AKI/ CKD/ ESKD/Dialysis/ Kidney Transplant/ Cirrhosis
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| Acute Kidney Injury is... | Sudden onset- rapid kidney loss demonstrated by a ↑ in creat & or ↓ UOP
proteinuria
3 Phases: Pre-renal, Intra-renal, and Post-renal
COMMON CAUSE: Acute Tubular Necrosis
COMMON CAUSE OF DEATH: Infection
* Potentially reversible
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| Risks of developing ATN are... | Major surgery, shock, sepsis, transfusion reaction, muscle injury, prolonged hypotension
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| R.I.F.L.E. | Risk: <0.5ml/kg/hr > 6hrs
Injury: <0.5 >12hrs
Failure <0.3 >24hrs (oliguria <400ml/day)
Loss: Persistent >4weeks Kidney Function LOss
End-Stage: Complete loss >3 months aka CKD
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| How does AKI progress? | Oliguric phase to diuretic, then recovery. If not CKD results requires dialysis & transplant.
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| Prerenal is.... | Caused by external factors: burns, shock, dehydration, MI, ↓CO, renal thrombosis, cirrhosis fluid shift
↓ circulation
↓ UOP (oliguria or <.3ml/kg/hr for 24hrs)
↓ renal perfusion
↓ GFR
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| Are kidneys damaged during Prerenal? | NO
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| Prerenal Azotemia | ↓ excretion in sodium = ↑NA/H2O Retention =↓ UOP
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| Intrarenal is.... | Caused by direct dmg to kidney tissue impairing nephrons- prolonged ischemia, nephrotoxins, sepsis, allergic reactions, AGN, SLE
ATN most common cause
Nephrotoxicity causes blockage of tubules
*potentially reversable
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| Nephrotoxic agents | Contrast, mycins, glycosides, antibiotics, sporins, NSAIDs, amphotericin, crush injury, chemical exposure to lead/ethanol/arsenic
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| Postrenal is.... | Caused: BPH, prostate or bladder cancer, trauma to pelvis region, extrarenal tumors, calculi, spinal cord disease
Bilateral ureter obstruction leads to hydronephrosis- if relieved w/48hrs poss recovery
Prolonged obstruction irreversible
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| Oliguric Phase is defined as... | <400ml/day 1-7 days post surgery, lasts 2wks
Urine: casts, rbcs, wbcs, spec gravity stationary 1.010, urine osmo 300, Proteinuria may be present if renal failure is related to glomerular membrane dysfunction.
Fluid retention causes heart failure, edema,
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| Best indicator of AKI is.. | ↑ creat> 0.6-1.2
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| Urea and creatinine is... | the end product of protein metabolism in kidneys
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| Diuretic Phase is | Caused by High Urea and GFR- Kideneys can excrete nut not concentrate
Lasts 1-3wks 1-5L daily in UOP
ML for ML replaced
bun/creat normalize at the end
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| Diuretic phase complications | Hyponatremia, hypokalemia, & dehydration
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| AKI diagnostics | Thorough PMH
Serum creat
urinalysis- casts, rbcs, wbcs, specific gravity 1.010, urine osmo 300
Kidney US
Renal Scan
CT w/o contrast
Renal Biopsy
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| Hyperkalemia in AKI treatment | Tx: Insulin and sodium bi-carb
Calcium gluconate
Kayexelate
HD
Dietary restriction
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| First step in treating AKI is | Determine if adequate intravascular vol & CO to perfuse kidneys bc diuretic therapy may be used if AKI is not established loop diuretics lasix bumex mannitol
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| Fluid restriction in AKI | 600ml + previous 24hr loss = intake restriction for the day
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| Never give kayexalate to | Paralytic illeus
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| AKI risks | Nephrotoxic drugs
age
trauma
surgery
burns
heart failure
sepsis
ob complications
pelvic trauma
pre-existing ckd
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| Azotemia is | ↑ bun and- urea- creat in blood
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| AKI nutrition | Protein 1gm, K+ restriction, NA restriction, Phos restriction, Calcium supps or Phos binders, ↑Fat, 30-35kcal, cal 1000-1500mg, carbs
