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Kidney failure

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is the partial or complete impairment of kidney function. It results in an inability to excrete metabolic waste products and water and causes functional disturbances of all body systems.

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acute kidney injury (AKI)

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is the term used to encompass the entire range of the syndrome, ranging from a slight deterioration in kidney function to severe impairment - characterized by a raid loss of kidney function, shown by a rise in serum creatinine and/or reduction in urine output

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azotemia

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an accumulation of nitrogenous waste products (urea nitrogen, creatinine) in the blood

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Acute kidney injury (AKI)

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usually develops over hours or days with progressive elevations of blood urea nitrogen (BUN), creatinine, and potassium with or without oliguria. It is a clinical syndrome characterized by a rapid loss of kidney function with progressive azotemia.

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AKI

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The causes of this are multiple and complex. They are categorized into prerenal (most common), intrarenal, and postrenal causes.

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Prerenal causes

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are factors external to the kidneys (e.g., hypovolemia) that reduce renal blood flow and lead to decreased glomerular perfusion and filtration.

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Intrarenal causes

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include conditions that cause direct damage to the renal tissue, resulting in impaired nephron function. Acute tubular necrosis accounts for most cases of intrarenal failure.

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Postrenal causes

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involve mechanical obstruction of urinary outflow. Common causes are benign prostatic hyperplasia, prostate cancer, calculi, trauma, and extrarenal tumors.

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RIFLE classification

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The ___________ (risk, injury, failure, loss, and end-stage disease) is used to describe and standardize the stages of AKI.

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Risk

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- serum creatinine increased x 1.5 OR GFR decreased by 25% - urine output <0.5 mL/kg/hr for 6 hrs

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Injury

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- Serum creatinine increased x 2 OR GFR decreased by 50% - urine output <0.5 mL/kg/hr for 12 hr

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Failure

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- Serum creatinine increased x3 OR GFR decreased by 75% OR serum creatinine >4mg/dL with acute rise >0.5 mg/dL - urine output <0.3 mL/kg/hr for 24 hr (oliguria) OR anuria for 12 hr

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Loss

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Persistent acute kidney failure; complete loss of kidney function > 4wk

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End-stage kidney disease

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Complete loss of kidney function >3 mo

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acute tubular necrosis (ATN)

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is the most common intrarenal cause of AKI and is primarily the result of ischemia, nephrotoxins, or sepsis

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AKI

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Clinically, this may progress through three phases: oliguric, diuretic, and recovery.

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true

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In some situations, the patient does not recover from AKI and chronic kidney disease (CKD) results, eventually requiring dialysis or a kidney transplant.

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oliguria

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a reduction in urine output to less than 400 mL/day

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Oliguric Phase

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- Fluid and electrolyte abnormalities and uremia occur during this phase. - Neurologic changes can occur as the nitrogenous waste products increase.

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oliguria

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The most common initial manifestation of AKI is this.

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diagnostic studies; AKI

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- Common electrolyte abnormalities include hyperkalemia, hyponatremia, and hypocalcemia. Elevated BUN and creatinine levels are found. - Other findings include metabolic acidosis, anemia, and platelet abnormalities. - is based on the history and physical as well as changes in urine output and serum creatinine.

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infection

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The most common cause of death in patients with AKI is this.

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diuretic phase

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This begins with a gradual increase in daily urine output of 1 to 3 L/day but may reach 3 to 5 L or more. - The nephrons are still not fully functional. - The uremia may still be severe, as reflected by low creatinine clearances, elevated serum creatinine and BUN levels, and persistent signs and symptoms.

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recovery phase

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This begins when the glomerular filtration rate (GFR) increases, allowing the BUN and serum creatinine levels to plateau and then decrease. Renal function may take up to 12 months to stabilize.

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collaborative care; AKI

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- treatment of precipitating cause - fluid restriction (600 mL plus previous 24-hr fluid loss) - nutritional therapy o adequate protein intake (0.6-2 g/kg/day) depending on degree of catabolism o potassium restriction o phosphate restriction o sodium restriction - measures to lower potassium (if elevated) - calcium supplements or phosphate-binding agents - enteral nutrition - parenteral nutrition - initiation of dialysis (if necessary) - continuous renal replacement therapy (if necessary)

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renal replacement therapy (RRT)

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indications are 1. volume overload, resulting in compromised cardiac and/or pulmonary status 2. elevated serum potassium level 3. metabolic acidosis (serum bicarbonate level less than 15 mEq/L) 4. BUN level greater than 120 mg/dL 5. significant change in mental status 6. pericarditis, pericardial effusion, or cardiac tamponade

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nursing assessment; AKI

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- monitor VS and I&O - examine urine - assess general appearance - if dialysis is being received, observe site - evaluate mental status and LOC - examine mucosa for dryness and inflammation - auscultate lungs and heart sounds and ECG - review lab results

