1. Robinson, Janie R. PhD, RN

Article Content

End-stage renal disease (ESRD), also known as chronic renal failure or stage 5 kidney disease, is characterized by the loss of most or all kidney function. In ESRD, the kidneys function at 10% or less. The kidneys can't excrete waste from the blood, regulate fluids and electrolytes, produce erythropoietin to stimulate the bone marrow to make red blood cells (RBCs), regulate BP, activate vitamin D, or regulate acid-base balance.


Q: Who's at risk for ESRD?

A: Those with chronic kidney disease, usually caused by uncontrolled diabetes and hypertension, heart disease, genetic disorders (such as polycystic kidney disease), and other systemic diseases, are at risk for developing ESRD. Kidney trauma (sometimes from repeated kidney infections), obstructions, major blood loss, and toxic agents can also cause ESRD. Other nonmodifiable risk factors include having a family history of kidney disease, being older than age 60, or Black, Hispanic, American Indian, or Asian ethnicity.


Q: What causes ESRD?

A: Anything that can damage the nephrons (the basic functioning unit of the kidney) will cause ESRD. Some conditions, such as diabetes and hypertension, can cause rapid decline, whereas other conditions may cause a slow decline. The normal process of aging decreases blood flow to the kidneys, which in turn can damage them. For this reason, the rate of ESRD in adults ages 65 to 74 has increased.


Diabetes is the leading cause of ERSD. High blood glucose levels damage the walls of the nephrons, thickening them and making them leak. This thickening causes the kidneys to work harder to filter more blood. After years of doing extra work, the nephrons (or filters) become ineffective. Small amounts of protein that should be reabsorbed into the body begin to leak into the urine through damaged glomeruli. This condition is called microalbuminuria. Eventually, the kidneys become weaker and more protein appears in the urine; this is called macroalbuminuria. The kidneys lose their filtering ability, and waste products and fluid buildup in the blood. These buildups are indications of ESRD.


Hypertension, the second leading cause of ESRD, damages the kidneys as a result of increased BP. Think of BP as the force of blood against the blood vessel walls. The increased pressure makes the arteries around the kidneys narrow, weaken, or harden. The result? Decreased blood flow to the kidneys, and without blood flow, the kidneys and nephrons can't function properly. Increased BP also damages the nephrons, and damaged nephrons lead to ESRD.


Q: What are the signs and symptoms of ESRD?

A: Clinical manifestations are different in each person. In ESRD, signs and symptoms may progress slowly because the disease usually causes damage over time-unless trauma or immediate assault to the kidney is involved. Although the kidneys can compensate for lost function for a while, by the time signs and symptoms of ESRD appear, the damage can't be undone. Clinical manifestations include the following.


* High BP may be due to fluid retention because the kidneys aren't functioning or it may develop when the failed kidneys activate the renin-angiotensin-aldosterone system. This system causes vasoconstriction of the blood vessels and reabsorption of sodium and water. Both of these responses cause increased BP.


* Heart failure, pulmonary edema, shortness of breath, and edema of the face, feet, and ankles are due to the kidneys' inability to excrete excess fluid. Shortness of breath can also be due to anemia because the kidneys aren't producing erythropoietin, a vital component in the manufacture of RBCs.


* Chest pain is caused by fluid or uremic toxins that have accumulated around the heart. This is called pericarditis.


* Changes in urineoutput are due to the kidneys not functioning. Although some patients have a normal urine output, other patients can be anuric, oliguric, or polyuric. Some individuals with ESRD continue to excrete water as urine but the urine doesn't contain waste products that the kidneys normally excrete from the body through urine.


* Muscle twitching and cramps are caused by calcium deficiency. The damaged kidneys can't control electrolytes or synthesize vitamin D to absorb calcium.


* Altered level of consciousness(LOC) is the result of uremic waste products accumulating in the blood. A patient with an altered LOC may be confused, agitated, or unable to concentrate.


* Gastrointestinal (GI) discomfort, including anorexia (loss of appetite), nausea, vomiting, a bad taste in the mouth, or hiccups, is caused by the GI tract compensating for the increased urea in the body by excreting more urea through the intestinal tract. Urea enzyme, in turn, breaks the urea down to ammonia. When ammonia stimulates the intestinal tract, nausea and vomiting are the result. Gastrin levels and acidosis are other causes of GI discomfort.


