Case study Seventy-five-year-old Sally presents for her annual checkup with her provider. She had previously been diagnosed with diabetes and high blood pressure, but when asked about her medication compliance, she says she stopped her medications because they had been causing diarrhea. Her doctor is concerned that her kid- ney function may be declining, and Sally is scared that this means she will have to go on dialysis. After Sally’s lab results came back with her serum creatinine came at 1.2mg/dL, an estimation of her glomerular filtration rate needs to be made. Some additional information from Sally’s chart that may be needed in the calculation includes: ● Age: 75 years. ● Ethnicity: Chinese.
Self-Assessment Quiz Question #3 Using the recommended equation, what is Sally’s estimated GFR?
a. 65 mL/min/1.73m 2 . b. 25 mL/min/1.73m 2 . c. (correct) 44 mL/min/1.73m 2 . d. 36 mL/min/1.73m 2 .
Self-Assessment Quiz Question #4 Due to her low GFR, Sally’s provider is ready to diagnose her with chronic kidney disease. In order to determine the most appropriate treatment options to discuss with the patient, the stage of her disease should be determined. Given her GFR cal- culated in the previous question, what stage of CKD would she fall into?
● Height: 5 feet 3 inches. ● Weight: 165 pounds. Self-Assessment Quiz Question #2
a. Stage 2. b. Stage 3a. c. Stage 3b. d. Stage 4.
The clinic protocol is to use the calculation recommended by the National Kidney Foundation for estimating GFR. Which of the following would be most appropriate to use? a. CKD-EPI creatinine equation.
b. Cockroft–Gault equation. c. 24-hour urine collection. d. Jelliffe equation.
EPIDEMIOLOGY
According to the Centers for Disease Control and Prevention, some level of chronic kidney disease can be seen in one out of every seven American adults (CDC, 2021). Chronic kidney disease is noted to be the ninth leading cause of death in the U.S. (US Department of Health and Human Services, 2019). Chronic kid- ney disease prevalence increases significantly with age, occurring in approximately 10% of adults under 65 years of age, and ap- proximately 39% of adults 65 years of age and older. End-stage renal disease (ESRD) incidence rates appear to be increasing, with roughly 2,200 cases occurring per 1 million people in 2018, an increase of 2.3% from 2017 (U.S. Renal Data System, 2020).
Chronic kidney disease occurrence can vary with gender and race. Incidence rates of end-stage renal disease in the U.S. for Black pa- tients are around 16%, compared to 13% for White patients and 14% for Hispanic patients. Chronic kidney disease is slightly more common in women compared to men, affecting 14% of women and 12% of men (CDC, 2021). It is also noted that specific causes of chronic kidney disease can occur at different frequencies for different races. For example, the risk of nephropathy associated with diabetes or hypertension is higher in Hispanic and Black rac- es (U.S. Renal Data System, 2020). ● Glomerular disease, such as focal and segmental glomerulo- sclerosis (FSGS). ● Glomerular disease can also be secondarily caused by a vari- ety of conditions including lupus, rheumatoid arthritis, sclero- derma, endocarditis, HIV, parasitic infections, and heroin use. ● Tubulointerstitial disease, which can be caused by infections, certain medications such as sulfonamides and allopurinol, chronic hypercalcemia or hypokalemia, heavy metal poison- ing, and radiation. ● Urinary tract dysfunction or obstruction, which can be caused by kidney stones, benign prostatic hypertrophy, tumors, neu- rogenic bladder, and urethral stricture. ● Congenital defects of the kidney or urinary system. ● Acute kidney injury due to infection, medications, or illicit drug use.
CAUSES OF CHRONIC KIDNEY DISEASE
There are a wide variety of causes of chronic kidney disease. Di- abetes and high blood pressure are among the most common causes of CKD. The increased blood sugar levels associated with diabetes can damage the kidney’s ability to filter waste and fluid over time, thus reducing kidney function. High blood pressure can damage blood vessels in the kidneys, reducing their ability to re- move fluid and waste. This can lead to fluid retention and further increases in blood pressure, perpetuating the cycle of damage. Less common causes of chronic kidney disease include (DiPiro et al., 2019; National Institute of Diabetes and Digestive and Kidney Diseases, 2016b): ● Vascular disease, such as renal artery stenosis or renal vein thrombosis. ● A genetic disorder causing cysts to grow in the kidneys, known as polycystic kidney disease .
COMPLICATIONS OF CHRONIC KIDNEY DISEASE
Volume overload In chronic kidney disease, salt and water processing is impaired, decreasing sodium and free water excretion. Failure to remove adequate fluids and salts can cause volume overload. Since the body develops alternative methods for dealing with this reduc- tion in fluid and salt removal, clinical manifestation of this impair - ment is often seen when the GFR falls to less than 10–15 mL/ min/1.73m 2 , after alternative systems have been exhausted. Vol- ume overload can also be seen in patients with a higher GFR if in- gested quantities of water and salts exceed the body’s decreased
ability for removal. Volume overload can lead to edema, worsen- ing congestive heart failure, and hypertension (Rosenberg, 2021). Chronic kidney disease patients in volume overload often respond to a combination of diuretic medications and dietary sodium re- striction. Loop diuretics, such as furosemide, are often used for diuresis in symptomatic patients. The KDIGO Work Group recom- mends restricting dietary sodium to less than 2 grams per day in all adult CKD patients unless contraindicated (Rosenberg, 2021; KDIGO Work Group, 2013).
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Book Code: RPTX3024
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