Polycystic Kidney Disease

Polycystic Kidney Disease


PolycysticKidney Disease

Inthis case study, I will focus on Mr. Jones who was recently diagnosedwith an end stage renal failure due to Polycystic Kidney problem. Mr.Jones is a widowed veteran who has been living in a senior elderlyhome in Newport.Mr. Jones has been living with the Polycystic Kidney disease for overfifteen years and was diagnosed after M. Jones began to experiencegreat pain while passing urine. Polycystic Kidney disease is largelyan inherited disease and is manifested in form of cysts that developsin kidneys. Cysts are sac like features that contains water-likefluid and may vary in size as more liquid accumulates in the cyststhey can grow into large sacs. Cysts largely develop in Kidneys butin other cases the cysts may develop in livers and other parts of thebody. Prior the condition of Polycystic led to serious complications,Mr. Jones had received great counseling concerning his condition andpossible treatments. Some of the complications that Mr. Jones hasbeen suffering are headache, back pain, blood in urine, frequenturination, high blood pleasure and kidney failure. Mr. Jones wasrequested to decide the form of renal replacement therapy he wantedto treat the end-stage kidney disease.

Medicalpractitioners recommend dialysis in conditions where it is difficultto control fluid overload. This was after considered information hadbeen passed to Mr. Jones regarding the dialysis process. Since Mr.Jones has had the polycystic condition for long, he had undergonesome significant dialysis. Previously, Mr. Jones has undergonehemodialysis four hour treatments three times per week. However, thetreatment has not been effective and the problem still persists withthe patient exhibiting signs of anteriovenos fistula (AVF) andincreased blood pressure.

Theaim of this case study

Inthis case study, my focus is reviewing an alternative approach ofdialysis that could help improve the patient condition. To this end,an exhaustive review of Haemodiafilterationmethods and its efficacy in treating polycystic condition will beanalyzed. The case study also seeks to understand the importance ofHaemodiafilterationrenal therapy and pharmacotherapy as vital methods of controllingblood pressure, treat cyst and urinary infections. Also focused on inthis case study is Mr. Jones nursing care needed by the patientthrough a team of professional team. In addition, this custody willexplore the legal and ethical aspects that are considered during thecare of the patient. Lastly, an evaluation of the effectiveness ofthe care provided will be assessed as well as the analysis of thepatient’s care.

Analysisof Care needed by Mr. Jones

Mr.Jones is suffering from high blood pressure and severe kidney failuresymptoms. After the initial dialysis, Mr. Jones developed an inincreased blood pressure of intradialytic hypertension type. Severalstudies affirm that increased high blood pressure is prevalent in allpatients who undergo haemodialysis. Studies indicate that high bloodpressure that arises from dialysis signifies poor outcome and is dueto inadequate volume removal and high dialysate sodium use (Chazot2009, p. 483). Other studies indicate that increase in hypertensionis as a result of endotheline excess for patients who have undergonethrough dialysis. Mr. Jones condition became complicated due tohypertensionduring the dialysis. In part, hypertensionis associated with unequal volume of sodium Chloride in the body(Simons and Walz 2006, p. 857).To this end, it is imperative to understand Mr. Jones blood pressurecondition before embarking on the renal replacement therapy.


Intradialytichypertension is an increase in blood pressure while haemodialysis isin progress or after the process is complete(Inrig, 2010).The systolic blood pressure usually rises by over 10mm Hg during orafter haemodialysis. A number of clinical studies have defined thiscomplication quite differently. The following are the most commondefinitions gathered from these studies:

  • An increase in blood pressure that exhibits resistance to ultrafiltration (Locatelli, Cavalli, &amp Tucci, 2010)

  • Hypertension during the second or third hour of haemodialysis when considerable ultrafiltration has occurred (Horl, 2010 Locatelli, Cavalli, &amp Tucci, 2010)

  • An increase in MAP by 15 mmHg or more during or after haemodialysis (Inrig, 2010)