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nursing diagnosis; AKI

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- excess fluid volume - risk for infection - fatigue - anxiety - potential complication

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planning; AKI

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1. completely recover without any loss of kidney function 2. maintain normal fluid and electrolyte balance 3. have decreased anxiety 4. adhere to and understand the need for careful follow-up care

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nursing implementation; AKI

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- prevention and early recognition - careful monitoring of I&O and fluid and electrolyte balances - replacement/diuretic therapy - ACE inhibitors - meticulous aseptic technique is essential for decrease of infection - perform skin care - educate on s/s - Because this is potentially reversible, the primary goals of treatment are to eliminate the cause, manage the signs and symptoms, and prevent complications while the kidneys recover. - Recovery from this is highly variable and depends on the underlying illness, the general condition and age of the patient, the length of the oliguric phase, and the severity of nephron damage.

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evaluation; AKI

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- regain and maintain normal fluid and electrolyte balance - adhere to the treatment regimen - experience no complications - have a complete recovery

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nursing management; AKI

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- Prevention of this is primarily directed toward identifying and monitoring high-risk populations, controlling exposure to nephrotoxic drugs and industrial chemicals, and preventing prolonged episodes of hypotension and hypovolemia. - The patient with this is critically ill and suffers not only from the effects of renal disease, but also from the effects of co-morbid diseases or conditions, such as diabetes. - You have an important role in managing fluid and electrolyte balance during the oliguric and diuretic phases. Because infection is the leading cause of death in AKI, meticulous aseptic technique is critical. - The long-term convalescence (3 to 12 months) may cause psychosocial and financial hardships for the family, and appropriate counseling, social work, and psychiatrist/ psychologist referrals are made as needed. If the kidneys do not recover, the patient will eventually need dialysis or transplantation.

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dialysis

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Common indications for this in AKI are volume overload, elevated potassium level with ECG changes, metabolic acidosis, significant change in mental status, and pericarditis, pericardial effusion, or cardiac tamponade.

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renal replacement therapy (RRT)

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Three types of this may be used: hemodialysis, peritoneal dialysis, and continuous renal replacement therapy (CRRT).

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continuous renal replacement therapy (CRRT)

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is provided continuously over approximately 24 hours through cannulation of an artery and vein or cannulation of two veins - this has much slower blood flow rates compared with intermittent

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gerontologic considerations; AKI

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- The older adult is more susceptible than the younger adult to AKI as the number of functioning nephrons decreases with age. - Causes of AKI include dehydration, hypotension, diuretic therapy, aminoglycoside therapy, prostatic hyperplasia, surgery, infection, and contrast media.

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Chronic kidney disease (CKD)

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involves progressive, irreversible loss of kidney function.

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CKD

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usually develops slowly over months to years. Death associated with cardiovascular disease is a more common outcome for patients with chronic kidney disease than survival to need dialysis. The prognosis of CKD is variable depending on the etiology, patient's condition and age, and adequacy of follow-up.

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end-stage kidney disease

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occurs when the GFR is less than 15 mL/min. At this point, RRT is required to maintain life

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true

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An elevation in serum creatinine is demonstrated only after over 50% of functioning kidney function (nephron mass) has been lost.

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Uremia

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is a syndrome that incorporates all the signs and symptoms seen in the various systems throughout the body in CKD.

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clinical manifestation; CKD

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- Fatigue, lethargy, and pruritus are symptoms associated with progression of kidney dysfunction. - Hypertension is both a cause and a consequence of CKD. - Hyperglycemia, hyperinsulinemia, dyslipidemia, and abnormal glucose tolerance tests may be seen.

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Metabolic derangements

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including hyperkalemia, hyponatremia, and metabolic acidosis tend to occur in the later stages of CKD

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Normocytic anemia

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is due to decreased production of endogenous erythropoietin.

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cardiovascular disease

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- The most common cause of death in patients with CKD is this, including ischemic heart disease, heart failure, cardiac dysrhythmias, and pulmonary edema. - Other complications include infections, neurologic changes, peripheral neuropathy, CKD-mineral and bone disease, pruritus, infertility, personality and behavioral changes, lethargy, and depression.

