemodialysis Services: Home Hemodialysis training and followup

careiscurrentlyofferedatHealthSciencesCentreandSevenOaksHospital.
Patients are taught to initiate and manage their own hemodialysis care.
Adequatewatersupplyandsewagecapacityareneeded.
Renal Health Clinic Services: Renal Health Clinics focus on renal health
diseasepreventiontodelaytheonsetandprogressionofrenaldiseaseand
to prepare for renal replacement therapy such as hemodialysis, peritoneal
dialysis or transplant. In Manitoba, this service is currently operated
throughHealthSciencesCentre(HSC),St.BonifaceHospital(SBH),SevenOaks
Hospital (SOH), Brandon Regional Health Centre (BRHC), as well as various
ruralcentres.
Renal Education Services: Under the direction of the WRHA, the MRP
providestheManitobaNephrologyNursingCourse(MNNC)tonursesasthey
progress in their careers with the speciality of nephrology nursing. The
ManitobaLocalCentresDialysisUnits(MLCDU),HSC,SBGH,SOGH,andBRHC
collaboratewiththeRenalEducationDepartmenttoprovidethiseducationfor
nurses hired for individual units. Ongoing continuing educational events are
alsoprovidedinvariousformats(MBTelehealth,SelfLearningPackages,MRP
AnnualConference,etc.).
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THERENALEDUCATIONDEPARTMENT
TheManitobaRenalProgram,RenalEducationDepartmentwishesyouwellas
you learn nephrology nursing. Our aim during the MNNC is to assist you in
havingasuccessfulperiodofstudy.
WRHARENALEDUCATIONDEPARTMENT
BettyLouBurke
JulieLorenz
WRHAProgramDirector,MRP
WRHARegionalEducator,MRP
ManagerofRenalEducation
NA338,IsabelMStewartBldg.
2PD082300McPhillipsSt.
700McDermotAvenue
Phone:6323427
Phone:7873458
Fax:6326168
Fax:7871573
Email:bburke@hsc.mb.ca
Email:jlorenz@exchange.hsc.mb.ca
RobinHanson
RenalEducationSecretary
NA379,IsabelM.StewartBldg.
700McDermotAvenue
Phone:7873317
Fax:7871573
Email:rhanson@hsc.mb.ca
IfyouhavequestionsabouttheSelfLearningPackage,youmaycalloneofthe
WRHARegionalEducatorsforassistanceatanytime.Shouldyoureachavoice
mailbox, please leave a message with your name, phone number and a time
when you can be reached. The instructor will make every attempt to return
yourcallwithina24hourtimeperiod.TheEducatorsarepreparedtoassistyou
byphone,sopleasedonothesitatetocall.
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SITEEDUCATORS:
HealthSciencesCentre
PatriciaBowers
NurseEducatorRenal Program,
HSC
700McDermotAvenue
Phone:7878016Fax:7871573
Email:pbowers@hsc.mb.ca
GuineadeHaanWard
NurseEducatorRenalProgram,
HSC
NA336,IsabelM.StewartBldg
700McDermotAvenue
Phone:7872564Fax:7871573
Email:gdehaanward@hsc.mb.ca
CindySoulsby
HSC
700McDermotAvenue
Phone:7871066Fax:7871573
Email:csoulsby@hsc.mb.ca
St.BonifaceHospital
LindaDzydz
ContinuingEducatorRenal
Program,SBH
C4409TacheAve.
Phone:2353765Fax:2353478
Email:ldzydz@sbgh.mb.ca
SevenOaksHospital
RobertLajeunesse
SOH
2PD112300McPhillipsStreet
Phone:6323439Fax:6329539
Email:rlajeunesse@sogh.mb.ca
GiseleRoy
SOH
2PD092300McPhillipsStreet
Phone:6323624Fax:6329539
Email:groy@sogh.mb.ca
BrandonRegionalHealthCentre
ArlaKirk
Educator,Dialysis
BrandonRegionalHealthCentre
159McTavishAvenueEast
Phone:5782151Fax:5784960
Email:kirka@brandonrha.mb.ca
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COURSESTRUCTUREANDDESIGN
ToentertheMNNCprogram,youmustbehiredatanMRPsite.Onceyou
are hired, you must complete the MNNC Self Learning Package (SLP) and
PreEntrance Exam. Alternately, you may complete the SLP and Pre
EntranceExampriortoapplyingtofacilities.YouwilltaketheMNNCduring
the next course offering before you begin working in a dialysis unit. The
MNNCisofferedseveraltimesthroughouttheyear.
MNNCCOURSEFEESTRUCTURE

SelfLearningPackage
NoCharge

PreEntranceExam
NoCharge

TuitionFees
$200.00

RecommendedTextBooks
$254.95(optional)

TOTAL
$454.95
YourhiringfacilitywillprovideastipendwhileyoutaketheMNNC.Please
contactyourhiringfacilityformoreinformation.
Therecommendedtextsare:
Handbook of Dialysis, 4th ed., Daugirdas, Blake and Ing, Wolters Klewer,
Lippincott,WilliamsandWilkins,2007($90.95)
Contemporary Nephrology Nursing: Principles and Practice, 2nd ed.,
Molzahn and Butera, American Nephrology Nursing Association, 2006.
($164.00)
Both texts are available through the University of Manitoba Bookstore,
BannatyneCampus.www.umanitoba.ca/bookstoreor2047893601.
TheMNNCconsistsofthreemaincomponents:
SelfLearningPackageandExam
TheoryandClinicalComponent
Preceptorship
SelfLearningPackageandExam:
The Self Learning Package provides baseline knowledge of Chronic Kidney
Disease,areviewoftheanatomyandphysiologyofthekidneys,aswellas
anoverviewofthetreatmentmodalities.TheMNNCPreEntranceExamwill
focusspecificallyonthematerialscoveredinthisSelfLearningPackage.A
passing grade of 70% is required on the PreEntrance Exam and remains
validforoneyear.Onerewriteopportunitywillbeprovided.Theexamis
administeredataMRPdialysissitethroughtheMRPRegionalEducatorsand
themanagerofthehiringdialysisunit.YouarenotrequiredtohaveaMRP
dialysisnursepositionpriortowritingtheMNNCPreEntranceExamination.
Toscheduleanexam,call(204)7873317oremail:mrp.ed@hsc.mb.ca.
TheoryandClinicalComponent:
ThetheoryandclinicalcomponenttakesplaceinWinnipegandconsistsof6
weeksofclassroomandclinicalstudy.Toenterintothiscomponent,thenurse
mustbehiredbyaMRPdialysissite;thedialysissitemanagerwillarrangefor
course admission. The theoretical component is provided at the Health
SciencesCentreandwillbuildupontheSelfLearningPackage.Inthissection
one can expect to learn more advanced aspects of renal replacement
therapies,withafocusonhemodialysis.
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TheoryandClinicalComponent(continued):
ClinicalexperiencesareavailableatHSC,SOH,SBHandBRHC.Everyeffortwill
bemadetoaccommodateclinicalsiterequests,butattendingthesiteofyour
choicecannotbeguaranteed.
Preceptorship:
Thepreceptorshipcomponentrequires120hoursofclinicalpracticeunderthe
guidanceofanexperiencednephrologynursepreceptor.Youwillfollowyour
preceptorsshiftscheduleduringthistime.
ThesuccessfulcompletionoftheaboveMNNCrequirementsentitlesyouto
practice as a renal nurse in the position you obtained prior to starting the
MNNCprogram.
