Renal Failure, Dialysis, Kidney Transplantation, Immunosuppressants

Acute Kidney Injury (AKI)

• sudden onset (Hours to days)

• affect many systems

• 50-95% nephron involvement

• Full recovery possible

• Prognosis ~ Good when fx maintained/returns

• MAIN S/S azotemia, Urinary ~ oliguria, anuria,

  • S/S fluid overload ~ dependent edema, generalized

    edema (anasarca), lung crackles/SOB

KCD

• gradual (Months to years)

• most common cause HTN and DM (gene: PKD; lupus)

• IRREVERSIBLE

• affects every system

• 90-95% nephron involvement

• Fatal without RRT (Dialysis or transplant)

• Reduced life span

• Azotemia becomes UREMIA

  • s/s: Anorexia, N & V, metallic taste in mouth, FATIGUE, uremic “frost”

Azotemia

– Buildup of nitrogenous wastes in blood (no clinical S/S)

Acute Tubular Necrosis (ATN)

death of cells that form the renal tubules of the kidneys

Uremia 

Elevated BUN/creatinine levels & clinical S/S of disease

CRI ~ Chronic Renal Insufficiency

Years of ↓ kidney fx not yet incompatible with life

Urinary Output (U/O)

Normal urinary output 

Anuria

Oliguria

at least 30 ml/hr

– no U/O or LT 100 ml/day

– LT 400 ml/day

creatinine clearance (CrCl)

Best estimate of kidney fx along with persistent proteinuria, creatinine

Kidney Failure is Disruption in renal fx that impairs the body’s

ability to maintain homeostasis…impacts

F/E, acid-base balance

• Erythropoietin ~ hormone that stimulates RBC production

• RAA system ~ BP regulation

AKI types

• Prerenal ~ HYPOPERFUSION (↓ blood flow to kidneys)

  • Blood/fluid loss/shock ~ surgery, bleeding, dehydration

  • ↓ CO ~ heart attack/HF, sepsis, severe anaphylaxis

  • BP meds, aspirin, ibuprofen

• Intrarenal (Intrinsic) ~ Actual physical, chemical, hypoxia

or immunologic damage directly to kidney tissue

• Glomerulonephritis, pyelonephritis

• Lupus,

• antibiotics, chemo, contrast media

• Postrenal ~ Obstruction of urine flow

• Calculi, BPH, neurogenic bladder, strictures ~ hydronephrosis

prevention of AKI in hospitalized clients

Monitor for dehydration, labs & report any ↓ U/O (LT 30 ml/hr X 2 hrs)

AKI comp

METABOLIC: Hyperkalemia

CV: HTN

GI: Ulcer formation/ bleeding

Neurologic: Mental status changes, Asterixis

Hematologic:  Bleeding, anemia

Nephrotoxic substances for AKI

Antibiotics ~ sulfonamides, vancomycin, rifampin

»Aminoglycosides

–NSAIDS

–PPIs

–Chemo agents, dyes, solvents, heavy metals

AKI labs

BUN & creatinine ↑, creatinine clearance ↓

– Sodium (normal)

– Potassium ↑

– Phosphorus & magnesium ↑ (there is an assciation btwn p=m, p inc, ca dec)

– Calcium ↓

– CO2, arterial pH & bicarb ↓ (metabolic acidosis)

*HCT & HGB ↓ (anemia) ~ CHRONIC form

unless hemorrhage cause of AKI

AKi diagnostic

KUB - hydronephrosis

Renal ultrasonography/scan and CT w/o dye

• Cystoscopy, pyelography ~ obstruction

  – Kidney biopsy if AKI cause unknown

AKI goal

Avoid hypotension and maintain MAP 80-85 range

fluid balance

• be careful of contract dye bc they cause Contrast-induced nephropathy

AKI trx

meds: Diuretics

Nutrition Therapy 

RRT: ST dialysis

Monitoring of BUN/creatinine, electrolytes, U/A

– Fluid restriction & daily wgts

CKD stages and NC for each, values

1. Kidney damage/normal GFR (at risk) GFR > 90

• Screen for risk factors

2. Kidney damage/mild ↓ in GFR (proteinuria) 60-89

• Focus on reduction of risk factors

3. Moderate ↓ in GFR (moderate CKD) 30-59

• Strategies to slow progression (*HTN/DM mgmt)

4. Severe ↓ in GFR (severe CKD) 15-29

• Manage complications, educate/prepare RRT

5. Failure/ESKD ~ cannot maintain homeostasis LT 15

• Dialysis or transplant required to sustain life

CKD ~ Metabolic Changes

BUN & creatinine inc

Sodium early is hypon and then hypern (HTN/worsening fliud retention)

hyperk→ fatal dysrhythmias

Acid-base balance ~ kidneys cannot excrete excessive H+ (H+ is acidic) → metabolic acidosis which would be indicated by kussmaul respirations (EMERGENCY)

With CKD:

– ↑ Phosphate ~ hyperphosphatemia

– ↓ Ca+ ~ hypocalcemia

– ↓ Vit D ~ bone demineralization → Mineral & Bone Disorder (MBD) →Renal osteodystrophy

CKD cardiorenal system

Cardiorenal syndrome ~ RAAS ~ ↓ perfusion

– HTN ~ cause OR result in this case (YOU WANT TO CONTROL BP)

ANEMIA ~ ↓ erythropoietin by kidney, edema

CKD GI

ammonia breath, stomatitis, anorexia

– Peptic ulcer disease/GI bleeding

CKD urinary system should be checked for

proteinuria

Polyuria/nocturia (early); oliguria/anuria (later)