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CKD mineral and bone disorder

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develops as a systemic disorder of mineral and bone metabolism caused by progressive deterioration in kidney function

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diagnostic studies; CKD

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- H&P - identification of reversible kidney disease - renal ultrasound - renal scan - CT scan - renal biopsy - SUN, serum creatinine, and creatinine clearance levels - serum electrolytes - lipid profile - protein-to-creatinine ratio in first morning voided specimen - urinalysis - hematocrit and hemoglobin levels

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collaborative care; CKD

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- correction of extracellular fluid volume overload or deficit - nutritional therapy - erythropoietin therapy - calcium supplementation, phosphate binders, or both - antihypertensive therapy - ACE inhibitors or ARBs - measures to treat hyperlipidemia - measures to lower potassium - adjustment of drug dosages to degree of renal function - renal replacement therapy dialysis

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collaborative care; CKD

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- The primary goal of care in this is directed at reducing the risk of cardiovascular disease and premature death. - Secondary goals of this is to deter the progression of kidney dysfunction, recognize and treat the associated complications, and provide for the patient's comfort. - Medical management is instituted in an effort to postpone the need for maintenance dialysis. - In certain situations, CKD progression can be delayed by using drug therapy to reduce the damaging effects of proteinuria and hypertension. - Erythropoietin and iron replacement are used for the treatment of anemia. - Statins (HMG-CoA reductase inhibitors) are the most effective drugs for lowering low-density lipoprotein (LDL) cholesterol levels. - Prior to dialysis, dietary protein may be restricted to slow the progression of kidney dysfunction. Once the patient starts dialysis, protein intake is usually increased. - Water intake depends on the daily urine output.

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nursing management; CKD

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- Most persons with this are cared for in an ambulatory care setting. Hospital care is required for the management of complications. - Nursing care for the patient revolves around the nursing diagnoses of excess fluid volume, risk for injury, imbalanced nutrition, and grieving. - teach pt about lifestyle, diet, and drugs - teach pt to take daily BPs and identify s/s of fluid overload, hyperkalemia, and other electrolyte imbalances

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planning; CKD

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The overall goals are that a patient with this will; 1. demonstrate the knowledge and ability to comply with treatment and 2. participate in good self-care practices. 4. Individuals need to be empowered to actively participate in determining their own treatment plans to the highest degree that is achievable.

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evaluation; CKD

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pt will maintain; - F&E levels within normal ranges - an acceptable weight with no more than 10% weight loss

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Dialysis

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is a therapeutic intervention in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate). Dialysis solutions have an electrolyte composition similar to that of plasma.

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true

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The two methods of dialysis are peritoneal dialysis (PD) and hemodialysis (HD).

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peritoneal dialysis (PD)

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in this, the peritoneal membrane acts as the semipermeable membrane

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hemodialysis (HD)

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in this, an artificial membrane is used as a semipermeable membrane and is in contact with the pts blood

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true

answer

Two types of PD are automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). • Learning the self-management skills required to do PD at home usually requires a 3- to 7-day training program.

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PD

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is indicated when there are vascular access problems or poor response to the stress of HD. - The three phases of the this cycle (called an exchange) are inflow (fill), dwell (equilibration), and drain (outflow).

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inflow phase

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a prescribed amount of solution, usually 2 L, is infused through an established catheter over about 10 mins

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dwell phase

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during which the diffusion and osmosis occur between the pts blood and peritoneal cavity

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drain phase

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this takes about 15-30 mins and may be facilitated by gently massaging the abdomen or changing the position

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true

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The patient dialyzing at home will be given a daily prescription of exchanges that is specific for the individual patient

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automated peritoneal dialysis (APD)

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is the most popular form of PD because it allows pts to do dialysis while they sleep. An automated device is used to deliver the dialysate for APD

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continuous ambulatory peritoneal dialysis (CAPD)

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is done while the pt is awake during the day. Exchanges are carried out manually by exchanging 1.5 L to 3 Lof peritoneal dialysate at least 4 times a day

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PD

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- The most common complications associated with this are; - infection of the peritoneal catheter exit site, - peritonitis, - and pain. - Additional complications include hernias, lower back pain, protein loss, bleeding, atelectasis, pneumonia, and bronchitis.

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vascular access

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The types of ________ include arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) and temporary and semipermanent (cuffed) venous catheters.

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arteriovenous fistula (AVF)

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are created most commonly in the forearm with an anastomosis between an artery (usually radial or ulnar) and a vein (usually cephalic). - Native fistulas have the best overall patency rates and least number of complications.

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Arteriovenous grafts (AVG)

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are made of synthetic materials and form a "bridge" between the arterial and venous blood supplies. - Grafts are placed under the skin and are surgically anastomosed between an artery (usually brachial) and a vein (usually antecubital).

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HD patients

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- The majority of these are treated in community-based dialysis facilities and routinely dialyze for 3 to 4 hours 3 days each week. -- Prior to each dialysis, nurses complete an assessment that includes evaluation of a patient's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds), condition of vascular access, temperature, and general skin condition.

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complications; HD

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include; - hypotension, - muscle cramps, - and blood loss.