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| Nursing assessment of AKI | Fluid intake and output
Daily weight
UOP color, glucose, gravity,protein,blood,casts
skin color edema
JVD
bruising
inflammation
LOC
crackles
murmurs
ecg for dysrythmias
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| Treatment of CAN | Contrast assoc neuropathy- reversed by hydration plus bicarb or sodium chloride and mucomyst
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| Loss of 1kg is equal to | 1000ml
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| Leading cause of death in aki is | Infection
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| CKD is | Progressive, irreversible loss of kidney function GFR <60ml/min/1.73 >3 months
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| CKD stages | 1- >90 GFR/
2- Mild GFR 60-89/
3- Mod GFR 30-59/
4- 15-29/
5- <15 dialysis w/uremia present (uremia <10)
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| Uremia indicated by | GFR<10ml/min
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| Clinical manifestations CKD | Fatigue EARLY
polyuria at night
fixed gravity 1.010
Anuria UOP ↓40ml/24hrs
Uremic pleuritis
Hypertensive retinopathy
encephalopathy
amenorrhea or vaginal bleeding
anemia
osteo
paresthesias
scaly, flaky skin
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| Metabolic Distrurbances | ↑ trig levels
hyperinsulinemia stimulates
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| As GFR decreases... | BUN and Creat increase
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| Most common cause of death in CKD | Cardiovascular Disease
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| Fatal dysrhythmias can occur when K is.. | 7-8
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| Anemia in CKD occurs bc | Kidneys produce a hormone EPO, prompts bone marrow to make RBCs so when dmg occurs so does anemia
Tx: Iron, erythropoietin epogen, folic acid 1mg/day, bleeding tendencies
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| CKD Infection | Leukocytosis ↓ WBC
↑ Glucose- hyperglycemia- susceptible to infection
trauma
av/g site infection
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| You can feel a | Thrill
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| You can hear a | Bruit upon auscultation
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| Asterixis | High ammonia levels cause hepatic encephalapathy and flapping of the hands when extended- also seen in renal
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| Diagnostics of CKD | Persistent proteinuria 1+
300mg/albumin/gm creat = CKD
rbcs, wbcs, protein, casts, glucose
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| Drug therapy for CKD | Statins- ↓LDL and Trig to <200
CCB (not diabetics), Aces&ARBS (ok diabetics), Anti HTN
Phos Binder: PhosLo Calcium Acetate, Caltrate (cal carbonate), Renagel (sevlamer)
Calcitrol IV (phos must be ↓first)
Epogen,iron,folic, no transfusions
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| CKD nutrition is | K Restricted
NA Restricted 2-4g/day
Protein Restricted
↓ Phos 1000mg
Low Fat
↑carbs
No salt subs
600ml+prev 24hr loss+ intake restriction
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| Drug therapy complications CKD | Digoxin, Antibiotics, Demerol, NSAIDS, Fluid volume overload,
Electrolyte imbalances
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| Early signs of CKD | GFR<15ml >3months
FATIGUE, lethargy, proteinuria, pruritus, HTN
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| Nursing Mgt CKD | Daily weight
Constant BP's
Fluid overload monitoring
Hyperkalemia (n/v, fatigue, paresthesias, brady)
Strict Dietary
Med Teaching
HD & PD avail for home
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| Calories allowed | HD 30-35/kcal/kg
PD 25-35 kcal/kg/day (includes glucose fm dialysate)
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| CRRT | Hemodynamically unstable clients- 24hr round the clock dialysis thru cannulation of artery or vein- much slower fluid pull than HD
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| Indications for RRT are... | Volume overload
hyperkalemia
Metabolic Acidosis
Bun >120
↓LOC
Pericarditis
Peri-effusion
Cardiac Tamponade
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| Hemodialysis is.. | 4hrs daily or every other day 3-4x wk
Used when rapid changes are needed in short time
Req special staff, heparin, and close hypotension monitoring, weight monitoring pre and post dialysis
