NURS 3012: Hepatic/ Renal

Acute Kidney Injury

This is a sudden decline in kidney function due to loss of renal system circulation or glomerular/tubular damage. This can range from mild to severe, but luckily can be reversed if treated early. There are three forms: Prerenal, intrinsic and postrenal

Prerenal AKI (Before the kidneys)

Caused by low blood flow to the kidneys. Decreased blood flow means reduced oxygen. Prerenal, pre-perfusion

Prerenal AKI symptoms

-Low glomerular filtration rate (poor filtration

-oliguria (low urine output)

-High urine concentration (specific gravity high)

-High BUN & creatinin

-Low sodium in urine

cause of prerenal AKI

Obstruction, or vessel occlusion. Could be from an embolus, tumour or low blood pressure (shock, low bp, heart failure, hypovolemia).

Intrinsic AKI (inside the kidney)

is also known as acute tubular necrosis. Could be a result of direct damage to the kidney structures, such as the kidney blood vessels, tubules, glomeruli and interstitial tissue.

Cause of intrarenal AKI

Typically caused by infection, such as glomerular nephritis, sepsis, nephrotoxins, ischemiaor autoimmune, like lupus.

Intrarenal AKI symptoms

-Damage to the kidney tubules, which are responsible for the filtration of waste and fluid, causes the kidneys to be unable to filter properly, causing these toxins and fluid to build up in the body.

-Vascular blood flow issues or tubular inflammation and blockage trigger vasoconstriction and inflammation.

-Protein, blood or cast in urine

-Low GFR, high creatinine & BUN

Does CT contrast dye or antibiotics effect the kidneys

CT contrast killing the kidneys, antibiotics and long-term NSAIDS

Postrenal AKI (after the kidney)

caused by urine blockage.

cause of postrenal AKI

Renal calculi, tumour, benign prostatic hyperplasia, bi,g swollen prostate can cause this.

Postrenal aki signs and symptoms

-Low or no urine output (anuria/oliguria)

-Pain in lower abdomen or flank

-Backflow of urine can cause kidney damage

Chronic kidney disease

the progressive loss of renal function over months or years. Usually caused by long term

Causes of chronic kidney disease

1. Older age, geriatrics, typically lose 10% of renal function each decade

2. Long-term damage:

-Uncontrolled diabetes, from unchecked blood sugars (thick cement, in dilated kidneys)

-Unchecked hypertension: high blood pressure (high pressure pounding against the delicate glomerulus, hardening them

-Unchecked autoimmune disease: where the body attacks its own kidneys.

3. Infection: Cueing glomerular nephritis

4. Polycystic kidney disease

5. Acute renal failure that progresses

signs and symptoms of chronic kidney failure

-Oliguria (low urine)

-Hypertension, fluid overload

-Stroke, heart attack, worsen kidney damage

-Headache

-Nausea and vomiting

-Change in mental status

KEY SIGNS

-Anemia: less erythropoietin

-Metabolic acidosis

-Urea= Uremic frost (crystal on skin)=puritus

chronic kidney failure labs

(over 1.3= bad kidney)

-> Creatinine clearance test. How well the glomerular filtration rate is working to filter the waste

Dysrhythmias (from high k+)

-> IV Gluconate

High sodium, phosphorus, low calcium(osteoporosis), high potassium (peak t wave and ST elevation)

liver failure

Condition in which all normal functions of the liver are severely deficient

What is the role of the liver

1. Detox ammonia: Converts ammonia= urea (BUN)

2. Drug metabolism

3. Storing glycogen: used for energy reserves

4. Produce bile, coagulation factors and albumin

What leads to hepatic encephalopathy with liver failure

Liver fails to detoxify ammonia and other neurotoxins, which cross the blood-brain barrier and affect brain function. This can be triggered by GI bleeding, infection, high protein intake, or constipation

Purpose of albumin

-protein inside the blood that transports drugs in the body

-Attracts water(keep it inside the vascular space)

-Binds with calcium (keeps bones strong)

-> Trousseaus + Chevostek's

Purpose of bile

Scoops up bilirubin and cholesterol-via bowels

High bilirubin=causing jaundice

purpose of clotting factors in the liver

Helps the blood to clot

With liver failure, what does the development of portal hypertension cause

1. Esophageal varices: enlarge esophagus

2. Splenomegaly

3. Ascites: look pregnant

With liver failure, what does the development of hepatic encephalopathy cause

-Twitching in the extremities in to arms & legs=Asterixis

-Mental status changes/ sleepiness

Key assessment: assess hand movement with arms extended. Assess mental status with those from previous shifts. Assess recent blood draws for ammonia levels.

signs and symptoms of liver failure

1. Portal hypertension

2. Hepatic encephalopathy

3. Jaundice

4. Anemia

5. Leukopenia

6. Thrombocytopenia

7. Bleeding risk

8. Elevated ALT and AST

9. Puritus: itchy skin from toxins and bile salts.

Diagnostic of liver failure

Liver biopsy: see the tissue

-Lye on the right side after the procedure

Ascites= paracentesis

-Draining fluid

-Must empty bladder prior to and check BP, measure abdomen and weight

Urine microalbumin

Detects small amount of albumin in urine, an early sign of kidney damage, especially in diabetes or hypertension.

