kidneys - cherry

oliguria

Decreased urine output

<400mL/day

anuria

absence of urine

<50mL/day

uremia

presence of urinary waste in the blood due to not excreting

azotemia

(excessive) urea and nitrogenous substances in the blood

diagnostic studies

- CT and MRI what you usually start with

- urinalysis / urine culture

- renal function tests

- ultrasonography

- POTASSIUM

BUN normal levels

7-20 mg/dL

CR

normal .7-1.4

renal function tests

Tests for diagnosing kidney disease

Evaluating their severity

Monitoring their progress

Determining renal clearance

Determining glomerular filtration rate;

BUN and Creatinine

Palpation of kidney

The right kidney is easier to detect, because it is somewhat lower than the left one. In patients with obesity, palpation of the kidneys is more difficult.

Prone:

left kidney is palpated by reaching over to the patient's left side and placing the right hand beneath the patient's lower left rib. Push the hand on top forward as the patient inhales deeply.

Ca+ levels

8.5-10.5

Potassium

3.5-5.0

Monitoring ABGs for....

metabolic acidosis

monitor in fluid retention

- daily weight (MOST ACCURATE PREDICTOR); 1 KG weight gain is = 1 L of fluid

- I & Os

urinalysis

First morning void; needs to be examine within an hour

Creatinine Clearance

Collect 24 hour urine specimen, closely approximates GFR

- more accurate indicator of clearing out substances that are going in and ability to secrete

Urodynamics

diagnostic study of urine storage, bladder pressure, and urine flow throughout the urinary tract

CONTRAST INDUCED NEPHROPATHY

Contrast agents → nephrotoxic, major cause of hospital-acquired ARF

Risks:

- baseline Cr > 2.0 mg/dL

- diabetes

- metformin use

Prevention:

- hydrate pre-procedure

- consider ultrasound instead

- hold metformin 48 hrs before/after to decrease risk of lactic acidosis

Follow facility policy (guidelines vary)

acute renal issues

- lethargic

- ill

- dry skin & mucous membranes

- central nervous symptom s/s: confusion

- decreased GFR of sudden onset

(GFR - 1 25mL/min/1.73m2)

chronic renal issues

- progressive, irreversible loss of

function

- eventually affects other organ

systems leading to end-stage renal disease

(ESRD)

ACUTE KIDNEY INJURY

- Rapid loss of kidney function → ↑ Cr, ↓ urine output

- Normal Cr: 0.6-1.2 (M), 0.4-1.0 (F)

- Risks: hypovolemia, hypotension, HF, ↓ CO, HTN, DM, nephrotoxins, obstruction, infections, severe hypotension, toxins/metals, idiopathic

- Complications: metabolic acidosis, fluid/electrolyte imbalances (life-threatening)

Risks for AKI

- hypovolemia

- hypotension

- HF

- ↓ CO

- HTN

- DM

- nephrotoxins

- obstruction

- infections

- severe hypotension

- toxins/metals

- idiopathic

High creatinine =

impaired kidney function or kidney disease (kidneys not filtering waste effectively)

> 1.2 mg/dL

neprotoxic medications

- Aminoglycosides (gentamicin, tobramycin, amikacin)

- [MICINs]

- Vancomycin

- NSAIDs (ibuprofen, naproxen, indomethacin)

- ACE inhibitors / ARBs (lisinopril, losartan) - can worsen renal perfusion

- Amphotericin B

- Cisplatin (chemo)

- Radiographic contrast dye

- Cyclosporine, Tacrolimus (immunosuppressants)

Chronic Kidney Disease (CKD)

Kidney damage or ↓ GFR ≥ 3 months

Leads to ↓ quality of life, financial burden, ↑ mortality

Progresses to ESRD → uremia, dialysis or transplant needed

Chronic Kidney Disease (CKD) risks / causes

Risks:

- CVD

- DM

- HTN

- obesity

Causes:

- glomerulonephritis

- glomerulosclerosis

- PKD

- hereditary/congenital disorders

- renal cancers

- nephrosclerosis (arterial hardening from HTN)

Aging & Kidneys

- 30-90 yrs: kidney size/weight ↓ 20-30%

- By 70s: glomerular function ↓ 30-50%

- Atherosclerosis accelerates decline

- Prostate enlargement (males)

Age-Related Physiological Renal Changes

- ↓ elasticity & muscle support

- ↓ renal blood flow → ↓ GFR

- ↓ ability to concentrate urine (hormonal)

- Altered excretion of water, Na, K, acid

Gerontologic Considerations (Kidneys)

- Older adults = ↑ risk for AKI

- Risks:

- dehydration (polypharmacy → diuretics, laxatives)

- illness, immobility, hypotension, aminoglycosides, obstruction, surgery, infection

