End Stage Renal Failure

As with any major organ failure, severe renal disease is associated with significant morbidity and increased mortality. In recent years, it is expressed that end stage renal disease is a growing problem in the United States. In my especial case this is a very important topic due to one member of my family suffered this disease and it was a very stressful process for my entire family. That is the reason that I decided to investigate more about end stage renal disease. This paper involves a basic review of what is end stage renal disease, what are the risk factors and prevalence, which are the causes and symptoms, how can end stage renal disease be diagnosed and how to manage the process including dialysis and renal transplantation. The goal is to get a better understanding about the disease including the risk factors that can be preventable like diabetes and high blood pressure. As it has been demonstrated, those medical conditions are the fundamental causes of chronic kidney disease and end stage renal disease. Therefore, all people should be aware of that.

Introduction

When I was assigned to do a research paper for my advanced health assessment class on a topic of my own, I immediately thought about end stage renal disease due to this disease caused many worries and suffering in my entire family. My grandmother was diagnosed with it when she was seventy two years of age. She had a medical history of Diabetes Mellitus type I for thirty years. She had dialysis treatment since she was diagnosed and unfortunately, she could not survive to this sad disease, so she died five years later. Based on the knowledge that diabetes is inherited, and the strong family history that I have, I always wanted to know more about this serious and dangerous disease. In addition to that, having the opportunity to become a registered nurse and to be a future educator, when I finish my bachelor degree in nursing, I know that I will have more understanding and I will be able to bring diabetic education to patients and families in the community that I work for.

Kidneys are very important organs in the body; they remove waste products and excess of fluid and salt from the body. Also, they balance electrolytes and produce hormones. End stage renal disease is when kidneys stop working enough, therefore waste and water builds up in the body resulting in uremia, edema, and too high blood pressure.

End stage renal disease is a chronic disease characterized by the permanent loss of renal function that affects quality of life, physical and mental health, functional status, general wellbeing, personal relationship, and social functioning. It is a condition requiring nursing and medical interventions including dialysis, education on lifestyle changes, dietary regimen, and fluid restrictions, and finally kidneys transplant to live.

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Rates for end stage renal disease have slowed in some countries while raising or remaining stable in others. The United States continues having some of the highest rates; it affects more than two out of every one thousand people. In addition to that, the prevalence is growing most rapidly in people ages sixty and older. Older adults with chronic kidney disease are more likely to die from any cause that progress to end stage and are more likely to die from cardiovascular causes that develop end stage renal disease.

African Americans have the highest incidence of end stage renal disease in the United States. Blacks with chronic kidney disease were at increased risk for end stage renal disease and death prior to end stage renal disease. In 2004, the age and sex-adjusted incidence of end stage renal disease in blacks was 2.6 times higher than that in non-blacks (Derose, Rutkowski, Levin, Liu, Shi, Jacobsen ,& Crooks, 2009).

The racial disparity in end stage renal disease incidence may be due to several populations’ differences, including the risks that lead to kidney disease, kidney disease type and severity, and comorbities that affect mortality before end stage renal disease. These populations’ differences may result from more distal causes such as variations in genetic expressions, environmental exposures, health related behaviors, health care access and quality, or response to therapy (Derose, Rutkowski, Levin, Liu, Shi, Jacobsen, & Crooks, 2009).

There are many causes leading to end stage renal disease, it almost always comes after chronic kidney disease, kidneys may slowly stop working over ten to twenty years before end stage occurs. Many other diseases and conditions can damage the kidneys, for example, birth conditions like polycystic kidney disease; arteritis; injury or trauma; kidneys infections; stones; reflux; tobacco use; hyperlipidemias; etc. Besides that, some medications for pain like non-steroidal medications, opiates; drugs like cocaine; toxics chemical; auto immune disorders such as Systemic Erythematous lupus, Scleroderma. However, the most common causes of end stage renal disease in the United States are diabetes and high blood pressure (Macias, Steward ,& Oreopoulos, 2008). Diabetes is the biggest risk factor for developing the disease, one third of people that develop the disease has diabetes. (Macias, Steward ,& Oreopoulus, 2008).

