MEDICAL DNA PRESENTATION

Alterations in kidney function and elimination

Renal A&P Review

• Remove the byproducts and toxins of metabolism
• Regulate ions to maintain acid-base balance
• Regulate osmalarity to maintain fluid and electrolyte balance
• Produce erythropoietin for red blood cell production
• Regulate blood pressure by producing renin
• Converts inactive vitamin D to active calcitriol

Nephrons and Circulation

• Nephrons
• Filter waste from the blood and make urine
• Glomerulus
• Bowman's capsule
• Afferent arterioles
• Efferent arterioles
• Glomerular filtration barrier

• Renal circulation
• Blood enters the kidney through the renal artery
• Moves through the afferent and efferent arterioles to return to venous circulation

Glomerular Filtration Rate (GFR)

• Amount of blood and plasma filtered over one minute
• Based on serum creatinine, age, gender, and race
• Usually decreases with age
• Regulated afferent arterioles
• Controlled by the sympathetic nervous system and the renin-angiotensin-aldosterone system
• Also controls blood pressure

Renal-Specific Labs

BUN

Creatinine

GFR

Urine Tests

Glomerulonephritis

• Immune-mediated damage to portions of the glomerulus
• Acute, rapidly progressive, or chronic
• Multiple causes (but cause may remain unknown)
• Risk factors and comorbidities
• Recent infection
• Middle age or older males
• Diabetes mellitus (1 and 2)
• Autoimmune diseases
• One of the top three causes of end-stage renal disease (ESRD)
• In most cases, the disease is progressive

Glomerulonephritis Nursing Process

Generate Solutions (Planning)

Recognize Clues (Assessment)

Analyze Cues (Analysis)

Take Actions (Implementation)

Prioritize Hypotheses (Analysis)

Evaluate Outcomes (Evaluate)

Acute Renal Failure

• Also known as acute kidney injury (AKI)
• Sudden onset and usually reversible
• Types
• Pre-renal
• Decreased blood flow to the kidneys
• Intra-renal
• Damage to the functional part of the kidney
• Post-renal
• Obstruction of urine
• Risk factors/comorbidities
• Hypovolemia
• Sepsis
• Nephrotoxic drugs
• Hypertension
• Hyperlipidemia

• Acute tubular necrosis (ATN)
• Renal tubule cells damaged and cell death occurs
• Due to sepsis, acute ischemic event, nephrotoxic substance
• Most common cause

• Rhabdomyolysis
• Breakdown of muscle fibers release myoglobin into blood
• Myoglobin accumulates in the renal tubules
• Undiscovered falls and long-distance running

• Nephrotoxic drugs
• Aminoglycosides (-mycin)
• NSAIDs
• Contrast dye

• Treatments/Therapies
• Fluid challenge (if improvement, cause is pre-renal)
• Loop diuretics (furosemide)
• Hyperkalemia
• Polystyrene sulfonate
• Insulin, IV dextrose, calcium gluconate, salbutamol (only given with insulin and dextrose)

Acute Kidney Failure Nursing Process

Generate Solutions (Planning)

Recognize Cues (Assessment)

Analyze Cues (Analysis)

Take Actions (Implementation)

Prioritize Hypotheses (Analysis)

Evaluate Outcomes (Evaluation)

"Kidneys can be very persuasive to the other organs. 'Hey I'm failing! Come join me!" (McLean, 2024)

Chronic Kidney Disease

• Gradual loss of kidney function over time
• Also known as chronic renal failure
• Progresses to end stage renal disease (ESRD)
• Complete recovery is not possible due to kidney structure damage
• Five stages
• Causes
• Diabetes mellitus (type 2 more often than type 1)
• Hypertension
• Diseases of the kidney
• Risk factors
• Modifiable: hypertension, proteinuria, dyslipidemia, hyperuricemia, insulin resistance, obesity, smoking
• Non-modifiable: race, ethnicity, gender, age
• Comorbidities
• Will likely require dialysis sooner than those without comorbidities

CKD NURSING PROCESS

Generate Solutions (Planning)

Recognize Cues (Assessment)

Analyze Cues (Analysis)

Take Action (Implementation)

Prioritize Hypotheses (Analysis)

