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CGN Presentation by Rebira Workineh.pptx
- 1. Institute of Health Science Department of Nursing Postgraduate Program of Adult Health Nursing Chronic Glomerulonephritis Seminar Presentation Set By: Rebira Workineh (AHN Student) Rebira W. (AHN student) 2/13/2024 1
- 2. Objectives Rebira W. (AHN student) At the end of this session, the participants will be able to: Define chronic glomerulonephritis Identify the development of chronic glomerulonephritis Explain etiologies of chronic glomerulonephritis Understand how to diagnose chronic glomerulonephritis Describe the differential diagnosis of chronic glomerulonephritis Identify possible management for patients with chronic glomerulonephritis 2/13/2024 2
- 3. Outlines 2/13/2024 Rebira W. (AHN student) 3 Introduction to CGN Epidemiology Pathophysiology Etiology Clinical manifestations Investigations Differential diagnosis Medical mgt. Nursing mgt. Prevention Complications References
- 4. Introduction to CGN 2/13/2024 Rebira W. (AHN student) 4 Nearly all forms of AGN have a tendency to progress to chronic glomerulonephritis. CGN is characterized by irreversible & progressive glomerular & tubulointerstitial fibrosis, leading to a reduction in the GFR & retention of uremic toxins. If disease progression is not halted with therapy, it results in CKD, ESRD, & CVD. CGN is the 3rd leading cause of CKD, & accounts for about 10% of all patients on dialysis. (Kawasaki Y et al, 2011)
- 5. Introduction to CGN Cont’d… 2/13/2024 Rebira W. (AHN student) 5 Definition CGN is a kidney disorder caused by slow, cumulative damage and scarring, usually by inflammation, of the tiny blood filters in the kidneys. These filters, known as glomeruli, remove waste products from the blood. Inflammation typically results in one or both of the nephrotic or nephritic syndromes.
- 6. The National Kidney Foundation 2/13/2024 Rebira W. (AHN student) 6 NKF defines CKD on the basis of either of the following criteria o Evidence of kidney damage based on abnormal urinalysis results or structural abnormalities observed on ultrasound images o A GFR of < 60 mL/min for 3 months or longer According to this criteria, the NKF developed guidelines that classify the progression of renal disease into five stages This classification includes treatment strategies for each progressive level as follow
- 7. The NKF Cont’d… 2/13/2024 Rebira W. (AHN student) 7 Stage 1 This stage is characterized by kidney damage with a normal GFR - ≥ 90 mL/min The action plan consists of diagnosis and treatment, treatment of comorbid conditions, slowing of the progressing of kidney disease, and reduction of CVD risks Stage 2 This stage is characterized by kidney damage with a mild decrease in the GFR- 60-90 mL/min The action plan is estimation of the progression of kidney disease
- 8. The NKF Cont’d… 2/13/2024 Rebira W. (AHN student) 8 Stage 3 This stage is characterized by a moderately decreased GFR- 30-59 mL/min The action plan consists of evaluation and treatment of complications Stage 4 This stage is characterized by a severe decrease in the GFR - 15-29 mL/min The action plan is preparation for renal replacement therapy Stage 5 This stage is characterized by kidney failure The action plan is kidney replacement if the patient is uremic
- 9. Epidemiology 2/13/2024 Rebira W. (AHN student) 9 In the United States, CGN is the 3rd leading cause of ESRD It accounts for 10% of patients on dialysis In Japan and some Asian countries, CGN has accounted for as many as 40% of patients on dialysis However, subsequent data suggest that in Japan, the rate of CGN in patients on dialysis is 28%. The cause of this decline rate is not known (Nakai S et al, 2004)
- 10. 2/13/2024 Rebira W. (AHN student) 10
- 11. Etiology 2/13/2024 Rebira W. (AHN student) 11 The progression from AGN to CGN is variable, based on the cause of the condition Complete recovery of renal function occurs in patients with poststreptococcal glomerulonephritis Other glomerulonephritis, such as IgA nephropathy, often has a relatively benign course Many do not progress to ESRD Progression patterns may be summarized as follows
- 12. Etiology Cont’d… 2/13/2024 Rebira W. (AHN student) 12 Rapidly progressive glomerulonephritis or crescentic glomerulonephritis About 90% of patients progress to ESRD within weeks or months Focal segmental glomerulosclerosis About 80% of patients progress to ESRD in 10 years This form may be related to HIV infection Membranous nephropathy About 20-30% of patients with membranous nephropathy progress to CRF & ESRD in 10 years
- 13. Etiology Cont’d… 2/13/2024 Rebira W. (AHN student) 13 Membranoproliferative glomerulonephritis About 40% of patients with membranoproliferative glomerulonephritis progress to CRF & ESRD in 10 years IgA nephropathy About 10% of patients with IgA nephropathy progress to CRF & ESRD in 10 years Poststreptococcal glomerulonephritis About 1-2% of patients with poststreptococcal glomerulonephritis progress to CKD & ESRD