It is demonstrated the high likelihood of older patients with chronic kidney disease to die than reach end stage of disease. High blood pressure damages the small blood vessels in the Kidneys preventing the kidneys from filtering wastes from the blood, and cardiovascular death is the second leading cause of death. Therefore it is very important for doctors care and counsel their older patients with chronic kidney disease and stress the importance of cardiovascular risk reduction and screening for those disorders. (Dalrymple, L. S., Katz, R., Kestenbaum, B., Shlipak, M. G., Sarnak, M. J., Stehma-Breen, C., & Fried, L. (2011). Risks chronic kidney disease and risk of end stage renal disease versus death. Journal of General Internal Medicine, 26(4), 379-385.

African American people have a higher prevalence of chronic kidney disease compared with other racial groups, due to higher rates of high blood pressure. There is a risk of end stage renal disease with gout. Since gout frequently coexists with diabetes and hypertension, it is often overlooked as a genuine risk factor for chronic renal disease and end stage renal disease. A previous study reported the existence of a significant association between the uric acid levels and deterioration of renal function.

End stage renal disease can manifest as a diversity of symptoms that include general malaise, weakness, dry skin, pruritus, and headaches, loss of appetite, and sometimes nausea and vomiting. Also, drowsiness, confusion, muscle twitching or cramps, easy bruising, nosebleeds, edema, low urine output, etc. If kidney failure is untreated, it can develop to seizures, coma, and death. The health care provider may hear abnormal lungs or heart sounds, the evaluation starts with a medical history and physical examination. Blood testing to measure kidney function is usually done, for instance, complete blood count, calcium level, phosphorus, potassium levels. Testing to determine the underlying cause may include urine exam, ultrasound, CT scan, and kidneys biopsy. Blood urea nitrogen and creatinine are performed to see if kidneys are working adequately. If they are not working appropetialy, excess of urea and creatinine will be on blood. Glomerular filtration rate measures how well the kidneys are processing wastes based on gender, age, body size, and blood creatinine levels. The concentration of electrolytes in the blood will be abnormal, for example, hyperpotassemia will be dangerous. In addition to that, urine tests will show proteins. Ultrasound, CT scan and MRI’s will be useful showing it there are problems with flow of urine, any obstruction, or change in the size of kidneys.

Morbidity and mortality remain high in people with end stage renal disease, and the medical, social, and economic repercussions of this condition are widespread. Cardiac disease is the major cause of death in patients with end stage renal disease (Macias, Steward ,& Oreopoulos, 2008). Integrated care by the primary care physician and nephrologist from an early stage is vital. The management of the disease is a dynamic process, Dialysis or kidneys transplantation is the only treatment for this condition, but there is a conservative treatment. It refers to management without dialysis, includes active management of the renal disease to slow deterioration of renal function and to minimize complications of disease. Also includes active management of symptoms, psychological care, social and family support. This will include communication detailed with the patient and family as well as advance care planning. Due to prevalence of end stage renal disease is increasing, dialysis if being offered to older and more medically complex patients. (O’connor &, Corcoran, 2012).

The decision not to dialyze can be done after discussion between the renal team, the patient, and relatives. Patient should be given information about prognosis and quality of life with or without dialysis, and if patient is assessed appropriately, it is possible identify those for whom dialysis offers little or no survival advantage and advise them, however predicting survival with or without dialysis can be difficult. (Goldsmith, Jayawardene ,& Ackland, 2007). Other treatments are offered like erythropoietin therapy and phosphate control.

The number of patients who need renal replacement therapy for end stage renal disease grows steadily. It is indicated to start renal replacement therapy with chronic kidney disease stage five ranges (estimated GFR-10-15 ML/min). There are some basic facts about replacement therapy, for example, the most common cause of end stage renal disease is diabetic nephropathy. (Macias, Steward ,& Oreopoulos, 2008).

Demand for dialysis will continue in the next years, mortality rate is about twenty percent annually, commonest causes of death in cardiovascular disease (Macias, Steward ,& Oreopoulos, 2008).

Timely and preparation for renal replacement therapy is crucial, the choice of dialysis modality should be free, sufficient time and information must be provided to allow patients and family make decisions. The vascular access of choice for hemodialysis remains the arteriovenous fistula, if there are no suitable peripheral veins, then a piece of synthetic material can be inserted and is needled for access. For the reasons of the time needed for the arteriovenous fistula to mature, and an initial failure rate, this procedure must be done ahead of time.