Intradialytichypertension is also associated with high morbidity and mortalitybesides lower patient comfort. Unlike Intradialytic hypotension, thiscondition does not depend on UF. Despite the limited researchavailable on Intradialytic hypertension, a number of factors havebeen identified as major contributors to its prevalence. Thesefactors include volume overload, activation of the renin angiotensinaldosterone system, endothelial cell dysfunction, and sympatheticover activity(Dousdampanis, Trigka, Giannopoulos, &amp Fourtounas, 2014).Other factors such as net sodium gain, highly ionized calcium, andhypokalemia have also been identified to cause Intradialytichypertension. The latter factors arise during the process ofhaemodialysis(Inrig, 2010, p. 582).

Olderpatients like Mrs. Smith are more susceptible to exhibitingintradialytic hypertension. Patients with lower body weight, lowerserum creatinine, or albumin, and those with prescribedantihypertensive medication are also more likely to exhibit thecondition.

Basedon the various definitions for intradialytic hypertension, it isevident that a number of treatment procedures are available. However,the aforementioned contributing factors are selective with regard tothe patient. Therefore, it is vital to identify the particular factorresponsible for the development of hypertension before commencing ona treatment procedure(Denker &amp Cohen, 2015 p. 533).General treatment procedures thus include subcutaneous ESAs,adjustment of the haemodialysis prescription, inhibition of therenin-angiotensin-aldosterone, inhibition of the sympathetic nervoussystem, and volume management(Denker &amp Cohen, 2015).

Sodiumand UF Profiling

Accordingto Izmir reports, the best treatment of hypertensionis through fluid removal and must be done with caution to avoid riskyhypertensiondrops especially in elderly patients such as Mr. Jones. It isrecommended that patients undergo longer sessions of dialysis toavoid UF side effects or increase hypertensioncomplications. However, it becomes a complex problem especially whena patient is nearing the end of dialysis and suffers fromhypertensionlevels like the case of Mr. Jones. Ideally, prolonging the dialysissession is effective in controlling UF rates but this problem may bedifficult if the patient refuses or there are health organizationconstraints. Empirical studies indicate that hypertensionlevels decreases significantly.

Accordingto Torres,Harris and Pirson (2007, p. 1290) administeringcalcium channel blockers is an appropriate way of addressing thesituation. To this end, it is important to profile Sodium and UF tofacilitate effective fluid removal. For adequate haemodiafilteration process, an exchange volume of 80-120% of total water body water isrequired. Sodium profiling is vital in preventing hypertensiveeffects after fluid withdrawal. However, a combination of ultrafiltration and sodium profiling gives better results.Haemodiafilteration is better than hemodialysis in achieving betweenmiddle-molecular clearances but this depends on ultra filtration andfluid substitution (Simonsand Walz 2006, p. 859).Due to Mr. Jones multiple problems associated with Polycystic Kidneydisease such as cardiovascular and hypertensioninstability, Haemodiafilterationbecomes a better choice of renal replacement therapy for Mr. Jones.


Haemodiafilteration is a renal replacement therapy that is mostly used to treat patientswith acute Kidney injury or failure. Haemodiafilteration involvespassing the patients’ blood through a filtration circuit in which amachine with a semi permeable membrane separates waste products fromwater through a convention process. Replacement fluid is added to theblood which is in turn pumped into the patient’s body. One distinctaspect of haemodiafilteration is that a conventional and not adiffusion principle are used to enhance solute movement. The use ofconventional principle in haemodiafilteration helps overcome thereduced removal rate of larger solutes due to their low speed ofdiffusion as it is the case with hemodialysis (Torres,Harris and Pirson 2007, p. 1282).

Underthe Haemodiafilterationprocess, a dialysate is not used but a hydrostatic pressure aids indriving water and solutes across the filter membrane from bloodcompartment to the filtrate compartment where it is drained. Anisotonic fluid is added to blood as a replacement of fluid volume andusually contains lactate or acetate (Torres,Harris and Pirson 2007, p. 1290).At times, the haemodiafilteration process is used in combination withhemodialysis. In this case blood is pumped through a bloodcompartment that has high flux dialyzer with high rate of Ultrafiltration.

