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1. Discuss how Robert’s lifestyle choices have contributed to the development and . progression of chronic kidney disease.

From the case study, it is evident that Robert’s lifestyle choices have contributed to the development and progression of chronic kidney disease. Robert drinks heavily and consumes at least 6 cans of beer each night despite of his hypertensive and diabetic condition. Kidneys filter toxic substances from the blood. One of such substances is alcohol that can give rise to changes in kidneys function and make the kidneys less capable from filtering the blood. In addition to it, kidneys maintain the correct amount of water within the system. However, alcohol affects the kidneys in maintaining adequate amount of water within the system. Alcohol dehydrates the entire system and such drying affect the normal functioning of the organs and cells that also include the kidneys. Excessive alcohol consumption elevated Robert’s blood pressure. Alcohol may dilate the blood vessels due to the presence of various chemical triggers like serotonin, histamine, and the heart has to work harder to push blood throughout the system that in turn raise pressure (Koning et al., 2015). While Robert has a medical history of blood pressure and diabetes, he should have include a healthy diet but he has not controlled his alcohol consumption, not even managed to have a good diet. Also, it is evident from the case study that his medication dosage for both conditions has increased over that time, which indicates his ignorance towards his medical conditions or medication adherence, which ultimately cause progression of chronic kidney disease.

2. Provide the rationale for cardiovascular disease and type 2 diabetes as major risk factors for chronic kidney disease.

Cardiovascular disease is a major risk factors for chronic kidney disease. Reduced changes in kidney function is evidenced by lessened glomerular filtration rate and presence of albumin in urea. These are potential cardiovascular risk factor. Impaired kidneys lessen the production of hormone erythropoietin (EPO) that helps in red blood cell production from the bone marrow. Impaired kidney functions leads to anaemia, which can cause left ventricular hypertrophy. This leads to cardiac cell death via apoptosis and worsen cardiac condition. Reduced amount of EPO in renal insufficiency causes cardiac stress through tachycardia and also raised stroke volume. Reduced blood flow within the renal system and fluid retention add further stress to the heart. Inflammation plays a major role in commencement and progression of atherosclerotic process that is a type of inflammation. It is evident that ESRD patients provide serological evidence of activated inflammatory responses because of various causes like reduced renal clearance of cytokines (pro-inflammatory), accumulation of glycation end-products, co-morbidities and other relevant factors associated with dialytic procedure, for example: membrane bioincompatibility, contaminated dialysate and vascular access infections (Adejumo, Okaka, Madumezia, Okwuonu, & Ojogwu, 2015).

Diabetes damages small blood vessels inside the human system. When blood vessels in the kidneys are injured, it fail to properly purify the blood and the system retains more salt and water than it should. This further gives rise to swelling of ankle, weight gain and high protein build up in urine, as seen in Robert’s case. Diabetes may also damage the nerves, which could further obstruct emptying the bladder (Li et al., 2015). The pressure causing from full bladder provide back pressure and injure the kidneys. If urine with elevated sugar level remains in the bladder for longer time, it can cause infection due to rapid bacterial growth.

3. What stage of chronic kidney disease Robert has developed? Explain why Robert’s symptoms (nausea, vomiting and tiredness) have arisen now.

As the renal specialists recommends Robert to commence dialysis, it indicates, Robert has developed end stage renal disease (ESRD). In this condition kidneys stop functioning adequately for an affected individual to live without a transplant or dialysis. This type of kidney failure is permanent and cannot be reversed. This is also referred to as stage 5 chronic kidney disease with a GFR of 15ml/min or less than that. Robert’s estimated GFR is only 11 mL/min, which further confirms the extent of his renal damage.

Robert’s symptoms (nausea, vomiting and tiredness) have arisen in this stage due to electrolyte imbalance, acidosis and uremia. Renal failure causes elevated level of blood urea nitrogen (BUN). Metabolic acidosis happens as number of active nephrons declines in chronic kidney disease. Urea enzymes decompose urea into ammonia that can further stimulate gastrointestinal mucosa, which further lead to nausea and vomiting (Murtagh, Addington-Hall, & Higginson, 2007). Kidney failure may also decline the renal ‘concentration’ capacity. Frequent night urination causes high BUN and hemoconcentration, which further lead to vomiting and nausea. Anaemia can give rise to extreme fatigue and may worsen Robert’s condition. Impaired kidneys lessen the production of hormone erythropoietin (EPO) that enables red blood cell production from the bone marrow. This condition further leads to shortness of breath on exertion. It is evident from the case study that Robert worked as manual labour, so putting strain on health in the form of physical effort is a part of his daily activities that further worsen his condition.

4. Explain in detail the role of dialysis in managing Robert’s condition.

As mentioned in the case study, Robert has large concentrations of protein in his urine, which indicates the presence of proteinuria and a sign of kidney damage. As proteins are reabsorbed from urine, presence of large concentrations of protein indicates insufficient absorption or decreased filtration. Accumulation of harmful waste materials could raise blood pressure and excessive fluid collection may lead to swelling or oedema. This shows a need to commence dialysis for Robert on an immediate basis. Dialysis helps in filtering salt, harmful waste and excessive fluid from the blood and restores blood to a healthy and normal balance. Thus, dialysis replaces the kidneys’ certain important functions. In case of ESRD, various uremic toxins build up takes place, which could be cleaned by dialysis. During haemodialysis, the blood flow through a specific filter inside the dialysis machine, where the filter eliminates waste products and excess fluids from the system but maintains adequate balance of various minerals like sodium and potassium (Puljak, Burilovic, & Brkovic, 2016). After the cleaning of blood, it is returned into the system. However, Kwiatkowska, Domanski, & Pawlik, (2015) in this regard stated that the uremic toxic levels do not reduce to a normal range merely by dialysis and even in case of a transplant, the transplanted kidney may not be effective enough to clean 100% waste materials, which could be monitored by creatinine level. Toxins demonstrate various cytotoxic activities and contain various molecular weights, in certain cases those toxins may bound to proteins like albumin. Such complicated toxic complexes are presently matter of attraction of numerous scientist working to develop the standard of contemporary dialysis procedures.

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