Urine analysis

Checks for substances like protein, blood, glucose, and signs of infection or kidney problems.

Elevated AST and ALT

suggest liver cell injury.

Alkaline phosphate and GGT

indicate possible bile duct problems or liver

lipid profile

Measures cholesterol levels (LDL, HDL, triglycerides) to assess cardiovascular risk and metabolic health.

Albumin

A protein made by the liver that reflects liver function, nutritional status, and can indicate kidney disease if low in the blood

Ammonia

High levels suggest the liver isn't removing toxins properly, which can cause hepatic encephalopathy (confusion or altered mental state).

Coagulation profile

Assesses blood clotting ability, aften used to check liver function or bleeding risk.

Electrolyte

Evaluates the body's fluid balance, kidney function, and acid-base status

Creatinine: A waste product filtered by the kidneys; elevated levels indicate reduced kidney function or damage.

Blood-urea-nitrogen

Another kidney function test; elevated BUN may suggest kidney dysfunction, dehydration, or high protein breakdown.

CBC with differential

Measures red and white blood cells and platelets to assess for anemia, infection, inflammation, or immune system issues.

what are theabs for diagnosing Chronic kidney failure

GFR: Over 90 ml/min is normal, but we will see less than that with each phase of chronic kidney failure.

-Means less and less blood is being washed

Creatinin over 1.3= Bad Kidney *most critical lab value as it show clogging of kidneys*

BUN Over 20= is very bad 💀

Urine output 30ml/hr less= kidneys in distress 😧

treatment for chronic kidney disease

-New kidney, for a GFR of less than 15. (SEVERE)

-Dialysis: machine version of kidneys that wash the blood

acute kidney injury common diagnosis

-Creatinin over 1.3= Bad Kidney *most critical lab value as it show clogging of kidneys*

-BUN Over 20= is very bad 💀

-Urine output 30ml/hr less= kidneys in distress 😧

-Metabolic ACIDosis pH below 7.35 (retension of all those hydrogen ions)

-High specific gravity

Treatment for acute kidney injury

Diuretics (FUROSIMIDE): push the kidneys from oliguria phase to diuresis phase

Liver enzymes (AST, ALT) lab

-Detect liver cell injury

-High levels indicate acute damage; tracking trends helps monitor disease progression or recovery.

Alkaline phosphatase (ALP) & GGT lab

-Assess bile duct function

-Elevated in cholestasis or bile obstruction; may require imaging or biliary intervention.

Total and Direct Bilirubin lab

-Measures bilirubin levels

-High levels cause jaundice; indicates liver's inability to excrete bile. Guides need for supportive care and monitoring.

Albumin lab

-Assesses liver's protein synthesis

-Low levels = poor liver function. Influences nutritional support and fluid management.

Prothrombin Time (PT)/INR lab

-Tests clotting ability

-Liver makes clotting factors; high INR = bleeding risk. Guides decisions about procedures and may require vitamin K or plasma.

Ammonia lab

-Detects toxin buildup

-Elevated in hepatic encephalopathy. Guides treatment with lactulose, rifaximin and monitoring of mental status.

CBC (Complete Blood Count) lab

-Assesses anemia, infection, and platelet count

-Low platelets may reflect portal hypertension or splenomegaly; infection risk must be managed.

Electrolytes, BUN, Creatinine

-Kidney and metabolic status

-Liver failure may cause or worsen renal dysfunction (e.g., hepatorenal syndrome). Guides fluid/electrolyte management and dialysis need.

Abdominal Ultrasound purpose for liver failure

-Evaluates liver size, texture, blood flow, presence of ascites or masses

-Helps diagnose cirrhosis, portal hypertension, ascites, or tumors. Guides paracentesis, surveillance, or transplant referral.

CT or MRI of the Liver purpose for liver failure

-More detailed liver imaging

-Used to assess tumors, vascular abnormalities, or staging hepatocellular carcinoma. Affects oncology referral or surgical planning.