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Coronary artery disease, chronic obstructive pulmonary disease, and cancer in patients receiving dialysis has increased, and also, it is seen cognitive impairment. Pain is one of the symptoms that has been reported by patients receiving dialysis that results in impaired quality of life. Pain can be due to renal or nonrenal causes. The etiology of pain and the patient’s renal function should be taken in consideration by pain management. Some pain medications should be avoided, and others should be adjusted. (O’connor ,& Corcoran, 2012).

For peritoneal dialysis, a catheter to allow fluid to be installed into the peritoneal cavity, can be inserted either at laparoscopy, laparoscopically or percutaneous.There are complications of hemodialysis like related to vascular access, hypotension, malnutrition, infections, gastrointestinal bleeding (Macias, Steward ,& Oreopoulos, 2008). Dietary specialists should be needed to establish degree of restriction in potassium, phosphate, sodium, and water intake.

Management nondialytic may be preferred to dialysis in older patients that includes fluid balance; electrolytes disbalances corrections, like high levels of potassium; treatment of anemia; as well as monitoring of blood pressure and dietary modifications.

Regarding advance care planning, patients with end stage renal disease should have advance directives including documentations of situations in which they would no longer want dialysis. Besides that, other topics should be addressed like cardiopulmonary resuscitation, hospice evaluation, etc. (O’connor ,& Corcoran, 2012).

Finally, Renal transplantation is the only current therapy for patients with end stage renal disease that offers freedom from daily or alternate-day dialysis therapy, al for patient’s survival, quality of life or cost-effectiveness. However, this option is available to only about thirty percent of renal replacement therapy patients (Macias, Steward ,& Oreopoulos, 2008).There are two categories of kidney donor: cadaveric or living. Cadaveric are either heart-beating or non-heart beating. The largest group of transplants comes from brain-stem dead patients with maintained cardiac output due to intracranial hemorrhage or trauma. Kidneys from non-heart beating donors, example post circulatory arrest, have shown success. Transplantation is considered suitable for patients with chronic renal failure requiring dialysis or predicted to require dialysis within 6 to 12 months. (Goldsmith, Jayawardene ,& Ackland, 2007). For recipient, specific clinical factors must be considered such as, infection, malignancy, cardiovascular disease, bladder function. Most kidneys function immediately, immediate post-operative concerns are with fluid balance and risk of bleeding.

Deterioration in kidney function may be reversible or irreversible. Acute tubular necrosis is the most likely cause of delayed graft function. (Goldsmith, Jayawardene ,& Ackland, 2007).

Immunosuppression is initiated at the time of transplant; those immunosuppressive agents prevent rejection and minimize dose-related side effects. There are complications related to surgery, or problems related to rejection, infection, malignancy, and recurrence of the original disease. There is risk of mortality during the first a hundred post-operative days. Immunosuppressive treatment is necessary for the life of the kidney transplant- therefore compliance is a major issue in the graft survival. (Goldsmith, Jayawardene ,& Ackland, 2007). “Patients with a history of psychosocial problems like drug addiction should be assessed and rehabilitated before entered onto the transplant waiting list” (Goldsmith, Jayawardene ,& Ackland, 2007, p.61).

Conclusions

In my opinion, I think, this paper has been very helpful for me because by doing this, I have had the opportunity to investigate about such dangerous disease end stage renal disease, and how it can be prevented by controlling risk factors that convey to the disease process like hypertension, diabetes, cardiac problems, etc. As I said before, unfortunately my maternal grandmother suffered of Diabetes Mellitus type I for many years, she got end stage renal disease, she went to dialysis, and finally, after a lot complications of disease, she died. Therefore, I think we need to be aware of some risks in order to avoid that lamentable disease and as a registered nurse; we have to play an important role on education of patients and families about disease process, causes, risk factors, dietary regimen, etc., in order to better understanding.

In brief, this research was very instructive to me, I could review all information regarding end stage renal disease, what I learned is that renal disease is a temerous condition that we have to be afraid, we have to be aware of risk factors for development of disease, like diabetes, hypertension; and I think, regular monitoring of blood pressure can be very useful.