Thecombination of hemodialysis and haemodiafilteration is useful sinceit results in good removal of large and small molecule solutes.Haemodiafilteration treatment is administered continuously orintermittently but for patients in intensive care, a continuoushaemodiafilteration is the best choice. Haemodiafilteration isadministered as an online intermittent hemofitration (IHF) which canbe given in outpatient dialysis, three or more sessions per week. InIHF the substitution fluid is prepared from dialysis solution throughset of two membranes before it is infused into the blood system.Continuous hemofitration was advanced by Kramer in 1977 as atreatment for potassium(k+) (Bruceand Bruce, 2013).There is an increased debate on whether haemodiafilteration iseffective as an end stage treatment for acute Kidney failureconditions.

Treatmentand drugs

Inaddition to the renal replacement therapy, treatment of kidneydisease involves dealing with complications that come with kidneyproblem. This usually involves controlling high blood pressure byeducating the patient and caregivers on nutritional requirement andlifestyle changes for the patient to control high blood pressure.Pain is more chronic in severe cases of polycystic kidney disease anddoctors recommend surgical procedures to remove cysts this is arecommended treatment action for Mr. Jones. Mr. Jones also needs tobe encouraged to drink lots of fluids to eliminate blood in theurine. As the problem of kidney failure persists, Mr. Jones wasadvised to undertake a kidney transplant if the Haemodiafilterationdialysis proves in effective.

Afterevaluating Mr. Jones condition, detailed information was given to himbased on his condition and possible effective treatment approaches.We discussed more about the appropriate treatment that Mr. Jonesrequires with the nurse attendants at the senior elderly home whereJones lived. In particular, Mr. Jones requires medication to addresshis high blood pressure and use of haemodiafilteration method toreduce recurrence of hypertension. All aspects of lifestylemodification and nutritional requirement were explained to thecaregivers at the Senior Elderly home where Mr. Jones lives.Collaboration with all people responsible for patient care iseffective in enhancing the quality of life for Mr. Jones especiallythrough constant communication.


PolycysticKidney disease is a genetic disease that is characterized withabnormal cyst development in kidneys. In both the autosomal andrecessive cases PKD is related with cilia-mediated signaling activity(Badani, Hemal and Menon 2004, p. 222).Disorganized cell divisions lead to the impairment of cilium that isresponsible for regulating the functions in the kidneys. PolycysticCysts may manifest anywhere and at any point of human growthinfancy, childhood and adulthood. Polycystic disorder occurs inhumans as well as some animals(Stiller, Bonnie- Schorn and Grassman 2001, p. 338).Polycystic diseases are characterized by the presence of multiplecysts in both kidneys (Wuthrich,Serra and Kistler 2009,p.386).

Studiesestimate that 17% of the polycystic condition is observable in onekidney and progresses as one ages this is the case with Mr. Jonescondition. Empirical studies attribute polycystic conditions tosevere morbidity and mortality rates due to the genetic complexity ofthe problem (Porth 2011).As cysts expand in the kidney area, the kidney may enlarge renderingthe renal insufficiency.

Polycysticis inherited as an autosomal dominant (ADPKD) or in recessive form(ARPKD).The condition is known to occur in 1 out of 800 people andaccounts for an estimated 2.5% of all end-stage renal diseases(Torres, Harris and Pirson 2007, p. 1287).Autosomal dominant is characterized by an enlarged kidney and renalfailure that occurs in the sixth and fifth grades of the patient’slife. Autosomal recessive polycystic disease on the other hand,occurs in younger patient population and the condition ischaracterized by cystic dilation in the collecting ducts of thekidney (Harris, Torresand Vicente 2009, p. 332).There are various clinical representations of polycystic disease butall are believed to originate from similar phenotype genes. Majorityof the Autosomal dominant polycystic disease exhibit few or nosymptoms at the time of diagnosis (Badani, Hemal and Menon2004, p. 222)