Evaluate Outcomes (Evaluation)

Hemodialysis

• Machine and filter act as the kidney and remove toxins from the blood; dialysate washes the blood
• Accessed through AV fistula, graft, or vas-cath
• Only for dialysis
• No venipuncture or blood pressure in arms with fistula or graft
• Assess for thrill (pulsation) and bruit (swishing sound)
• In-patient, outpatient centers, home
• Three days/week for four hours
• Ultrafiltration rate and dialysate individualized to the patient
• Electrolyte levels
• Amount of fluid to be removed
• Hemodynamic stability
• Acidosis
• Complications during dialysis

• Pre-dialysis
• Hold medications (especially antihypertensive drugs)
• Assess AV fistula/graft
• Post-dialysis
• Closely monitor vital signs
• Monitor for bleeding
• Assess site for thrill, bruit, bleeding, infection
• Give held medications
• ESRD drugs
• Epoetin (stimulates RBC production to treat anemia)
• Iron (stimulates RBC production)
• Sevelamer (phosphorus binder - remove excess phosphorus)
• B-complex vitamins, folic acid
• Midodrine (treats hypotension)

Peritoneal Dialysis

• Done through a catheter surgically placed in the patient's abdomen
• Peritoneal membrane acts as a filter
• Sterile dialysate instilled in abdominal cavity, dwells for a set amount of time, then out-flowed
• Two types
• Continuous ambulatory (CAPD)
• Automated (APD)
• Complications
• Infection (peritonitis)
• Bleeding
• Fibrin strands

Coming Soon to a Hospital Near You

Changes coming in determining AKI: Network (AKIN) classification of AKI

SCr: >0.3 mg//dL rise or rise to 1.5-1.99 x baseline Urine output: <0.5 mL/kg/h x 6h Give Lasix or Bumex

SCr: Rise to >2-2.99 x baseline Urine output: <0.5 mL/kg/h x 12 h Kidney replacement therapy considered

SCr: >3 x baseline or >4 mg/dL rise with an acute rise of at least 0.5 mg/dLUrine output: <0.3 mL/kg/h for 24 h or anuria for 12 h Kidney replacement therapy needed

ReferencesAti engage adult medical-surgical (2023). Assessment technologies institute Mclean, B., Vollman., K., Posa, P., Kupchik, N. (2024) What Would you do: detecting and understanding the role of the kidney in critical illness. retrieved from https://ntivirtual2024.aacn.org/library/search/VRSS921

• Vas-cath also for dialysis only
• Fistula/graft may only be accessed/de-accessed by dialysis nurse
• Complications: strictures, aneurysm, thrombosis, infection
• Hemodialysis complications
• Hypotension (bolus of NS and decrease ultrafiltration rate [UFR])
• Muscle cramps
• Dialysis disequilibrium syndrome
• Water shifts into CNS, causing increased intracranial pressure
• Confusion, headache, restlessness, muscle twitching, coma
• Hemolysis
• Decrease in hematocrit
• Venous blood line maroon
• Air embolism
• Fatal
• Venous blood line looks like foam
• Churning to chest auscultation
• Electrolyte disturbances

• Medications
• High-dose corticosteroids
• Reduce inflammation and suppress immune system
• Do not use if the patient has an active infection
• Rituximab
• Immunosuppression
• Cyclophosphamide
• Antineoplastic, immunosuppressant
• ACEs: control blood pressure
• Loop diuretics: remove excess fluid, lower blood pressure
• Trend
• Renal function tests
• Serum albumin levels
• Urine protein excretion rate
• Diet counseling
• Dialysis
• Treat the underlying cause

• Family and self medical history
• Contrast dye given recently
• Nephrotoxic drugs
• Uremic frost crystals
• Results of diagnostic studies
• Pre-renal, intra-renal, post-renal?
• Presence of infection
• Extent of renal failure

• GFR to determine stage and severity
• GFR below 15 requires dialysis
• Urine albumin: kidney damage if present
• Elevated BUN and creatinine
• Electrolyte imbalances (hyperkalemia especially a problem)

• Desired outcomes
• Pain relief
• Fluid balance
• Trend toward normal lab values