– Straw-colored (early); concentrated/cloudy (later)

CKD diet

Restrict fluid fluids, limit, sodium and potassium, phosphorus, and limit alcohol sugar, high calorie drinks

CKD skin

dry, yellow/gray pallor, itching, osteodystrophy

CKd drug regimen avd

avd opiopids, NSAIDs, aminoglycosides, IV contrast Dyes

CKd drug regimen

HTN meds ~ ACEs, ARBs

• Loop diuretics ~ , statins

• Metabolic acidosis ~ sodium bicarb tabs

• Phosphate/Phosphorus Binders

– Ca+ acetate (PhosLo)

• Parathyroid Hormone Modulator

• Vitamin D ~ calcitriol (active form of Vit D)

• Erythropoieten (RBC)-Stimulating Agents (ESAs)

- Epogen given IV/dialysis or SQ 3X/week

**Add to this…meds if DM

CKD Hyperkalemia

if high then its Potassium-induced cardiotoxicity where you will se peaked T waves on EKG

• give odium zirconium cyclosilicate (Lokelma) PO/powder or Calcium gluconate, 10 U reg insulin IV (with D50)

ESKD trx

RRT: Hemodialysis (artificial kidney- extracorporeal), peritoneal dialysis, transplant

to know: primary ESRD death are a result of CV complications

Dialysis: Diffusion, Osmosis, Ultrafiltration

how do you know if Hemodialysis is working

dry weight ( need to have heparin/citrate to prevent clotting, protamine on hand)

permanent vs temporary vascular access for HD

Internal arteriovenous (AVF) fistula

–Access of choice ~ created surgically

vs

Traditional central line

AV fistula care

Priority ~ maintain PATENCY/LT use

• No BPs, IVs, venipuncture in AVF

• palpate thrill and bruit

Hemodialysis ~ Complications

Dialysis disequilibrium syndrome

Cardiac events

ESKD ~ Peritoneal Dialysis advantage vs disadvantages

managed @ home with fewer diet restrictions but Risk for peritonitis (s/s cloudy dialysate output

PD monitoring

Monitor effluent for S/S infection (cloudy)

Meticulous PD catheter care using ASEPTIC tech

CKD ~ Community-Based Care

PREVENTION is KEY: screening, Detect HTN early, BP mgmt

• Check U/A ~ proteinuria, Dx & mgmt of DM

education is limiting red meat

kidney transplant are normally done due to

DM and HTN if GFR is 20

Main kidney transplant contradictions

nonadherence

financial resources

organ donor types

living donor- often family related

Non-Heart-Beating Donors (NHBDs) (declared dead by cardio pulmonary criteria)

Cadaveric- most common (brain dead from trauma)

• dead require sterile autopsy procedure vs alive requires laparoscopic

kidney donor criteria

• 18yrs old

• Absence of systemic disease/infection

• No current active cancer

• No HTN, obesity, glucose intolerance, lower GFR

compatibility effort

Simple (ABO) blood typing ~ MUST match

– Human leukocyte antigen (HLA) ~ close as possible

*GOAL ~ Optimize success/prevent rejection

Dialysis usually done within 24 hrsof surgery along

with blood transfusion from donor

under what conditions is the failed kidney removed during transplant

only remove for chronic infection or polycystic/pain

kidney transplant post op care

Immunosuppressants used to prevent tissue rejection but ↓ immunity, impair healing, ↑ risk of infection, inc risk of neoplasms (lymphoma)

HIGH doses needed to suppress graft rejection (Major TOXIC effects are also lifelong)

goals is to prevent infection & rejection (must take life long Immunosuppressants

– Calcineurin inhibitors, mTOR inhibitors

– Corticosteroids

post op kidney transplant Foley catheter

Decompress bladder, strict I & O

–Hourly U/O for 1st 48 hrs

–Monitor fluid status

–Continuous bladder irrigation (CBI) if clots

–Monitor urinary color (pink/bloody just after)

–Daily U/A glucose, acetone & specific gravity

–Culture (if indicated)

–Meticulous cath care to prevent CAUTI

kidney transplant post op monitor

Fluid Volume Status 

BP every 2-4 hrs

Daily wgts & strict I & O

LABS: creatinine, GFR

kidney transplant post op reporting

Oliguria/anuria ~ possible rejection

Fluid status ~ 500-1000 ml output GT intake

– Hypotension (affects perfusion)

– Excessive diuresis (hypovolemia)

kidney transplant comp

EARLY detection for rejection

Kidney Transplantation ~

Home Care/Education

Nutrition

– Activity level

– S/S graft rejection, infection, fluid overload, etc.

– Lifelong immunosuppressants…ADHERENCE

Immunosuppressants Calcineurin Inhibitors Cyclosporine

 Drug of choice to prevent rejection

Nephrotoxic ~ monitor BUN/creatinine

NO grapefruit juice (inc toxicity)

Immunosuppressant Therapy ~

Glucocorticoids PREDNISONE

Large doses required, full range of adverse effects

– Suppression of HPA axis

– ↑ risk of infection

– Thinning of skin

– Bone dissolution with fractures

Immunosuppressant Therapy ~

Cytotoxic Drugs Azathioprine (Imuran)

Toxic to ALL cells

• Bone marrow suppression (CBC @ baseline & after)

• GI disturbances

• Alopecia (hair loss)

• ↓ fertility