Kidney disease is a growing health concern affecting over 37 million American adults. As a nurse, having a strong understanding of renal failure, chronic kidney disease (CKD), and end-stage renal disease (ESRD) is essential for providing competent care and preparing for nursing certification exams. This comprehensive guide covers key information on kidney disease progression, signs and symptoms, diagnostic tests, treatment options, and nursing care plans.
Overview of Kidney Function
The kidneys are bean-shaped organs that filter waste and excess fluid from the blood to produce urine. They also help regulate blood pressure, red blood cell production, and maintain electrolyte and acid-base balance. As blood flows through the kidneys, specialized nephron structures filter out urea, creatinine and other waste while reabsorbing water, glucose and amino acids back into circulation.
Healthy kidneys filter about 120-150 quarts of blood to produce 1-2 quarts of urine per day. When the kidneys become damaged from disease, their filtering capacity is diminished. This allows waste and fluid to build up in the body, leading to:
- Elevated waste levels (urea/creatinine)
- Electrolyte imbalances
- Fluid retention and edema
Stages of Chronic Kidney Disease
Chronic kidney disease involves gradual loss of kidney function over time. There are 5 stages of CKD based on glomerular filtration rate (GFR), which measures how efficiently the kidneys filter blood:
Stage 1 – GFR ≥ 90 mL/min with kidney damage
Stage 2 – GFR 60-89 mL/min with kidney damage
Stage 3 – GFR 30-59 mL/minStage
Stage 4 – GFR 15-29 mL/minStage
Stage 5 – GFR <15 mL/min (kidney failure)
As CKD progresses through the stages, signs and symptoms appear based on rising waste levels in the blood and fluid retention.
Patients in stages 1-3 are often asymptomatic and may only have slightly elevated creatinine. Later stages involve more pronounced symptoms.
Signs and Symptoms
- No symptoms
- Mildly elevated creatinine
- Abnormal urine sediment
- Weakness, fatigue
- Poor appetite, weight loss
- Difficulty concentrating
- Peripheral neuropathy
- Restless legs
- Fluid retention
- Electrolyte disorders
- End-stage symptoms
- Severe fluid overload
- Metabolic acidosis
Patients with diabetes and hypertension are at increased risk for developing CKD. Family history, autoimmune disorders, recurrent kidney infections, bladder obstruction, heavy metal exposure, and certain medications can also damage kidney function over time.
- Serum creatinine – Byproduct of muscle metabolism used to estimate GFR. Levels increase as kidney function decreases.
- BUN – Urea nitrogen is filtered by the glomeruli so BUN rises with kidney impairment. Helpful to assess severity of acute kidney injury.
- Creatinine clearance – Measures actual creatinine filtered by the kidneys per minute. Low creatinine clearance indicates poor GFR.
- Microalbuminuria – Sensitive marker of early kidney damage, especially in diabetics.
- Urinalysis – Presence of RBC casts, WBCs, glucose, or concentrated urine can signal kidney disorders.
- Renal ultrasound – Identifies structural abnormalities or blockages.
- Kidney biopsy – Examines tissue for diagnosis, prognosis, and treatment options for kidney disease.
Treatment focuses on slowing disease progression and managing complications. Common interventions include:
- ACE inhibitors/ARBs – Lowers BP and proteinuria to delay disease progression.
- Sodium/fluid restriction – Prevents fluid overload.
- Phosphate binders – Helps regulate phosphorus levels.
- Erythropoiesis agents – Manages renal anemia.
- Dialysis – Filters wastes and fluid several times per week. Indicates ESRD.
- Kidney transplant – Offers best outcomes for ESRD if candidate eligible.
Dietary changes to control protein, sodium, potassium, phosphorus and fluid intake are key. Other medications help regulate blood pressure, anemia, bone disease, electrolytes, and metabolic acidosis associated with progressive CKD.
Nursing Care for Kidney Disease
As a nurse, priorities in caring for patients with kidney disease include:Patient Education
- Teach about disease process and kidney function
- Reinforce medication regimen and compliance
- Review dietary and fluid restrictions
- Provide psychosocial support
- Track intake/outputs
- Assess edema, shortness of breath
- Monitor lab results for electrolyte imbalances
- Watch for signs of uremia
Prepare Patient for Renal Replacement Therapy
- Arrange vascular access placement for hemodialysis
- Educate on process of peritoneal dialysis or transplantation
Promote Quality of Life
- Encourage activity tolerance and sleep hygiene
- Assist with coping through positive reinforcement
- Provide resources for social services support
As kidney function declines, additional nursing responsibilities include coordinating care with nephrology specialists, the renal dietitian, and social services. Counseling patients through each stage can help ease anxiety related to disease progression, dialysis, and potential kidney transplant.
End-Stage Renal Disease (ESRD)
End-stage renal disease occurs when CKD has progressed to kidney failure (stage 5) with a GFR rate under 15 mL/min. At this point, renal replacement therapy with dialysis or kidney transplant is necessary to sustain life.In ESRD, the kidneys can no longer adequately filter fluid and waste from the body.
This leads to life-threatening electrolyte disturbances, fluid overload, and uremia. Without intervention, ESRD progresses to multi-organ failure and death.ESRD Signs and Symptoms
- Extreme fatigue
- Uremic breath odor
- Severe hyperkalemia
- Uncontrolled hypertension
- Pulmonary edema
- Heart failure
Uremia results as kidney failure allows waste products like urea to accumulate in the blood, causing severe illness. Symptoms involve:
- Nausea, metallic taste
- Cognitive changes
Preparing for Nursing CKD/ESRD Exams
Key topics to review for nursing certification exams on kidney disease include:
- Stages of CKD and corresponding GFR rates
- Signs, symptoms and diagnostic findings with CKD progression
- Dietary and medication management of CKD
- Providing patient education on kidney function and disease process
- Risk factors for developing CKD and populations at increased risk
- Nursing responsibilities and priorities caring for patients with kidney impairment
- Dialysis, transplant, and ESRD concepts
Thoroughly reviewing kidney anatomy/physiology, pathophysiological effects of declining kidney function, and nursing interventions through each stage of CKD can help prepare for exam questions. Know common lab value changes, patient education priorities, diet modifications, and complications to monitor with progressive kidney disease.
As CKD prevalence increases, nurses play a vital role in detecting early kidney damage, monitoring ongoing disease progression, educating patients, and helping minimize complications from fluid/electrolyte imbalances and uremia.
Having a strong grasp of the stages of chronic kidney disease, related signs and symptoms, laboratory changes, and treatment approaches allows nurses to provide competent, holistic care to this growing patient population.
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