- Normal aging kidneys can maintain homeostasis, but sudden stressors (blood volume, acid load, insults) may overwhelm function

prerenal failure

Outside of kidney

Caused by shock, dehydration, burns, sepsis

An episode of ARF is pre renal only if it is reversed when the underlying cause of hypoperfusion is corrected

intrarenal failure

direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced blood supply

- Most common: Acute Tubular Necrosis (ATN)

- Causes: ~30% meds (aminoglycosides, contrast, chemo) |

- 50% ischemia (↓ perfusion)

postrenal failure

sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor, or injury

Pre-Renal AKI Causes

- Volume depletion → hemorrhage, diuretics overuse, GI losses (vomit/diarrhea), severe dehydration

- Impaired cardiac function → HF, MI, cardiogenic shock, valve disease, renal artery damage

- Vasodilation → meds, anaphylaxis, sepsis

Intra-Renal AKI Causes

- Prolonged ischemia → myoglobinuria (burns, trauma, muscle injury), hemoglobinuria

- Nephrotoxic agents → aminoglycosides, NSAIDs, contrast dye

- Infection → pyelonephritis, glomerulonephritis (E. coli, bacteria, fungi, protozoa, viruses)

aminoglycosides antibiotics

Gentamicin,

Streptomycin,

Amikacin,

Neomycin,

Tobramycin,

Post-Renal AKI Causes

- Obstruction of urine flow (ureters → urethra)

- Urolithiasis (stones), clots, strictures

- Tumors: prostate, ovarian, cervical, colon

- Bladder dysfunction

- Obstructions: BPH, blocked catheter, ureteral blockage

Trauma

Obstruction to urine outflow

- GFR decreases

- hydronephrosis: kidney failure

- pressures interfere with function: cannot filter / remove waste

- obstruction: increased pressure

AKI phases / classifications

- Phases: oliguric → diuretic → recovery

If no recovery → may progress to CKD

RIFLE classification:

R = Risk

I = Injury

F = Failure

L = Loss

E = ESRD

Initiation period

begins with the initial insult and ends when oliguria develops

- Onset: 1-7 days after injury; lasts 10-14 days

- Most common sign: oliguria

- UA: casts, RBCs, WBCs

- Uremic s/s: weakness, fatigue, anorexia, weight loss, mental status changes, muscle cramps, visual changes, ↑ thirst, shallow respirations

Oliguric Phase

-Urine output decreases

-UO of 100-400 mL/24 hours

-This client is in fluid volume excess

-The potassium will be increased!

- Support renal fx

- keep client stable until injury heals/resolves

Diuretic Phase

increased urine (water, not wastes).

Kidney unable to conserve Na and H20. High BUN. Deficit of K, Na and H20. Azotemia

- volume may reach elevated values

- Hyponatremia

- Hypokalemia

- Dehydration

UREMIA S/S

- weakness

- fatigue

- anorexia

- weight loss

- mental status changes

- muscle cramps

- visual changes

- ↑ thirst, shallow respirations

hypermagnesium

flushing, drowsiness, ↓ reflexes, weakness, resp depression, cardiac arrest;

Tx: Ca gluconate, ventilation, dialysis

Hypocalcemia

→ cramps, tetany, Chvostek/Trousseau, tingling, ECG changes;

Tx: Ca replacement

therefore, HYPERPHOSTEMIA

Fluid volume excess

→ wt gain ≥5%, edema, crackles, JVD, ↓ Hct/BUN; Tx: restrict fluids/Na, diuretics, dialysis

Metabolic acidosis

→ HA, confusion, ↑ RR, warm skin; Tx: bicarb, dialysis

RECOVERY PHASE

•Lab values return to patient's normal level

- Recovery can take several months(up to a year)

- Goals: patient education (drink fluids unless CKD), followup, preventive measures

prevention of AKI/ARF

- Adequate hydration

- Prompt treatment: shock, hypotension, infection

- Meticulous catheter care

- Monitor/limit nephrotoxic meds & dosages

Medical Management of AKI/ARF

- Monitor/adjust nephrotoxic meds

- Weight loss, exercise

- ↓ Na & alcohol

- Smoking cessation, education, nephrology referral

- Control HTN (<130/80), treat hyperglycemia

- Manage anemia, manage CVD risk factors

Nutritional Education

- Maintain adequate caloric intake

- Restrict sodium

- Increase dietary fat

- Prevent/treat infections promptly

- Enteral nutrition

epoeitin

stim RBC production

Focused Renal Assessment

Physical exam: cardiopulmonary, renal, hemodynamic status

Hx: renal problems, nephrotoxic meds, heavy metals/solvents

Events: hypotension >25 min, tumors/clots, infection

Nursing Assessment

- Neuro: mental status, LOC

- Oral: mucosa hydration

- Pulmonary: lung sounds, circulatory overload

- Cardiac: rhythm, ↓ CO, S3 (HF)

- Labs/Diagnostics: review results