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HD

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- Individual adaptation to maintenance this varies considerably. - The primary nursing goals are to help the patient regain or maintain a positive self-image and achieve the highest degree of independent functional capacity possible.

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Continuous renal replacement therapy (CRRT)

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is an alternative or adjunctive treatment for AKI

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CRRT

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- Uremic toxins and fluids are removed, while acid-base status and electrolytes are adjusted slowly and continuously from a hemodynamically unstable patient. - Vascular access is achieved through the use of a double-lumen catheter placed in the femoral, jugular, or subclavian vein. Anticoagulation is used to prevent blood clotting during CRRT.

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nursing interventions; CRRT

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- obtaining weights and monitoring and documenting lab values - assessment of I&O, vitals, hemodynamic status - observe insertion site

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Kidneys

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are the most frequently transplanted organs.

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kidney transplantation

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One-year graft survival rates for ___________ are 90% for deceased (cadaveric) donor transplants and 95% for live donor transplants. At present, the wait time for a deceased kidney transplant is 2 to 5 years or more.

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donor sources

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Kidneys for transplantation may be obtained from compatible-blood-type deceased donors, blood relatives, emotionally related living donors, and altruistic living donors.

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true

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Kidney transplantation for treatment of kidney failure offers the greatest chance for long-term survival and quality of life.

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contraindications; transplantation

answer

include; - disseminated malignancies, - refractory or untreated cardiac disease, - chronic respiratory failure, - extensive vascular disease, - chronic infection, and - unresolved psychosocial disorders. - HIV and Hep B or C are NOT contraindicating

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Live donors

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must undergo an extensive evaluation to be certain that they are in good health and have no history of disease that would place them at risk for developing kidney failure or operative complications.

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live donor transplant

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In this, the donor nephrectomy is performed either through an open (conventional) incision or laparoscopically.

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kidney transplant recipient

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- transplanted kidney is placed extraperitoneally in the iliac fossa - before any incisions are made, a urinary catheter is placed into the bladder - an antibiotic solution is instilled to distend the bladder and decrease risk of infection - crescent shaped incision is made - rap-id revascularization is critical to prevent ischemic injury - the donor vein is anastomosed to the recipients external iliac vein

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nursing care; kidney transplant

answer

- emotional/physical prep for surgery - review procedure - review list of immunosuppressive drugs and possible need for dialysis at first - assess pt preop - label vascular access extremity "dialysis access, no procedures" - postop, monitor renal function and hematocrit - don't forget about attention to the donor - first goal is F&E balance - measure I&O

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Deceased kidney donors

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are relatively healthy individuals who have suffered an irreversible brain injury. - Permission from the donor's legal next of kin is required after brain death is determined even if the donor carried a signed donor card.

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complications; transplant

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- rejection - infection - malignancies - recurrence of original kidney disease - corticosteroid-related complications

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corticosteroid-related complications

answer

- aseptic necrosis of hips, knees, and other joints - PUD - glucose intolerance and diabetes - cataracts - dyslipidemia - infections - malignancies

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nursing management; kidney transplant

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- Nursing care of the patient in the preoperative phase includes emotional and physical preparation for surgery. - For the kidney transplant recipient, the first priority during this period is maintenance of fluid and electrolyte balance. Very large volumes of urine may occur in the immediate postoperative period, resulting in volume depletion, hypokalemia, and metabolic acidosis - Postoperative teaching should include the prevention and treatment of rejection, infection, and complications of surgery and the purpose and side effects of immunosuppression.

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Rejection

answer

a major problem following kidney transplantation, can be hyperacute, acute, or chronic.

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Immunosuppressive therapy

answer

is used to prevent rejection while maintaining sufficient immunity to prevent overwhelming infection.

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Infection

answer

is a significant cause of morbidity and mortality after kidney transplantation. - Transplant recipients usually receive prophylactic antifungal drugs. Viral infections, including CMV, are common.

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Cardiovascular disease

answer

is the leading cause of death following kidney transplant. Hypertension, dyslipidemia, diabetes mellitus, smoking, immunosuppressive medications, rejection, and infections can all contribute to the development of this.

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true

answer

The overall incidence of malignancies in kidney transplant recipients is higher than in the general population. The primary cause is the immunosuppressive therapy.

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gerontologic considerations

answer

- Approximately 35% to 65% of patients who have CKD are 65 or older. Physiologic changes in the older CKD patient include diminished cardiopulmonary function, bone loss, immunodeficiency, altered protein synthesis, impaired cognition, and altered drug metabolism. - Most older end-stage kidney disease (ESKD) patients select hemodialysis as their choice for renal replacement therapy. However, establishing vascular access for HD may be challenging because of atherosclerotic changes. - The most common cause of death in the older ESKD patient is cardiovascular disease (MI, stroke), followed by withdrawal from dialysis.

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