Acute and Chronic Kidney Disease

Acute kidney disease differences

• Sudden onset

• Acute Tubular Necrosis - most common cause

• Acute reduction in UOP and/or increase Cr

• Potential reversibility

• Main cause of death is infection

Chronic Kidney disease differences

• Gradual Onset

• Diabetic Nephropathy is most common cause

• GFR <60 ml/min x 3 months and/or kidney damage > 3 months diagnostic criteria

• Reversibility is progressive and irreversible

• Main cause of death is cardiovascular disease

AKI

• Rapid loss of kidney function

• Ranges from slight deterioration to severe impairment

• Develops of hours or days with rise in serum creatine, BUN, and potassium

• May or may not have a decrease in UOP

• Potentially reversible depending on extent of damage and identification/ treatment of cause

• Cause my be pre-renal, intra-renal, or post renal

Causes of AKI - Pre-renal

Decreased renal blood flow

• Hypotension

• Hypovolemia

• Sepsis

• Renal artery thrombosis

• Burns

Causes of AKI - Intra-renal

Direct damage to kidney tissue

• Prolonged ischemia

• Nephrotoxins

• Hemolysis or myoglobinemia

• SLE

• Glomerulonephritis

Causes of AKI - Post-renal

Mechanical obstruction in urine outflow

• Stone

• Tumor

• BPH

Phases of AKI

• Oliguric

• Diuretic

• Recovery

Classification of AKI

Risk

• GFR decr 25% increase x1.5

Injury

• GFR decr 50% or Cr incr x2

Failure

• GFR decr 75% or Cr incr x3 or Cr >4

Loss

• Persistent acute failure x >4 weeks

End Stage Renal Disease

• Complete loss x 3 months

Increased over baseline

Oliguric Phase

Most common 1st manifestation and usually pre-renal

• <400 ml/day; occurs within 1-7 days of kidney injury

• Urinalysis- Casts, RBC’s WBC’s sp gr fixated at 1,010

• Metabolic acidosis

  • Due to decr excretion of H and decr reabsorption/ production of BiCarb

• Hyperkalemia

  • Decreased excretion and acidosis

• Hyonatremia

  • Dilution and decreased reabsorption

• Elevated BUN and Creatine

• Fatigue and Malaise

Think volume overload

Diuretic Phase

• Gradual increase in urine output - 1-3 L/day; may reach 3-5 L/day

• Hypovolemia, dehydration

• Hypotension

• Hypokalemia

• Hyponatermia

• BUN and Creatinine levels begin to normalize

• Last 1-3 weeks

Recovery Phase

• Begins when GFR increases

• BUN and Creatinine levels plateau then decrease

Management of AKI - Fluid Balance

• Daily weights, I & O’s, vital signs

• Ensure adequate hydration

• Diuretics Ex furosrmide, Bumetanide

• Fluid restriction

  • 600ml + previous day UOP

Management of AKI- Electrolytes

Hyperkalemia

• Insulin

• Sodium Polystyrene Sulfonate ( Kayexalate)

• Sodium Bicarb ( if acidotic)

• Calcium Gluconate

  • Stabilizes Myocardium

• Dialysis

Management of AKI- Nutrition

• Adequate calories including protein but manly CHO and fats

  • Decreased ketosis from fat breakdown

• May need Na and K restriction

Management of AKI- Renal Replacement Therapy

Indications

• Volume overload

• High K

• Metabolic acidosis

• BUN >120

• Change in mental status

• Pericarditis

• Pleural effusion

• Cardiac Tamponane

Intermittent Hemodialysis or Continuous Renal Replacement

High Potassium Fods

• Avocado

• Apricots

• Broccoli

• Potatoes

• Spinach

• Chocolate

Oz-mL

1 oz= 30 ml

• Ex 4oz = 120 mL

Chronic Kidney Disease

• Irreversible, progressive loss of function

• 1 in 7 adults

• Risk factors

  • Diabetes

  • Hypertension

  • Cardiovascular Disease

  • Nephrotoxic

  • Drugs

  • >60 years

  • Family History

  • Ethnicity

• Prevention

  • Control BS

  • Control HTN

  • Screening for early diagnosis

• Often asymptomatic and unrecognized until there is a considerable loss of nephrons

