Chronic Kidney Disease & Chronic Glomerulonephritis

The urinary system is responsible for the regulation of blood volume & pressure, concentration of solutes in the blood, extracellular fluid pH, red blood cell & Vitamin D synthesis, and most especially waste excretion. These major functions are mostly performed by the kidneys. These are bean-shaped organs, each about the size of tightly clenched fists, composed of millions of nephrons. These nephrons are considered to be the functioning unit of the kidney. Each nephron consists of a renal corpuscle, a proximal tubule, a loop of Henle, and a distal tubule. The renal corpuscle of a nephron consists of a Bowman’s capsule and the glomerulus.  Blood filtration is concentrated here.

When this certain part of the kidney is injured, the body is unable to excrete wastes and extra fluid in the body. This ailment is called glomerulonephritis, and it has two types—acute and chronic. The acute form is sudden in onset: a person may get this after a throat or skin infection. On the other hand, the chronic form develops silently (without symptoms) over several years: of which the cause is usually unknown. Nearly all forms of acute glomerulonephritis have a tendency to progress to chronic glomerulonephritis. The condition is characterized by irreversible and progressive glomerular and tubulointerstitial fibrosis, ultimately leading to a reduction in the glomerular filtration rate (GFR) and retention of uremic toxins.

If disease progression is not halted with therapy, the net results are chronic kidney disease (CKD), end-stage renal disease (ESRD), and cardiovascular disease. The diagnosis of CKD can be made without knowledge of the specific cause. The Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) work group has defined chronic kidney disease (CKD) as the presence of markers of kidney damage (abnormalities in blood, urine, or imaging tests ) for ≥3 months or a glomerular filtration rate (GFR) <60 mL/minute/1.73 m2 for ≥3 months, with or without other signs of kidney damage.

I.            INCIDENCE RATE

Local Incidence rate

Kidney disease continues to be among the deadliest among Filipinos victims, said a member of the Department of Health (DOH) 11’s Renal Disease Control Program (Redcop) last June 1, 2013. Redcop spokesperson Dr. Maria Theresa Lorenzo Bad-ang said the disease remains in the top ten diseases causing mortality.

In 2010, Region 11 comprised 5.9 % of the 9,716 new cases in the country. Other high-placing regions when it comes to kidney disease are the National Captial Region (12.5%), Northern Luzon (11.7 %), and Western Visayas (5.6 %). Statistics for 2011 are yet to be released by the DOH, Bad-ang said.

The prevalence of kidney/renal diseases has been in an increasing trend, especially the end-stage renal disease (ERSD) as reported in the Philippine Renal Disease Registry (PRDR). The rate of death due to end-stage renal disease has been in the top ten list of the mortality of the Department of Health (DOH).

In the past, chronic glomerulonephritis was the most common cause of chronic renal failure. Today, diabetes mellitus and hypertension have taken center stage in the causation of ESRD which together account for almost 60% of dialysis patients and according to the Philippine Renal Disease Registry Annual Report in 2008, the leading cause of kidney failure in the Philippines is diabetes (41%), followed by an inflammation of the kidneys (24%) and high blood pressure (22%). Patients were predominantly male (57%) with a mean age of 53 years.

Worldwide Incidence Rate

Kidney diseases rank as the 7th largest killer amongst all the diseases prevalent worldwide. What makes it more deadly is that it encroaches silently, manifesting most of the symptoms only in the advanced stages. Moreover as the disease strikes in the end stage, it brings along its wake not only great physical and mental trauma but financial hardships too due to the high cost of treatment.

http://www.hindawi.com/journals/ijn/2012/639653.fig.001.jpgFor every patient with clinically apparent Glomerulonephritis, approximately 5 to 10 patients have undiagnosed subclinical disease. Acute Glomerulonephritis is most common in boys ages 3-7, but it can occur at any age. Up to 95% of children and 70% of adults recover fully: the rest especially elderly patients, may progress to Chronic Renal Failure.

In the US and Europe, Glomerulonephritis is the third commonest cause of end-stage renal disease (ESRD), after diabetes and HTN. But in worldwide, Glomerulonephritis is the commonest cause of ESRD, as the result of various infectious agents in developing countries.

The incidence of CKD is increasing most rapidly in people ages 65 and older.

Line graph showing incidence of CKD for age groups 20–64 and 65 and older.People ages 65 and older more than doubled between 2000 and 2008 and among 20- to 64-year-olds is less than 0.5 percent.

