End-stage renal disease pathophysiology and patient case study

End Stage Renal Disease

End-Stage Renal Disease

Genogram

This study addresses a patient named 'George White', born 7/15/1950. He is married to Donna White, born 1/5/65, and has two children: Jamal (male), born 9/25/92, and Rasheeda (female), born 7/11/97. Mr. White has a 2nd daughter and two grandchildren. His oldest child Kia, from prior relationship, was born 10/23/70, and she has 2 children: Kijay, born 6/18/90, and Quadir, born 8/14/96.

Summary of health problems/disease:

Medical history of patient George White: (a) Diabetes Type 2; (b) Hypertension; (c) Congestive heart failure; (d) Chronic hepatitis C; (e) end-stage renal disease (analysis topic); and (f) patient has been on Hemodialysis treatment since June, 2011.

Medical history of Patient

diabetes type 2

hypertension

congestive heart failure

chronic hepatitis C

currently he has end stage renal disease (Which will be the subject of our analysis)

The patient is on Hemodialysis since June of 2011

End-Stage Renal Disease & Pathophysiology

End-stage renal disease (ESRD), also known as chronic renal failure, consists of irreversible and progressive deterioration of kidney (renal) function that is inevitably fatal for the individual. In ESRD, the patient has severe azotemia and/or uremia, retention of nitrogenous waste products such as urea in the blood due to the failure of the renal system to filter out waste products, occurring concomitantly with the failure to maintain electrolyte, fluid, and metabolite balance.

There are a variety of potential physical origins from which ESRD may develop. This may be the result of chronic and systemic disorders, of which the leading cause is diabetes mellitus. It may also arise as a consequence of exposure to and intake of toxic agents; can result from medications, infections, and vascular disorders; and may be a consequence of polycystic kidney disease and concomitant hereditary lesions. Other possible physical disease states that may lead to ESRD include: hypertension; obstruction of the urinary tract; inflammation of the renal pelvis, or pyelonephritis; and as a consequence of chronic glomerulonephritis. In addition, other health conditions may contribute to the high mortality rate for individuals having end-state renal disease (Finnegan-John and Thomas, 2013).

Factors influencing the pace at which renal failure progresses are both dependent upon, and related to, the rate of protein excretion in the urine, extent of concomitant hypertension, and the nature of any underlying disease state. As reported by Finnegan-John and Thomas (2013), end-stage renal disease may develop at a faster rate for those patients who are hypertensive, as well as those excreting large amounts of protein as compared with patients who are not hypertensive or displaying symptoms of proteinuria.

Adult origins of ESRD vary. Health conditions that may result in ESRD include: Alport syndrome, glomerulonephritides, lupus nephritis, obstructive uropathy, diabetic glomerulopathy, complications from kidney transplant, chronic pyelonephritis, and polycystic kidney disease. As well, renal failure may be the result of exposure to occupational and/or environmental compounds such as the heavy metals chromium, lead, mercury, and cadmium. Uremic syndrome, regardless of origin, consistently presents as a loss of the individual's renal system to maintain and regulate body fluid composition.

Uremia may result in a variety of other health complications. Cardiovascular complications may include: capillary fragility, congestive heart failure (CHF), pericarditis, arrhythmias, and hypertension. As well, there may be effects upon the lungs, such as pleural effusions and pulmonary edema. The nervous system may become involved as well, with altered mental states that can vary widely, from coma to simple lethargy, as well as peripheral neuropathy and diverse other psychological changes, including depression. Alterations of the musculoskeletal system include metastatic calcifications, renal osteodystrophy, and generalized muscle weakness.

Without dialysis, untreated end-stage renal disease can produce imbalance of important electrolytes (calcium, potassium, magnesium, and phosphorus), leading to increased and excessive intravascular volume, acidemia, and the potential of involvement of other organ systems in what is called secondary dysfunction. In terms of hematology, uremic effects include a shifted oxy-hemoglobin dissociation curve, anemia, and platelet dysfunction. Other symptoms include intestinal disorders, vomiting, nausea, and ulceration of the gastro-intestinal tract. Impaired cellular immunity may be observed, along with general depression of the immune response. Given the diversity of untoward symptoms, dialysis or kidney transplant may be the only effective options, and generally dialysis will reduce many of these symptoms as well as improving the patient's sense of physical well-being (Finnegan-John and Thomas, 2013).