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| Hypovolemia.. | Can exacerbate all forms of AKI
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| Metabolic Acidosis | Kidneys cant synthesize ammonia, bicarb ↓acidic, and pt may develop kussmaul's
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| Peritoneal Dialysis | Manual PD 30-50min- Auto 1-2 hrs
Less invasive then HD
Preferred in diabetic
issue infection/perotonitis
temporary cath
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| Complications of PD | Site infection
Peritonitis
Hernias
Atelectasis, pneumonia, bronchitis
displacement of tube
protein loss 10-20g/day or .5g/l exchanged
lower back problems
bleeding
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| PD pros and cons are.. | Fewer dietary restrictions
Greater mobility
Great for pt w/bad vascular access
Diabetics bc insulin can be given intraperitoneal
Heparin not required
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| CAPD | Continuous Ambulatory Peritoneal Dialysis
1.5L-3L removed 4xday
Manual w/4hr dwell times
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| Foods high in phospherus | Meat, milk, icecream, cheese, yogurt, dairy in general, pudding, chicken, fish, nuts, beans
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| Food high in salt | Cured/processed meat, pickled, canned soup, canned veggies, stews, hot dogs, soy sauce, salad dressing
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| Foods high in Potassium | Oranges, Bananas, melon, tomato, prune/raisin, deep green leafy veggies except kale, yellow veggies, white and sweet potato, beans, legumes, chocolate, granola, milk, PB, mushrooms, carrots, salt subs, salt-free broth
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| Why does hypocalcemia occur | GI tract unable to absorb calcium in absence of VIT D.
Phosphate binders can help.
Phoslo admin w/ea meal- may need stool softener
Vit-d <30- supplement cholecalciferol needed
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| Osmosis | Movement of fluid to LESSER to GREATER of solutes
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| Diffusion | Movement fm GREATER to LESSER concentrate.
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| Ultrafiltration | Water & fluid removal- osmotic pressure gradient
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| Dialysis Solution | 1-2L w/glucose 1.5/2.5/4.25%
Similar to plasma
Warmed to body temp
High levels of peritoneal absorption lead to obesity , ↑trig, ↑BG
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| PD Inflow Phase | 2L infused over 10min, flow rate can be ↓ for pain, close clamp after infused.
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| PD Dwell phase | AKA Equilibrium
Diffusion and osmosis b/t pt's blood & solution in perotoneal cavity
20min-8hrs (avg 4)
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| PD Drain phase | Lasts 15-30 min may be facilitated w/gentle massaging or changing position
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| APD | Automatic cycler times and controls equilibrium so pt can dialize while sleeping
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| CAPD | Manual 1.5-3L exchanges x4day 7 12 5 10
risk for peritonitis
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| AV fistula | forearm anastomosis of radial & cephalic vein
2lg needles used
bruit you hear
thrill you feel
3 months prior to HD
not good for HTN, Vascular problems, DM
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| AV graft | Bridge b/t brachial artery & vein antecubital
2-4 wks healing
2 lg needles used
can't take bp, sticks, in that arm
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| Steal syndrome | distal ischemia too much blood being shunted, pain, paresthesias, poor cap refill
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| Temp Vascular Access | Jugular, femoral- preferred over sub
only 1-3 weeks use
ICU setting
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| Dialyzer | Long plastic cartridge w/hollow tubes & filters - blood pumped into top fibers-dialysate pumped through bottom- clean blood then returns to pt
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| HD procedure | 2 needles placed into fistula/graft
one pulls blood to HD other returns it
Heparin added to blood
Diasilate warmed
Alarms for air or blood leaks, temp, bp changes
At the end, dialyzer is flushed with saline at the end,gentle pressure to site.