Percent with CKD among adult U.S. population by age, sex, and race/ethnicity. Overall:14%; 20-44 years:4%; 45-64 years:12%; 65 years +:43%; Male:11%; Female:15%; Non-Hispanic white:14%; Non-Hispanic black:12%; Mexican American:8%According to the National Chronic Kidney Disease Fact Sheet 2010, More than 10% of people, or more than 20 million, aged 20 years or older in the United States have CKD.

CKD is more common among women than men. More than 35% of people aged 20 years or older with diabetes have CKD and more than 20% of people aged 20 years or older with hypertension have CKD

II.            ANATOMY AND PHYSIOLOGY

The urinary system, also known as the excretory system, is concerned with the removal of water-soluble waste products from the body in the form of urine. The various components or organs of the urinary system are associated with the production, storage, and then expulsion of urine from the body. At the same time, the system also takes part in several vital functions of the body.

The basic functions are removal of waste products from the body in the form of urine. Each part of the system is concerned with some specific functions

The urine formed in both the kidney is carried to the bladder by two narrow tubes, known as ureters. Ureters prevent the back flow of urine during urination, when the bladder contracts to pass urine to the urethra. If this function of the ureters is impaired, then diseases like, cyctitis and kidney infection may occur. The urinary bladder is a triangular hollow organ, which stores urine, until it is expelled from the body. It is located in the lower abdomen region, and it has the ability to expand for storing urine and then, contract to expel it.

Urine is expelled though the urethra, which is a tube like structure. The sphincter muscles are circular muscles that play an important role in keeping the urine within the bladder. In other words, they prevent the leakage of urine, by closing tightly around the opening of the bladder. The nerves present in the bladder controls the process of urination or micturition. When the bladder is full and it is time urinate, the nerves of the bladder transmit this information to the brain. The brain then, signals the bladder muscles to contract and sphincter muscles to relax, so as to facilitate urination.

The main components of the urinary system are two kidneys, two ureters, a urinary bladder, two sphincter muscles and the urethra. Each of these organs performs some specific functions, associated with the elimination of waste products generated within our body, during the metabolic processes.

Ø  MAJOR ORGANS AND THEIR FUNCTION:

1.      Kidneys

Pair of bean shaped, brownish-red structures located on the posterior wall of the abdomen and are protected by the ribcage. The right kidney is slightly lower than the left due to the location of the liver.It measures 10-12 cm long, 6 cm wide and 2.5 cm thick.

They are covered by the renal capsule, which is a tough capsule of fibrous connective tissue. Adhering to the surface of each kidney is two layers of fat to help cushion them. There is a concaved side of the kidney that has a depression where a renal artery enters and a renal vein and a ureter exit the kidney.

Deep to the renal capsule is the soft, dense, vascular renal cortex. The renal cortex is part of the kidneys containing mostly nephrons and blood vessels. Nephrons are the basic functional units of the kidneys, with each kidney having one million or more of these important structures.

Seven cone-shaped renal pyramids form the renal medulla deep to the renal cortex. It is the innermost part of the kidney. The renal pyramids are aligned with their bases facing outward toward the renal cortex and their apexes point inward toward the center of the kidney. Each apex connects to a minor calyx, a small hollow tube that collects urine. The minor calyces merge to form 3 larger major calyces, which further merge to form the hollow renal pelvis at the center of the kidney.

The renal pelvis exits the kidney at the renal hilus, where urine drains into the ureter.

Ø  FUNCTIONS OF THE KIDNEY

o   Regulation of water, electolytes excretion and waste products of metabolism

 The kidneys excrete a variety of waste products produced by metabolism. These include the nitrogenous wastes called "urea", from protein catabolism, as well as uric acid, from nucleic acid-metabolism. Formation of urine is also the function of the kidney.   Through urine, the waste products are excreted from the body. The kidneys also serve as the primary mechanism for excreting drug metabolites. Regulation of the amount of water excreted is an important function of the kidney as well. It is important to consider all fluid gained and lost when evaluating a fluid volume status 

When the kidneys are functioning normally, the volume of electrolytes excreted per day will be equal to the amount ingested. The kidneys are responsible for regulation of electrolyte loss and approximately 90% of the sodium contained in the renal filtrate is reabsorbed in the renal tubules specifically the loop of henle and proximal tubules. On the other hand, potassium is the most abundant intracellular ion. And to maintain a normal serum balance the kidneys are responsible for excreting more than 90% of the total daily potassium intake. The regulation of sodium and potassium volume excreted depends on the aldosterone, a hormone synthesized and released from the renal cortex.

o   Regulation of acid-base balance

        The organs involved in regulation of external acid-base balance are the lungs are the kidneys. The lungs are important for excretion of carbon dioxide (the respiratory acid) and there is a huge amount of this to be excreted. While the kidney performs two major functions to assists in this balance. The first is to reabsorb and return to the body’s circulation any bicarbonate from the urinary filtrate and the second is to excrete acid in the urine.

o   Auto regulation of blood  pressure

Although the kidney cannot directly sense blood, long-term regulation of blood pressure predominantly depends upon the kidney. This primarily occurs through maintenance of the extracellular fluid compartment, the size of which depends on the plasma sodium concentration.