Nursing theorist

Regardless of the age of a patient, dialysis is useful and effective in correction of toxicities (Finnegan-John and Thomas, 2013). Indeed, either kidney transplantation or dialysis may ultimately become a necessity in order for the patient to survive. Uremia development in end-stage renal disease results in a worsening of many of the symptoms. Proteinuria occurs as well, when the kidneys no longer function to excrete end-products of protein metabolism. As waste products increase (azotemia/uremia) the general symptoms worsen (Finnegan-John and Thomas, 2013).

Quality of Life

Quality of Life, and the extent to which this is impacted will be examined in this study, which may potentially assist in future understanding of how renal disease affects the individual patient, as well as their family, friends, and associates. In the United Kingdom (UK) the NICE National Institute for health and Care Excellence has established guidelines to address psycho-social issues for patients with physical health problems that may result in depression. This will obviously be pertinent to individuals having end-state renal disease. The data presented herein will focus on quality of life, as addressed by Skevington (1994). However, findings presented here may not apply in future to all patients with end-stage renal disease. This will be a major limitation of this work, even with respect to the framework of Quality of Life. The guidelines established by the NICE national institute for health and care excellence suggest treatment of depression in adults having chronic health problems, which would obviously include end-stage renal disease (Nice, 2009).

Care Management Analysis

Complications

When a patient presents with end-stage renal disease, there are numerous concerns and complications for Nurses, some of which may result in an approach that is necessarily collaborative in nature. Examples of conditions that may exacerbate ESRD include: (a) Anemia; (b) Hypertension; (c) Bone disorders; (d) Hyperkalemia; and (e) Pericarditis. Each of these conditions may have additional origins and symptoms. Anemia can result from blood loss during hemo-dialysis, from decreased erythropoietin production, from toxin-induced GI-bleeding (gastro-intestinal tract), from ulcer formation, and from decreased red blood cell life span. Hypertension may arise as a consequence of malfunctioning of the aldosterone-angiotensin-renin system, as well as from water and sodium retention. Bone disorders may arise from elevated aluminum levels, low serum calcium levels, abnormal metabolism of Vitamin D, and from vascular calcifications originating in phosphorus retention, as well as metastatic bone disorders. Hyperkalemia (elevated potassium) may arise due to excessive fluid intake and/or retention just from daily fluids as well as from medications and diet, as well as from altered patterns of excretion, catabolism, and metabolic acidosis. Pericarditis, as well as pericardial tamponade, and pericardial effusion can occur as a result of inadequate dialysis and/or retention of uremic waste products.

Medical management

Medical management of end-stage renal disease has as its goals the maintenance of kidney homeostasis and function for the longest period of time achievable. While management is primarily achieved through provision of appropriate dietary therapy and pharmaceutical regimens, it is the goal of the medical staff, and particularly the Nurse, to identify, address, and treat as many ESRD contributory factors as possible. One focus is to specifically address reversible factors such as any obstruction. Control of azotemia/uremia may require hemo-dialysis to control electrolyte balance as well as to lower the uremic toxins in the blood.

Plan for Patient Care

In cases of renal failure, the plan for patient care should include: complete medical history; physical examination; and specific diagnostic evaluation for the state of renal health.

The latter should consist of: (a) Kidney biopsy, in which either a surgical procedure or a needle is used to remove kidney tissue samples for microscopic examination, to check for abnormal and/or cancerous cells; (b) Blood tests, to examine levels of kidney function by measurement of electrolyte levels, protein in the blood, toxins such as uremic waste, and blood cell counts; (c) Sonography (ultrasound examination of the kidneys), using a transducer, this non-invasive test produces sound waves that transmit a picture of the kidney to the operator, and may reveal the presence of kidney stones, cysts, or other obstructions; (d) Urine tests; and (e) CAT scan, also known as computed tomography or CT. This method uses a combination of computer technology and X-rays to produce views of the kidney; dyes cannot normally be used in cases of kidney disease.

Subsequent to the completion of initial diagnostic protocols, treatment will be established depending upon the diagnosis that is established. In the case of end-stage renal disease, treatment may include: specific dietary requirements; hospitalization; diuretic therapy including pharmaceuticals to increase urine output (diuretic drugs) and increased fluid intake, both orally and by administration of IV (intravenous) fluids to ameliorate depleted blood volumes; medications to control/avoid hypertension; and monitoring of electrolyte levels (calcium, potassium, and sodium). Electrolyte imbalance is a serious concern, as is fluid overload. In a few instances, patients might develop severe electrolyte disturbances as well as toxic levels of some waste products usually removed by the kidneys.

Once chronic renal failure has been diagnosed, the treatment regimen prescribed will be dependent upon the extent to which the kidneys are impaired. When possible, treatment may include pharmaceuticals, diuretic therapy, and dietary restrictions. Medications will address hypertension, increase fluid output, aid in cases of lost bone density, and aid in cases of anemia. When medication and other means do not help with the end-stage renal disease, often kidney transplant and/or dialysis may be recommended.