• Goals
• Prevention or slowing of progression
• Increased physical and psychological well-being
• Treatment of complications
• Education needs
• Self-management
• Diet and food restrictions
• Daily weights (diary; report changes)
• Medication
• Lifestyle changes (weight control, limit dietary salt)

• Maintain electrolytes WNL
• Stable BUN, creatinine
• Vital signs within baseline range
• Adequate urine output

• Diagnostic tests
• CBC: elevated WBC

• Renal function tests: decreased GFR

• BMP: elevated BUN/creatinine
• C3 and C4 levels
• Antistreptolysin O titers: elevated
• Urinalysis: decreased urine amount, dark color, elevated specific gravity
• Chest x-ray: pulmonary edema, pleural effusion
• Renal ultrasound: kidney size and structure

• Kidneys damaged due to chronic nephropathies
• Fibrosis and destruction of the glomeruli, tubules, and/or vessels
• Often unaware of damage until it has progressed
• Stages (based on GFR)
• Stage 1
• GFR > 90: normally functioning kidneys
• Stage 2
• GFR 60-89: normally functioning kidneys; mild damage
• Stage 3a
• GFR 45-59: kidneys no longer functining normally; mild-moderate damage
• Stage 3b
• GFR 30-44: moderate-severe damage
• Stage 4
• GFR 15-29: kidneys close to not functining; severe damage
• Stage 5: GFR < 15: lack of kidney function; most severe damage
• Diagnosis of ESRD
• Other causes of CKD: glomerulonephritis, hereditary/cystic disease
• Comorbidities: hypertension, diabetes, hyperlipidemia, cerebrovascular disease, malignancies, liver disease, anemia, ischemic heart disease, gout, connective tissue disease (lupus), CHF, TB

• Notify provider of any nephrotoxic drugs
• Strict I&Os, daily weight
• Administer diuretics, as ordered
• Elevated HOB for ease of breathing
• Monitor for mental status changes
• Monitor electrolytes closely
• Severe hyperkalemia would require immediate hemodialysis
• Closely monitor blood pressure
• Restrictions
• Fluid
• Potassium
• Phosphorus
• Monitor caloric intake (35-50 kcal/kg/day)

• Initially asymptomatic
• Volume overload
• Edema, JVD, crackles, SOB, hypertension (poorly controlled)
• Anemia (fatigue, altered mental status)
• Electrolyte imbalances
• Uremia
• Dry skin, pruritis, restless leg syndrome, encephalopathy, platelet disorders, pericarditis, malnutrition
• Uremic frost crystals
• Joint pain and muscle cramping
• GI: nausea/vomiting/diarrhea, loss of appetite
• Changes in urinary output

• If absolutely necessary to give contrast dye with impaired kidney function
• NS infusion during test
• Lowest possible amount

• Hyperkalemia: lethal arrhythmias
• Fluid volume overload: pulmonary edema

• CAPD
• 7 days/week; 4-5 exchanges daily
• 30 minutes to indwell and outdwell
• Dwell 4-6 hours
• APD
• Machine does exchange at night during sleep
• 7 days/week; 8-10 hours
• Peritonitis
• Teach good handwashing and sterile technique
• Fever, nausea, vomiting, abdominal pain and distention (hard)
• Cloudy outflow
• Education
• Exchange
• Blood pressure measurement
• Troubleshooting
• Low outflow: turn patient, reposition drainage bag

• Caught and treated early, ARF is reversible
• May take as long as a year to return to pre-illness functioning
• Pre-renal
• Hypovolemia, hypotension, shock
• Heart failure, liver failure
• NSAIDs, ARBs, ACEs, cyclosporine
• Arterial/venous obstruction
• Intra-renal
• Damage to the parenchyma
• Acute tubular necrosis, rhabdomyolysis
• Contrast dye
• Glomerulonephritis
• Post-renal
• Enlarged prostate
• Masses, clots, stones
• Trauma

• ESRD patients may have chronic hypotension
• Before treating hypotension, ask patient their normal blood pressure
• Sevelamer
• Orally with meals
• Take 1 hour before or three hours after other drugs
• GI side effects

