NURM-103 Renal Disorders Exam Review

How is AKI measured via labs?

• Increased serum Cre by 0.3mg/dL+ in 48hr

• Cre increase by 1.5x baseline

What should be assessed in AKI?

Urine output + GFR

AKI risk factors

• HTN

• DM

• PVD

• CKD

What does AKI cause?

• Decreased renal perfusion

• Renal tissue damage

• Obstructed urine outflow

Can timely intervention prevent AKI from becoming CKD?

Yes

PRErenal AKI Causes

• Blood/fluid loss + Shock

• Hypotension

• Burns

• Dehydration

• Sepsis

• Renal artery stenosis + Renal vessel bleed/clot

• MAP < 65

MAP is short for

Mean Arterial Pressure

Intrinsic AKI causes

• Acute tubular necrosis

• Injury to glomeruli/nephrons/tubules

POSTrenal AKI causes

Anything obstructing urine outflow

• Bladder/prostate cancer

• BPH/renal calculi

• Neurogenic bladder

What can cause severe AKI in someone without any history?

Dehydration

How many mL/hr should most people be drinking?

30mL/hr

How many L/day should most people be drinking

2-3L

Urine characteristics include

• Color

• Odor

• Amount

Report a urine output below ________.

0.5mL/kg/hr

Labs for renal function

• Cr + BUN + EGFR

• Electrolytes

Which electrolytes are most important with renal function?

• Na⁺

• K⁺

Nephrotoxic medications/substances

• NSAIDs

• ACE-Is

• -mycin abx

• Contrast media

• Heavy metals

• Chemo

How can procedures requiring contrast media be approached?

• Renal (lower dose)

• Pre-procedure hydration (IV)

• Post-procedure hydration

How do the kidneys compensate for AKI?

Activating RAAS + Releasing ADH

Oliguria

Urine output < 400mL/day

Azotemia

Nitrogenous waste buildup

How does AKI affect metabolism?

• Acidosis

• HLD

• Hyperkalemia

How does AKI affect cardiopulmonary?

• Peripheral + Pulmonary edema

• HF

How can AKI affect neuro?

• Seizures

• Mental status change

How can AKI affect the immune system?

PNA and sepsis

How does AKI affect GI?

• N/V

• Decreased peristalsis

• GI bleed + ulcer

What is one significant finding in AKI relating to blood?

Anemia!

Hx red flags pointing to AKI

• Recent surgery/transfusion/trauma

• Abx/NSAID usage

• Recent imaging with contrast

• Systemic infection

• Acute illnesses

• Shock/hypotension

• Obstruction issues

What should be assessed hourly after surgery regarding the kidneys?

Hourly urine output!

• < 0.5mL/kg/hr for 2+ hrs → AKI

Fluid overload s/s

• Crackles/rales + Edema

• Decreased SpO₂

• Tachypnea + SoB

Hypoperfusion VS

• Tachycardia

• Thready pulses

• LOC change

• MAP < 65

Normal BUN

10 - 20 mg/dL

Normal Cre in FEMALE

0.5 - 1.1 mg/dL

Normal Cre in MALE

0.6 - 1.2 mg/dL

Normal sodium levels

136 - 145 mEq/L

Normal phosphate levels

3.0 - 4.5 mg/dL

Potassium in AKI is (increased/decreased).

Increased

Phosphate in AKI is (increased/decreased).

Increased

Normal calcium levels

9.0 - 10.5 mg/dL

Calcium in AKI is (increased/decreased) in AKI

Decreased

Normal Magnesium levels

1.3-2.1 mEq/L

Magnesium is (increased/decreased) in AKI.

Increased

How does AKI affect acid-base?

Metabolic acidosis

• Decreased pH + HCO₃

Urine Diagnostics

• Urine sodium

• Dilute urine

• Urine sediment

What can be found in a urine sediment test that damages nephron?

• RBCs

• Casts

• Myoglobin

• Hemoglobin

KUB XR

Kidneys Ureter Bladder

• Obstruction + size of kidneys

Prerenal/Intrinsic AKI is associated with…

hypOtension

Postrenal AKI is associated with…

hypERtension

What is the urine output goal if contrast dye is needed for prerenal/intrinsic AKI?

150mL/hr for first 6 hrs

• Enough hydration to produce this much

How is fluid balance measured?