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| HD nursing | fluid status, site, temp, skin, WEIGHT, lungs
pre and post weight
no more than 1-1.5kg gain b/t tx
hypotension
vs q30-60min
HOLD MEDS PRIOR TO HD
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| HD complication hypotension | d/t rapid removal hypovolemia, ↓CO, ↓vascular resistance,
s/s: dizziness, vision changes, chest pain
tx: ↓volume of fluids removed, increase saline 100-300ml
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| HD complication Muscle cramps | d/t rapid removal of NA and H2O
tx: reduce rate and infuse hypertonic or NS bolus
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| HD complication Blood Loss | Blood incompletely rinsed, separation of tube, membrane rupture, bleeding site, too much heparin
tx: rinse back blood, monitor pt/inr heparin
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| HD complication Hepatitis | Blood transfusions lack of precautions or blood screening for hep c
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| Diff between CVVH and CVVHD | CVVH doesn't require dialysate
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| Kidney transplant | Less than 25% ppl receive one
Eliminates need for dialysis
Pre-emptive if living donor avail
Persons <70 yr, that dont smoke, drugs, refractory CV diseases, chronic pulm, cancer that is wide spread
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| Procedures that may be required prior to tx | refractory HTN- bilateral nephrectomy
Polycystic Kidney Disease
CABG or stent
cholecystectomy
in general both kidneys in recipient are usually not removed.
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| Histocompatibility | Testing for HLA antigens for both donor and recipient
ABO - O universal donor
Test recipient for antigens- if negative that good match
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| Kidney transplant donor sources | deceased w/compatibility
blood relatives
emotionally related donors
paired organ donation
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| Expired donor | fm relatively healthy person who suffered irreversible brain damage
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| Live donor | Min Cold time- immediate organ avail
Labs: 24hr clearance, creat, t protein, cbc, eletrolyte, aids/hep
nephrectomy- donor goes first 1-2hrs, kidneys flushed, takes 3hrs, lap
r illiac fossa preferred in recepient placed extraperotonealy
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| Post-op KT care | Fluid Balance- prefusion- UOP
HCT watch for fall >3pts
Creat >1.4 maintain
Fluid replaced ml for ml 12-24hrs
cvp 8-15
Sudden decrease in UOP
ATN can occur and dialysis may be needed
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| Sudden drop in UOP KT | May be due to dehydration, rejection, urileaks, or obstruction
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| Nrsg Mgt KT | Pre-op discuss immunosupps, ecg, cxr, labs, prevent infection
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| Immunosuppressive Drugs | Tacrolimus, Cyclosporine - nephrotoxic
Mycophenolate- thrombocytopenia, Prednisone/solumedrol- corticosteroids
Sirolimus- leukopenia, Imuran- Anemia, Cyclophosphamide- neutropenia
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| S/E Immuno drugs | peptic ulcers, HTN, Na/H2O retention, easy bruising, joint pain, delayed healing
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| KT infections | CMV most common
candida, cryptococcus, aspergillus, epstein-barr, hsv, utis pneumocystis- occurs first month
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| KT CV complications | ↑atheroscerosis
immunosupps ↑htn ↑hyperlipidemia
Adhere to diet, htn meds, weight, dm, dash diet
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| Most common malignancies in KT | Basal cell carcinoma- sunscreen avoid sun
Lymphoma
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| Recurrence of Renal Disease in KT | Glomerulonephritis
IgA nephropathy
DM
Focal segmental Sclerosis
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| Corticoid related complications | aseptic necrosis hips, joints
peptic ulcer
DM
dylipidemia
cataracts
↑ cancer
↑infection
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| Hyperacute rejection | minutes to hours
sudden ↑ BP
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| Acute rejection is | days to months 3mo
T cells attack, ↑bun, ↑creat, ↑temp, ↑BP, dec UOP
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| Chronic Rejection is | Over months to years is irreversible