Renin is the first in a series of important chemical messengers that make up the renin-angiotensin system. Changes in renin ultimately alter the output of this system, principally the hormones angiotensin II and aldosterone. Each hormone acts via multiple mechanisms, but both increase the kidney's sodium chloride, thereby expanding the extracellular fluid compartment and raising blood pressure. When renin levels are elevated, the concentrations of angiotensin II and aldosterone increase, leading to increased sodium chloride reabsorption, expansion of the extracellular fluid compartment, and an increase in blood pressure. Conversely, when renin levels are low, angiotensin II and aldosterone levels decrease, contracting the extracellular fluid compartment, and decreasing blood pressure.

o   Production of Hormones

The kidneys secrete a variety of hormones, including erythropoietin, and the enzyme renin. Erythropoietin is released in response to hypoxia (low levels of oxygen at tissue level) in the renal circulation. It stimulates erythropoiesis (production of red blood cells) in the bone marrow. Calcitriol, the activated form of vitamin D, promotes intestinal absorption of calcium and the renal reabsorption of phosphate. Part of the renin-angiotensin-aldosterone system, renin is an enzyme involved in the regulation of aldosterone levels.

o   Osmolality regulation

Any significant rise in plasma osmolality is detected by the hypothalamus, which communicates directly with the posterior pituitary gland. An increase in osmolality causes the gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the plasma osmolality to its normal levels. Urea is usually excreted as a waste product from the kidneys. However, when plasma blood volume is low and ADH is released the aquaporins that are opened are also permeable to urea. This allows urea to leave the collecting duct into the medulla creating a hyper osmotic solution that 'attracts' water. Urea can then re-enter the nephron and be excreted or recycled again depending on whether ADH is still present or not.

        i.            Nephrons

Nephrons are the structures located within the renal parenchyma that are responsible for the initial formation of the urine. It is also the functional unit of the kidney which consists of both vacular and tubular elements.

Its chief function is to regulate water and soluble substances by filtering the blood, reabsorbing what is needed and excreting the rest as urine. Nephrons eliminate wastes from the body, regulate blood volume and pressure, control levels of electrolytes and metabolites, and regulate blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.The filtration begins at the renal glomerulus. The glomerular tuft (glomerulus) contains capillaries and the beginning of the tubule system called Bowman’s capsule. Filtrate from the glomerulus enters Bowman’s capsule and then passes through a series of tubule segments that modify the filtrate as it passes through the renal cortex and medulla and finally flows into the renal calyces. A second capillary bed, the peritubular capillaries, carries the reabsorbed water and solute back towards the vena cava.

ii.            Renal Vein

The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava. Because the inferior vena cava is on the right half of the body, the left renal vein is generally the longer of the two. Unlike the right renal vein, the left renal vein often receives the left gonadal vein (left testicular vein in males, left ovarian vein in females). It frequently receives the left suprarenal vein as well.

ii. Renal Artery

The renal arteries normally arise off the abdominal aorta and supply the kidneys with blood. The arterial supply of the kidneys is variable and there may be one or more renal arteries supplying each kidney. Due to the position of the aorta, the inferior vena cava and the kidneys in the body, the right renal artery is normally longer than the left renal artery. The right renal artery normally crosses posterior to the inferior vena cava. The renal arteries carry a large portion of the total blood flow to the kidneys. Up to a third of the total cardiac output can pass through the renal arteries to be filtered by the kidneys.