* Itching is due to increased uremia in the blood and the imbalance of serum calcium and phosphorus. Hyperphosphatemia (elevated phosphorus levels) causes itching, as can high levels of parathyroid hormone.


* Bone pain is caused by the release of parathyroid hormone. This triggers low levels of calcium and pulls calcium from the bones back into the bloodstream to compensate.


* Fatigue is the result of anemia, hyperkalemia (elevated potassium levels), and hyperphosphatemia. Anemia is caused by the lack of erythropoietin and decreased RBC production.


* Abnormal ECG changes are caused by hyperkalemia, which occurs when the body can't excrete potassium. These changes include peaked T waves, prolonged PR intervals, a widened QRS complex, and a flat P wave.



Q: How's ESRD diagnosed?

A: A series of diagnostic tests can be performed to diagnose ESRD. To screen for kidney disease, the National Kidney Foundation recommends three tests: a BP measurement, a spot check for protein or albumin in the urine, and a calculation of glomerular filtration rate (GFR) based on creatinine clearance. Measuring serum creatinine levels and blood urea nitrogen (BUN) provides additional information (see Diagnostic tests for ESRD).


Elevated BP is a strong indicator of kidney disease. Patients with any risk factors for kidney disease should have their BP assessed daily.


The GFR, the best indicator of kidney disease, is the amount of plasma filtered through the glomeruli per minute. Normal GFR is 120 mL/min, but GFR decreases with kidney damage. In ERSD, the GFR is less than 15 mL/min. Creatinine clearance, which measures the volume of blood cleared of creatinine in 1 minute, allows the GFR to be estimated.


Serum creatinine levels, which indicate how well the kidneys are working, are used to measure the waste products in the blood. Creatinine is the end product of muscle energy metabolism. This test isn't conclusive in diagnosing ESRD because serum creatinine can be elevated due to increased meat consumption or ingestion of certain medications.


BUN measures the amount of urea (a nitrogenous end product of protein metabolism) in the blood, but this test isn't a conclusive determinant of ESRD either. A high-protein diet and dehydration are two factors that can also increase the BUN level. However, patients with ESRD usually have elevated serum creatinine and BUN levels.


Q: How's ESRD treated?

A: ESRD is treated with pharmacologic and nutritional therapies, dialysis, and/or kidney transplant (see Pharmacologic therapy for ESRD).


* Nutritional therapies. Patients with kidney disease should limit their intake of potassium, phosphorus, sodium, fluids, and fats. Although patients should limit their intake of protein in the early stages of kidney disease, after dialysis has been started, these patients will need more protein. In some cases, those on peritoneal dialysis (PD) will need potassium supplements due to the loss of excessive amounts of potassium. Hyperkalemia can cause arrhythmias, slowed heart rate, fatigue, and weakness. Hyperphosphatemia causes itching and elevated parathyroid hormone, bone pain and bone weakness, anxiety, and fatigue. Sodium should be restricted because it increases BP and makes patients thirsty. Thirst can cause increased fluid intake despite a patient's fluid restriction.


* Dialysis. Hemodialysis (HD) is the most common treatment for ESRD. An artificial kidney (dialyzer) connected to a machine outside the body is used to filter the waste from the blood. The blood is then returned to the body. HD treatments, which are usually administered three times a week, can last 3 to 4 hours.



Patients need vascular access to receive HD treatments. Although immediate access can be achieved through a double-lumen vascular catheter inserted into the subclavian, internal jugular, or femoral vein, this type of access isn't recommended for long-term HD because it slows blood flow and raises the risk of infection. Because the dialyzer's filtering ability is decreased by a slowdown in blood flow, the blood isn't as "clean". Three weeks is the recommended maximum usage time for a vascular catheter.


An arteriovenous (AV) fistula, the preferred access device for HD longer than 3 weeks, is created by surgically connecting an artery to a vein. It takes about 14 days to mature; in other words, to heal and be ready for use. An AV graft is created by connecting a synthetic graft between an artery and vein. This access is usually used for patients with compromised vascular systems. Sometimes an AV graft can be used within 24 hours of placement.