Definition of Dialysis

The medical procedure known as dialysis is a process whereby the patient's blood is 'washed' or treated to remove both excess fluid and toxic/waste substances. Both excess fluid and toxins are normally removed by the kidneys in a 'healthy' individual. Prescription of a dialysis regimen occurs on a routine basis for those patients having end-state renal disease, chronic renal failure, and acute renal failure; as well, dialysis may be prescribed in cases where a patient has either ingested and/or been exposed to occupational and environmental toxins. In the latter case, this may be a wholly remedial approach in order to prevent a subsequent failure of the renal system.

Peritoneal dialysis.

In peritoneal dialysis, a surgeon inserts a specially designed soft hollow tube into the area of the lower abdomen near the navel. This tube enables the dialysate solution (which contains sugar among other compounds) to be infused or instilled into the peritoneal cavity. This fluid fills the peritoneal cavity, an extra-organ space having two membrane layers. The dialysate remains in the cavity for the time ordered by the physician, during which it absorbs waste products and toxins. After the designated time period, the fluid is drained by the patient, precisely (hopefully) measured, and then discarded. Peritoneal dialysis is generally one of three types: IPD, intermittent peritoneal dialysis; continuous ambulatory peritoneal dialysis, CAPD; and continuous cyclic peritoneal dialysis (CCPD). How these protocols works varies. With CAPD, no machine is required, and the peritoneal fluid can be passed (exchanged) from three to five times daily during the hours when the patient is awake. With CCPD, a special home-dialysis machine is required, and this can occur even while the patient is sleeping. For IPD, the CCPD equipment is also used, but the duration of treatment is longer. IPD, while it is possible to do in-house, is most often done in the hospital, or under the supervision of trained medical personnel.

Peritoneal dialysis can result in complications, particularly if a strict regimen of cleanliness is not observed. In particular, it is possible to have an infection of the peritoneum, called peritonitis, at the insertion site for the catheter; this can result in severe stomach pain and fever. For patients using IPD, diet is generally prescribed and/or planned with the assistance of a dietician, who will adapt and suggest dietary items in accordance with the physician's instructions. In general, there may be potassium restrictions as well as special fluid, salt, and protein requirements for the patient. It is also likely that calorie intake will have to be regulated and/or decreased, due to the presence of sugar in the dialysate, which can induce weight gain.

Hemodialysis.

Hemodialysis can be accomplished in an out-patient clinic, a hospital, or in some cases at home, or in a special 'dialysis center'. The presence of trained health care professionals may be warranted. The procedure involves insertion of an AV (arteriovenous) fistula, a surgical opening, into the arm (generally speaking). The AV fistula actually involves linking an artery and vein together, as suggested by its name. Subsequently, the patient is linked to the hemodialysis equipment, which drains and 'washes' the blood, using a dialysate solution to remove toxins, and then returning the blood.

The procedure for hemodialysis is generally scheduled several times weekly, and is expected to take from four to five hours. Nursing staff generally recommend that patients bring reading material, or alternatively a TV may be provided. In-home hemodialysis generally requires a partner's assistance, and special training will be provided. Hemodialysis may result in complications (side-effects), such as cramping of muscles, sudden drops in blood pressure (hypotension), as well as nausea and dizziness.

The physician will prescribe a diet that is intended to assist the patient's well-being, and potentially prevent development of further complications. Adherence to the pharmaceutical regimen prescribed is also important. Dieticians will aid in the diet prescription and/or plan. Dietary recommendations are likely to include: high protein, but with potassium restrictions; limitation of liquid intake; avoidance of salt; and avoidance of high-phosphorus foods such as dairy foods (cheese, milk, ice cream, nuts and legumes). Following the regimen prescribed by the physician can prevent the occurrence of side effects.

Long-term outlook for ESRD

Modern medical and clinical approaches to end-stage renal disease generally mean that individuals with this disorder have significantly longer potential lives than was formerly possible. While dialysis treatments, either peritoneal dialysis or hemodialysis, cannot 'cure' end-stage renal disease, they can significantly improve the patient's symptoms and improve relative health and lengthen potential life as compared to what might occur without such treatment. Unfortunately, long-term consequences of end-stage renal disease may include anemia (decrease in red blood cell count), bone disease, nerve damage, and high blood pressure, all of which must be a part of the treatment regimen addressed by the physician. The Nurse and dietician may also significantly ameliorate the problems of the patient.