2.      Ureters

Description: The ureters are two tubes that drain urine from the kidneys to the bladder. Each ureter is a muscular tube about 10 inches. Muscles in the walls of the ureters send the urine in small spurts into the bladder. ). After the urine enters the bladder from the ureters, small folds in the bladder mucosa act like valves preventing backward flow of the urine. The outlet of the bladder is controlled by a sphincter muscle. A full bladder stimulates sensory nerves in the bladder wall that relax the sphincter and allow release of the urine. However, relaxation of the sphincter is also in part a learned response under voluntary control. The released urine enters the urethra

3.      Urinary Bladder

The urinary bladder is a hollow, muscular and distensible or elastic organ that sits on the pelvic floor. The urinary bladder can hold approximately 17 to 18 ounces (500 to 530 ml) of urine. When the bladder fills with urine (about half full), stretch receptors send nerve impulses to the spinal cord, which then sends a reflex nerve impulse back to the sphincter (muscular valve) at th e neck of the bladder, causing it to relax and allow the flow of urine into the urethra.  The Internal urethra l sphincter is involuntary. The ureters enter the bladder diagonally from its dorsolateral floor in an area called the trigone. The trigone is a triangular shaped area on the postero-inferior wall of the bladder. The urethra exits at the lowest point of the triangle of the trigone. The urine in the bladder also helps regulate body temperature. A bladder when operating normally empties completely upon a complete discharge, otherwise it is a sign that its elasticity is compromised, when it becomes completely void of fluid, it may cause a chilling sensation due to the rapid change of body temperature.

4.      Urethra

The urethra arises from the base of the bladder. Its wall is lined with mucous membranes and contains a relatively thick layer of smooth muscle tissue. It also contains numerous mucous glands, called urethral glands that secrete mucus into the urethral canal. In the human male, the urethra is about 8 inches long and opens at the end of the head of the penis. It functions as a urinary canal and a passageway for cells and secretions from various reproductiveorgans. In the human female, the urethra is about 1-2 inches long and opens in the vulva between the clitoris and the vaginal opening. Men have a longer urethra than women.

III.      ASSESSMENT OF THE CLIENT

Ø  History- Thorough urologic health history taking is essential in diagnosing though sometimes it is troublesome to many patients because they are uncomfortable to discuss genitourinary illness or symptom. So it is important to have a good communication skill and patience to make them feel comfortable when taking history.

Urologic health history includes age, gender, race, and ethnicity. It should also covers family history of renal problems, diabetes and auto immune diseases like Systemic Lupus Erythematous (SLE) and Good Pasture’s Syndrome. It also includes past medical history of any renal disease, streptococcal infection, uncontrolled hypertension and diabetes, abdominal or pelvic surgery that can cause denervation injury to the bladder or previous surgery that can cause urinary incontinence and neurological diseases that may cause abnormal bladder function. Medication history of analgesic abuse may be a cause of renal failure and dosages of some drugs may need to be adjusted or stopped in renal failure. Occupational history of exposure to chemical carcinogens such as 2-naphthylamine or benzidine in the chemical or rubber industries may induce bladder cancer many years later. Diet history is also included. The excessive intake or omission of cer­tain categories of foods is noted. Information about food and fluid intake is obtained. If the client has followed a diet for weight reduction, the details of the diet plan are pertinent. A high-protein intake can result in temporary renal problems. Clients susceptible to calculi (stone) formation who ingest large amounts of calcium-containing products or have an in­sufficient fluid intake may form new stones.

Obtaining history of genitourinary pain, abnormalities during voiding and presence or history of genital lesions are all essential. Furthermore, Psychosexual history is also important to take though this needs to be conducted sensitively. It requires experience, knowledge and good clinical judgment to recognize and define underlying psychosexual problems and differentiate them from other causes of symptoms.

Ø  Physical assessment

Assessment of the kidneys, ureters, and bladder is performed in conjunction with an abdominal assessment. Auscultation is performed before percussion and palpation because these ac­tivities can enhance bowel sounds and obscure abdominal vascular sounds.

Inspection

Inspect the abdomen and the flank regions with the client in both the supine and the sitting position. The client is observed for asymmetry (e.g., swelling) or discoloration (e.g., bruising or redness) in the flank region. The patient is also assessed for signs of edema and changes in body weight. Deep tendon reflex of the knee are also assessed for quality and symmetry. This is an important part of testing for neurologic causes of bladder dysfunction.

http://64.19.142.13/intranet.tdmu.edu.ua/data/kafedra/theacher/meds/vnm_horodeckiy/Engl/Recommendations%20for%20preparing%20practical%20classes/Assessment_of_the_Renal-Urinary_System.files/image028.jpgAuscultation

Listen for a bruit over each renal artery on the mid-clavicular line. A bruit is an audible swishing sound pro­duced when the volume of blood or the diameter of the blood vessel changes. A bruit is usually associated with blood flow through a narrowed vessel, as in renal artery stenosis.

