NSG2HPB Nursing Health Priorities and Kidney Disease

Answers:

Mr. Goodpasture's Presentation and the Pathophysiology of his Kidney Disease

End-stage renal disease (ESRD) as presented in My Goodpasture is characterised by irreversible deterioration in renal function characterised by the body’s inability to maintain metabolic and fluid and electrolyte balance as expected (Smeltzer, Bare, Hinkle, & Cheever, 2010). As such, its presentation is manifested across different interrelated systems ranging from cardiovascular, neurologic, pulmonary, integumentary, hematologic, musculoskeletal to reproductive.

Patients with end-stage kidney disease often present with neurologic complications such as Mr. Goodpasture's state of agitation. Common neurological complications in end-stage renal failure include cognitive dysfunction, encephalopathy, stroke, and peripheral and autonomic neuropathies (Arnold, Issar, Krishnan, & Pussell, 2016). The pathophysiologic mechanisms of CNS injury in ESRD is proposed to be multifactorial i.e. including both vascular and neurodegenerative mechanisms. Alongside irritability, other common neurologic signs and symptoms include disorientation, seizures, weakness and fatigue, inability to concentrate, behaviour changes, asterixis, seizures and burning sole of the feet (Smeltzer, Bare, Hinkle, & Cheever, 2010).

On respiratory examination, Mr. Goodpasture presentments with scattered crackles over bases which are also a typical presentation in end-stage kidney disease. Pulmonary presentation in ESRD may also include shortness of breath, crackles, Kussmaul-type respirations, thick, tenacious sputum, uremic pneumonitis, tachypnoea, pleuritic pain and depressed cough reflex (Smeltzer, Bare, Hinkle, & Cheever, 2010). The pulmonary effects are as a result of the intimate relation between lung and kidney function. Changes in respiratory function are a mitigation of the systemic effects of renal acid-base disturbances (Cury, Brunetto, & Aydos, 2010). The patient also presents with cardiovascular system problems. According to Smeltzer, Bare, Hinkle, and Cheever (2010), typical signs and symptoms of chronic failure in the cardiovascular system may include hypertension, oedema, hyperlipidemia, pericarditis, and hyperkalaemia. The current patient presents with both oedema and hypertension. Cardiovascular disease is actually the leading cause of death in patients with ESRD who receive dialysis owing in part to the shared risk factors for ESRD and cardiovascular disease (Sweety, Arzu,, Rahman, Salim, & Mahmood, 2014). Gastrointestinal manifestations may include uremic fetor, constipation or diarrhoea, anorexia, and mouth ulcerations and bleeding (Smeltzer, Bare, Hinkle, & Cheever, 2010).

The decline in renal function leads to the accumulation of the products of protein metabolism in blood. The rate of decline in the functioning of the kidneys is actually related to urinary excretion of protein. Patients with ESRD often exhibit elevated urea and creatinine levels (Khalidah & Suhad, 2015). Additionally, according to Paige and Nagami (2009), patients with ESRD also exhibit increases in serum phosphorous and potassium levels as evidenced in My Goodpasture.

On hematology, Mr. Goodpasture presents with below normal haemoglobin, red cell count, haematocrit, white cell count, neutrophils levels. This is in agreement with Suresh, Mallikarjuna, Sharan, Hari Krishna, and Shravya (2012) who concluded that patients with chronic renal failure exhibit abnormal haematological parameters. The authors propose that the main reason for the decline in haemoglobin concentration, red blood cell count, platelet count, haematocrit, and total leucocyte count is due to the impaired production of erythropoietin as the main reason alongside other associated factors such as increased haemolysis, and haematuria.

Mr. Goodpasture's Kidney Disease and his Medical History

The rate of decline in the functioning of the kidneys and progression of CKD is correlated to the underlying disorder of protein excretion by the kidneys and the presence of hypertension. Mr. Goodpasture also presents with hypertension which is a known risk factor for chronic kidney disease and ESRD. Other than diabetes, hypertension is claimed to be the second leading cause of kidney failure (Tomiyama & Yamashina, 2014). As reported by Tomiyama and Yamashina (2014), the incidence and prevalence of both hypertension and ESRD have been on the rise for more than two decades. Hypertension is both a cause and consequence of ESRD as evidenced by the high prevalence of the condition in patients undergoing haemodialysis.

Severe high blood pressure as expressed in the patient’s vital signs can harm the functioning of the kidneys within a relatively short period of time. Moreover, other mild forms of high blood pressure are also known to lead to damage to the kidneys when spread over several years. An uncontrolled hypertensive patient has an elevated risk of easily and quickly progressing to end-stage kidney disease. Hypertension accompanied with other risk factors of smoking, obesity and alcohol consumption (as evidenced in the current patient’s case) increases the risk for ESRD (Rumeyza, 2013).

In hypertension, the unmanaged high blood pressure has the potential of causing harm to blood vessels throughout the body. Arterioles and venules are often the ones that are prone to the much of the damage. The kidneys have plenty of these vessels which become damaged by the high pressure. Systemic hypertension is conveyed to the capillary pressure of the glomerulus hence causing glomerulosclerosis and loss of kidney function; and as a result, a significant risk of impaired renal function among patients with hypertension subjects (Lastra, Syed, Kurukulasuriya, Manrique, & Sowers, 2014). Notably, for patients with chronic kidney disease, hypertension increases the risk of worsening kidney disease and the development of cardiovascular problems.

