 Hi, welcome to Nursing School Explained, and this video on chronic kidney disease. Let's look at the causes first. So number one cause of chronic kidney disease is diabetes and it's long-term complications. About 50% of all cases are from diabetes. Number two cause is from chronic changes from hypertension, and that's about a quarter of the cases, 25% here. The other quarter is a combination of causes, such as chlomerular nephritis, other urologic disorders, or autoimmune diseases such as lupus. When we talk about chronic kidney disease, we always need to look at kidney function and particularly chlomerular filtration rate, which is also abbreviated as GFR. And then chronic kidney disease gets divided into stages one through five, depending on the filtration rate of the kidney, from one being barely any impairment to five, where the GFR is less than 15, and the patient now needs to be on dialysis to manually wash out the blood because the kidney is no longer functioning appropriately and doing its job. In order to really understand chronic kidney disease, the easiest way is to look at the functions of the kidney that it usually performs when it's functioning properly, and that way we can look at signs and symptoms that occur when the kidney is not functioning, and then also nursing care that pertains to that. So we have three different colors here. Function of the kidney, signs and symptoms, and treatment and nursing care are color coded so that you know what applies to what. So number one function of the kidney is to filter the blood. We know it's heavily involved in electrolyte balance, such as sodium, chloride, and potassium. Really the sodium and potassium mean the main electrolytes that are exchanged at the renal tubules in order to maintain fluid balance. The kidney also plays a major role in blood pressure control by activation of the renin angiotensin aldosterone system or RAS, in short, also antidiuretic hormone as well as aldosterone. And then it's also heavily involved in homeostasis for maintaining the pH level of the blood by regulating bicarbonate and hydrogen ion at the renal tubules, again, in exchange for potassium, sodium, hydrogen ion, and bicarbonate so that we maintain that pH balance. Now when the kidney is not working appropriately, it's not going to be able to filter the blood, and the electrolytes are going to be out of balance, and the most common electrolyte imbalance is hyperkalemia, which is also the most lethal one, because you know that it can lead to dysrhythmias. Now also the sodium can be out of balance, but depending on the patient's fluid volume status, sodium might be high. If the patient is more on the dehydrated side, hemoconcentration, it might be low. If the patient has more fluid overload or the sodium is diluted, or it might be normal. Now in terms of blood pressure control when the kidney is not functioning, it cannot secrete the rennet that needs to be activated in order to activate that whole RAS system. Therefore, the blood pressure will go up, which can then lead to heart failure and those signs and symptoms, specifically edema is what we're worried about. And the other thing here, if the pH goes out of balance because the kidney exchanges potassium for hydrogen ion, and so if the potassium comes out of the cell, the hydrogen ion will be elevated in the blood stream leading to metabolic acidosis. And there's one specific term that always applies and that's called uremia, and that basically just means waste products in the blood. Think about urea as a blood urea nitrogen, and then uremia always means blood. That's waste products that build up in the blood. And the urea and creatinine being those two that we discussed that are going to be elevated. And then uremia also leads to platelet dysfunction and can lead to bleeding. So that might just be bleeding from minor trauma, such as patients that are on anticoagulants have or it might be gastrointestinal bleeding, such as bloody stools or blood illnesses. Now what are we going to do about this? How are we going to manage these patients? So when the kidney is not able to filter the blood appropriately and we know that the potassium can go up, we need to recommend a low sodium and a low potassium diet. And the reason here for the low sodium diet is that we know that sodium and water always go together so if the patient has edema and is prone to water retention, we don't want to give them more sodium because otherwise they'll hold on to more fluid leading to heart failure, edema, and fluid volume excess. Now regarding the blood pressure here, certainly very simple measures such as weight loss, exercise, not smoking, not drinking alcohol will help. And then the patient will need to be on a medication regimen to control their blood pressure. The most common blood pressure medications for patients with kidney disease are ACE inhibitors and ARVs because they work on blocking that RAS system, therefore it continues to work and we're blocking this pathway and therefore the blood pressure can be lowered. Now keep in mind we have to actually have some type of kidney function for this to be working so if the patient is in end stage renal disease at stage five, these medications won't be very effective as well as diuretics. So diuretics are medications that we oftentimes use to reduce the patient's edema due to fluid volume overload and heart failure but sometimes if the kidney is no longer working they have to be very carefully administered. And then knowing that the patient will retain more fluid because of all these things we just discussed they're gonna have to be on fluid restriction but the amount will depend on their urine output. So depending on how their filtration rates is functioning or the level of their filtration rate will depend on how much urine output they have. The higher stage of renal failure the less urine output because the less the kidney is working to filter everything. So it is quite possible that a patient who is in end stage renal disease will have zero urine output or maybe 10 mLs