ADPKDsymptoms and signs

Mostpatients with APKD show none or few symptoms. However, when symptomsoccur, they appear at 30 to 50 years and include Abdominal pains,hypertension (occurs in 60%) of patients with ADPKD (Halvorson,Bremmer and Jacobs 2010, p. 74).Impaired renal functioning is the last symptom exhibited by patientsof ADPKD. Other signs and symptoms include palpable kidneys,microscopic hematuria and recurring urinary infections, back pain,satiety and shortness of breath (Badani,Hemal and Menon 2004, p. 224).Development of hepatic cysts occurs after the development of renalcysts. Other extrarenal manifestation of ADPKD include pancreatic,thyroidal and seminal vesicles cysts. In complicated situation,Nephrolithiasis occurs in 20% to 30% of patients(Johnson, Feehally and Floege 2014).

ARPKDsigns and symptoms

InARPKD condition an enlarged kidney is a common symptom of severepolycystic disorder(Badani, Hemal and Menon 2004, p. 223).Respiratory complications and spine deformities may develop leadingto fatal incidents. Other symptoms include hepatic fibrosis,cholangitis and hepatomegaly. ADPKD patients live normal lives untilsevere cases leads to kidney dysfunction at the age of 40 to 60 years(Halvorson,Bremmer and Jacobs 2010, p. 78).Present studies indicate that there are absolutely few or notherapies that can prove effective in preventing the progression ofpolycystic kidney disease in autosomal conditions(Cochrane)(Torres, Harris and Pirson 2007, p. 1289).Mr. Jones PKD may be attributed to genetic inheritance. Mr. Jonesshowed the ADPKD signs and symptoms but his case is a severepolycystic condition at advanced level. Mr. Jones was first diagnosedfor ADPDK in his late forties and the condition worsened since he wasliving alone. Mr. Jones got a reprieve when the community admittedhim at the Senior Elderly home where he was booked immediately fordialysis to avert fatal complications.

Professional,Legal and Ethical aspects of care

Allhealth practitioners are required to observe good ethics in theirprofessional roles under legal and ethical codes of conduct.Healthcare providers are required to provide patients with allinformation covering their health and possible preventive andtreatment measures used. The relationship between health practitionerand patient should be purely professional and one of sympathy,concern and care. Patients are entitled to consent in all activitiesand procedures used in care provision and this consent is onlypossible through providing patient with all information coercingtheir health. Health practitioners are under legal obligation toprovide quality and patient centered care under law, patient’sneeds surpass those of the care giver. In the case of Mr. Jonestreatment, all information concerning his PKD was provided as well astreatment methods. This was achieved by enlisting the care givers andguardians from the elderly home in the treatment plan.

Theguardians and care givers are allowed to select the team ofprofessional doctors and nurses that would oversee the treatment ofthe patient. Effective and timely communication is essential ethicalaspect in this case as it ensures that the patient and the guardiansare informed on all aspects of treatment. In addition, our hospitaluses the internationally accredited dialysis equipments andprocedures. During the entire treatment phase, confidentiality,accountability and capacity will be enhanced as required byhealthcare provision ethics. Legal aspects will be achieved byfollowing all the guidelines, policies and statues of healthcareprovision.


AlthoughMr. Jones had gone through various phases of dialysis at the elderlyhome, he showed confidence that our team would help relieve his pain.Mr. Jones had lived with PKD for almost 15 years and he was lessoptimistic that he would get well. However, our team was dedicated togive Mr. Jones the best quality treatment he needed especially inlowering his blood pressure, back pain and a near kidney failure. Asthe leading nurse, I was instrumental in leading the other caregiversin understanding the whole aspect concerning Mr. Jones’s health.The first step was informing the patient and the guardians allaspects of ADPKD as diagnosed from the patient current and historicalailments as explained by Johnson,Feehally and Floege (2014, p.1).