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ACRONYMSANDABBREVIATIONS
This list represents commonly used abbreviations and acronyms in the
speciality of nephrology nursing. (These are not necessarily hospital
approved)
ACE....................................................................AngiotensinConvertingEnzyme
ANNA.................................................AmericanNephrologyNursingAssociation
APD......................................................................AutomatedPeritonealDialysis
ARF........................................................................................AcuteRenalFailure
ATN...................................................................................Acutetubularnecrosis
AV...................................................................................................Arteriovenous
AVG.......................................................................................ArteriovenousGraft
AVF.....................................................................................ArteriovenousFistula
BG..................................................................................................BloodGlucose
BS.......................................................................................................BloodSugar
BUN.....................................................................................BloodUreaNitrogen
BVM..................................................................................BloodVolumeMonitor
CAD................................................................................CoronaryArteryDisease
CANNT.....................CanadianAssociationofNephrologyNurses&Technicians
CAPD.................................................ContinuousAmbulatoryPeritonealDialysis
CCPD........................................................ContinuousCyclingPeritonealDialysis
CQI..................................................................ContinuousQualityImprovement
CKD..................................................................................ChronicKidneyDisease
Cr..........................................................................................................Creatinine
CrCl......................................................................................CreatinineClearance
CKF....................................................................................ChronicKidneyFailure
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CRRT.....................................................ContinuousRenalReplacementTherapy
CVAD.....................................................................CentralVenousAccessDevice
CVC................................................................................CentralVenousCatheter
DCT.................................................................................DialysisCareTechnician
DDS..................................................................DialysisDisequilibriumSyndrome
DM............................................................................................DiabetesMellitus
CDU..........................................................................CentralDialysisUnit(A6/B6)
DW......................................................................................................DryWeight
ECF............................................................................................ExtracellularFluid
EDW...................................................................................EstimatedDryWeight
eGFR..........................................................estimatedGlomerularFiltrationRate
ePTFE..............................................................expandedPolytetrafluiroethylene
ESRD..............................................................................EndStageRenalDisease
EPO.................................................................................................Erythropoetin
GFR.............................................................................GlomerularFiltrationRate
GN..........................................................................................Glomerulonephritis
HBV......................................................................................HighBiologicalValue
HCAAPD.......HealthCareAssistedAutomatedPeritonealDialysis
Hct......................................................................................................Hematocrit
HF.....................................................................................................HeparinFree
HD....................................................................................................Hemodialysis
Hgb....................................................................................................Hemoglobin
Hg............................................................................................................Mercury
HTN..................................................................................................Hypertension
ICF.............................................................................................IntracellularFluid
IgA...........................................................................................ImmunoglobulinA
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IP.............................................................................Intraperitoneal(medication)
K............................................................................................................Potassium
KDOQI.............................................KidneyDiseaseOutcomesQualityInitiative
Kecn.............................................K=clearancee=effectivec=conductivityn=Na
Kt/V.............................................................K=clearanceT=timeV=Ureavolume
Kuf................................................................................UltrafiltrationCoefficient
LVH.........................................................................LeftVentricularHypertrophy
MAP.................................................................................MeanArterialPressure
MRP..............................................................................ManitobaRenalProgram
MNNC......................................................ManitobaNephrologyNursingCourse
NKF
KDOQI.
NationalKidneyFoundationKidneyDiseaseOutcomesQualityInitiative
NSAID.......................................................NonsteroidalAntiinflammatoryDrug
NIDDM................................................NoninsulinDependentDiabetesMellitus
NS...................................................................................................NormalSaline
PCR....................................................................................ProteinCatabolicRate
PD............................................................................................PeritonealDialysis
PKD...............................................................................PolycysticKidneyDisease
PRI.......................................................................ProgressiveRenalInsufficiency
PTFE................................................................................Polytetrafluoroethylene
PTH....................................................................................ParathyroidHormone
PUR.......................................................................PercentageofUreaReduction
PVD...........................................................................PeripheralVascularDisease
Qa..............................................................................................AccessFlowRate
Qb.....................................................................................BloodPumpFlowRate
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Qd..........................................................................................DialysateFlowRate
OLC............................................................................................OnlineClearance
repo..............................................................recombinanthumanErythropoetin
RHC.........................................................................................RenalHealthClinic
RHO..................................................................................RenalHealthOutreach
RO..............................................................................................ReverseOsmosis
RRT..........................................................................RenalReplacementTherapy
SCDU....................................................................SherbrookCentreDialysisUnit
SP........................................................SinglePool(referstoKt/Vmeasurement)
TBW..........................................................................................TotalBodyWater
TCD............................................................TheoreticalConductivityofDialysate
TMP.............................................................................TransmembranePressure
UFR.........................................................................................UltrafiltrationRate
URR.....................................................................................UreaReductionRatio
V...................................................................................UreadistributionVolume
WRHA.........................................................WinnipegRegionalHealthAuthority
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WEBADDRESSES
AmericanNephrologyNursesAssociation:
http://www.annanurse.org/cgibin/WebObjects/ANNANurse
CanadianAssociationofNephrologyNurses&Technologists:
http://www.cannt.ca/
CanadianSocietyofNephrology:
http://www.csnscn.ca/english/home/default.asp?s=1
EuropeanDialysisandTransplantNursesAssociation/EuropeanRenalCare
Association:
http://www.edtna.org/
ManitobaRenalProgram:
http://www.kidneyhealth.ca/
NationalKidneyFoundation:
http://www.kidney.org/
RECOMMENDEDNEPHROLOGYJOURNALS
AmericanJournalofNephrology
CanadianAssociationofNephrologyNursesandTechsJournal
JournalofNephrology
KidneyInternational
Nephrology,Dialysis,Transplantation
NephrologyNursingJournal
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MANITOBANEPHROLOGYNURSINGCOURSESELFLEARNING
PACKAGELEARNINGOBJECTIVES
I.INTRODUCTION:
1. Thenursewillbeabletostatetheregulatorybodiesthat
guidenephrologypractice.
a.International
b.Canadian
II.NORMALKIDNEYFUNCTION
1. Thenursewillbeabletodescribethelocationofthekidneys.
2. Thenursewillbeabletostatetheaveragesizeofeachkidney.
3. Thenursewillbeabletostatethefourkeyfunctionsofthe
kidneys.
4. Thenursewillbeabletodescribehowmanylitersofblood
aresiftedbythekidneyseachday.
5. Thenursewillbeabletostatehowthekidneysaccomplish
fluidandelectrolytebalance.
6. Thenursewillbeabletostatehowthekidneysachieveacid
basebalance.
7. Thenursewillbeabletostatethreehormonalfunctionsthat
thekidneyisinvolvedin.
III.MEASURINGKIDNEYFUNCTION
1. Thenursewillbeabletostatethetwotermsmostoftenused
indescribingkidneyfunction.
2. Thenursewillbeabletodescribeacreatinineclearancetest.
3. Thenursewillbeabletostatethenormalcreatinineclearance
rate.
4. Thenursewillbeabletodescribeglomerularfiltrationrate
(GFR).
5. ThenursewillbeabletostatethenormalGFR.
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IV.RENALANATOMYANDPHYSIOLOGY
1. Thenursewillbeabletolabelthefollowingmacroanatomy
onadiagramofthekidneyandgiveabriefdescriptionof
each:
a. Hilum
b. RenalArtery
c. RenalVein
d. RenalCapsule
e. Cortex
f. Medulla
g. Pyramids
h. Papilla
i. Calyces/Calyx
j. RenalPelvis
k. Ureters
V.RENALCIRCULATION
1. Thenursewillbeabletostatehowmuchcardiacoutputthe
kidneysreceive.
2. Thenursewillbeabletostatetwouniquetraitsofthekidneys
sharedbynootherpartofthehumanbody.
3. Thenursewillbeabletodescribethepathwayofrenal
circulationfromtheaortatotheinferiorvenacava.
VI.THENEPHRON
1. Thenursewillbeabletostatehowmanynephronsare
presentinnormalhealthykidneys.
