Renal Failure, Dialysis, Kidney Transplantation, Immunosuppressants

Acute Kidney Injury (AKI)

Sudden loss of kidney function occurring over hours-days; often reversible if caught early; causes inability to maintain fluid/electrolyte and acid-base balance.

Chronic Kidney Disease (CKD)

Gradual, irreversible kidney damage over months-years; progresses through 5 stages; leads to ESKD requiring dialysis or transplant.

Azotemia

Buildup of nitrogenous wastes (BUN, creatinine) in blood; may be asymptomatic early.

Uremia

Clinical syndrome of kidney failure with symptoms including fatigue, N/V, metallic taste, pruritus, edema, confusion.

Normal Urine Output

At least 30 mL/hr; oliguria <400 mL/day; anuria <100 mL/day.

GFR (Glomerular Filtration Rate)

Best indicator of kidney function; decreases with age; used to stage CKD.

Prerenal AKI

Caused by hypoperfusion: dehydration, hemorrhage, shock, sepsis, burns, heart failure.

Intrarenal AKI

Direct kidney damage: ATN, nephrotoxic drugs, contrast dye, glomerulonephritis, lupus.

Postrenal AKI

Obstruction of urine flow: calculi, BPH, tumors, strictures.

Key AKI Risk Factors

Older age, dehydration, hypotension, major surgery, nephrotoxic meds (NSAIDs, aminoglycosides, contrast).

Nephrotoxic Medications

Aminoglycosides, vancomycin, NSAIDs, PPIs, contrast dye, chemo drugs.

AKI Early Signs

Oliguria, rising creatinine/BUN, fluid retention, edema, crackles, shortness of breath.

AKI Electrolyte Findings

↑K⁺, ↑Phos, ↑Mg²⁺, ↓Ca²⁺, metabolic acidosis.

Hyperkalemia ECG Changes

Peaked T waves, widened QRS, bradycardia, risk of cardiac arrest.

AKI Nursing Priority

Monitor urine output hourly; report <30 mL/hr for 2 hours.

AKI Imaging Tests

Renal ultrasound, CT (no contrast), KUB, nuclear scan (MAG3).

AKI Goals of Treatment

Maintain perfusion, avoid hypotension, correct fluid imbalance, prevent complications.

Diuretics in AKI

Used cautiously to treat fluid overload but do not "cure" AKI.

Fluid Challenges in AKI

500-1000 mL NS over 1 hr to assess response; avoid if fluid overloaded.

Indications for Dialysis in AKI

Severe hyperkalemia, metabolic acidosis, toxins, fluid overload, uremic symptoms.

CKD Stage 1

Kidney damage with normal GFR >90; screen/treat risk factors.

CKD Stage 2

GFR 60-89; mild loss; control DM/HTN.

CKD Stage 3

GFR 30-59; moderate CKD; symptoms begin; restrict protein, manage complications.

CKD Stage 4

GFR 15-29; severe CKD; prepare for dialysis/transplant.

CKD Stage 5 (ESKD)

GFR <15; requires dialysis or transplant to sustain life.

Major Causes of CKD

Diabetes (#1), hypertension (#2), chronic glomerulonephritis, polycystic kidney disease.

Sodium Changes in CKD

Early hyponatremia; later hypernatremia from poor excretion.

Potassium in CKD

Risk for fatal hyperkalemia; monitor closely.

Calcium/Phosphate Imbalance

↑Phosphate, ↓Calcium, ↓Vitamin D → renal osteodystrophy, fractures.

Metabolic Acidosis in CKD

Kidneys cannot excrete acid → Kussmaul respirations.

Anemia in CKD

Caused by ↓erythropoietin production; treated with epoetin alfa.

Uremic Frost

Late CKD finding: crystallized urea on skin.

Renal Diet Key Points

Low sodium, low potassium, low phosphorus; protein restriction varies by stage.

Phosphate Binders

Ca acetate, sevelamer; given WITH meals to reduce phosphate absorption.

Avoid in CKD

NSAIDs, Mg-containing antacids, contrast dye, potassium-sparing diuretics.

Indications for Hemodialysis

ESKD, severe hyperkalemia, acidosis, fluid overload, uremic symptoms.

Hemodialysis Mechanisms

Diffusion, osmosis, ultrafiltration remove wastes and fluid.

Dry Weight

Target weight after dialysis; used to determine fluid removal.

Vascular Access Types

AV fistula (preferred), AV graft, temporary central dialysis catheter.

AV Fistula Care

No BP, IV, or blood draw in that arm; check for bruit/thrill every shift.

Signs of AVF Dysfunction

Absence of bruit/thrill, bleeding, cold/pale extremity.

Hemodialysis Complications

Hypotension, dysrhythmias, disequilibrium syndrome, bleeding, infection.

Dialysis Disequilibrium

Rapid solute removal → headache, N/V, confusion, seizures.

Peritoneal Dialysis Advantages

Fewer hemodynamic shifts, done at home, more flexible diet.

Peritonitis in PD

Fever, rebound tenderness, cloudy effluent → send culture.

Poor PD Outflow

Often caused by constipation; reposition client.

Kidney Transplant Definition

Replacement of failed kidney with donor organ to restore function; not a cure but improves quality of life.

Living Donor Benefits

Best graft survival, fewer complications, shorter wait time.

Contraindications to Transplant

Active infection, active cancer, uncontrolled mental illness, nonadherence.

Pre-op Matching Requirements

ABO compatibility, HLA typing, negative crossmatch.

Post-op Priority in Transplant

Urine output hourly for first 48 hrs; pink urine expected; sudden drop = rejection.

Signs of Early Rejection

↑BP, ↑temp, pain over graft, oliguria/anuria, rising creatinine.

Types of Rejection

Hyperacute (immediate), acute (1 week-months), chronic (years).

Calcineurin Inhibitors

Cyclosporine and tacrolimus; first-line immunosuppressants.

Cyclosporine Key Risks

Nephrotoxicity, infection, lymphoma risk; NO grapefruit juice.

Tacrolimus Key Risks

More nephrotoxic than cyclosporine; neurotoxicity; NO NSAIDs.

mTOR Inhibitor (Sirolimus)

Used for renal transplant; increases lipid levels; infection risk; no grapefruit juice.

Mycophenolate (CellCept)

Prevents rejection; AE: severe neutropenia, GI distress, sepsis risk.

Azathioprine (Imuran)

Cytotoxic drug; causes bone marrow suppression and GI upset.

Prednisone in Transplant

Prevents rejection; causes immunosuppression, bone loss, hyperglycemia, mood changes.

Major Risk of All IS Drugs

Infection and malignancy; requires lifelong therapy and monitoring.

Transplant Patient Teaching

Lifelong immunosuppressants, avoid infection exposures, monitor weight, BP, urine output.

Hyperkalemia Emergency Treatment

Stop K sources; give calcium gluconate, insulin + D50, Lokelma; dialysis if severe.

Most Dangerous CKD Complication

Hyperkalemia → dysrhythmias → cardiac arrest.

Biggest Nursing Priority in Renal Disease

Protect remaining kidney function and prevent fluid/electrolyte complications.