N401: Alterations in Kidney Function, AKI/CKD, HD/PD, Kidney Transplant
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Acute Kidney Injury (AKI)
is a sudden decline in kidney function occurring over hours to days, resulting in the kidneys' inability to adequately:
Remove metabolic waste products.
Maintain fluid and electrolyte balance.
Regulate acid-base balance.
Maintain normal blood pressure and fluid homeostasis.
may be reversible if identified and treated early.
Diagnostic Criteria AKI
According to the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, AKI is diagnosed if ANY of the following occur: Don't memorize for exam, just nice to know.
Increase in serum creatinine by ≥ 0.3 mg/dL (26.5 µmol/L) within 48 hours.
Increase in serum creatinine to ≥ 1.5 times baseline within the previous 7 days.
Urine output less than 0.5 mL/kg/hour for at least 6 hours.
Causes of AKI
Prerenal _= Caused by reduced blood flow (perfusion) to the kidneys without initial structural kidney damage.
-Examples Prerenal _: Dehydration, Hemorrhage, Severe burns, Heart failure, Sepsis, Hypotension
Intrinsic (Intrarenal) _= Caused by direct damage to kidney tissue.
-Examples Intrinsic _: Acute tubular necrosis (ATN), Acute glomerulonephritis, Acute interstitial nephritis, Nephrotoxic medications (e.g., NSAIDs, aminoglycosides), Rhabdomyolysis
Postrenal _= Caused by obstruction of urine flow.
-Examples Postrenal _: Enlarged prostate (BPH), Kidney stones, Urinary tract tumors, Urethral strictures, Bilateral ureteric obstruction
Stages of AKI
Initiation phase= Initial kidney injury occurs, such as ischemia or nephrotoxic exposure.
Maintenance phase= Kidney function is impaired. Oliguria may occur, with increased risk of fluid overload, hyperkalemia and uremia- waste product build-up
Recovery phase= Kidney function begins to improve. Urine output may increase significantly (diuretic phase), creating a risk of dehydration and electrolyte loss. Can take several months.
How to Preventing AKI
Maintain adequate hydration.
Monitor patients at high risk.
Avoid unnecessary nephrotoxic drugs or renal dose (helps protect kidneys).
Monitor kidney function during high-risk treatments.
Treat sepsis and shock promptly- want to avoid hyper-perfusion.
Monitor fluid balance during hospitalization.
Relieve urinary obstruction early.
Key Points to remember for AKI
sudden decline in kidney function.
Three causes: prerenal, intrinsic, and postrenal.
Most important diagnostic markers: serum creatinine and urine output.
Hyperkalemia is a potentially life-threatening complication.
Renal ultrasound helps identify urinary obstruction.
Early identification and treatment can prevent permanent kidney damage.
Chronic Kidney Disease (CKD)
is defined as an abnormality of kidney structure or function that persists for at least/after 3 months and has implications for health.
_ is progressive and irreversible
The kidneys gradually lose their ability to: Filter waste products from the blood. Maintain fluid and electrolyte balance. Regulate acid-base balance. Control blood pressure. Produce erythropoietin (for red blood cell production). Activate vitamin D for calcium and bone metabolism.
_ is usually progressive and may eventually lead to kidney failure.- without treatment
Causes of CKD
Diabetes mellitus= High blood glucose damages the kidney's filtering units (glomeruli).
Hypertension= Long-standing high blood pressure damages renal blood vessels and kidney tissue.
Glomerulonephritis= Inflammation damages the glomeruli, reducing filtration capacity.
Polycystic kidney disease (PKD)= Genetic disorder causing multiple cysts to develop in the kidneys, genetic disorder.
Chronic urinary obstruction= Examples include kidney stones, enlarged prostate (BPH) and urinary tract abnormalities.
Other risk factors include: Recurrent kidney infections. Autoimmune diseases (e.g., lupus). Family history of kidney disease. Obesity. Long-term use of certain nephrotoxic medications- NSAIDs frequently.
Pathophysiology of CKD
Initial kidney injury occurs due to diabetes, hypertension or another disease.
Nephrons become damaged and are lost.
Remaining nephrons compensate by increasing their filtration rate (hyperfiltration).
Increased pressure within remaining glomeruli causes further damage.
Kidney filtration progressively decreases.
Waste products and fluids accumulate in the body.
End-stage kidney disease may eventually develop.