2. Thenursewillbeabletolocateonadiagramandgiveabrief
descriptionofthefunctionofthefollowingstructures:
a. Glomerulus
b. BowmansCapsule
c. ProximalConvolutedTubule
d. LoopofHenle
e. DistalConvolutedTubule
f. CollectingDuct
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3. Thenursewillbeabletostatewhatglomerularfiltrateis.
4. Thenursewillbeabletodescribethefinalprocessofurine
productionastheglomerularfiltrateleavesthekidney.
VII.CAUSESOFCHRONICKIDNEYDISEASE
1. Thenursewillbeabletodescribehoweachofthefollowing
causesofkidneydiseaseharmsthekidneys:
a. DiabetesMellitus
b. Hypertension
c. Glomerulonephritis
i.
IgANephropathy
ii.
GoodpasturesSyndrome
iii.
PostinfectiousGlomerulonephritis
d. AutosomalDominantPolycysticKidneyDisease
e. SystemicLupusErythematous
f. SystemicVasculitis
i.
WegnersGranulomatosis
ii.
HenochSchonleinPurpura
g. ThromboticMicroangiopathy:HemolyticUremic
Syndrome(HUS)
h. MultipleMyeloma
i. Amyloidosis
j. ProgressiveSystemicSclerosis:Scleroderma
k. UrinaryTractInfections:Pyelonephritis
l. ChronicDrugInducedTubulointerstitialNephritis
(TIN)
m. RenalArteryStenosis
VIII.CHRONICKIDNEYDISEASE(CKD)
1. Thenursewillbeabletodefinechronickidneydiseaseincluding
themarkersofdamage.
2. ThenursewillbeabletolisttheriskfactorsforCKD.
3. ThenursewillbeabletolisttheStagesofKidneyDiseaseandthe
therapeuticfocusofeachstage.
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4. Thenursewillbeabletodiscussthefollowingcomplicationsof
kidneydisease:
a. Cardiovasculardisease
b. Hypertension
c. Anemia
d. ProteinenergyMalnutrition
e. MetabolicAcidosis
f. Disturbancesinmineralandbonemetabolism
g. Neurologicaldisturbances
h. Dyslipidemia
i. Qualityoflife
j. Pregnancyandpreexistingrenaldisease
IX.ACUTERENALFAILURE(ARF)
1. Thenursewillbeabletodefineacuterenalfailure.
2. ThenursewillbeabletostatebywhatpercentagetheGFRmay
decrease.
3. ThenursewillbeabletodescribetheclinicalsymptomsofARF.
4. Thenursewillbeabletostatetheoverallmortalityrates.
5. ThenursewillbeabletostatethethreemaintypesofARFand
where/howthekidneydamageoccurs.
6. Thenursewillbeabletostatethemostcommoncausesofpre
renalfailure.
7. Thenursewillbeabletostatethemostcommoncausesofintra
renalfailure.
8. Thenursewillbeabletostatethemostcommoncausesofpost
renalfailure.
X.CKDINMANITOBA
1. ThenursewillbeabletodiscussESRDincidenceinManitobaand
Canada.
2. ThenursewillbeabletodiscussESRDprevalenceratesin
ManitobaandCanada.
3. Thenursewillbeabletodescribeapproximatenumbersof
peopleonhemodialysis,peritonealdialysis,HomeHemodialysis,
andfollowedthroughrenalhealthclinicsinManitoba.
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4. Thenursewillhavelimitedunderstandingofrelationshipof
diabetesandESRDinCanada.
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I.SLPINTRODUCTION:
Thefieldofmedicinethatstudieskidneysandtheirdiseasesarecalled
nephrology.NephroisfromanancientGreekwordmeaningkidney,
whilerenalcomesfromLatin.
Thereareinternationalstandardsthatguideprofessionalsinthecareofthe
patientwithkidneydisease.TheNationalKidneyFoundationKidneyDisease
OutcomesQualityInitiative(NKFKDOQI)orKDOQIprovidesevidence
basedclinicalpracticeguidelinesforallstagesofchronickidneydiseaseand
relatedcomplications.Toviewthesestandards,pleasevisit
http://www.kidney.org/professionals/KDOQI/.
TherearealsospecificCanadianguidelinesthroughtheSocietyof
Nephrology(CSN).TheCSNisasocietyofphysiciansandscientists
specializinginthecareofpeoplewithkidneydiseaseandinresearchrelated
tothekidneyandkidneydisease.Toviewthiswebsite,pleasevisit:
www.csnscn.ca.
Thereisanassociationforrenalnursesandtechnologistscalledthe
CanadianAssociationforNephrologyNursesandTechnologists(CANNT).
CANNTsgoalistopromotethedisseminationofknowledgeamongstthose
involvedinthecareofpatientswithrenaldisease.Theyalsopublish
NephrologyNursingStandardsandPracticeRecommendations.Toviewthis
information,pleasevisit:www.cannt.ca/.
II.NORMALKIDNEYFUNCTION
SUPPLEMENTALREADINGCH4,CONTEMPORARYNEPHROLOGY
NURSING
Thekidneysaretwoessential,beanshapedorgans,eachaboutthesizeof
anaveragefistoraconventionalcomputermouse.Theyarelocatedinthe
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flankregionsoneithersideofthespine.Thekidneysperformseveralkey
functions.
1. Removalofwasteproducts.Thekidneysprocess1200mlofblood
perminutetosiftouttwotothreelitresofwasteproductandwater
(calledurine)eachday.Thewasteisgeneratedfromendproducts
offood,bodymetabolism,andenvironmentalfactorssuchasdrugs
andwatersolubletoxins.Wasteproductsincludesubstancessuch
asurea,creatinine,anduricacid.
Thekidneysfilterout____________________litresofwasteproductsand
waterdailycalled____________________.Urea,uricacidand
____________________aresubstancesinthewasteproducts
2. Bodyfluidsandelectrolytesbalance.Healthykidneysexcreteand
resorbvaryingamountsofwaterandothersubstancessuchas
potassium,sodium,chlorideandphosphorus.Theamountofurineis
regulatedprimarilybyantidiuretichormone(ADH)andby
aldosterone.Thesehormoneshelpthekidneyregulatethetotal
volumeofextracellularfluids,theconcentrationoftheurine(water,
solutes)andthespecificquantityofdifferentelectrolytessuchas
sodium,potassium,andchloride.
4MAINFUNCTIONSOF
THEKIDNEYS:
*Removalofwaste
products
*Balanceelectrolytes
&fluids
*BalancepH
*Hormonal&
Enzymaticfunctions
Potassium,____________________sodiumand____________________
aresubstancesthekidneysexcreteand____________________.Waste
product,____________________,isregulatedbytwohormones:
_____________________and____________________.Thesetwo
hormonesregulatethetotalvolumeof____________________,the
____________________ofurineandthespecificamountof
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____________________suchassodium,potassiumandchloride.
ADHisproducedbythehypothalamus,suppressesthesecretionofurine,
andresultsinretentionofwater.
Aldosteroneisproducedbytheadrenalcortexandregulatesthevolumeof
bloodandextracellularfluidprimarilybythereabsorptionofsodium(Na)by
thekidneys.
Whentheextracellularvolumeistoohigh,thebloodvolumeisincreased,
causingincreasedvenousreturntotheheartandsubsequentincreasein
cardiacoutput.Theincreaseincardiacoutputresultsinincreasedarterial
pressurewhichcausesthekidneystoexcreteexcessfluid.Ifthekidneysare
unabletoexcreteexcessfluidduetounderlyingdiseaseprocesses,the
interstitialspacesareforcedtoexpandtoaccommodatetheextrafluid.
Excessfluidintheinterstitialspacesiscallededema.
ADHstandsfor____________________.DoesADHincreaseorinhibitthe
secretionofurine?