- 14. Etiology Cont’d… 2/13/2024 Rebira W. (AHN student) 14 Lupus nephritis About 20% of patients with lupus nephritis progress to CRF& ESRD in 10 years The presence of antineutrophil cytoplasmic antibody is also an independent risk factor for poor renal outcome. (Wang Y et al, 2016)
- 15. Pathophysiology 2/13/2024 Rebira W. (AHN student) Reduction in nephron mass from the initial injury reduces the GFR This reduction leads to hypertrophy and hyperfiltration of the remaining nephrons and to the initiation of intraglomerular hypertension These changes occur in order to increase the GFR of the remaining nephrons, thus minimizing the functional consequences of nephron loss 15 The changes, however, are ultimately detrimental because they lead to glomerulosclerosis & further nephron loss
- 16. Pathophysiology Cont’d… 2/13/2024 Rebira W. (AHN student) 16 In early renal disease, decline in the GFR leads to slight increases in serum creatinine levels Azotemia (i.e., a rise in blood urea nitrogen & serum creatinine levels) is apparent when the GFR decreases to < 60-70 mL/min Reduction in the GFR also results in the following
- 17. Pathophysiology Cont’d… 2/13/2024 Rebira W. (AHN student) 17 Decreased production of erythropoietin, thus resulting in anemia Decreased production of vitamin D, resulting in hypocalcemia, secondary hyperparathyroidism, hyperphosphatemia, & renal osteodystrophy Reduction in acid, potassium, salt, and water excretion, resulting in acidosis, hyperkalemia, hypertension, & edema Platelet dysfunction, leading to increased bleeding tendencies
- 18. Clinical Manifestations 2/13/2024 Rebira W. (AHN student) 18 Symptoms Weakness and fatigue Loss of energy, appetite, and weight Pruritus Early morning nausea and vomiting Change in taste sensation Reversal in sleep pattern Peripheral neuropathy Seizures Tremors
- 19. Clinical Cont’d… 2/13/2024 Rebira W. (AHN student) 19 Signs Hypertension Jugular venous distention Pulmonary rales Pericardial friction rubs in pericarditis Tenderness in the epigastric region or blood in the stool Decreased sensation and asterixis
- 20. Investigations 2/13/2024 Rebira W. (AHN student) 20 Clinical findings History collection Physical examination Urinalysis The presence of dysmorphic RBCs, albumin, or RBC casts suggest glomerulonephritis as the cause of kidney failure (Edgar V Lerma et al, 2022)
- 21. Investigations Cont’d… 2/13/2024 Rebira W. (AHN student) 21 Urinary protein excretion Estimated by calculating the protein to creatinine ratio on spot morning urine sample Complete blood count Anemia is a significant finding in patients with some decline in the GFR Is the result of marked impairment of erythropoietin production & alterations in iron absorption that accompany CKD from ferroprotein and FGF23
- 22. Investigations Cont’d… 2/13/2024 Rebira W. (AHN student) 22 Serum chemistry Serum creatinine & BUN levels are elevated Impaired excretion of potassium, free water, & acid results in hyperkalemia, hyponatremia, and low serum bicarbonate levels, respectively Impaired vitamin D-3 production results in hypocalcemia, hyperphosphatemia, and high levels of parathyroid hormone Low serum albumin levels may be present if uremia interferes with nutrition or if the patient is nephrotic
- 23. Investigations Cont’d… 2/13/2024 Rebira W. (AHN student) 23 Renal biopsy Kidney biopsy is usually unnecessary Imaging Studies Ultrasound: Presence of both kidneys, size & exclude structural lesions that may be responsible for azotemia
- 24. Differential Diagnosis 2/13/2024 Rebira W. (AHN student) 24 Azotemia, uremia, chronic kidney disease Crescentic glomerulonephritis Diffuse proliferative glomerulonephritis Glomerulonephritis associated with non-streptococcal infection Membranoproliferative glomerulonephritis Membranous glomerulonephritis Poststreptococcal glomerulonephritis Rapidly progressive glomerulonephritis
- 25. Management- Diet & Activity 2/13/2024 Rebira W. (AHN student) 25 Diet Protein restriction (0.4 to 0.6 mg/kg/day) Slow the decline in GFR and reduce hyperphosphatemia (serum phosphate > 5.5 mg/dl) in patient with serum creatinine levels > 4 mg/dl Should follow low potassium diets (2000-3000 mg/dl) Activity Patient should increase their activity level as tolerated This may aid in blood pressure control
- 26. Pharmacologic Therapy 2/13/2024 Rebira W. (AHN student) 26 BP Management Angiotensin converting enzyme inhibitors are the first treatment of choice Angiotensin II receptor blockers are used to retard the progression of CKD in patient with diabetic and nondiabetic nephropathy Combination of ACEIs and ARBs- to achieve better pressure control & preservation of kidney function
- 27. Pharmacologic… 2/13/2024 Rebira W. (AHN student) 27 Diuretics Are used to treat edema & hypertension Increase urine excretion by inhibiting sodium and chloride transporters Loop and thiazide are among classes of diuretics Examples: Furosemide (Lasix), bumetanide, torsemide, ethacrynic acid & hydrochlorothiazide, metolazone Others: Beta blockers, calcium channel blockers, alpha1 antagonists, direct vasodilators, etc.