Important: _can affect multiple body systems because the kidneys perform several essential functions.
eGFR of stage 1 CKD
90 or higher
Normal or high filtration with evidence of kidney damage
eGFR of stage 2 CKD
60–89
Mild decrease in kidney function
eGFR of stage 3 a and b CKD
45-59= Mild to moderate decrease
30-44= Moderate to severe decrease
eGFR of stage 4 CKD
15–29
Severe decrease, dialysis
eGFR of stage 5 CKD
Less than 15
Kidney failure (end-stage kidney disease)
Symptoms Associated With Each Stage
Stages 1–2: Early CKD, Usually no noticeable symptoms. Kidney damage may be detected through urine or blood tests. Blood pressure may be elevated.
Stage 3: Moderate CKD, Fatigue. Swelling in legs or feet. Changes in urination. Anemia may develop. Electrolyte imbalances may occur.
Stage 4: Severe CKD, Significant fatigue. Nausea and decreased appetite. Fluid retention. Shortness of breath. Anemia and bone mineral disorders. Preparation for dialysis or transplant may begin.
Stage 5: Kidney Failure, Severe reduction in kidney function. Uremia (buildup of waste products). Severe fluid and electrolyte imbalances. Nausea, vomiting, and itching. May require dialysis or kidney transplantation.
Common Symptoms of CKD
Fluid retention= Peripheral edema. Facial swelling. Shortness of breath. Hypertension.
Anemia= Fatigue. Weakness. Pale skin. Dizziness. Caused partly by reduced erythropoietin production.
Bone and mineral disorders= Bone pain. Muscle weakness. Increased fracture risk. Due to disturbances in calcium, phosphate, vitamin D and parathyroid hormone.
Gastrointestinal symptoms= Nausea and vomiting. Loss of appetite. Metallic taste. Weight loss.
Other manifestations: Nocturia (frequent urination at night). Itching (pruritus). Sleep disturbances. Muscle cramps. Peripheral neuropathy. Confusion in advanced disease.
Complications of CKD
Anemia | Reduced erythropoietin production |
Hyperkalemia | Reduced potassium excretion |
Metabolic acidosis | Reduced acid excretion |
Fluid overload | Reduced sodium and water excretion |
Hypertension | Fluid retention and RAAS activation |
Hyperphosphatemia | Reduced phosphate excretion |
Hypocalcemia | Reduced active vitamin D production |
Secondary hyperparathyroidism | Increased PTH due to mineral imbalance |
Uremia | Accumulation of metabolic waste products |
Cardiovascular disease | Increased risk of heart failure and cardiovascular events |
Diagnosis CKD
Investigation | Purpose |
Serum creatinine | Assess kidney function |
eGFR | Estimate kidney filtration |
Urine albumin-to-creatinine ratio (uACR) | Detect kidney damage |
Urinalysis | Detect blood and protein |
Urea/BUN | Assess waste accumulation |
Electrolytes | Detect potassium and sodium abnormalities |
Calcium and phosphate | Assess mineral balance |
CBC | Detect anemia |
PTH | Assess secondary hyperparathyroidism |
Renal ultrasound | Assess kidney size and structure |
CKD Management
The main goals are to slow disease progression, prevent complications and preserve kidney function.
Control underlying diseases
Control blood glucose in diabetic patients.
Control blood pressure.
Treat underlying glomerular disease where appropriate.
Stop smoking.
Medications CKD
choices depend on eGFR (is the kidney function they have able to get rid of), potassium, albuminuria and individual contraindications.
ACE inhibitors (e.g., lisinopril) | Reduce blood pressure and albuminuria |
ARBs (e.g., losartan) | Protect kidneys and reduce proteinuria |
SGLT2 inhibitors (e.g., dapagliflozin) | Slow CKD progression in eligible patients |
Diuretics | Manage fluid overload |
Erythropoiesis-stimulating agents | Treat selected cases of renal anemia |
Iron supplements | Correct iron deficiency |
Phosphate binders | Control hyperphosphatemia |
Vitamin D preparations | Manage selected mineral-bone disorders |
Dietary Management for CKD
Reduce sodium intake.
Avoid excessive protein (large molecule that can be difficult to breaintake.
Limit potassium when blood potassium is elevated.
Limit phosphate when phosphate levels are elevated.
Maintain appropriate fluid intake.
Avoid excessive processed foods.