Aldosteroneregulatesthevolumeofbloodand____________________,
mainlythroughthereabsorptionofsodium,abbreviatedas
____________________.
Iftheextracellularfluidvolumeisdecreasedduetoincreasedlossor
inadequateintake,thekidneysrespondbyretainingmorefluid.Ifthefluid
volumedeficitistoogreat,thekidneymaynotbeabletocompensatefor
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theimbalanceandothertreatment(suchasIVfluid)maybecome
necessary.
Circlethecorrectresponse:
ADH,urinesecretion(orornochange).Whenextracellularfluid
volume,thekidneys(excretefluid/retainfluid).
REMEMBER:
3. Acidbasebalance.
*VITAMINDISIMPORTANT
Thekidneysareconsideredthemostpowerfulregulatorofacid/base
balanceinthebodyandcanexcretevaryingamountsofacidorbase.Renal
insufficiencyorfailurecancausemetabolicacidosis.
FORBONEFORMATIONAND
CHEMICALBALANCE
*ERYTHROPOIETINSTIMULATES
REDBLOODCELLPRODUCTION
NormalbodyfluidpHisbetween7.35and7.45.IfthepHistoohigh(a
statecalledalkalosis),thekidneywillincreasetheexcretionofbicarbonate
(base)andincreasesreabsorptionofhydrogenions(acid).IfthebodypHis
low(calledacidosis),thekidneywilldecreasetheexcretionofbicarbonate
anddecreasetheabsorptionofhydrogenions.
*RENINISRELEASEDBYTHE
KIDNEYWHENBPISLOW
NormalbodyfluidpHisbetween_____________________.Alkalosis
means____________________whileacidosismeans
____________________.IfthepHistoohigh,thebodywantstomakethe
fluidmore____________________so/theexcretionofbicarbonate
and/theabsorptionofhydrogenions.
4.HormonalandEnzymaticfunctions
a.
ThekidneysarepartiallyresponsiblefortheconversionofVitamin
Dtoitsactivemetabolite.Thisisimportantfortheformationofboneand
chemicalbalanceinthebody.
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b.
Erythropoietinissecretedbythekidneyinresponsetolow
hemoglobin.Thishormonestimulatesthebonemarrowtomakeredblood
cells.
c.
Reninisanenzymethathelpstocontrolbloodpressure.The
kidneyreleasesreninwhenthebloodpressureislowandcausestheblood
vesselstoconstrictandthusincreasethebloodpressure.
These4essentialfunctionsdeclineindiseasedkidneys.However,with
early management by a team of Renal Health Professionals, this
declinecanoftenbesloweddramatically.
WhyistheconversionofVitaminDimportantinthebody?
WhatisoneeffectofErythropoeitinnotbeingsecretedbythekidneys?
Releasingrenincausesbloodpressureto____________________.
SectionIIReview:Whatarethe4mainfunctionsofkidneys?
1.
2.
3.
4.
Fillintheblanksorcirclethecorrectresponses:
Urinecontainswasteproductssuchas(creatinine,uricacid,aldosterone,
potassium,sodium,ADH,urea,chloride).Thetwohormonesthatregulate
theamountofurineare____________________and
____________________.ADHresultsinretention/excretionofwater.
DothekidneyshelpregulatepHinthebody?Yes/No
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Bicarbonateisa(n)(acid/base),hydrogenionsare(acidic/basic).
IfthepHistoohigh(acidosis/alkalosis),thekidneysexcretemore
____________________andincreaseabsorptionof
____________________.
Extracellularvolumeincreases,bloodvolume(increases/decreases)which
(increases/decreases)cardiacoutput.Increasedcardiacoutput
(increases/decreases)arterialpressurewhichcausesthekidneysto
(increase/decrease)excretion.Kidneysmaybeunabletoexcretefluiddueto
diseasewhichcasestheextracellularspacesto(expand/contract)to
accommodatetheextrafluid.
III.MEASURINGKIDNEYFUNCTION
NURSING
Kidneyfunctionismostoftenexpressedintermsofcreatinineclearance
(CrCl)orglomerularfiltrationrate(GFR).Thecreatinineclearancetest
comparesthelevelofcreatinineinurinewiththecreatininelevelinthe
blood,usuallybasedonmeasurementsofa24hoururinesampleanda
bloodsampledrawnattheendofthe24hourperiod.Clearanceisoften
measuredasmillilitres/minute(ml/min).Normalcreatinineclearancefor
adultsis75125ml/min/1.73m2.
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Creatinineclearancetestcomparesthelevelof____________________in
urinewiththecreatininelevelin_____________________.Normal
creatinineclearanceis____________________ml/_______/1.73m2.
eGFRisthestandardbywhichkidneyfunctionisassessed.Creatinine
clearanceisusedtocalculatetheeGFRbecausecreatinineis:
foundinstableplasmaconcentrations,
isfreelyfilteredandnotreabsorbed,and
isminimallysecretedbythekidneys.
NormalGFRforadultsis125ml/min.
REMEMBER:
*NORMALGFRFOR
ADULTSIS125ML/MIN.
TrueorFalse:
__________
Creatinineisextensivelysecretedbythekidneys.
__________
Creatinineiseasilyreabsorbed.
__________
Creatinineisfoundinstableplasmaconcentrations.
__________
Creatinineisnotfreelyfiltered.
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IV.RENALANATOMYANDPHYSIOLOGY
NURSING
Macroanatomyofthekidney:
Copyright,AmgenCanadaInc.,2007/8.Thisdiagramhasbeenincludedonthis
documenttosupportnursingeducationwithpermissionfromAmgenCanadaInc
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Fillintheblanks:
The____________________iswheretherenalbloodvessels,lymphatics,
nervesandtheuretersenterorexitthekidney.
Therenalarteryisthemainarterythatcarriesblood
____________________thekidney.
Therenalveinisthemainveinthatcarries____________________away
fromthekidney.
Thecapsuleorrenalcapsuleisafibrouslayercoveringthekidney.
Thecortexistheouterlayerofthekidneyandisunderneaththe
____________________.Thecortexcontains~8085%ofthenephrons
(corticalnephrons)andtheirbloodvessels.
Themedullaistheinnerportionofthekidney.Itconsistsofpieshaped
wedgescalledpyramids.Thepapilla,thepointofthepieofthepyramids,
projects(into/awayfrom)thecalyx.
Therearetwotypesofcalycesminorandmajor.Urinetravelsfromthe
papillaintoaminorcalyx.Severalminorcalyceswillformamajorcalyx
andurinewillmovefromheretotherenalpelvis.
Theinnerportionofthekidneywherethemajorcalycesmeettoempty
theurineiscalledthe____________________
____________________.
Theureterexitstherenalpelvisandtransportsurinetothe
____________________.
V.RENALCIRCULATION
NURSING
Thekidneysreceive25%ofthebodystotalcardiacoutputandtherefore
arevascularorgans.Thekidneyhastwouniquetraitssharedbynoother
partofthehumanbody:
1. theonlyplaceinthebodywherecapillariesarejoinedbytwo
arteriesand,
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2. havingtwosetsofcapillarybedsineachcirculationloop.
Bowmans capsule
Copyright,AmgenCanadaInc.,2007/8.Thisdiagramhasbeenincludedonthisdocument
tosupportnursingeducationwithpermissionfromAmgenCanadaInc.
Oxygenatedbloodleavestheheartviatheaortaandbranchesoffatthe
renalarterytoenterthekidneyatthe____________________.Fromthe
renalartery,therenalcirculatorysystembranchesintotheinterlobar
arteries,whicharesituatedbetweenthepapillae.Theoxygenatedblood
travelsthroughthearcuatearterieswhichrunalongtheborderbetween
themedullaandthecortex.Arcuatearteriesdivideintointerlobular
arteriesandthentheafferentarterioles.Theafferentarteriolessupplythe
glomerularcapillarieswhereglomerularfiltrationoccurs.Thebloodand
remainingfluidintheglomerularcapillariesdrainintotheefferent
arterioles.Onesetofefferentarteriolesleadtotheperitubularcapillary
network,whichprovideanextensivebloodsupplytothecortexofthe
kidney.