PD, another form of dialysis, gives patients more control over their treatments. A catheter is surgically inserted into the abdomen. The peritoneal cavity of the abdomen serves as the filter. A solution is instilled into the abdomen for a set period. The peritoneum allows the waste products from the blood and extra fluid to pass from the blood to the dialysis solution. The solution is then drained from the abdomen. Infection, bleeding, and a leaking catheter are complications associated with PD. The most serious complication is peritonitis, an infection of the peritoneum.

Table Pharmacologic ... - Click to enlarge in new windowTable Pharmacologic therapy for ESRD

* Transplant. Kidney transplantation has become an increasingly frequent treatment choice for ESRD. Transplanted kidneys can come from living or deceased donors. According to the National Kidney Foundation, 3,000 patients are added to the kidney transplant list every month, and 13 patients die each day waiting for a kidney transplant. If a patient receives a transplant, it's imperative that he or she take immunosuppressive agents to suppress the body's response to the new kidney for the duration of the transplant.



Q: How should I care for a patient with ESRD?

A: Provide teaching and emotional support for the patient and family. This disease requires many lifestyle changes that can be difficult for the patient to manage. Nursing diagnoses that can assist you in providing care for patients with ESRD include:


* excess fluid volume related to nonfunctioning kidneys


* fluid and electrolyte imbalance related to kidney failure


* imbalanced nutrition: less than body requirements because of nausea, vomiting, anorexia, dietary restrictions, hiccups, and bad taste in the mouth


* impaired skin integrity related to excess phosphorus and itching or the dialysis procedure


* knowledge deficit related to disease process and treatment


* activity intolerance related to anemia, fatigue, or the dialysis procedure


* grieving related to the loss of kidney function


* risk for infection related to the vascular catheter, HD procedure, and PD procedure/catheter


* risk for fluid volume deficit related to fluid restriction and systemic blood loss.



Q: What should I teach my patient with ESRD?

A: Patients should be taught self-management, with an emphasis on the importance of lifestyle changes required to improve their quality of life. Patients must adhere to the agreed-upon treatment regimen, including the dialysis treatment schedule, the renal diet, fluid restrictions, and medication use as prescribed.


Providing care for patients with ESRD can be challenging. It's important to know the disease process, as well as treatment modalities, to provide comprehensive care. If given proper care, including support and patient and family education, patients with ESRD will have better health outcomes and improved quality of life.


Diagnostic tests for ESRD


* Urinalysis


* Creatinine clearance


* Serum creatinine






* Kidneys, ureters, and bladder X-ray


* Ultrasound


* Computed tomography


* Magnetic resonance imaging


* Nuclear scans


* Biopsies of the urinary system


did you know?


* Foods high in phosphorus: dairy products, bran, oats, whole wheat, seeds, nuts, dried beans, brown rice, bacon, dark-colored sodas, and chocolate.


* Foods high in sodium: cured meats, pickled foods, snacks (chips, pretzels, cheese puffs, popcorn), cheese, canned vegetables, canned soups, salad dressings, condiments, frozen meals, and fast foods.


* Foods high in potassium: bananas, deep green and yellow vegetables, beans, potatoes, apricots, cantaloupe, and oranges.


Learn more about it


American Kidney Fund. End stage renal disease (ESRD).


Brogdon R. A self-care educational intervention to improve knowledge of dietary phosphorus control in patients requiring hemodialysis: a pilot study. Nephrol Nurs J. 2013;40(4):313-318.


Lingerfelt K, Thornton K. An educational project for patients on hemodialysis to promote self- management behaviors of end stage renal disease. Nephrol Nurs J. 2011;38(6):483-488.


National Kidney and Urologic Diseases Information Clearinghouse. The kidneys and how they work.


National Kidney Center. Chronic kidney disease stage 5.


National Kidney Foundation. High blood pressure and chronic kidney disease.


National Kidney Foundation. Organ donation and transplantation statistics.


United States Renal Data System. Incidence, prevalence, patient characteristics, and modality.


Willingham F. The dietary management of patients with diabetes and renal disease: challenges and practicalities. J Renal Care. 2012;38(suppl 1):40-51.