Dietary restrictions should be individualized according to laboratory results and _ stage
Difference between AKI and CKD
Feature | AKI | CKD |
Onset | Sudden | Gradual |
Duration | Hours to days | At least 3 months |
Cause | Acute injury | Chronic kidney damage |
Reversibility | Often reversible | Often progressive |
Anemia | Less common initially | Common |
Bone disease | Less common | Common in advanced disease |
Kidney size | Often normal | Often small, but may be normal or enlarged |
Treatment | Treat acute cause | Slow progression and manage complications |
Key Points for CKD
is kidney damage or reduced kidney function lasting at least 3 months.
Diabetes and hypertension are the leading causes worldwide.
eGFR is used to classify _ stages.
Albuminuria is an important marker of kidney damage.
Reduced erythropoietin causes anemia.
Reduced vitamin D activation contributes to hypocalcemia and secondary hyperparathyroidism.
Hyperkalemia can cause life-threatening cardiac arrhythmias.
Cardiovascular disease is a major cause of morbidity and mortality in _.
Dialysis and transplantation are kidney replacement therapies.
Hemodialysis (HD)
treatment used in patients with kidney failure to remove waste products, excess fluid and electrolytes from the blood using a dialysis machine and an artificial filter called a dialyzer.
It performs some of the functions of healthy kidneys but does not cure kidney disease.
Indications for HD
may be required in patients with: End-stage kidney disease (ESKD). Severe hyperkalemia. Severe metabolic acidosis. Fluid overload (e.g., pulmonary edema).Uremic complications (e.g., encephalopathy or pericarditis). Certain drug or toxin poisonings.
Remember AEIOU:
A – Acidosis
E – Electrolyte imbalance
I – Intoxication
O – Overload
U – Uremia
How HD Works
Blood is removed from the patient's body through vascular access.
Blood passes through the dialyzer.
Waste products and excess electrolytes move across a semipermeable membrane into the dialysate.
Excess fluid is removed by ultrafiltration.
Cleaned blood returns to the patient's body.
Arteriovenous fistula (AVF)
A surgically created connection between an artery and a vein.
Preferred long-term access.
Usually has the lowest infection risk.
Needs time to mature.
Arteriovenous graft (AVG)
A synthetic tube connects an artery to a vein.
Used when suitable veins are unavailable.
Can be used sooner than many fistulas.
Higher infection and clotting risk than AVF.
Central venous catheter (CVC)
A catheter inserted into a large vein, commonly in the neck.
Can be used immediately.
Higher infection and clotting risk.
Often used temporarily.
Frequency and Duration of Dialysis
A typical hemodialysis schedule is:
3 sessions per week.
Approximately 3–5 hours per session.
Individual schedules depend on the patient's condition and dialysis prescription.
Complications of Hemodialysis
Hypotension | Rapid fluid removal |
Muscle cramps | Fluid and electrolyte shifts |
Nausea and vomiting | Changes during dialysis |
Infection | Especially catheter-related, vascular sites |
Bleeding | Anticoagulant use or access problems |
Disequilibrium syndrome | Rapid changes in blood urea causing neurological symptoms |
Vascular access thrombosis | Blood clot blocks access |
Nursing Responsibilities before dialysis
Check blood pressure, pulse and temperature.
Obtain pre-dialysis weight.
Assess fluid status and edema.
Check vascular access for bruit and thrill.
Review laboratory results.
Avoid blood pressure measurements and venipuncture in the AV fistula arm.
Nursing Responsibilities during dialysis
Monitor vital signs regularly.
Observe for hypotension, cramps and nausea.
Monitor the dialysis access and blood flow.
Watch for bleeding and other complications.
Nursing Responsibilites after dialysis
Check vital signs.
Obtain post-dialysis weight.
Assess vascular access and bleeding.
Monitor for dizziness and hypotension.
Document fluid removed and patient response.
Key Points of HD
Removes waste and excess fluid from blood.
Dialyzer: Artificial kidney filter.
AV fistula: Preferred long-term vascular access.
Most common intradialytic complication: Hypotension.
Important nursing assessment: Check bruit and thrill.
Never: Take BP or perform routine venipuncture on the fistula arm.
Fluid removal: Called ultrafiltration.
Peritoneal Dialysis
is a type of dialysis used to treat people with kidney failure when their kidneys can no longer adequately remove waste products, excess fluid, and toxins from the blood.
Instead of using a dialysis machine to filter the blood outside the body, _ uses the body's own peritoneum (the lining of the abdominal cavity) as a natural filter.
How PD Works?
A catheter is surgically placed into the abdomen.
