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Renal Megan McClintock, RN, MS 10/27/11. “TO PEE IS TO LIVE”. "Bones can break, muscles can atrophy, glands can loaf, even the brain can go to sleep without immediate danger to survival. But should the kidneys fail … neither bone, muscle, gland, nor brain could carry on.”

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slide2

"Bones can break, muscles can atrophy, glands can loaf, even the brain can go to sleep without immediate danger to survival. But should the kidneys fail … neither bone, muscle, gland, nor brain could carry on.”

      • Smith HW: Fish to philosopher, Boston, 1953, Little, Brown.
kidney disease
Chronic kidney disease (CKD)KIDNEY DISEASE

Acute kidney injury (AKI)

Sudden onset

Acute decrease in urine output and/or increase in creatinine

Potentially reversible

Mortality 60%

Usually die from infection

Gradual onset

GFR < 60 mL/min for > 3 months

Progressive and irreversible

Mortality 19-24% (need dialysis to survive)

Usually die from CV disease

acute kidney injury
ACUTE KIDNEY INJURY
  • Prerenal causes – external to the kidney, sudden reduction in blood flow to the kidneys
      • Usually resolve quickly with correction of cause
  • Intrarenal causes – infections, toxins, drugs, or direct trauma, ATN
  • Postrenal causes –urinary tract obstructions
      • Usually resolve quickly with correction of cause
acute kidney injury clinical course
ACUTE KIDNEY INJURYCLINICAL COURSE
  • Oliguric Phase (10-14 days)
    • Urine output less than 400 mL/day
    • UA w/ casts, RBCs, WBCs, SG fixed at 1.010, urine osmo of 300 mOsm/kg (may have proteinuria)
    • Volume depletion but oftentimes fluid retention
    • Metabolic acidosis
    • Sodium imbalance
    • Potassium increase
    • Hematologic disorders
    • Waste product accumulation
    • Neuro disorders
acute kidney injury clinical course1
ACUTE KIDNEY INJURY CLINICAL COURSE
  • Diuretic Phase (1-3 weeks)
    • Begins with a gradual increase in daily urine output to 1-3 L
    • Nephrons still not fully functional
    • Kidneys can excrete waste, but still can’t concentrate the urine
    • Hypovolemia
    • Hypotension
    • Hyponatremia, hypokalemia
acute kidney injury clinical course2
ACUTE KIDNEY INJURY CLINICAL COURSE
  • Recovery Phase (12 months)
    • Begins when the GFR increases
    • BUN and creatinine plateau, then decrease
acute kidney injury treatment
ACUTE KIDNEY INJURYTREATMENT
  • Eliminate the cause, manage signs & symptoms, prevent complications
    • #1 goal is to ensure adequate cardiac output and intravascular volume
    • Careful monitoring of I/Os
    • Prevent hyperkalemia
    • Use RRT (renal replacement therapy) only if needed
    • Nutritional management
acute kidney injury treatment1
ACUTE KIDNEY INJURYTREATMENT
  • Avoid exposure to contrast media
  • Watch for nephrotoxic drugs
  • ACE inhibitors
  • Meticulous aseptic technique
  • Meticulous skin care
  • Meticulous mouth care
acute kidney injury nursing diagnoses
ACUTE KIDNEY INJURYNURSING DIAGNOSES
  • Decreased cardiac output
  • Excess fluid volume
  • Risk for infection
  • Imbalanced nutrition: less than body requirements
  • Fatigue
  • Anxiety
  • Dysrhythmias
  • Sensory/perceptual alterations
chronic kidney disease1
CHRONIC KIDNEY DISEASE
  • Frequently asymptomatic
  • Early on have no change in urine output, may even have polyuria
  • Uremia develops when GFR is <10 mL/min
  • Persistent proteinuria
  • Tend to die of CV disease before needing dialysis
chronic kidney disease treatment
CHRONIC KIDNEY DISEASETREATMENT
  • Treat high potassium
  • Control HTN
  • Treat anemia (EPO)
  • Treat hyperlipidemia
  • Restrict proteins
  • Restrict fluids
  • Restrict sodium, potassium, phosphates
  • Lots of teaching and reteaching
treating hyperkalemia
TREATING HYPERKALEMIA
  • Insulin
  • Sodium Bicarbonate
  • Calcium Gluconate IV
  • Dialysis
  • Sodium Polystyrene Sulfonate (kayexalate)
  • Dietary Restriction
dialysis
Dialysis

Peritoneal Dialysis (PD)

Hemodialysis (HD)

peritoneal dialysis
PERITONEAL DIALYSIS
  • Three phases of PD
  • Manual vs Continuous
  • Complications
slide25

Fig 45-12

Temporary catheters

Fig 45-13 placement of jugular vein temporary dialysis catheter

hemodialysis
HEMODIALYSIS
  • Pre & Post Dialysis Interventions
  • Complications
    • Hypotension
    • Muscle cramps
    • Blood loss
    • Hepatitis
pyelonephritis
PYELONEPHRITIS
  • Cause – Bacteria (most common)
  • S/S – abrupt onset of chills, fever, vomiting, malaise, CVA pain, dysuria, urinary urgency and frequency
  • Labs – UA w/ pyuria, bacteriuria, hematuria, WBC casts; CBC w/ left shift (increase in bands)
  • Cx – Urosepsis leading to septic shock and death, chronic pyelonephritis
pyelonephritis interventions
PYELONEPHRITIS INTERVENTIONS
  • Early tx for cystitis
  • Take antibiotics as prescribed
  • Follow-up urine culture
  • Drink at least 8 glasses of fluid daily
  • Rest
glomerulonephritis
GLOMERULONEPHRITIS
  • Cause – Antibody-induced injury (exposure to drugs, immunizations, microbial/viral infxn)
  • S/S – generalized edema, HTN, oliguria, hematuria, proteinuria, abd/flank pain
  • Labs – UA w/ proteinuria, hematuria, WBC casts; increased BUN and creatinine, ASO titer
  • Cx – Renal insufficiency, destruction of renal tissue
glomerulonephritis interventions
GLOMERULONEPHRITIS INTERVENTIONS
  • REST
  • Diuretics, restricted sodium and fluids
  • Restrict dietary protein if in BUN.
  • Treat severe HTN with anti-hypertensives
  • No abx unless infection still present
  • Prevention - Take the FULL course of antibiotics (treat strep)
nephrotic syndrome
NEPHROTIC SYNDROME
  • Cause – systemic disease, allergens, drugs, infxn, glomerulonephritis
  • S/S – edema, massive proteinuria, HTN, hypoalbuminemia, hyperlipidemia
  • Labs – low albumin, low protein, high cholesterol
  • Cx – Infection, thromboembolism, skin breakdown, malnourishment, body image problems
nephrotic syndrome interventions
NEPHROTIC SYNDROME INTERVENTIONS
  • ACE inhibitors, corticosteroids, diuretics, lipid-lowering agents
  • Low sodium, low-moderate protein diet (focus on preventing malnutrition)
  • Strict I/Os, daily weights
  • Protect skin
  • Prevention of infection
minute paper
Minute paper
  • On the provided 3x5 card answer the following:
  • What was the most important thing you learned today.
  • What important point remains unclear to you?