 Palpation

Renal palpation identifies masses and areas of tenderness in or around the kidney. The abdomen is lightly palpated in all quadrants. The nurse asks about areas of tenderness or dis­comfort and examines non tender areas first. The outline of the bladder may be seen as high as the umbilicus in clients with severe bladder distention. Special training and practice under the guidance of a qualified practitioner are necessary; there­fore appropriate education is essential before attempting the procedure. If tumor or aneurysm is suspected, palpation may harm the client.

For palpation of the right kidney, the client assumes a supine position while the nurse places one hand under the right flank and the other hand over the abdomen below the lower right part of the rib cage. The lower hand raises the flank, and the upper hand depresses the anterior abdomen as the client takes a deep breath .The left kidney is deeper and rarely palpable. A transplanted kidney is readily palpable in either the lower right or left abdominal quadrant. The kid­ney should feel smooth, firm, and non tender.

 Percussion

A distended bladder sounds dull when percussed. After gen­tly palpating to determine the general outline of the distended bladder, the nurse begins percussion on the skin of the lower abdomen and continues in the direction of the umbilicus until dull sounds are no longer produced.

Ø  Diagnostic testing

·         Urinalysis- Urinalysis is important clinical information about kidney function and helps diagnose other diseases

·         Urine culture- Urine culture determines whether bacteria are present in the urine as well as their strains and concentration

·         Blood Test

1.      Renal Function Test- blood test used to evaluate the status of a patient’s kidney by obtaining serum creatinine and BUN levels in the blood.

2.      ABG- Arterial Blood Gas is a blood test that is performed by getting blood sample in an artery. This test will measure the oxygen and carbon dioxide level in the blood. It will also determine how well the lungs or kidney can maintain the acid-base balance in the body.

·         Imaging Modalities

1.       X-ray study of the KUB- is a plain film of the abdomen taken without any specific client preparation. The KUB study shows gross anatomic features and may show obvious stones, strictures, calcifications, or obstructions in the urinary tract. This test identifies the organs' shape, size, and relationship to other parts of the urinary tract.

2.      Ultrasonography- noninvasive procedure that uses sound waves passed into the body through a transducer to detect abnormalities such as fluid accumulation, masses, congenital malformations, changes in the organ size and obstruction.

3.      CT scan- and Magnetic Resonance Imaging- non invasive technique that provides an excellentt cross sectional views of the kidney and urinary tract.

4.      Renal angiography/arteriography- provides an image of the renal arteries. It is used to evaluate renal blood flow in suspected renal trauma, to differentiate renal cysts from tumors and to evaluate hypertension.

5.      Cystoscopic examination- aka cystoscopy is a term used to describe an internal examination of the bladder. This procedure can also examine urethra or urinary channel and, in men, the prostate. Additionally, the two ureters - which are the small tubes that move urine from the kidneys to bladder - can be examined during this procedure.

·         Kidney biopsy- procedure in which a small sample of tissue is removed from a part of the body. The sample is looked at under a microscope, or tested in other ways.

VI.       GLOMERULONEPHRITIS

            Glomerulonephritis encompasses a variety of diseases most of which are caused by an immunologic reaction that result in proliferative and inflammatory changes in the glomerular structure that can lead damage to the basement membrane, mesangium or capillary endothelium.

Acute glomerulonephritis is defined as the sudden onset of hematuria, proteinuria, and red blood cell (RBC) casts. This clinical picture is often accompanied by hypertension, edema, azotemia (ie, decreased glomerular filtration rate [GFR]), and renal salt and water retention. Acute GN can be due to a primary renal disease or to a systemic disease.

Chronic glomerulonephritis is the advanced stage of a group of kidney disorders, resulting in inflammation and slowly worsening destruction of internal kidney structures called glomeruli. All forms of acute glomerulonephritis have a tendency to progress to chronic glomerulonephritis. The condition is characterized by irreversible and progressive glomerular and tubulointerstitial fibrosis, ultimately leading to a reduction in the glomerular filtration rate (GFR) and retention of uremic toxins. If disease progression is not halted with therapy, the net results are chronic kidney disease (CKD)

VI.1     ASSESSMENT OF THE CLIENT WITH DIFFERENT PATHOLOGICAL CONDITION

·         HISTORY

Patients suspected of Glomerulonephritis should obtain medical history of streptococcal infection, recent upper respiratory infection, family history of renal disease and an autoimmune disorder

 Most of the time the patient is male ages 3-7 years old that suddenly develops periorbital edema and change in color of the urine.