proteinuria, ↑creat
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| Cirrhosis in general | Chronic, slow progressive disease- abnormal re-shaping of the liver with fibrous tissue impedes blood flow, 8th leading cause of death
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| Two types of Cirrhosis are | Biliary obstructive and cardiac from long standing right sided heart failure
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| Cirrhosis S/S | Jaundice, thrombocytopenia, leukopenia, asteresis, edema/ascites, spider angiomas, palmar erythema, lesions, esophageal varices, libido, gynocomasteia, ammenorrhea, dec b12, dec folic
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| Causes of Cirrhosis | EARLY sign: Fatigue, thrombocytopenia, hyperaldosterone
Causes: alcohol, chronic hep c, protein malnutrition, environment, chronic inflammation
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| Decompensated cirrhosis is | When the complications occur: portal htn, varices, ascites, hepatic encephalopathy, hepatorenal syndrome
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| Portal HTN | ↑venous pressure
splenomegaly
large collateral veins in esophagus, abdomen, try to reduce ↑plasma load
HTN
varices
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| Cirrhosis Labs | ↑AST ↑ALT ↓Stool bilirubin, ↓plt, ↓wbc, ↓alb/protein,
↑BUN ↑CREAT
↑Serum Bilirubin
↑ Urine Bilirubin
↑PT bleeding time
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| Hepatorenal Syndrome | Renal failure w/Azotemia, oliguria, intractable ascites
No structural dmg of kidneys
Portal HTN leads to vasodilation leads to renal constriction
Tx: transplant
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| Hepatic Encepalapathy | Neurotoxic effect of ammonia
CHange in LOC impaired
asterexsis
fetor hepaticus
Tx: lactulose, rifaximin, antibiotic, prevent constipation, control gi bleeds
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| Cirrhosis diet w/o complication | ↑Cal 3000-cal/day
↑Carb
mod-low fat
↑Protein
↓NA (pts with edema)
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| Ascites | 3rd spacing belly
tx: NA restriction, albumin, potassium sparing aldactone amilodrine, tolvaptan, paracentesis, TIPS, vasopressor samsca
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| Esophageal varices | Prevent bleeding, airway, blood products,
baloon tamponade deflate 5 min q8-12
tips- non surgical transjugglar hepatoshunt
ligation band
sclera
vitamin k
PPI, lactulose,
surgical: portocaval & distal spleen shunt with severe bleeding
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| Cirrhosis nursing | rest, relief, teaching, nutrition
assess jaundice, ascites, loc, labs
relive pruitis
monitor stool, urine
girth measurement
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| Paracentesis | void prior to procedure
high fowlers sitting position
monitor bp post procedure
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| Mgt of esophageal varices | monitor for pettichiae, electric razor, soft bristle toothbrush, oral care, refractory bleeding may need shunt or tips, balloon tamponade, aspiration, scissors bedside for emergency
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| More s/s AKI | Hypotension early, htn after fluid overload,memory impairment, anemia, dec plt, proteinuria, casts, rbcs, specific gravity 1.010, osmo 300, pulm edema, kussmaul, hypocalcemia, dysrhythmias, leukocytosis
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| Iron supplements are only given if | Epogen/erythropoietin is being given
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| AKI Diet can have | 1gm protein, fat, 30-35 kcal, carbs
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| PD diet can have | K, phos 1.2g, protein, 25-35kcal
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| HD diet can have | carbs, low fat, water restriciton
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| CKD diet can have | carbs, low fat, water restriction
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| KT diet can have | high protein, high fiber, fresh fruit and veggies cleaned and peeled, low fat low sodium low dairy
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| Cirrhosis diet can have | High calorie 3000/day, high carb, 1500-2000, enteral protein nutrition prefferred
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| Hepatotoxic | statins, beta blockers, tylenol, cillins, myacins, thiazides
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| High ammonia levels cause | confusion
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