Kidney part 3

Chronic Kidney disease

Gradual loss, non reversible

Risk: HTN, obesity, DM, hyperlipidemia; Race-Asian, Hispanic, Black

S/s: early→asymptomatic, Dx with lab(GFR<60mg/mmol(disease), GFR<15(failure), increase albumin, CRE, K; decrease Na later), FVO, change LOC(toxin), Anxiety, depression

Prevention: >2L/day, no smoking/alcohol, diet/exercise→HTN/DM, avid nephrotoxic/NSAIDs, monitor albumin/yr(DM/HTN)

Treatment: remove waste, K(sodium polystyrene, calcium chloride, glucose/insulin), HTN(diuretics, beta-blockers,CCB, ACEi, ARBs), Anemia(iron supplements, erythropoietin, folic acid), Dyslipidemia(statin), Hypocalcemia(Ca, vitamin D), hyperphosphatemia(P binder/meals)

Nursing care: monitor vital/UO/weight; renal diet, fluid restriction, balance activity/diet, emotional support

Stages of chronic kidney disease

Stage 1: GFR>90, normal function, little damage

Stage 2: GFR 60-89, normal, mild damage

Stage 3a:GFR 45-59, not normal, mild-moderate damage

Stage 3b: GFR 30-44, not normal, moderate-severe

Stage 4: GFR 15-29, at risk not functioning, severe

Stage 5: GFR<15, stopped functioning, significant damage, failure, no urine/dialysis depend

Lab value related to kidney failure

CRE: 0.5-1.2

BUN: 8-21

P: 2.5-4.5

Ca: 8.2-10.2

CO2: 23-29

HGB: male 14-17.3, female 11.7-15.5

Hct: male 42-52, female 36-48

Urine protein: 6-8g/dl

CRE clearance: 88-137ml/min

Renal replacement therapy

Hemodialysis, continuous renal replacement therapy(CRRT), Peritoneal dialysis

Hemodialysis

fluid/electrolyte/acid-base balance, filter waste, restore internal hemostasis(osmosis, diffusion, ultrafiltration)

Body-blood-dialyzer-body; AV shunt, no BP/blood draw on that arm/site/IV

criteria: renal insufficiency, AKI, CKD, toxicity(med/drug), high K, failed hypervolemia treatment(diuretics)

inpatient/outpatient setting, 4hr/3days/wk, no Anti-HTN med before dialysis

Nursing care: assess vital, O2, daily weight, site assessment(thrill,bruit); monitor H+H, WBC, electrolytes, renal function, complications. Hold medication(dialyzed out, or lead to complication(hypotension); educate renal diet, fluid restriction, preventing infections

Complications: hypotension, muscle cramps, H/N, dizziness, malaise, bleeding, infection, dialysis disequilibrium syndrome(cerebral edema-N/V confusion, restlessness, headaches, seizures) Dialysis related edema(long-term)

Continuous renal replacement therapy (CRRT)

Critically ill, AKI, severe fluid overload, hemodynamic instability

Blood-hemofilter-patient, require collection devices, Fluid/electrolyte can be infused to replace volume

Peritoneal dialysis

Peritoneal cavity=dialyzing layer

Benefit: less diet restriction, greater patient mobility, avoid rapid fluid change=less s/s, no vascular assess

Contraindication: Hx of ABD surgeries, chronic ABD condition, recurrent hernia, obesity, back problem, severe COPD

Complications: peritonitis, ABD pain, hyperglycemia, hypertriglyceridema, respiratory compromise, protein loss

Continuous ambulatory peritoneal dialysis: 4-5x/day, dwell time 4-6hr, no machine needed

Automated peritoneal dialysis: overnight(multiple), dialysis free @day

Intermittent peritoneal dialysis: short dwell cycle using machine, 30-40 exchanges/wk 30-60min/each

Dialysis nursing management

All dialysis: assess vital, O2, daily wt, coagulation, H+H, WBC, electrolytes, renal function

HD: fistula assessment, central line assessment(if using CVC), monitor(muscle cramps, headache, nausea, dizziness, malaise) post dialysis due to fluid shift

CRRT: >hourly vital/filtrate assessment

PD: ABD girth, outflow, peritonitis, fluid purulent(infection)

Dialysis patient education

Disease process+dialysis

Social services, counseling services, support

S/s of dialysis access complication/infections

Diet recommendation/restriction for HD and PD patient