Informationsharing was important in ensuring that the patient and the guardiansagreed to the pharmacological and therapeutically treatmentprocedures for Mr. Jones. In my team, I suggested that we enlist thehelp of a counselor in order to enhance the patient collaborate andshed unnecessary anxieties. The support of a counselor was effectivein encouraging the patient to undergo haemodiafilteration andmedication before we considered kidney transplant. The goals of ourtreatment plan sought to address the following pain medication,blood pressure medication, use of antibiotics to treat UTI,haemodiafilteration to remove excess fluid and lastly conductingdiet and lifestyle adjustment training(Wuthrich, Serra and Kistler 2009, p. 382).

Achievinggood blood pressure was important in slowing the progression of renaldisease. This was done through antihypertensive therapy and drugadmistration. Regular monitoring of serum chemistry values was doneto avoid increasing k+levels(potassium). Gyraseinhibitors such as ciprofloxacin and chloramphenical were used totreat cysts infections. In order to maintain the electrolyte levels,calcium carbonate and calcium acetate were used since Mr. Jonescondition bordered severe renal failure. These pharmacologicaltreatments were done in phases of three weeks beforehaemodiafilteration was done in the last week of treatment. The aimof using pharmacologic therapy prior the haemodiafilterationwas to bring down the level of blood pressure(Halvorson, Bremmer and Jacobs 2010, p. 76).

Haemodiafilterationwas conducted in week four and five in phases of three sessions perweek. Each haemodiafilteration session lasted four hours per week toremove excess fluid from the patient’s kidney. On the sixth week,the patient was allowed to rest while diet and lifestyle adjustmentswere done to ensure that complications such as anemia and high bloodpressure were checked. During the last weeks of treatment caregiverswere advice to give the patient low-sodium diet. In addition, thepatient was advised against strenuous activities to minimize the riskof kidney rapture. A dietary sheet with recommendation on nutritionalneeds for the patient was given to caregivers. In addition, thecaregivers were trained on how to ensure that the patient took therequired medication at the right time and in the right dosage. Themonitoring of sodium levels remains a great concern for patientsunder dialysis and research are still been conducted to ensure thatthe right sodium levels, rates and temperature of the replacementfluid is maintained.

Evaluationon the care provided to Mr. Jones

Thetreatment approach used on Mr. Jones was effective since after aperiod of three months, Mr. Jones condition improved especially onhigh blood pressure, back pain reduced and less fluid in the kidney.The approach used to treat Mr. Jones was an evidence based practiceinformed by adequate analysis of patient condition, treatment historyand available treatment methods(Chapman 2008, p. 1198).All aspects of treatments were customized according to the patienthealth condition, nutrition status and facilities available. In Mr.Jones case, I was able to reduce his high blood pressure, back pain,and a significant reduction in kidney cysts. In addition, throughdietary and lifestyle adjustment, the patient regained his health.


Inthis case study, it is evident that although severe cases ofpolycystic condition leads to renal failure, adequate treatment thatis customized to patient health needs can be effective inameliorating adverse cases of PDK. In particular, the use ofhaemodiafilteration, the use of pharmacological therapies for HBP,Sodium and UT profiling helps in reducing the severity of polycysticdisease. The use of haemodiafilteration dialysis showed that it ispossible to reduce PDK condition. The treatment approach used in thecase study was based on evidence based empirical practice and theireffectiveness confirms that indeed PDK can be treated to reduceadverse complication on patients. The study also exemplifies the needof patient and health care provider interaction. Ongoing evaluationof patient care is enhanced through training the care givers on whatis needed to enhance the patient’s quality of life after treatment.The case study also confirms that a combination of IHF,pharmacological therapy, diet and lifestyle management is integralaspects in treating severe cases of PDK. Lastly, the case studyshowed that when the patient, care givers and guardians collaborate,there is positive improvement in chronic conditions such as PDK.


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