Clinical assessment and stages of kidney failure

Kidney Failure

The kidneys work to filter wastes from the human being's blood and works as well in regulation of the body. The kidneys additionally work to make hormones that keep the bones of the individual strong. When the kidneys fail treatment is needed to replace the work normally performed by the kidneys. Kidney failure results in a build up of harmful wastes in the body and generally the individual will experience a rise in blood pressure. As well the body will retain excess fluid and fails to produce enough red blood cells.

Clinical Assessment of Kidney Failure

Clinical assessment of Kidney Failure includes urine testing, blood testing, imaging testing including ultrasound and computerized tomography (CT), removal of a sample of kidney for testing or biopsy of the kidneys. (Mayo Clinic, 2012)

Differential Diagnosis

Acute Renal Failure can result in acute kidney injury which is a condition that may be reversed and which is assessed through tracking the rate the renal functioning is worsening. Differentials to acute kidney injury include alcoholic ketaoacidosis, Sickle Cell Anemia, Aneurysm in the abdomen, CHF and pulmonary edema, diabetic ketoacidosis, obstructive uropathy, GI bleeding, Protein Overloading, steroid use, pediatric dehydration, pediatric diabetic ketoacidosis, and pediatric inborn errors of metabolism. Pediatric sickle cell disease, pediatric urinary tract infections and pyelonephritis, renal calculi, renal failure, chronic and dialysis complications, toxicity due to alcohol use, urinary obstruction, female and male urinary tract infection and metabolic acidosis. Approximately 50-60% of all causes of acute kidney injury are reported as being "nonliguric, however, the identification of anuria, oliguria and nonoliguria may be useful in the differential diagnosis of AKI." (Workeneh and Batuman, 2012) the work of Pottelbergh, et al. (2011) reports that the "prevalence of chronic kidney disease (CKD) is high, especially among older patients." The study concludes "Baseline eGFR, diabetes, high cholesterol; high LDL, hypertension and female gender are independent risk factors for developing ESRD, Older age at baseline predicts a lower risk." (Pottelbergh, et al., 2011)

IV. Applications/Implications for Families

Family member of individuals diagnosed with acute renal failure should understand the dietary guidelines which include restrictions on protein, restrictions on salt, and restricts on fluid intake. There are also dietary restrictions and restrictions on phosphorus intake. The individual with this type of kidney disease should not take aspirin or ibuprofen and should not use fleets or phosphosoda enemas, laxatives or antacids containing magnesium and aluminum, ulcer medication such as cimetidine or rantidine or decongestants such as pseudoephedrine. As well, the individual with kidney failure should not use Alka Seltzer or herbal medications. (Kathurai, nd, paraphrased)

V. Stages of Kidney Failure

There are five reported Stages of Kidney Failure. The first stage or Stage One is characterized by Kidney damage, normal or elevated glomerular filtration rate (GFR) >90mL/min > 1.50mL/s per 1.73m2. Stage Two is characterized by kidney damage with mild decrease in FR 60-89 mL/min 1.00-1.48 mL/s per 1.73m2. Stage Three is characterized by kidney damage with modern decrease in GFR 30-59 mL/min 0.50-0.98 mL/s per 1.73. Stage Four is characterized by kidney damage with severe decrease in GFR 15-29 mL/min 9.25-0.48 mL/s per 1.73.m2. Stage Five is characterized by kidney failure with GFR

VI. Clinical Management

Identification of the reversible causes of kidney disease and identification of kidney disease requiring disease specific therapies as well as identification and treatment of factors associated with kidney failure. (Stigant, Stevens, and Levin, 2003) Estimated glomerular Filtation Rate (eGFR) is widely accepted as the best method of measuring kidney function and can be estimated from serum creatinine using predictive equations.

VII. Evidence-Based Protocol for NP Management

Evidence-based protocol for Nurse Practitioner management of kidney failure includes the goal of illustrating the "ddevelopment and utilization of clinical protocols" and the objectives of outlining a process for development of clinical protocols, description of a protocol for the management of kidney failure and comparison of the experiences of developing clinical protocol to personal workplace concerns.