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Theothersetofefferentarterioles,closesttothemedulla,sendbranches
intothemedulla,formingthevasarecta,whichfeedsthemedulla.Nowthat
thebloodhasbeenfilteredandhasnourishedthekidney,itcontinuesback
totheheartviatherenalveinandtheinferiorvenacava.
Note:thisarrangement:afferentarterioleglomerularcapillaries
efferentarterioleistheonlyplaceinthebodywherecapillariesjointo
arteries.
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Note:thetwosetsofcapillarybedsinonesystem
Copyright,AmgenCanadaInc.,2007/8.Thisdiagramhasbeenincludedonthisdocumentto
supportnursingeducationwithpermissionfromAmgenCanadaInc.
VI.THENEPHRON
NURSING
Thenephronisthepowerhouseofthekidney.Filtrationofthebloodand
reabsorptionofsubstancesoccursinthisapparatus.Thereare
approximately11.5millionnephronsineachnormalhealthykidney.
Whatisthenormalglomerularfiltrationrateinahealthykidney?
(fromSectionIII)
a) 115ml/min
b) 125ml/min
c) 130ml/min
Theglomerulusiswheretheglomerularcapillariesarelocatedandwhere
filtrationoccurs.Pressurecreatedbytheheartforceswater,electrolytes,
urea,creatinine,uricacid,glucoseandothersubstancesthroughtiny
filtrationslitsinsideofthesesmallglomerularcapillaries.Thiscollectionof
filtratedsubstancesiscalledglomerularfiltrate.Theglomerularfiltration
rateis125ml/min,whichwillgiveapproximately180litresofglomerular
filtrateeachday!TheglomerulusislocatedintheBowmanscapsuleor
Bowmansspacewhichistheareathatcollectstheglomerularfiltrate.
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Bowmans capsule
Copyright,AmgenCanadaInc.,2007/8.Thisdiagramhasbeen
includedonthisdocumenttosupportnursingeducationwith
permissionfromAmgenCanadaInc.
Wheredoesfiltrationoccurinthekidneys?____________________.The
collectedfiltratedsubstanceiscalled____________________
____________________andiscollectedinthe____________________
capsule.
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Copyright,AmgenCanadaInc.,2007/8.Thisdiagramhasbeen
includedonthisdocumenttosupportnursingeducationwith
permissionfromAmgenCanadaInc.
TheglomerularfiltrateflowsfromtheBowmanscapsuletotheproximal
convolutedtubule.Theproximalconvolutedtubuleslieinthecortexofthe
kidneyanditsprimaryfunctionisreabsorption.Intheproximalconvoluted
tubule,approximatelytwothirdsoftheglomerularfiltrateisreabsorbed
intothebloodstream.Inadditionto____________________filtrate,
plasma,water,nutrientsandelectrolytesarealsoreabsorbed.
Thelong,hairpinloopaftertheproximaltubuleiscalledtheloopofHenle.
TheloopofHenleconsistsofdescendingandascendinglimbs.Theloopsof
Henleextendfromthecortexdownintothemedullaandback.Likethe
proximal____________________tubule,theloopsofHenleareresponsible
forreabsorbingelectrolytesandsmallamountsofplasmawater.
ThedistalconvolutedtubuleisinbetweentheloopofHenleandthe
collectingducts.Liketheproximalconvolutedtubule,thedistalconvoluted
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tubuleislocatedinthe____________________ofthekidney.Itispartly
responsiblefortheregulationofpH,potassium,sodiumandcalcium.
Thecollectingductisthelastportionofthenephronstructure.Anumberof
convolutedtubulesjointogethertocreatethecollectingducts.The
collectingductsbegininthecortex,andextendthroughthemedullaand
emptyintothepapilla.IfADH(___________________________
____________________)ispresent,waterabsorptionoccurs;inthe
absenceofADH,littlewaterabsorptionoccurs.
Oncetheglomerularfiltratehaspassedthroughtheentirenephronportion,
theremainingfiltrate,nowcalledurine,willpassthroughtheminorthen
majorcalyces,intotherenalpelvisandfinallyouttheureters.Eachday,
thereisapproximately10003000mlofurineproducedfromthe180Liters
ofglomerularfiltratethatstartedtheprocess.Substancesfoundinurine
include____________________,____________________,
____________________,drugsandelectrolytes(sodium,potassiumand
phosphate,etc.).(RefertoSectionIIifrequired.)
VII.CAUSESOFCHRONICKIDNEYDISEASE(CKD)
SUPPLEMENTALREADINGCH6&CH7,CONTEMPORARY
NEPHROLOGYNURSING
DiabetesMellitis
DiabeticnephropathyisalongtermcomplicationofDiabetesMellitusthat
occurswhenthesmallcapillariesoftheglomerulusaredamagedfromyears
ofhighbloodsugar.Theglomerulusthickensresultinginglomerulosclerosis
definedasscarringorhardeningofthebloodvesselsinthekidney.Both
TypeIandTypeIIDMcancauseCKD.Althoughnotallpeoplewithdiabetes
willdevelopCKD,theriskincreasesifthebloodglucoseispoorlycontrolled.
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Hypertension
Prolongedhypertensioncancausenephrosclerosis,atermthatrefersto
hardeningofthekidney.Untreatedhypertensioncanleadtosclerosisof
therenalarterioles,whichdecreasesthebloodsupplytothenephrons.
Clinicalpresentationistypicallylongtermessentialhypertensionand
progressiverenalinsufficiencywithmildproteinuria,retinalchanges,and
leftventricularhypertrophy.
Patientswithdiabetesmellitusorwithevidenceofrenaldamageshould
havetheirbloodpressurecontrolledtolessthan130/80mmHg.
Glomerulonephritis
Glomerulonephritis(GN)referstoacomplexgroupofdiseaseprocesses
affectingtheglomerulus.GNisaninflammationoftheglomerulusleading
toanimpairmentofrenalfunctionpartlyduetotheformationof
antibody/antigencomplexes,whicharedepositedwithintheglomerulus.
Patientswithglomerulardiseasespresentwithabnormalitiesintheurine,
suchasproteinuria,duetodamagetothefiltratingmembrane.Arenal
biopsyisrequiredforadefinitivediagnosisaswellastoestablishchronicity
orreversibility.Therearethreecommontypesofglomerulonephritis.
IgAnephropathyisthemostcommonformofGNworldwide.Itisa
conditioninwhichthereisanaccumulationofIgAcomplexeswithin
theglomeruli.ThecauseofIgAnephropathyisnotknown.
However,itisfeltthatgeneticfactorsmaycontribute.
Goodpasturessyndrome(GPS)isadisorderinwhichthebody
developsanautoimmuneresponsetothealveolarcapillariesinthe
lungsandtotheglomerulus.
PostinfectiousGlomerulonephritis(PIGN)canoccuraftera
streptococcalinfectionofeithertheupperrespiratorytractorof
theskin.Thestreptococcalinfectioncausesinflammationofthe
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smallbloodvesselsoftheglomerulus.PIGNisrarebeforeage2,but
commoninschoolagedchildren,andcanoccuratanyageinadults.
Thereisusuallya714daylatentperiodafterarespiratoryinfection
and2128daysafteraskininfection.Childrenoftenrespondfullyto
medicalmanagement,butcompleterecoveryinadultsisless
certain.
Thecomplicationresultingfromdiabetesmellitusiscalled
________________________________________whichaffectsthe
kidneysbyeventuallycausingglomerulosclerosis.Glomerulosclerosis
means______________________________________________________.