Also, ask about the onset and duration of the illness. The onset is usually abrupt. In the setting of acute postinfectious glomerulonephritis (GN), a latent period of up to 3 weeks occurs before onset of symptoms. The onset of nephritis within 1-4 days of streptococcal infection suggests preexisting renal disease.

Inquire about the symptom of possible flank pain secondary to stretching of the renal capsule, scanty dark colored urine, decreased urine output, periorbital and facial edema and hypertension.

·         PHYSICAL ASSESSMENT

The physical examination begins with a careful assessment of vital signs, particularly blood pressure to check for hypertension, tachycardia, orthopnea and dyspnea due to symptomatic fluid overload. Careful abdominal examination for ascites is also important. Periorbital and facial edema from salt and water retention is seen in glomerulonephritis. Assessment for alteration in mental status due to malignant hypertension or hypertensive encephalopathy is also essential and demand prompt attention.

·         DIAGNOSTIC TESTING

Urinalysis usually provides the information necessary for diagnosis of glomerulonephritis. It shows a fixed specific gravity, small amounts of WBCs,  proteinuria exept during exacerbation and consistent hematuria. Gross hematuria and proteinuria are the cardinal findings. The urine usually has a dark, smoky, cola-colored or red brown hue. The proteinuria produces persistent and excessive foam.

Blood test for Serum BUN and Creatinine levels in the blood may be elevated and C-reactive proteins and antistreptolysin O titer are usually elevated in post streptococcal glomerulonephritis.

Kidney biopsy is the definitive diagnosis for glomerulonephritis

VI.2     PATHOLOGY OF DISEASE CONDITION

·         INCIDENCE RATE

Glomerulonephritis represents 10-15% of glomerular diseases. Despite sporadic outbreaks, the incidence of Acute Glomerulonephritis has fallen over the past few decades. Factors responsible for this decline may include better health care delivery and improved socioeconomic conditions. Acute Glomerulonephritis predominantly affects males (2:1 male-to-female ratio) and only 10% occur in patients older than 40 years old. Acute Glomerulonephritis has no predilection for any racial or ethnic group. A higher incidence (related to poor hygiene) may be observed in some socioeconomic groups.

·         RISK FACTORS AND ETIOLOGY

The definite cause of the glomerulonephritis remains unknown. But two classification of Glomerulonephritis based on etiology were formulated. The Primary Glomerulonephritis are disorders in which the glomerulus is the predominant or the sole tissue involved and if there’s immune response to pathogens.  If it is caused by another disease or if it’s related to a systemic disease, such as diabetes or lupus, infection, autoimmune disorder or drugs it is called Secondary Glomerulonephritis.

PATHOPHYSIOLOGY

Acute glomerulonephritis results from antigen-antibody complexes trapped in the glomerular capillary membrane produced by an infection in the body.

The source of antigens is either exogenous or endogenous. These antigens will stimulate immune response producing antigen-antibody complexes circulating in the general system. The circulating complexes and the other live antigens will lodge to the glomerular capillaries of the kidney. Activation of the biochemical mediators of inflammation will then start by releasing CHEMOKINES. Chemokines attracts t-cells, leukocytes and neutrophils which release lysosomal enzymes that can damage the glomerular cell walls causing t-cell mediated injury. Since there’s membrane damage, it will lead to platelet aggregation and activation of the coagulation system which will cause the fibrin to deposit in the bowman’s space. The result of these events will cause changes in the glomerular structure (crescent formation and thickening of the glomerular filtration membrane) that will eventually lead to glomerular damage. The changes in the glomerular structure (crescent formation and thickening of the glomerular filtration membrane) will cause decrease in GFR that will also cause decreased urine output fluid retention, facial and periorbital edema, pulmonary edema and hypertension. The glomerular damage will cause proteinuria and hematuria in the urine.

If this condition is left untreated and episodes of acute glomerulonephritis still occurs, further loss and damage to the structures of the kidney will happen it will progress to chronic glomerulonephritis. If disease is not halted with treatment and the damage becomes irreversible, it may lead to Chronic Kidney Disease.

CLINICAL MANIFESTATION

Classic manifestations of sudden onset include hematuria

and proteinuria caused by the damaged in the glomerulus. Generalized edema, particularly facial and peri orbital swelling is a typical finding caused by the fluid volume excess in the body. The client may have ascites, dyspnea and orthopnea and crackles upon lung auscultation due to pulmonary edema. The client is likely to have headache and moderate to severe hypertension. Decreased urine output or oliguria may ba present for several days: the longer it persist, the more irreversible the kidney damage.