The Nurse Practitioner role in treating patients with kidney failure includes clinical assessment, diagnostics, blood pressure management, bone and mineral management, nutritional review, virology review and immunization, pathology review, education, anemia management, medication management, conservative management. (ACT, 2012 ) Also included is diabetes management, podiatry for management of foot ulcers, complicated renal management, cardiac investigations, diagnostic groups that include hematology and biochemistry and other conditions. (ACT, 2012)

VIII. Health Teaching Plan

The health teaching plan for patients and their families coping with kidney disease will include several components related to diet, lifestyle management, functioning, the stages of kidney failure and the appropriate treatment and monitoring of the patient during each stage of kidney failure. The health plan will be inclusive of the following components: (1) Diet; (2) Lifestyle Management; (3) medications and adherence to treatment; (4) information on dialysis and kidney transplant; (5) coping with the emotional aspects of kidney failure; (6) physical aspects of living with kidney failure; (7) financial assistance available for kidney failure treatment options; and information on support groups for the patient and families of patients with kidney failure.

X. Pharmacokinetics of Medications Used in Treatment and Prevention of Kidney Failure

Dialysis is reported to affect the pharmacokinetics of a drug so much that dosage adjustment is required. This requirement occurs when "a significant fraction of the drug or active metabolites are removed by the dialysis process." (U.S. Department of Health and Human Servicing, 2010 ) Drugs that are likely to be administered to patients treated with dialysis requires that PK be studied in these patients under both dialysis and non-dialysis or between dialysis and conditions determining the extent to which dialysis contributes to the drug's elimination and ponteially active metabolites. Generally omission of the study of effect of dialysis on drug KP is only foregone if the dialysis procedure "is unlikely to result in a significant elimination of a drug or active metabolites." (U.S. Department of Health and Human Servicing, 2010) This is reported to be true for drugs and active metabolites with a large volume of distribution or drugs that are primarily nonrenally cleared. The volume of distribution when greater than 350 L. less than 10% of the amount from that initially in the body will be removed during an unbound dialysis of 200mL min. When the drug and metabolites have mainly nonrenal clearance dialysis contributes very little to the overall clearance. (U.S. Department of Health and Human Services, 2010)

XI. Future Trends for Clinical Management

The work of Henderson (2000) reports that future developments in management of kidney failure "will need to be pharmacoeconomically persuasive in reducing the life-cost of treatment to obtain entry into the market. Increased automation, with closed-loop sensing technology, will occur in the near-term. Clearance-based terminology for quantifying performance of equipment will give way to direct quantification of toxin removal. Experiments on the frequency and duration of treatment will redefine what is considered to be adequate therapy in terms other than simple urea removal. Near-term changes in current vascular access technology will be driven by the current cost of access failure. Automated peritoneal dialysis will displace continuous ambulatory peritoneal dialysis, and online compounding of solution for use is likely for both hemodialysis and peritoneal dialysis. In a longer time frame these technologies will merge." In addition, Henderson reports "Xenografting from the pig will be a reality, and gene therapy of the mesothelium will provide a more user-friendly therapy for end-stage renal disease." (2000)

XII. Evaluation of Outcomes-Evaluation and Time Frame

Outcomes of evaluation are dependent upon the stage of renal failure that the patient is in however, adherence to dietary, medication, lifestyle, and other management plans for the disease will be primary outcomes to be measured.

XV. Referral Plan patients with a Referral to a nephrologist is generally recommended for cute kidney failure "persistent estimated glomerular filtration rate less than 30 mL/min/1.73 m2, progressive decline of kidney function, ratio of urine protein to creatinine greater than 100 mg/mmol (about 900 mg/24 h) or urine albumin to creatinine ratio greater than 60 mg/mmol (about 500 mg/24 h), inability to achieve treatment targets, or rapid changes in kidney function." (Levin, 2008)