Themaincomplicationaffectingthekidneysthatresultsfromhypertension
iscalled____________________Thistermmeanshardeningofthe
kidney.Peoplepresentwiththefollowing:
_________________________,_________________________,
_________________________,_________________________.
Thereare____________maintypesofglomerulonephritiswhichis
diagnosedthrougharenal____________________.Generally,GNisan
inflammationoftheglomerulusleadingtoanimpairmentofrenalfunction
partlyduetotheformationof____________________complexes.These
aredepositedwithintheglomerulus.Patientswithglomerulardiseases
presentwithabnormalitiesinthe____________________,suchas
proteinuria.
Themostcommontypeofglomerulonephritisiscalled
____________________.Whenthebodydevelopsanautoimmune
responsetothealveolarcapillariesinthelungsandtotheglomerulus,a
conditioncalled________________________________________results.
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Childrenoftenfullyrecoverfrom____________________
____________________,whichoccursaftera____________________
infectionoftheupperrespiratorytractortheskin.
AutosomalDominantPolycysticKidneyDisease(ADPKD)
ADPKDisthemostcommoninheritedkidneydiseasewhichaffectsboth
malesandfemales.Normalkidneytissueisreplacedwithgrapelikeclusters
thatcompressanddestroythesurroundingtissue.ADPKDaffectsbothmen
andwomenofallethnicgroups.Complicationsincludehypertension,
painfulruptureofcysts,hemorrhagiccysts,hematuria,urinarytract
infections,andnephrolithiasis.Treatmentgoalsincludemanagementof
hypertensionandpreventionofinfection.About50%ofpeoplewithADPKD
developendstagerenaldisease(ESRD).
SystemicLupusErythematosIs(SLE)
SLEisachronicsystemicinflammatorydisorderoftheconnectivetissues
resultingfromtheformationofautoantibodies.Femaletomaleratio
occurrenceis9:1.RenalinvolvementisreferredtoasLupusNephritisandis
clinicallypresentin50%ofpatientsatthetimeofdiagnosis.Immune
complexesaredepositedintheglomerularcapillariesandaninflammatory
responsefollows,whichinturncausesdamagetothecapillariesand
adjacentstructures.Specificsignsandsymptomsincludemalarorbutterfly
rashonface,photosensitivity,fever,arthralgia,elevatedESR,proteinuria,
hematuria,and,hypertension.
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SystemicVasculitis
Systemicvasculitisischaracterizedbyinflammationofthebloodvessels.
Virtually,anysizeortypeofbloodvesselinanyorgancanbeaffected.The
followingbrieflydiscussestwotypesofvasculitis.
WegnersGranulomatosispredominantlyaffectsthesmallandmedium
sizedarteriesofthekidneysandrespiratorytract.Theexactcauseisnot
known.
HenochSchonleinPurpura(HSP)isatypeofvasculitis/inflammation
involvingthesmallvesselsinthejoints,skin,kidneys,andGItract.Itismost
oftenseeninyoungchildrenwithaslightlyhigherincidenceinmales.The
exactetiologyisunclear.However,incidenceincreasesinthewinterand
springwhenupperrespiratorytractsinfectionsaremorecommon,
suggestingthepossibilityofaninfectiousetiologyinsomepatients.
ADPKDwhichstandsfor
__________________________________________________isthemost
commoninheritedkidneydiseaseandabout_______%ofpeoplewith
ADPKDwilldevelopEndStageRenalDisease.Complicationsinclude
____________________,____________________,
_________________________________________________________,
painfulruptureofcysts,hemorrhagic____________,andnephrolithiasis.
SLE,______________________________________________________,
overwhelminglyoccursinfemales.Therenalassociationiscalled
________________________________________Commonsignsand
symptomsincludeabutterflyrashonthefacecalleda
____________________,_____________________,arthralgia,
____________________,fever,____________________,hypertensionand
____________________.
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Thediseasecharacterizedbytheinflammationofthebloodvesselsis
knownas____________________.____________________hastwo
maintypesthataffectthekidneys:Wegners____________________
whichaffectsthesmallandmediumsizedarteriesinthekidneysand
respiratorytractandHenochSchonlein____________________(HSP)
involvessmallvesselsinthe____________________,kidneys,
____________________,____________________and
____________________.
ThromboticMicroangiopathy:HemolyticUremicSyndrome
Thisadiseasecharacterizedbymicroangiopathichemolyticanemia,
thrombocytopenia,andvariousrenalandneurologicalmanifestations.
HemolyticUremiaSyndrome(HUS)isincludedinthisdiseasecategory.HUS
(alsoknownasHamburgerdisease)ismostoftencausedbyastrainof
bacteriaknownasE.coli0157:H7.InHUS,redbloodcellsaredestroyedand
plateletandfibrinthrombioccludetheglomerularcapillariesandarterioles
causingischemiaandsometimesnecrosis.
MultipleMyeloma
MultipleMyelomaisatumorofplasmacellsinthebonemarrowthat
producesexcessiveimmunoglobulin(Mprotein).Thechainsof
immunoglobulinproducedinexcessarenephrotoxicandcausetubular
damage.Renaldysfunctionoccursinmorethan50%ofpatients.
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Amyloidosis
Amyloidosisisasystemicchronicdiseasecharacterizedbyanaccumulation
ofabnormalfibrillarscleroprotein,whichinfiltratesbodyorgansandsoft
tissue.Whenamyloidosisinvolvesthekidneys,theglomerulusisdamaged.
Renalinvolvementoccursinmorethan90%ofpatients.
ProgressiveSystemicSclerosis:Scleroderma
Sclerodermaisamixedconnectivetissuediseasecharacterizedby
connectivetissueproliferationandvascularlesions.Inpatientswithrenal
involvement,thediseaseresultsinnarrowingofthelumenofthesmall
interlobularandarcuatearteries.Glomerularischemiacommonlyleadsto
elevatedreninlevelsandsubsequenthypertension.
Hamburgerdiseaseisactuallycalled____________________
____________________SyndromeandisusuallycausedbyE.coli
0157:H7.Itischaracterizedby____________________
________________________________________,
________________________________________andotherrenaland
neurologicalmanifestations.HUSdestroys____________________
________________________________________whichultimatelyresults
in____________________andoccasionallynecrosis.
Renaldysfunctionoccursinmorethan50%ofpeoplewithmultiple
_____________________,atumorofbonemarrowplasmacellswhich
produces____________________immunoglobulinwhichthencauses
tubulardamageinthekidneys.
Anaccumulationofabnormalfibrillarscleroproteincharacterizes
____________________whichdamagesthe____________________in
thekidney.Morethan________%ofpeoplewithamyloidosisdevelop
renalproblems.
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Thenarrowingoflumenofinterlobularandarcuatearteriesiscausedby
____________________.Ischemiainthispartofthekidneyleadsto
(elevated/decreased)levelsof____________________andhypertension.
UrinaryTractInfections(UTIs):Pyelonephritis
Pyelonephritisisaninflammationoftherenalparenchyma(structure)
causedbybacteriathathaveascendedtheurinarytractintothekidney.
Withrepeatedinfection,healthyrenalparenchymamaybereplacedwith
chronicscartissueleadingtochronickidneydisease.
ChronicDrugInducedTubulointerstitialNephritis(TIN)
ChronicdruginducedTINisaformofCKDthatresultsfromlongtimeuseof
prescriptionandnonprescriptiondrugs.Themostcommonformis
analgesicnephropathy.Thisformofnephritiscausesinflammationtothe
tissuesofthekidneyssurroundingtherenaltubules.Theinflammationof
thetissuesdamagestherenaltubules.TINcanoccurwithprolongeduseof
medicationssuchasNSAIDS,aspirin,andacetaminophen.
RenalArteryStenosis(RAS)
RASisdefinedasnarrowingoftherenalarterylumenby50%ormore.RAS
resultsinasignificantdecreaseinrenalbloodflow,whichtriggerstherenin
angiotensinaldosteronesystemwithresultingvasoconstriction,retention
offluidwithvolumeexpansion,andhypertension.RASiscausedby
atherosclerosisinover90%ofcases.