• I&Os

• Daily wts

• Lung sounds

Fluid challenge

Promoting perfusion with 500-1000mL over an hour

What is monitored in a fluid challenge?

• Central Venous Pressure (CVP)

• Pt response → Titrate

• Respiratory status

CVP monitoring

Central venous pressure

• Measure BP in R atrium and vena cava near heart for fluid balance

Catabolism

Increased protein breakdown

• Kidneys cannot handle

Anabolic state

Positive nitrogen balance

What may renal patients too till for an adequate diet get for nutrition?

• Nepro

• Suplena

• Renalcal

• Novasource renal

Sodium for renal patient

60 - 90 mEq/kg

Potassium for renal pt

60 - 70 mEq IF ELEVATED

Fluid intake for renal patient

Urine volume + 500mL

Protein restrictions for pre-dialysis pt

0.6/kg

Protein restrictions for dialysis pt

1-1.5g/kg

What should be checked before dialysis?

Wt + VS

What should be assessed DURING dialysis?

Hypotension + cramping + bleeding

What should be assessed post-dialysis?

• Wt

• Dialysis disequilibrium syndrome

• Site bleed/infection

Indications to call a rapid

• Potassium > 6.5

• pH < 7.1

• Fluid overload

• Drug/alcohol intoxication

• Symptomatic uremia

Symptomatic uremia s/s

• Pericarditis

• Neuropathy

• Cognitive changes

Can a vascular access for dialysis also be used for blood or meds?

No

How long is intermittent KRT delivered over? How many times a week?

• 3-6 hrs

• 3-4 times a week

CRRT

Continuous renal replacement over 12-24 hrs in the ICU for hemodynamically unstable pts

Which specialties are typically consulted after AKI treatment?

Nephrology + Dietician

CKD

Abnormalities in renal structure/function altering health > 3 months

ESRD

When renal function declines and cannot sustain life

Uremia s/s

• Metallic taste + hiccups

• Itching + Uremic frost skin

• Anorexia + Vomiting

• Edema + Muscle cramps + SoB

CKD renal changes

• Decreased GFR + urine output

• F&E balance issues

• Nephron remodeling

• Increased BUN + Cr

• Overload risk

Creatinine

Byproduct of skeletal muscle breakdown

CKD acid-base changes

• Metabolic acidosis follows nephron destruction

• Kidneys cannot excrete H⁺

How does the body compensate for not being able to excrete H⁺?

Kussmaul respirations

• Higher rate + depth

Renal osteodystrophy

Bone mineral loss

• Due to PTH increase in response to phosphorus overload

Renal osteodystrophy s/s

• Increased fractures

• Bone pain

What is the leading cause of death in CKD?

HF

CKD Cardiac Changes

• HTN from fluid overload

• HLD from fat metabolism changes

• HF from left ventricular enlargement

• Pericarditis from uremic toxins

How is anemia treated?

ESAs!

• Epogen + Procrit

How does uremia affect immunity?

Disrupts WBC production

Uremic fetor

Halitosis due to excess urea being broken down into ammonia in the mouth

How does CKD affect the blood?

• Anemia from less erythropoietin

• Bruises/bleeding from impaired platelets

How does CKD affect the GI?

• Uremic fetor

• Anorexia

• N/V + hiccups

• Peptic ulcer disease

Primary CKD causes

HTN + DM

How many liters of water per day is encouraged?

2 liters daily

CKD Neuro + CV assessment findings

• LOC

• HR + Rhythm

What causes fatigue in CKD?

Anemia

CKD Respiratory assessment findings

• Uremic fetor + Kussmaul respirations

• Thick sputum + cough + pleural friction rub

CKD hematologic assessment findings (and resulting symptoms)

• Anemia + bleeds

• Fatigue + lethargy

CKD GI assessment findings

• Mouth ulcerations

• Halitosis

CKD skin assessment findings

• Uremic frost on skin

• Yellowish discoloration

• Pruritus

CKD skeletal assessment findings

Fragile bones from renal osteodystrophy

How can renal osteodystrophy be found?

Bone XR

CKD potential complications

• Fluid overload

• Pulmonary edema

• Decreased cardiac function

• Insufficient nutrition

• Potential for injury + infection

• Fatigue