- 28. Pharmacologic… 2/13/2024 Rebira W. (AHN student) 28 Fibrosis inhibition Progressive fibrosis is the hallmark of chronic glomerulonephritis Inhibitors of fibrosis is intended to slow the progression Pirfenidone is the best candidate, inhibits transforming growth factor & collagen synthesis Others: Mineralocorticoid antagonists, nonsteroidal mineralocorticoid antagonists (better, b/c the former induce hyperkalemia) (DeFronzo RA et al ,2022)
- 29. Pharmacologic… 2/13/2024 Rebira W. (AHN student) 29 Sodium bicarbonate Reduce tubulointerstitial injury & endothelin production Slow progressive kidney damage In one study on patients with advanced kidney failure, the administration of sodium bicarbonate preserved GFR decline Even in patients with relatively preserved GFR in stage 2 CKD, the administration of sodium bicarbonate was shown to preserve kidney function over 5 years (I de Brito-Ashurst et al, 2009 & Mahajan A et al, 2010)
- 30. Renal Replacement Therapy 2/13/2024 Rebira W. (AHN student) 30 These options of renal replacement therapy are used when GFR falls below 20-25 ml/min Renal transplantation must explored when GFR falls below 20 ml/min Hemodialysis Peritoneal dialysis Renal transplantation
- 31. Nursing Management 2/13/2024 Rebira W. (AHN student) 31 Nursing diagnosis Acute pain R/T inflammation of renal cortex AEB facial expressions & verbalization of patient Goals To reduce pain Intervention Assess pain characteristics Provide comfort devices, quite environment and calm activities Administer the analgesic according to physician order
- 32. Nursing Management Cont’d… 2/13/2024 Rebira W. (AHN student) 32 Nursing diagnosis Excess fluid volume R/T accumulation of fluid in the body AEB edema & weight gain. Goal To maintain the fluid volume Intervention To change the position frequently To elevate the edematous extremities To administer the diuretics to promote the diuresis To administer the albumin helps in shifting the fluid from the ISC to IVC
- 33. Nursing Management Cont’d… 2/13/2024 Rebira W. (AHN student) 33 Nursing diagnosis Ineffective breathing pattern R/T accumulation of fluid in the peritoneal cavity AEB respiration rate, dyspnea. Goal To improve the breathing pattern Intervention Instruct the patient to perform the deep breathing exercise To provide the semi-fowler position Encourage the rest between the activities to avoid the overexertion
- 34. Prevention 2/13/2024 Rebira W. (AHN student) 34 One should seek medical assistance as soon as possible if they have impetigo or a sore throat due to a strep infection. Follow safe-sex guidelines and abstain from intravenous drug use to prevent infections like HIV & hepatitis, which can cause some types of glomerulonephritis. Control high blood pressure to reduce the risk of kidney damage from hypertension. In order to help avoid diabetic nephropathy, control blood sugar.
- 35. Complication Metabolic acidosis Pericarditis, pulmonary edema Uremic encephalopathy Uremic gastrointestinal bleeding Uremic neuropathy Severe anemia & hypocalcaemia Hyperkalemia 2/13/2024 Rebira W. (AHN student) 35
- 36. References 2/13/2024 Rebira W. (AHN student) 36 Kawasaki Y, (2011). Mechanism of onset and exacerbation of chronic glomerulonephritis and its treatment. Nakai S, et al, (2006). An overview of regular dialysis treatment in Japan (as of 31 December 2004). de Brito-Ashurst I, et al, (2009). Bicarbonate supplementation slows progression of CKD and improves nutritional status. Mahajan A, et al, (2010). Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy. DeFronzo RA, et al, (2022). Modifying chronic kidney disease progression with the mineralocorticoid receptor antagonist finer none in patients with type II diabetes.
- 37. 2/13/2024 Rebira W. (AHN student) 37 Stay Bless!