A sterile dialysis solution (dialysate) flows through the catheter into the abdominal cavity.
Waste products and excess fluid move from the blood vessels through the peritoneal membrane into the dialysis solution.
The solution remains in the abdomen for a prescribed amount of time (called the dwell time).- how long fluid sits in peritonemium or how many dwells
The used solution is drained and replaced with fresh solution.
This process is called an exchange.
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Performed manually.
Usually 3–5 exchanges daily.
Does not require a machine.
Can be performed at home or work.
Automated Peritoneal Dialysis (APD)
Uses a machine called a cycler.
Usually performed overnight while sleeping.
Automatically fills and drains the abdomen.
Allows more flexibility during daytime hours.
Advantages of PD
Can be performed at home.
Provides greater flexibility and independence.
Allows a more continuous form of dialysis.
No need for repeated needle insertion into blood vessels.
May allow fewer dietary and fluid restrictions than hemodialysis.
Potential Complications PD
Peritonitis: Infection of the peritoneal cavity; a serious complication.Most common complication
Catheter-site infection.
Hernias due to increased abdominal pressure.
Weight gain from glucose absorption in dialysis fluid.
Inadequate fluid or waste removal.
Protein loss through dialysis fluid.
Important warning sign= Cloudy drainage fluid, abdominal pain, fever, or chills may indicate peritonitis and require immediate medical evaluation.
Drainage is usually clear
Nursing Responsibilities for PD
Monitor vital signs, weight, and fluid balance.
Assess the catheter insertion site for infection.
Maintain strict aseptic technique during exchanges.
Monitor the color and clarity of drainage fluid.
Measure intake and output.
Monitor laboratory values, including electrolytes, BUN, and creatinine.
Assess for abdominal pain, fever, and signs of peritonitis.
Educate patients on proper catheter care and infection prevention.
Peritoneal Dialysis vs. Hemodialysis
Feature | Peritoneal Dialysis | Hemodialysis |
Location | Usually home | Often dialysis center |
Filter | Peritoneal membrane | Artificial dialyzer |
Access | Abdominal catheter | Vascular access |
Schedule | Daily | Usually 3 times weekly |
Machine | Optional | Required |
Infection risk | Peritonitis | Vascular access infection |
Continuous Renal Replacement Therapy (CRRT)
is a type of dialysis used primarily in critically ill patients, usually in the Intensive Care Unit (ICU), who have acute kidney injury or severe kidney dysfunction. Patients are very unstable and unable to go to dialysis. Goes at a slower rate to help maintain the patient at a stable as possible.
Unlike traditional hemodialysis, which removes waste and fluid over a few hours, _ works slowly and continuously, typically over 24 hours a day. For very unstable patients.
How CRRT Works
Blood is removed from the patient through a large central venous catheter.
Blood travels through tubing into a CRRT machine.
A special filter (hemofilter) removes waste products and excess fluid.
Electrolytes and fluid balance are carefully controlled.
Cleaned blood returns to the patient.
_ provides gradual fluid and waste removal, making it easier for unstable patients to tolerate.
Why Is CRRT Used?
is commonly used for critically ill patients who have:
Acute kidney injury (AKI).
Severe fluid overload.
Severe electrolyte imbalances, such as hyperkalemia.
Metabolic acidosis.
Hemodynamic instability (low blood pressure).
Multiorgan failure requiring continuous fluid and metabolic management.
Important: _ is especially useful for patients who cannot tolerate the rapid fluid and electrolyte shifts associated with traditional hemodialysis.
Advantages of CRRT
Gradual fluid removal.
Better tolerated by patients with low blood pressure.
Allows continuous electrolyte and acid-base management.
Helps manage severe fluid overload.
Useful in critically ill patients with unstable cardiovascular status.
Potential Complications CRRT
Hypotension.
Bleeding due to anticoagulation.
Blood clotting in the dialysis circuit.
Electrolyte imbalances.
Hypothermia.
Infection at the central venous catheter site.- in a much more controlled and monitored enviroment
Blood loss if the circuit clots or fails.
Nursing Responsibilities CRRT
Important nursing interventions include:
Monitor vital signs and hemodynamic status frequently.
Assess catheter placement, patency, and insertion site.
Monitor intake and output closely.
Monitor fluid removal goals and cumulative fluid balance.
Assess the _ machine for alarms, clots, and interruptions.
Monitor laboratory values, including BUN, creatinine, potassium, calcium, and bicarbonate.