CHRONIC KIDNEY DISEASE

Chronic kidney disease (CKD) is an important source of long-term morbidity and mortality. It has been estimated that CKD affects more than 20 million people in the United States. Given that most patients are asymptomatic until the disease has significantly progressed, they remain unaware of the condition. Renal failure is the ninth leading cause of death among Filipinos according to the survey conducted by the Philippine Information Agency dated June 4, 2012.

CKD is a worldwide public health problem. It is recognized as a common condition that is associated with an increased risk of cardiovascular disease and chronic renal failure (CRF). In the United States, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost. On the other hand, in the country, the National Kidney and Transplant Institute (NKTI) Executive Director, Dr. Aileen Reigo-Javier said based on the Philippine Renal Disease Registry (PRDR), the top causes of kidney failure in the country is diabetes (44.6%), followed by the high blood pressure (23%) and inflammation of the kidneys (19.3%).

Chronic kidney disease, also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease

CKD is classified into five stages. Stage I is the mildest, usually causing few symptoms like slightly diminished function; kidney damage with normal or relatively high GFR of ≥90 mL/min/1.73 m2. On the other hand, stage 5 is established kidney failure of GFR <15 mL/min/1.73 m2 and permanent renal replacement therapy. (Kidney Disease Outcome Quality Initiative, 2009) Stage V is also referred to as “established” CKD, also called End-Stage Renal Disease (ESRD), Chronic Kidney Failure and Chronic Renal Failure. The prevalence of kidney disease has been an increasing trend, especially the End-Stage Renal Disease as reported in the Philippine Renal Disease Registry.

            As aforementioned in the above paragraphs, Diabetes and Hypertension individually aggravates the risk of developing chronic kidney disease. But in the case of patient EVG, she possesses both the co-morbidity thereby increasing her risk two-folds. As critical care nurses, our interest rocketed and our desire to understand and explore this scenario jolted us to choose the case of the patient.

PATHOPHYSIOLOGY

                        There are many diseases that cause CKD like diabetes mellitus, because when you have DM, there’s too much glucose in your blood. High levels of glucose are toxic to the tiny, fragile capillaries in the kidneys’ glomeruli. Holes form in the capillary walls and the glomeruli lose their ability to filter blood. Another cause of CKD is Hypertension, because high blood pressure damages both arteries leading to kidneys and tiny capillaries inside them. Larger vessels stiffen and narrow so that the kidneys don’t get enough blood. Capillaries inside the glomeruli become brittle and develop holes. Eventually, the glomeruli shrink and are replaced by scar tissue.

Another is Obstruction in the Urinary Tract, cystic kidney disease, Glomerulonephritis, and recurrent urinary infection; each has its own pathophysiology. However, there are common mechanisms for disease progression. Pathologic features include fibrosis, loss of renal cells, and infiltration of renal tissue by monocytes and macrophages. Proteinuria, hypoxia, and excessive angiotensin II production all contribute to the pathophysiology. In an attempt to maintain glomerular filtration rate (GFR), the glomerulus hyper filtrates; this results in endothelial injury. Proteinuria results from increased glomerular permeability and increased capillary pressure. Hypoxia also contributes to disease progression angiotensin II increases glomerular hypertension, which further damages the kidney.

Proteinuria is one of the strongest predictors of progression of CKD, proteinuria occurs due to damage capillary walls  in the kidney due to hypertension or diabetes. As the glomerular filtration rate(GFR) declines, clients may show not only proteinuria but also hypertension as a compensatory mechanism because of decrease oxygen in the blood because of this event the heart will pump faster to circulate oxygenated blood and because of the workload the heart is prone to cardiomegaly. A wide range of lab abnormalities, and manifestation resulting from disorders in the organs. Like anemia, the hormone EPO is produced in the kidney, EPO travels to the bone marrow to meet stem cells, EPO signals the stem cells to produce 2 million red blood cells (RBC) each second. In CKD damaged kidney tissue can’t produce enough EPO to stimulate the creation of adequate numbers of red blood cells, resulting in anemia, and a lack of RBC in the blood, leads to a shortage of oxygen in the body’s tissues. When the heart pumps harder to try to make up for the lack of oxygen. It can become enlarged and damaged from overwork. Bone disease, protein energy malnutrition, and neuropathy; alterations in health status.

   FORMULATION OF APPROPRIATE NURSING DIAGNOSIS

·         Fluid volume excess related to failure of regulatory mechanism and fluid retention as evidenced by edema and blood pressure changes

·         Disturbed body image related to visible facial and periorbital swelling

·         Ineffective tissue perfusion related to vasoconstriction as manifested by fatigue and headache

BOOK REFERENCE

·         Black JM, Hawks JH. (2009). Medical-Surgical Nursing, Clinical Management for Positive Outcomes 8th Edition. Elsevier PTE LTD.