Management of End?Stage Kidney Disease

Two options available for patients like Mr. Goodpasture include haemodialysis and kidney transplant.   Kidney transplantation is considered the treatment of choice for most patients with ESRD. This preference is attributed to the significant improvement in the quality of life and survival compared to those treated by dialysis (Berns, 2016). Patients who receive transplants have an average increase of 8 to 12 years. Generally, kidneys from living donors are known to function better and for longer periods compared to those from deceased kidneys. Additionally, younger patients are known to benefit more from transplantation compared to older adults. However, there are factors that can prevent a patient’s eligibility for transplantation. These may include severe obesity, chronic illness that could lead to death within a few years, active or recently treated cancer, current drug or alcohol abuse, dementia, and the inability to remember to take medications (Berns, 2016). the primary downside of transplantation is the requirement to take medications and frequent monitoring so as to minimize the risk of organ rejection. Haemodialysis, on the other hand, involves pumping the patient’s blood through a dialysis machine to remove excess fluids and waste products. Haemodialysis is however contraindicated in events of unstable cardiac rhythm, hemodynamic instability, hypotension, and patient refusal (Crawford & Lerma, 2008).

Pertaining to risks and psychosocial implications, on transplantation, studies indicate a rise in the quality of life of most of the recipients, but an overall low improvement in the physical and emotional spheres after the transplantation (Lopes, et al., 2011). The main negative psychosocial effects often reported by the recipients include depression and anxiety. Regarding the recipient-donor relationship, some studies report twice as many well-functioning relationships after positive outcomes (Pasquale, et al., 2014). The risks associated with transplantation are surgery risk, the risk of rejection of the donor organ and side effects of anti-rejection medications or immunosuppressants (Saha & Allon, 2016).On haemodialysis, the primary risks and health complications are serious and they include hypertension, cardiovascular disease, infection, nerve damage, bone disease and anaemia. Pertaining to the psychosocial impact, depression, anxiety, fatigue (due to anaemia, malnutrition and sleep disorders), and decreased the quality of life (due to uncertainty about the future and lack of energy) (Wang & Chen, 2012).

References

Arnold, R., Issar, T., Krishnan, A. V., & Pussell, B. A. (2016). Neurological complications in chronic kidney disease. JRSM Cardiovasc Dis.

Berns, J. (2016). Patient education: Dialysis or kidney transplantation — which is right for me? (Beyond the Basics). Retrieved from UpToDate: https://www.uptodate.com/contents/dialysis-or-kidney-transplantation-which-is-right-for-me-beyond-the-basics

Crawford, P., & Lerma, E. (2008). Treatment Options for End Stage Renal Disease. Prim Care Clin Office Pract, 407-432.

Cury, J., Brunetto, A., & Aydos, R. (2010). Negative effects of chronic kidney failure on. Rev Bras Fisiote, 91-8.

Khalidah, M., & Suhad, H. (2015). The Biochemical Changes in Patients with Chronic Renal Failure. International Journal of Pharma Medicine and Biological Sciences, 75-79.

Lastra, G., Syed, S., Kurukulasuriya, L. R., Manrique, C., & Sowers, J. R. (2014). Type 2 diabetes mellitus and hypertension: An update. Endocrinol Metab Clin North Am, 103-122.

Lopes, A., Frade, I., Teixeira, L., Oliveira, C., Almeida, M., Dias, L., & Henriques, A. (2011). Depression and anxiety in living kidney donation: evaluation of donors and recipients. Transplant Proc, 131-6.

McQuillan, R., & Jassal, S. (2010). Neuropsychiatric complications of chronic kidney disease. Nat Rev Nephrol, 184-193.

Paige, N., & Nagami, G. (2009). The Top 10 Things Nephrologists Wish Every Primary Care Physician Knew. Mayo Clin Proc, 180-186.

Pasquale, C. D., Veroux, M., Indelicato, L., Sinagra, N., Giaquinta, A., Fornaro, M., . . . Pistorio, M. L. (2014). Psychopathological aspects of kidney transplantation: Efficacy of a multidisciplinary team. World J Transplant, 267-275.

Rumeyza, K. (2013). Risk factors for chronic kidney disease: an update. Kidney Int Suppl (2011), 368-371.

Saha, M., & Allon, M. (2016). Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies. Clin J Am Soc Nephrol ?, 1-13.

Smeltzer, S. O., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth's Textbook of Medical-surgical Nursing,. Philadelphia: Lippincott Williams & Wilkins.

Suresh, M., Mallikarjuna, r. N., Sharan, B. S., Hari Krishna, B., & Shravya, k. (2012). Hematological Changes in Chronic Renal Failure. International Journal of Scientific and Research Publications, 1-4.

Sweety, S., A. J., Rahman, M., Salim, M., & Mahmood, M. (2014). Cardiovascular complications in patients with end stage renal disease on maintenance haemodialysis. Mymensingh Med J, 329-34.

Tomiyama, H., & Yamashina, A. (2014). Beta-Blockers in the Management of Hypertension and/or Chronic Kidney Disease. Int J Hypertens, 919256.

Wang, L.-J., & Chen, C.-K. (2012). The Psychological Impact of Hemodialysis. In M. Polenakovic, Renal Failure - The Facts (pp. 217-236). Shanghai: InTech.