a. End result of the gradual, progressive destruction of
nephrons and decrease in glomerular filtration rate (GFR),
resulting in loss of kidney function that produces major
changes in all body systems
b. Chronic kidney disease (CKD), although ultimately irreversible,
may be slowed by improved standardized blood
tests and availability of new drugs to control blood pressure
II. CKD stages correspond to the degree of nephron loss
(Choka, 2005; Verrelli, 2006).
a. Decreased renal reserve
i. GFR may be normal; slightly higher than normal, stage I:
greater than or equal to 90 mL/min/1.73 m2; or somewhat
less than normal, stage II: 60 to 89 mL/min/1.73 m2.
ii. Kidney dysfunction is present; however, it may be undiagnosed
due to lack of symptoms—blood urea nitrogen/
creatinine (BUN/Cr) ratio is normal and nephron loss at
less than 75%.
b. Renal insufficiency
i. Nephron loss at 75% to 90%; GFR is moderately
(stage III: 30 to 59 mL/min/1.73 m2) to severely
(stage IV: 15 to 29 mL/min/1.73 m2) reduced.
ii. Slight elevation in BUN/Cr
iii. Polyuria and nocturia present—high output failure
c. End-stage renal disease (ESRD)
i. Nephron loss at greater than 90% with a GFR of only
10% to 15% (stage V: less than 15 mL/min/1.73 m2)
ii. Fluid and electrolyte abnormalities
iii. Azotemia and uremia present
iv. Dialysis required
III. Etiology (Holcomb, 2005; Verrelli, 2006)
a. Multiple causes
i. Acute tubular necrosis (ATN) from unresolved acute
renal failure (ARF)
ii. Chronic infections: glomerulonephritis, pyelonephritis,
beta-hemolytic streptococci infection
iii. Vascular diseases: hypertensive nephrosclerosis, renal
artery stenosis, renal vein thrombosis, vasculitis
iv. Obstructive processes: long-standing renal calculi,
benign prostatic hyperplasia (BPH)
v. Cystic disorders: polycystic or medullary kidney disease
vi. Collagen diseases: systemic lupus erythematosus
(SLE) and collagen vascular disease
vii. Tumors: malignant (multiple myeloma) or benign
viii. Nephrotoxic agents: drugs, such as aminoglycosides,
tetracyclines; contrast dyes; heavy metals
ix. Endocrine diseases: diabetes mellitus (DM), hyperparathyroidism
x. Long-standing systemic hypertension
b. Such comorbidities as diabetes and hypertension are
responsible for more than 70% of all cases of ESRD.
c. Highest incidence of ESRD occurs in individuals older than
age 65 years (Verrelli, 2006); over the last decade, there has
been a 98% increase in incidence in those aged 75 years
and older (Alper & Young, 2008).
a. Morbidity: In 2005, 485,000 individuals were treated for
ESRD in the United States; with 90,000 new cases reported
annually, 341,000 receiving dialysis, and more than
140,000 having a functioning kidney transplant (National
Kidney Foundation [NFK], 2008); renal transplantation
success rates exceed 90% (National Institutes of Health
b. Mortality: In 2005, 81,500 deaths were associated with
ESRD in the United States (Morbidity and Mortality
Weekly Report [MMWR], 2007) due to (1) cardiovascular
disease, (2) sepsis, and (3) cerebrovascular disease
c. Cost: The Medicare program spends approximately
$19 billion for care of patients with ESRD, representing
6% of Medicare expenditures (NIH, 2007)
Primary focus is at the community level, although inpatient
acute hospitalization may be required for life-threatening
Anemias—iron deficiency, anemia of chronic disease,
pernicious, aplastic, hemolytic,
Fluid and electrolyte imbalances,
Heart failure: chronic,
Metabolic acidosis—primary base bicarbonate deficiency,
Psychosocial aspects of care,
Upper gastrointestinal/esophageal bleeding,
Additional associated nursing diagnoses are found in:
Renal dialysis—general considerations,
Renal failure: acute,
1. Maintain homeostasis.
2. Prevent complications.
3. Provide information about disease process, prognosis,
and treatment needs.
4. Support adjustment to lifestyle changes.
1. Fluid and electrolyte balance stabilized.
2. Complications prevented or minimized.
3. Disease process, prognosis, and therapeutic regimen
4. Dealing realistically with situation and initiating necessary
5. Plan in place to meet needs after discharge.