• Dialysis is covered as medicare benefit, ESRD is recognize as a disability

Serum creatinine

• Waste product in blood

• Inversely and non-linearly related to GFR

• Normal 0.6-1.2

• varies according to age, sex, and body size

Estimated Glomerular Filtration Rate ( eGFR)

• How much blood is flittered through glomeruli minute

• Calculation factors in age, race, body size

• Normal 90-120 ml/min (decr with age)

Creatine Clearance

• Estimated the GFR with a 24 hour urine test

• Compares serum creatine with excreted creatinine in urine

• Normal 100-140 mL/min

  • Decr with age

Urinalysis

Have client empty bladder. Start clock and collect all urine for 24 hours, At the end of time, have pt void once more, Keep urine on ice or refrigerated

Stage 1

Kidney Damage w/ normal GFR

• Dx and treatment

• CVD risk reduction

• Slow progression

Stage 2

Kidney damage w/ mild decr GFR

• Estimation of progression

Stage 3a

Moderate decr GFR

• Evaluate and treatment of complications

Steps 3b

Moderate decr GFR

• More aggressive treatment of complications

Stage 4

Severe decr GFR

• Preparation for dialysis or kidney transplant

Stage 5

Kidney Failure

• Renal replacement therapy if uremia is present and client desires treatment

Clinical Manifestations

Urine output

• Decreases as CKD progresses- Normal, oliguria, anuria

Volume Overload

• Fluid retention

Increased BUN/Creatinine r/t decreased excretion

Hyperglycemia r/t impaired glucose metabolism and hyperinsulinemia

Elevated triglycerides r/t incr trig production from liver d/t hyperinsulemia

Hyperkalemia r/t decreased excretion and acidosis

• Fatal arrhythmias when levels are 7-8 mEq/L Peaked T waved, wide QRS

Sodium: High, low, or normal, Decr Na excretion. Incr H20 retention (dilution)

Metabolic Acidosis related to decr H excretion and impaired HCO3 reabsorption/production May be 16-20

Anemia related to decr erythopoitein production, iron deficiency

Bleeding r/t impaired platelet function

Increased risk for infection r/t changes in WBC function and altered immune repsonse

More Clinical Manifestations

Increased risk of CV disease related to

• Arterial stiffness and vascular calcification

• Abnormal bone metabolism, impaired renal excretion, high total calcium phosphorous

Stomatitis, metallic taste in mouth, anorexia, nausea, vomiting, uremic fetor, risk for Gi bleeding

Neuro changes such as

• Change in LOC, neuropathies, r/t incr waste productions, electrolyte imbalance, metabolic acidosis, and demyelination of nerve fibers

Mineral and bone disorder r.t decr vit d activation resulting in decr serum calcium, Leads to incr PTH and bone reabsorption to Incr calcium