Elastography (FibroScan) purpose with liver failure

-Measures liver stiffness (fibrosis)

-Non-invasive assessment of fibrosis/cirrhosis severity. Helps determine prognosis and need for transplant evaluation.

Endoscopy (EGD) purpose with liver failure

-Evaluates for esophageal varices

-Helps prevent/treat GI bleeding from varices. Determines need for banding or beta-blocker therapy.

Jaundice

Impaired liver function leading to the accumulation of bilirubin (a byproduct of red bleed cell breakdown) in the blood. The liver cannot conjugate and excrete it properly, causing yellowing of the skin and eyes

jaundice assessment/prevention

-Monitor for yellowing: Skin, sclera, mucous membranes

-Check bilirubin levels

-Prevent liver samage by avoiding hepatotoxic drugs, alcohol, and managing hepatitis

jaundice intervention

Treat underlying liver condition

Portal Hypertension

Scarring (cirrohosis) increasing resistance to blood flow through the liver, causing increased pressure in the portal vein. Blood backs up into surrounding vessels (e.g. esophagus, spleen)

Portal Hypertension assessment/ prevention

-Monitor for signs like splenomegaly, ascites, varices, and low platelets

-Prevent with early treatment of liver disease, avoiding alcohol, and controlling hepatitis

intervention for portal hypertension

-Beta blockers: reduce portal pressure

-Monitor and treat complications such as varices and ascites

-Emergency bleeding: vasopressor and compression of carotids with an inflatable tube or balloon.

Ascites

Portal hypertension and low albumin levels cause fluid to leak into the peritoneal cavity. Sodium and water retention by kidneys also contribute

ascites assessment/diagnosis

-Assess for abdominal distension

-Weight gain, abdominal girth measurement

-Prevent through managing liver disease and salt intake

ascites treatment

-Sodium restrictions

-Diuretics (spironalactone, furosemide)

-Paracentesis: IF SEVERE

-Albumin infusion may help in sever fluid loss

Esophageal varices

Portal hypertension causes blood to divert into smaller veins in the esophagus, forming fragil varices that can rupture and bleed massively.

Esophageal varices assessment/prevention

-Monitor for signs of GI bleeding (hematemesis, melena)

-Anemia

-Screen high-risk with endoscope

Esophageal varices treatment

Emergency: endoscopic banding, vasopressors, and blood transfusions.

Long term: repeat endoscopy, beta-blocker

Beta blockers: lower the pressure in the portal venous system

hepatic encephalopathy

Liver fails to detoxify ammonia and other neurotoxins, which cross the blood-brain barrier and affect brain function. This can be triggered by GI bleeding, infection, high protein intake, or constipation

hepatic encephalopathy assessment/prevention

-Monitor for confusion, altered LOC, asterixis (flapping tremor), personality changed

-Assess ammonia levels

hepatic encephalopathy treatment

-Administer lactulose to recude absorption

-Rifaximin to reduce ammonia-producing bacteria

-Treat underlying cause (infection, GI bleed)

-Monitor neuro status closely

neurological manifestations of worsening kidney function

weakness, fatigue, confusion, tremor, seizures, asterixis, restlessness of legs, burning soles of feet and behavioural changes

integumentary manifestations of worsening kidney function

Grey bronze skin color, dry flaky skin, pruritus, ecchymosis, purpa

cardiovascular manifestations of worsening kidney function

HTN, edema, JVD, pericarditis, hyperkalemia, hyperlipidemia

pulmonary hypertension manifestations of worsening kidney function

Crackles, thick tenacious sputum, pleuretic pain, SOB, tachypnea, Kussmaul-type respiration, iremic pneumonititis.

gastrointestinal manifestations of worsening kidney function

Mouth ulceration and bleeding,constipation, diarrhea, anorexia, nausea and vomiting.

hematological manifestations of worsening kidney function

Anemia, thrombocytopenia

Reproduction manifestations of worsening kidney function

Amenorrhea, testicularatrophy

Peritoneal dialysis

Is a homebased treatment where a dialysis solution is infused into the abdominal cavity (peritoneum) through a catheter. The peritoneal membrane acts as a filter to remove waste and excess fluid. Fluid is later drained and replaced.

Goal is to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance.

Hemodialysis

Blood is pumped out of the body through a machine that filters waste, excess fluids, and electrolytes, then returns clean blood to the body. Usually done 3 times/week at a dialysis center.

Kidney transplant:

Surgical placement of a donor kidney from a living or deceased donor.

No treatment:

Supportive care, non-dialysis care focused on symptom control, comfort, and quality of life. Chosen by patients who decline dialysis or are not a conditate for transplant.

what is the one situation that you can give sedatives to a patient with liver risks

alcohol withdrawal