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Aninflammationofarenalstructurecausedbybacteriathathave
ascendedtheurinarytractintothekidneyiscalled
_____________________.Repeatedinfectionsleadtoscarringofthe
____________________whichcanleadtochronickidneydisease.
TINstandsfor________________________________________which
canbecausedbylongtimeprescriptionandnonprescription
____________________use.ThemostcommonformofTINis
_________________________________________.
Anarrowingoftherenalartery____________________by50%ormore
(increases/decreases)renalbloodflowwhichtriggersthe
___________________/____________________/____________________
systemandresultsin____________________,retentionoffluidand
____________________.
VIII.CHRONICKIDNEYDISEASE(CKD)
SUPPLEMENTALREADING:CH10,CONTEMPORARYNEPHROLOGY
NURSING
CKDisdefinedasirreversiblekidneydamagefor3monthsormore,orGFR<
60ml/min.Markersofdamageincludeabnormalitiesinthebloodorurine
testsorimagingstudies.
Kidneydiseasecanbeasilentdiseaseandisoftenundetecteduntilitisin
laterstages.Earlyidentificationofpatientswhomaybeatriskfor
developingkidneydiseaseisimportanttohelppreventendstagerenal
disease.Theriskfactorsinclude:
RISKFACTORSOFCKD:
*DiabetesMellitus
*Hypertension
*Urinarytract
abnormalities
*Knownsystemic
autoimmunedisorders
*Excessiveuseof
knownnephrotoxins
(NSAIDS)
*Symptomssuggestive
ofasystemicillness
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DiabetesMellitus
Hypertension
Urinarytractabnormalities
Knownsystemicautoimmunedisorders
Excessiveuseofknownnephrotoxins(NSAIDS)
Symptomssuggestiveofasystemicillness
TheKidneyDiseaseOutcomeQualityInitiative(K/DOQI)workinggroup
developedaclassificationsystemofthestagesofchronickidneydisease
basedonthelevelofkidneyfunctionmeasuredbyGFR.Adverseoutcomes
ofCKDcanbebasedonthelevelofkidneyfunction,thustheclassification
systemprovidesaframeworkfortheevaluationanddevelopmentofa
clinicalactionplanforpatientswithCKD.Theclassificationsystemisbased
onthecalculatedGFR,whichiswidelyacceptedasthebestmeasureof
kidneyfunctioninhealthanddisease.
Inadditiontoestablishmentofadiagnosis,itisimportanttoassessthe
severityofkidneydysfunctionandestablishthestageofCKD.Interventions
duringtheearlystagesofCKDarecriticalinslowingdiseaseprogression.
However,CKDoftengoesundetectedbecausepatientsarefrequently
asymptomatic.
ThisdiagramdepictstheManitobaRenalProgramstagingsystem,whichis
basedontheKDOQIguidelines.TherearefivestagesofCKDwithfour
therapeuticzonesidentifiedbeforerenalreplacementtherapy(RRT).
STAGES&THERAPEUTIC
FOCUS:
STAGE1PREVENT
KIDNEYFAILURE
STAGE2DECREASE
RATEOFDECLINE
STAGE3DECREASE
RATEOFDECLINE
STAGE4MANAGECRF
COMPLICATIONS
STAGE5PREPAREFOR
RENALREPLACEMENT
THERAPY
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ChartcourtesyoftheManitobaRenalProgram.
AsGFRdeclines,patientsbegintoshowsignsofhypertension,awiderange
oflababnormalities,andsymptomsduetodisordersinotherorgan
systems,includingcardiovascularcomplications,anemia,dyslipidemia,
disordersofbonemetabolism,proteinenergymalnutrition,neuropathy,
andalterationsinhealthstatus.
ComplicationsassociatedwithdecliningGFR:
CardiovascularDisease(CVD)isverycommonamongpeoplewithCKDand
complicationscanincludehypertension(seebelow),leftventricular
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hypertrophy,congestiveheartfailure,angina,andmyocardialinfarction.
CVDistheleadingcauseofdeathofpatientswithstage5CKD.
HypertensionisaleadingcauseofCKDbutitisalsoacomplicationofCKD.
Thehigherthebloodpressurethegreatertheriskofmyocardialinfarction,
heartfailure,andkidneydamage.ImprovedBPcontroldecreases
progressionofCKD.
AnemiaiscommoninCKDmainlyduetoadeclineinthestimulationofred
bloodcellproduction,orerythropoietinsynthesis,bythekidneys.
ProteinEnergyMalnutrition(PEM)causesaremultifactorial.Theyinclude,
poornutritionalintakeduetouremiainducedanorexia,increasedprotein
catabolismcausedbymetabolicacidosis,negativeeffectofinflammation
andinfectionondecreasingvisceralproteinsynthesis,andendocrine
disorders.Aswell,patientswithlaterstagesofCKDareoftenplacedon
restricteddietsthatlimitthevarietyoffoodstheycaneat.
MetabolicAcidosisoccursasthenumberoffunctioningnephronsdeclines
resultinginimpairedretentionandexcretionofH+(hydrogen)andHCO3
(bicarbonate)ions.
DisturbancesinMineralandBoneMetabolismdevelopsastheGFR
declines.Abnormalcalciumandphosphorousmetabolismandelevated
parathyroidhormonecanleadtopruritis,bonedisease,myopathy,andsoft
tissuecalcifications.
NeurologicalDisturbanceisacommoncharacteristicofCKD.Increased
levelsofuremictoxinshavecorrelatedwithreductionofnerveconduction
velocityandperipheralmanifestationsofneuropathy.Cognitiveimpairment
mayalsooccurasaresultofuremiaandanemia.
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DyslipidemiaiscommoninpatientswithCKD.Thetypicalpatternconsists
ofelevatedtriglyceridesandloweredhighdensitylipoprotein(HDL)
cholesterol.
QualityofLife:ThereisgoodevidencethatdecliningGFRisassociatedwith
abnormalitiesinhealthstatus,functioning,andwellbeing.
PregnancyandPreexistingRenalDisease:Mildrenalimpairmentatthe
onsetofpregnancyisassociatedwithalowriskofdeclineinrenalfunction.
Chronickidneydiseaseinpregnancyincreasestheriskoffetalloss,preterm
birth,andlowbirthweight.Therefore,contraceptionisrecommended
althoughmensesmaybecomeirregularandmayhavestopped.
Approximately1%7%offemalepatientsondialysisbecomepregnant.
Pregnancyfollowingrenaltransplantisnotuncommon,butshouldbe
avoidedforthefirstyear(livingdonor)ortwoyears(deceaseddonor)to
allowforstabilizationofimmunosuppression.
Whatisthetherapeuticfocusineachstage?
Stage1:
Stage2:
Stage3:
Stage4:
Stage5:
Thereare10commoncomplicationsassociatedwithCKD.Listthem:
DRAFT
47
47

TheleadingcauseofdeathinpeoplewithStage5CKDis
____________________.
____________________isbothacomplicationandacauseofCKD.
Thekidneysmakelessofthehormone,_____________________,
whichaffectsredbloodcellproductionandresultsin
____________________inpeoplewithCKD.
List3causesofProteinEnergyMalnutrition:
1.
2.
3.
Theimpairedexcretionandretentionofhydrogenionsand
bicarbonateionsresultsin____________________
____________________.
Abnormalcalciumandphosphorousmetabolismandelevated
____________________hormonecanleadto____________________,
____________________,____________________andsofttissue
calcifications.
DRAFT
48
48
Whichcomplicationhasapatternofelevatedtriglyceridesand
loweredHDLcholesterol?____________________
WhymightneurologicaldisturbanceresultfromCKD?