Hypocalcemia , hypperphospatemia

Prutitis r/t dry skin, neuropathy, and Ca/pH deposits in skin

Hypertension

• Lifestyle mod

• DASH diet

• Usually need 2 meds

Mineral and Bone disorders

Phosphate binders TID with meals

Incr CA, Decr Ph, stabels bone density

• Calcium acetate

• Calcium carbonate

• Sevelamer

  • Non calcium based

• Ferrous Citrate

  • Iron based

  • Constipation- may need stool softeners

Vitamin D supplementation

• Calcirol

Avoid magnesium containing antacids

Anemia

• iron supplements

• Epoetin

Increased H/H RBC’s

Dyslipidemia

Improved Chol, and Trig levels with statin therapy

Pre-ERSD

• Calcium 1000-1500 mg/day

• 30-35 kcal/kg/day

• Fluids Varies based on UOP

• Iron supplementation w/ EPO

• Phosphate Client specific, 1-1.8 g/day

• Potassium based on labs

• Protein 0.6-1.2g/kg/day

• Sodium client specific 1-3 day

Hemodialysis

• Client specific 30-35 kcal

• Calcium is client specific

• Urine output +600 ml

• Iron Supplement w/ EPO

• Phosphate Client specific 0.6-1.2g

• Potassium client specific 2-4g/day

• Protein 1.2 g

• Sodium Client specific 2-3 g/day

Peritoneal Dialysis

• Calcium is client specific

• 20-25 kcal a day

• Fluids Unrestricted if wt and Bp ok

• Supplement w/ EPO

• Phosphate client specific 0.6-1.2g/day

• Potassium usually no restriction

• Protein 1.2-1.3 needs increasing

Renal Replacement Therapy

• Hemodialysis

• Peritoneal Dialysis

• Continuous Renal Replacement Therapy

• Renal Trasplant

Criteria

• GFR <15 mL/min

• Creatinine >6 mg/dL

• Encephalopathy, Neuropathy

• Hyperkalemia

• Uncontrolled hypertension

• Heart failure

• Uremic symptoms

• Nausea

• Vomiting

• Anorexia

• Itching

• Fatigue

Dialysis

• Solutes and water move across semipermeabe membrane to dilysate or dialysaye to blood ( high to low)

• Urea, Cr, Uric acid, and electrolytes move from blood dialysate to lower concentrate

• An osmotic gradient is created with glucose in dialysate for PD to remove excess fluid

• A pressure gradient is created in HD by the pump to remove fluid

Hemodialysis

• Usually 3-4 hours, 3 days in dialysis center

• Home HD: 2.5-3 hours, 5-6 days per week

• CRRT: 24 hours continuous dialysis, lower volume exchanges, mimics normal kidney

• Requires vascular access- AV Fistula Vascath

• Monitor wt pre/post, VS q30-60 min during procedure

Complications

• Hypotension

  • Provider may hold BP meds prior to dialysis

• Antibiotic dialyzation

  • Provide may hold antibiotics within 4 hours of HD

• Muscle cramps

• Loss of blood

• Hepatitis

Peritoneal Dialysis

• Catheter inserted through abdominal wall

• Continuous Ambulatory Peritoneal Dialysis (CAPD)

  • Done 4 times daily with dwell time of 4 hours

• Three phases

  • Inflow: 2L infused over 10 min

  • Dwell ( equilbration): Usually between 4-6 hours

  • Drain - Take 15-30 minutes

• Automated Peritoneal Dialysis

  • Cycles at nightime while pt is sleeping

  • 4 or more exchange cycles, w-2 hours dwell

  • May need 1-2 exchanges during day

• Complications

  • Exit Site infection

  • Peritonitis

  • Hernias

  • Bleeding

  • Pulmonary Complications r/t displacement of diaphragm

  • Protein loss: Peritoneal membrane is permeable

  • Mortality: Similar to HD for 1sr 2 years then increased

Kidney Transplant Highlights

• Less than 4% of pt. with ESRD receive due to low supply

• Criteria is GFR ,15 ml/min (on or off dialysis)

• Must meet center specific criteria for other candidacy

  • Co-morbidities

  • Substance use

  • Adherence

• Donors may be living or decreased (brain or cardiac), ABO and HLA typing and matching is important to prevent rejection

• Surgery: native kidneys are left in and new kidney attached. Signs kidney is working is increase UOP and decreased creatinine

• Requires lifelong immunosepressants including corticosteroids

Complications

• Infection

• Rejection

• Delayed Graft Function

• Cancer

• Recurrent Kidney disease

• Corticosteroid related complications