AKI and CKD

acute kidney injury

can range from slight deterioration in kidney function to severe impairment

rapid loss of kidney function with or without decreased urine output

can be reversed

can need dialysis for a short amount of time

increased BUN, creatinine, and potassium- potassium excreted by kidneys

usually affects people with other life threatening problems

categorized as prerenal, intrarenal, and post renal

causes of AKI

prerenal: decreased cardiac output, decreased peripheral vascular resistance, decreased renovascular blood flow, hypovolemia

intrarenal: interstitial nephritis, nephrotoxic injury, acute glomerulonephritis

post renal: bladder cancer, prostate cancer, trauma

prenreal

factors that reduce systemic circulation causing a reduction in renal blood flow

decreased glomerular perfusion and filtration of kidneys

prerenal oliguria

prerenal azotemia

intrarenal

conditions that cause direct damage to kidney tissue, resulting in impaired nephron function

results from: prolonged ischemia, nephrotoxins, hemoglobin (hemolyzed RBCs), myoglobin (necrotic muscle cells)

acute tubular necrosis: most common; major surgery, shock, blood transfusion reaction, muscle injury from trauma, prolonged hypotension

postrenal

mechanical obstruction in the outflow of urine

BPH, prostate cancer, calculi, trauma, extrarenal tumors, bilateral ureteral obstruction, hydronephrosis, prolonged obstruction leads to tubular atrophy and irreversible kidney fibrosis

3 phases of AKI

oliguric phase

diuretic phase

recovery phase

RIFLE classification for AKI

risk

injury

failure

loss

end stage renal disease

AKI diagnostic studies

thorough hx

serum creatinine

urinalysis

kidney ultrasonography

CT scan

renal biopsy

MRI- contraindicated in pts with kidney failure r/t dye

AKI interprofessional care

eliminate the cause, manage the s/s, and prevent complications while the kidneys recover

diuretic therapy- furosemide, bumetanide

calculate fluid restrictions- add all the losses for previous 24hr + 600mL

tx for hyperkalemia- insulin and sodium bicarbonate, calcium carbonate, sodium polystyrene sulfonate (kayexalate)

nutritional therapy

AKI renal replacement therapy

indications: volume overload, elevated serum potassium, metabolic acidosis, BUN over 120, significant change in mental status, pericarditis, pericardial effusion, cardiac tamponade

peritoneal dialysis

intermittent hemodialysis

continuous renal replacement therapy

AKI health promotion

measure daily weight

monitor I&O

monitor electrolyte balance

replace significant fluid losses

provide aggressive diuretic therapy for fluid overload

use nephrotoxic drugs sparingly

AKI gerontologic considerations

more susceptible to AKI:

• dehydration

• polypharmacy

• illness and immobility

• hypotension

• diuretics

• aminoglycosides

• obstructive disorders

• surgery

• infection

chronic kidney disease

leading causes are: hypertension and diabetes mellitus

either the presence of kidney damage or decreased GFR less than 60mL/min longer than 3 months

end stage renal disease: GFR is less than 15mL/min

can be managed not reversed

CKD clinical manifestations

uremia

accumulation of nitrogenous wastes

alterations in water, electrolyte, and acid base balance

mineral and skeletal disorders

anemia and coagulation disorders

HTN and alterations in cardiovascular function

GI and neuro complications

disorders of skin integrity

immunologic disorders

CKD tx

correct fluid volume overload or deficit

control BP and glucose

control hyperkalemia

control BP

drug therapy

dialysis

kidney transplant

nutrition therapy

dialysis

peritoneal dialysis

hemodialysis

started when uremia can no longer be treated with conservative management

diffusion, osmosis, ultrafiltration

periotoneal dialysis

catheter inserted through anterior abd wall

done by putting dialysis solution into the peritoneal space

3 phases: inflow, dwell (equilibrium), drain

solutions and volume vary depending on peritoneal cavity and goal fluid removal

ultrafiltration: fluid removal; dextrose mostly used

automated (during night) and continuous (every few hours)

peritoneal dialysis complications

site infection

peritonitis: abd pain, rebound tenderness, cloudy effluent, increase in WBC, positive cultures

hernias

lower back problems

bleeding

pulmonary complications

protein loss

hemodialysis AV fistula

created on forearm or upper arm with an anastomosis between artery and vein; allows arterial blood to flow through the vein

essential to provide rapid blood flow for HD

6 weeks to mature

thrill can be felt palpating the fistula and bruit can be heard with stethoscope

hemodialysis graft

synthetic material

2-4 weeks to heal

more likely to become infected and form blood clots

will need surgical removal if infected

safety alert

never perform BP measurements, IV insertion, or venipuncture in an extremity with an AV access

to prevent infection and clotting

place signs in the toom and label the arm that says no BP, IV, or blood draw

hemodialysis temporary vascular access

if immediate access is needed, can be done at bedside, jugular or femoral

one lumen is used for blood removal and one for blood return

used when they are waiting for fistula placement

high infection rates, dislodgment, and malfunction

hemodialysis procedure

two large bore (16) needles inserted into fistula or graft

one to pull and one to return

heparin needed to prevent clotting

dialyzer- filter

monitor fluid status- weight, BP, peripheral edema, heart/lung sounds; before during and after

most people receive it 3-4 days a week and it takes 3-4 hours

dialysis complications

hypotension

muscle cramps

loss of blood

hepatitis

continuous renal replacement therapy

method of treating AKI

uremic toxins and fluids are removed while acid base status and electrolytes are adjusted slowly and continuously in a hemodynamically unstable pt

dialyze over 24hrs

vascular access, jugular, or femoral vein

filter removes plasma water and nonprotein solutes

runs slower, so may improve hemodynamic stability