during the course of the 24 hour period. Hence the fluid restriction. And the potassium diet it's so important it's on a twice. So then function number two of the kidney is RBC production. The kidney secretes erythropoetin that usually responds if there's low renal profusion or low blood pressure. That's another mechanism that's built in just like the RAS system in order to bring up blood pressure in a patient or in anybody who does not have renal failure. Now the erythropoetin is a precursor to building erythrocytes which are the red blood cells. So if the kidney is not functioning it's not going to be able to secrete the erythropoetin hence RBC production will go down. Which will result in anemia. And this is anemia of chronic disease resulting in low levels of hemoglobin and hematocrit and certainly low levels of RBCs. Now what's the treatment for that? If the kidney is not secreting erythropoetin we need to give that to the patient that precursor so that now the bone marrow can produce the red blood cells. So we need to administer erythropoetin alpha and the two most common medications you'll see are epitone and aromids. And the difference is just the frequency and administration. So the patients that mostly need that are those on hemodialysis that go to their treatment center several times a week and they will just get the injections at that time of the treatment. Now function number three of the kidney, vitamin D activation. So the kidney actually activates vitamin D which we know is essential for calcium absorption. So calcium and vitamin D go together and calcium is needed, sorry, vitamin D is needed for the calcium to be absorbed. So now if the kidney is not working it cannot activate the vitamin D. Therefore we are going to absorb less calcium. So no vitamin D leads to decrease calcium and remember that calcium and phosphate have an inverse relationship that's regulated by a parathyroid gland. Now if that happens, if there's less serum calcium the body says, wait a minute, I have storage of calcium in the bone. So in order to balance the serum calcium out there will be bone demineralization meaning that the calcium will come out of the bone and go into the serum to balance and keep the calcium level up. So then we'll need to bone demineralization and that's called chronic kidney disease mineral bone disease. So then what do we do about that? This bone demineralization and the body does that to increase calcium levels which then can lead to dysrhythmia. So we'll have to carefully watch the patient because we know that they are already at high risk for hyperkalemia here as well. And then what can happen because the calcium is low and it has the inverse relationship with that phosphate, phosphate levels will rise resulting in what's called uremic frost. And that means that in patients mostly with end stage renal disease they will have this kind of a grayish layer of their skin that will be very flaky and that is basically that phosphate depositing underneath their skin. That can be visible and you might have seen that in patients with end stage renal disease already. And then also the phosphate gets deposited in the joints which can lead to joint pain. It can lead to bone fractures and it can lead to a lot of painful events for these patients. Now what do we do about this? If we have problem with vitamin D activation we give the patient the vitamin D supplement. We also recommend a low phosphate diet because of this relationship with the calcium. We are already prone to retaining more phosphate so we definitely don't want to give the patient phosphate in their diet and then there are phosphate binding medications that the patient will take with every meal and they have to be given with meals. And this is something that comes up often as a side effect is constipation. And then the fourth major function of the kidney has more to do with the causes so with the diabetes as a cause. So diabetes is a cause constantly high levels of blood sugar will lead to hyperinsulinemia which then stimulates the liver to produce more triglycerides. So this will lead to hyperlabidinium specifically triglycerides and cholesterol levels. So these patients are already at high risk for clots and other complications of cardiovascular nature and now they have this hyperinsulinemia leading to the elevated levels of triglycerides which puts them even at higher risk for cardiovascular disease such as heart attacks and strokes. And how is that done? Well, certainly the patient will have a low fat diet and every patient on renal with renal disease will typically be on a statin to manage their cholesterol levels. And what I have done here, I have circled the difference important things in terms of a diet. So the patient not only needs to be on a low sodium and low potassium diet, they also need to maybe be on fluid restriction depending on their stage of their kidney disease. They need to be on a low phosphate diet, a low fat diet as well as a low protein diet. And that is the case because the proteins are larger molecules and if the kidney is damaged that filtration membrane will not be able to hold onto the proteins and they'll just kind of slip through there and therefore we need to give them a low protein diet. So everything here in red is circled so you can look up what foods are high in these electrolytes so that you know what the patient should avoid or what a good diet for a patient would be because this is something that frequently comes up on exams. And then the other treatment options for chronic kidney disease besides all these would be renal transplant. So basically removing that kidney that is no longer working, peritoneal dialysis or femo dialysis to actually use a machine or a filtration membrane to filter out the blood artificially because the kidney is not able to do it on its own. Thanks for watching this video on chronic kidney disease. Please also consider watching the video on acute kidney injury so that you can be aware of the differences between the two. Thanks for watching Nursing School Explained.