·         Udan, J.Q. (2002). Medical-Surgical Nursing: Concepts and Clinical Application: A Reference Book and Study Guide. Manila: Educational Pub. House.

·         Smeltzer S.H., et.al (2008). Brunner and Suddarth’s Textbook of Medical Surgical Nursing 11th Edition. Lippincott Williams and Wilkins.

·         Porth CM. (2007). Essentials of Pathophysiology, Concepts of Altered Health States 2nd Edition. Lippincott Williams and Wilkins.

·         Nettina, S.M. (2006). Lippincott Manual of Nursing Practice, 8th Edition. USAL: Lippincott Williams & Wilkins.

·         Saladin KS. (2007). Anatomy and Physiology, The Unit of Form and Function 4th Edition. McGraw-Hill.

·         Essentials of Anatomy & Physiology, Sixth Ed., Seeley Et Al., McGraw-Hill International Edition, 2007, Asia, 508-509

·         WEBSITE REFERENCE

·         Glomerulonephritis(2011). Mayo Clinic. Retrieved on September 26, 2013 from http://www.mayoclinic.com/health/glomerulonephritis/DS00503

·         Parmar, MS (2013). Medscape Reference: Drugs, Diseases & Procedures. Retrieved on September 26, 2013 from http://emedicine.medscape.com/article/239278-overview#showall

·         Sharma, P., Kumar, A. (2013). Glomerulonephritis. Epocrates Online: An Athenhealth Company. Retrieved on September 26, 2013 from https://online.epocrates.com/noFrame/showPage.do?method=diseases&MonographId=207&ActiveSectionId=11

·         National Chronic Kidney Disease Fact Sheet: General Information and National Estimates on Chronic Kidney Disease in the United States (2010). Centers for Disease Control and Prevention.  Retrieved on September 28, 2013 from http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm

·         National Kidney And Urologic Diseases Information Clearinghouse: A Service Of The National Institute Of Diabetes And Digestive And Kidney Diseases (NIDDK). National Institutes Of Health(NIH) Retrieved on September 28, 2013 from http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/

·         Welch, RT (2012). Review Article: An Approach to the Child with Acute Glomerulonephritis. Retrieved on September 30, 2013 from http://www.hindawi.com/journals/ijped/2012/426192/

·         Danguilan, R.A., (2008). The Burden Of Kidney Disease In The Philippines. Retrieved on September 30, 2013 from http://www.abs-cbnnews.com/node/14995

·         Renal disease in Top 10 leading cause of death in the Philippines (2007). Davao Today Breaking News. Retrieved on September 30, 2013 from http://davaotoday.com/main/2007/06/19/renal-disease-in-top-10-leading-cause-of-death-in-philippines/

·         Romero, BW, et.al (2009). Epidemiology and Pathophysiology Of Glomerulonephritis. Retrieved on September 30, 2013 from http://execmsn-e-learning.forumotion.com/t73-epidemiology-and-pathophysiology-of-glomerulonephritis

·         Draper, R. (2010). Genitourinary History And Examination. Patient.Co.Uk Professional Reference: Trusted Medical Information And Support. Retrieved on September 30, 2013 from http://www.patient.co.uk/doctor/Urological-History-Taking-and-Examination.ht

·         Assessment of the Renal/Urinary System (2012). Retrieved on September 30, 2013 from http://intranet.tdmu.edu.ua/data/kafedra/theacher/meds/vnm_horodeckiy/Engl/Recommendations%20for%20preparing%20practical%20classes/Assessment_of_the_Renal-Urinary_System.htm

·         DOH 11 says - Kidney disease is one of region’s top 10 deadliest (2012). Edge Davao: Serving A Seamless Society. Retrieved on September 30, 2013 from http://www.edgedavao.net/index.php?option=com_content&view=article&id=7336:doh-11-says-kidney-disease-is-one-of-regions-top-10-deadliest&catid=68:the-big-news&Itemid=96

·         Kidney health Plus. National Kidney And Transplant Institute: Asia’s Leading Kidney Transplant Center. Retrieved on September 30, 2013 from http://www.nkti.gov.ph/kidney_health.do

·         Slifu et. Al., Chronic Glomerulonphritis, Medscape, Updated: Jul 31, 2012, ://emedicine.medscape.com/article/239392-overview#a0101