• Medical history
• Recent infection, diabetes mellitus, cardiac valve replacement, hepatitis, fever, sore throat, IV drug use
• Manifestations
• Periorbital edema, peripheral edema
• Dark and frothy urine
• Hypertension
• Weakness, malaise
• Fever
• Abdominal discomfort
• Oliguria

• Types
• Acute
• Abrupt onset
• Inflammation thickens the glomerular membrane
• Rapidly progressive
• Antibodies form against the glomerular membrane
• Cell proliferation into Bowman's capsule
• Chronic
• Slow progressive process leading to renal failure
• Causes include
• Infectious disease (strep or staph, endocarditis, hepatitis B/C, viral infection, HIV)
• Autoimmune disease (lupus, Goodpasture's syndrome, IgA nephropathy (Berger's disease)
• Vasculitis (inflammation of blood vessels)
• Poorly controlled hypertension and diabetic nephropathy

• Monitor BUN, creatinine, and GFR for return to normal range
• Mental status WNL
• No edema
• Adequate hydration

• Correct fluid and electrolyte imbalances
• Maintain adequate cardiac output
• Kidney perfusion

• Afferent arterioles
• Constrict when the blood pressure is high
• Dilate when the blood pressure is low

• Glomerulus
• Filters blood that flows through
• Allows smale molecules to pass through (waste and fluid)
• Restricts large molecules (protein)
• Resistant vessels
• Regulate intraglomerular pressure
• Filter large amounts of blood
• Efferent arterioles: bring blood to the glomerulus
• Afferent arterioles: take blood away from the glomerulus
• Glomerular filtration barrier (GFB)
• Filters blood plasma

• Fluid restriction
• Strict I&O/daily weights
• Signs for family not to empty urine
• Education: blood pressure
• How to take, how to record results, strict control)
• Education: blood glucose levels
• Strict control (high glucose = kidney damage)
• Education: food choices and cooking methods
• Education: avoid nephrotoxic drugs, smoking, alcohol
• Education: routine follow-up
• Education: complications (fluid volume excess, electrolyte imbalance, acid-base imbalance, anemia)
• Education: dialysis (educate before it becomes a necessity)

• Correct underlying cause
• Prevent progression of failure
• Treat fluid and electrolyte imbalances
• Treat oliguria (hemodialysis vs. continuous renal replacement therapy)
• Continuous renal replacement therapy (CRRT) is a continous hemodialysis that removes fluid slowly
• Better for hypotensive/shock patients
• Education
• Fluid and diet restrictions
• Disease management
• Fluid management

• Assess health history (diabetes, hypertension)
• Weight, I&Os
• Extremity edema
• Lung sounds (crackles)
• JVD
• Asterix (flapping hands)
• Lethargy
• Seizures
• Lab results

• 24-hour bladder diary (if at home)
• Strict I&Os
• Daily weights
• Education
• Dietary salt elimination (acute)
• If progressive
• Protein 40-60g/day

• Sodium 2g/day
• Potassium 2g/day
• 24-hour urine collection
• Dialysis

• This information will not be tested on
• This information may not yet be used at every facility yet (my information comes from AACN NTI May, 2024)
• For testing purposes and NCLEX, continue to use 30 mL/h unless redirected by ATI or us

Additional information: KDIGO recommends using eGFRcr-cys for making clinical decisions regarding AKI (serum creatinine, GFR, and cystine-c (McLean, et.al., 2024). For fluid resuscitation, LR is becoming the recommended fluid due to an increase in acidosis with NS (McLean, et. al., 2024).

• Fluid restrictions, diuretic drugs
• Accurate I&Os and daily weights
• Education: blood pressure monitoring
• Education: blood glucose control
• High blood glucose damages kidneys
• Education: food choices and cooking methods
• Education: avoidance of nephrotoxic drugs, smoking, and alcohol
• Education: routine follow-ups with primary provider
• Education: begin teaching dialysis before needed

• Decrease blood pressure
• Remove excess fluid
• Treat the underlying cause

• Blood
• Enters the kidney via the renal artery
• Moves into interlobular arteries
• Branches into afferent arterioles
• Enters the glomerulus of Bowman's capsule
• Exits through efferent arterioles
• Divides into peritubular capillaries
• Leaves the kidney