________________________________________________________
ACUTERENALFAILUREIS
THESUDDENINABILITYOF
THEKIDNEYSTOREMOVE
EXCESSBODYFLUID,
MINERALSANDWASTE
PRODUCTS.
IX.ACUTERENALFAILURE(ARF)
SUPPLEMENTALREADING:CH9,CONTEMPORARYNEPHROLOGY
NURSING
Acuterenalfailureisdefinedasthesuddeninabilityofthekidneysto
removeexcessbodyfluid,mineralsandwasteproducts.Thereisarapid
declineinglomerularfiltrationrate(GFR)bygreaterthan50%.Thischange
inthekidneysperformancemaybecausedbytrauma,surgicalprocedure,
medications,poisoning,orasacomplicationofcriticalillness.Clinically,
symptomsareoften:
Elevationinurea,creatinineandpotassium
Metabolicacidosis
Oliguria(urineoutput<400)oranuria(urineoutput<100),
althoughnonoliguria(normalurinevolume)mayoccur
Fluidoverloadforthoseexperiencingoliguriaoranuria
Theprognosisforrecoveryofrenalfunctionvarieswiththecauseand
extentofinjury.Thelongerthedurationoftherenalinjuryandthemore
severetheclinicalsymptoms,thehigherthemortalityrate.Overall
mortalityratesareapproximately50%andinfectionisthemajorcauseof
death.Incriticallyillpatients,themortalityrateisashighas85%.
CAUSESINCLUDE
TRAUMA,MEDICATIONS,
POISONING,SURGERYOR
COMPLICATIONOFA
CRITICAL ILLNESS
3TYPESOFARF:
*PRERENALKIDNEYSARE
STRUCTURALLYNORMAL;
DAMAGEDBYLACKOFBLOOD
SUPPLY
*INTRARENALKIDNEY
TISSUEISINJURED;DAMAGE
TOGLOMERULI,VESSELS,
RENALTUBULES
*POSTRENALKIDNEYSARE
STRUCTURALLYNORMAL;
BLOCKAGEINFLOWOR
URINE;PRESSURECAUSES
NEPHRONSTOSHUTDOWN.
DRAFT
49
49

TherearethreemaintypesofARF.
1.Prerenal.InthistypeofARF,thekidneysarestructurallynormalbutare
damagedbythelackofbloodsupplytothekidney.Commoncausesofthis
are:
Decreasedcardiacoutput(CHF,MI,pulmonaryembolism)
Uncontrolledvasodilation(sepsis,anaphylacticshock)
Hypovolemia/volumedepletion(hemorrhage,burns,GIlosses)
Renalvascularobstruction(renalarterystenosis,renalartery
thrombosis)
Kidneyfunctioncanberecoveredifbloodsupplytothekidneycanbere
established.ProlongedprerenalARFcanresultinpermanentdamage.
Prerenal
(beforethekidneys)
2.Intrarenal.InthistypeofARF,thekidneytissueitselfisinjuredand
involvesstructuraldamagetoglomeruli,vessels,andrenaltubules
Prerenalcausesthatarenotcontrolledwillleadtointrarenalfailure.
CommoncausesofintrarenalARFare:
Largevesselinjury(renalarterystenosis,thrombosis,emoboli,
endocarditis,tumor,afib)
Smallvesselinjury(scleroderma,HUS,vasculitis,postpartum,
medications)
DRAFT
50
50
Overall,theprognosisforrecoveryofrenalfunctionforthistypeofARFis
poor.Iftheunderlyingconditioncanbecorrected,renalfunctioncan
significantlyimprove.
Intrarenal
(withinthekidneys)
3.Postrenal.InthistypeofARF,thekidneysarestructurallynormaland
goodbloodsupplyexists,butthereisablockageintheflowofurinealong
theurinarytract.Theexcessivefluidpressurecausesthenephronstoshut
down.Commoncausesofthisare:
Obstructions(enlargedprostateglands,bladderstones,pregnancy,
uterineprolapse)
Tumors
KidneyfunctioninpostrenalARFcanoftenberestored.Recoverydepends
ondurationandseverityoftheobstruction.
Postrenal
(afterthekidneys)
DRAFT
51
51

WhatarethethreetypesofARF?
InwhichtypesofARFarethekidneysstructurallynormal?
InwhichtypesofARFcankidneyfunctionberestored?
CKD&MANITOBA:
X.ESRDINMANITOBA
In2009,Manitobaisamongstthehighestratesconcerningincidenceand
prevalenceratesofESRDinCanada,whichis232.4RPMPand1431.3RPMP
respectivelyincomparisontoCanadasaverageof159.3RPMPand1118.7
RPMPrespectively.AccordingtotheCanadianInstituteforHealth
Information(CIHI),thatafter20years,thenumberofCanadianslivingwith
kidneyfailureratesarenowappearingtostabilize.Also,33%of
Manitobanschosetransplantasatreatmentstrategy,whichisamongstthe
lowestpreferenceinrelationtootherprovinces.Thissectionincludessome
statisticstohelpyouappreciatethecontextofchronickidneydiseasein
Manitoba.
*HIGHESTINCIDENCEAND
PREVALANCERATEIN
CANADA
1749ON
DIALYSIS(DECEMBER
2009)
946HEMODIALYSIS
87CONTINUOUS
AMBULATORYPERITONEAL
DIALYSIS
135AUTOMATED
PERITONEALDIALYSIS
581TRANSPLANT
DRAFT
52
52
INCIDENTERSD,AGESPECIFICRATEPERMILLIONPOPULATION,
CANADA,1990TO2009
DRAFT
53
53
PREVELENCERATEFORPATIENTSONDIALYSISORWITHFUNCTIONING
TRANSPLANTINCANADA,1990TO2009(RATEPERMILLION
POPULATION)
DRAFT
54
54
CONCLUSION
Congratulations!StudyingtheinformationintheSelfLearning
PackagewillprepareyoutoentertheManitobaNephrologyNursing
Course(MNNC)whereyouwilldevelopknowledgeandskillsbuilding
ontheSelfLearningPackage.WhenyouarereadytowritethePre
EntranceExam,pleasecontacttheManitobaRenalProgramRenal
EducationDepartmenttobookanappointmentdateandtime.
DRAFT
55
55
References
AMGENCanada.(2001).Essentialconceptsinrenalfailureapractical
continuingeducationseries.Mississauga,ON
CanadianInstituteforHealthInformation.(2011).2011CORRreport
treatmentofendstageorganfailureinCanada2000to2009.
Retrievedfrom
https://secure.cihi.ca/estore/productSeries.htm?pc=PCC24
JanssenOrthoInc.andBaxterCorporation(1999).Progressiverenal
insufficiency:Educationresourceguide.Toronto:The
MedicineGroupLtd.
ManitobaRenalProgram(2008).Frompresentation:Visionforthe
sustainabledeliveryofrenalcareinManitoba.
Molzahn,A.&Butera,E.(2006).Contemporarynephrologynursing:
Principlesandpractice,2ndEd.AmericanNephrologyNurses
Association;AnthonyJannettiInc.
Wikipedia(n.d.)Kidneyretrievedfrom
http://en.wikipedia.org/wiki/Kidney
DRAFT
56
56
Wikipedia(n.d.)Nephronretrievedfrom
http://en.wikipedia.org/wiki/Nephron
WinnipegRegionalHealthAuthority,2010
Allrightsreserved.Nopartofthisdocumentmaybealtered,
reproduced,storedortransmitted,inanyformorbyanymeans,
withoutthepriorwrittenpermissionofthecopyrightholderexcept
inaccordancewiththeprovisionsoftheCopyrightAct.Applications
forpermissiontoreproduceoralteranyportionofthisdocument
shouldbeaddressedto:[mrp.ed@hsc.mb.ca]
DRAFT
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