Monitor anticoagulation and coagulation studies as ordered.
Assess for bleeding and signs of infection.
Monitor the patient's temperature.
CRRT vs. Traditional Hemodialysis
Feature | CRRT | Hemodialysis |
Duration | Continuous, often 24 hours | Usually 3–4 hours |
Setting | ICU | Dialysis center or hospital |
Patient | Critically ill | Often more stable |
Fluid removal | Slow and gradual | Faster |
Blood pressure | Better tolerated in unstable patients | May cause hypotension |
Machine | Continuous therapy machine | Hemodialysis machine |
Key Takeaway of CRRT
is a continuous form of dialysis used primarily for critically ill patients with acute kidney injury, fluid overload, or severe electrolyte imbalances.
Critically ill + Continuous treatment + Gradual fluid removal.
The most important nursing priorities are:
Monitor hemodynamic stability.
Maintain accurate intake and output.
Monitor electrolytes and fluid balance.
Prevent infection and bleeding.
Monitor the dialysis circuit for clotting and alarms.
Clinical pearl: _ is often preferred over intermittent hemodialysis in patients who are hemodynamically unstable because it removes fluid and waste more slowly.
Kidney Transplant
is a surgical procedure in which a healthy kidney from a living or deceased donor is placed into a person whose kidneys no longer function adequately. Able to get kidney from dead or living donor.
It is a treatment option for patients with end-stage renal disease (ESRD) and can provide better long-term quality of life compared with ongoing dialysis for eligible patients.
How Kidney Transplantation Works
A healthy kidney is obtained from a living or deceased donor.
The donor kidney is surgically placed in the lower abdomen.
The surgeon connects the kidney's blood vessels to the recipient's blood vessels.
The ureter is connected to the bladder.
The transplanted kidney begins filtering blood and producing urine.
Advantages of Kidney Transplant
Improved quality of life.
Greater independence from dialysis.
Improved kidney function.
Fewer dietary and fluid restrictions for many patients.
Potentially longer life expectancy compared with remaining on dialysis for eligible patients.
Potential Complications of Kidney transplant
Early complications: Bleeding. Infection. Blood clots. Delayed graft function. Urinary leakage. Acute organ rejection.
Long-term complications: Chronic rejection or graft dysfunction. Opportunistic infections.Hypertension. Diabetes related to immunosuppressive medications. Increased risk of certain cancers.
Organ Rejections
Hyperacute | Occurs within minutes to hours; rare. |
Acute | Usually occurs within days, weeks, or months, but can occur later. |
Chronic | Gradual loss of transplanted kidney function over time. |
occurs when the recipient's immune system recognizes the transplanted kidney as foreign and attacks it.
Three types include: Don't know specific just know acute and chronic rejection occur.
Symptoms of organ Rejection
Increased creatinine.- kidneys no filtering waste products
Decreased urine output.
Fever.
Pain or tenderness over the transplant site.
Swelling or fluid retention.
Increased blood pressure.
Some patients have no noticeable symptoms, so routine laboratory monitoring is essential.
Medications for Organ Transplant
Patients must take immunosuppressive medications to prevent their immune system from rejecting the transplanted kidney.
Important: Immunosuppressants must be taken consistently, usually for the life of the transplanted kidney. Patients should never stop these medications without consulting their transplant team. DON'T MEMORIZE MEDS JUST KNOW THAT PATIENT WILL HAVE TO TAKE THESE MEDS FOR REST OF LIFE TO PREVENT REJECTION.
Tacrolimus (Prograf) | Prevents immune system activation. |
Mycophenolate (CellCept) | Suppresses lymphocyte activity. |
Prednisone | Reduces inflammation and immune response. |
Cyclosporine | Suppresses immune system activity. |
Nursing Responsibilities of Kidney Transplant
Monitor vital signs and hemodynamic stability.
Monitor urine output closely.
Monitor BUN, creatinine, and electrolyte levels.
Assess for signs of infection.
Monitor for signs of organ rejection.
Assess surgical incision and transplant site.
Administer immunosuppressive medications as prescribed.
Monitor medication levels, especially tacrolimus.
Maintain accurate intake and output.
Educate patients about medication adherence and infection prevention.
Key Takeaways for Nursing Students for Kidney transplant
is a treatment for end-stage kidney disease.
Organ rejection occurs when the immune system attacks the donor kidney.
Immunosuppressive medications are essential to prevent rejection.
Monitor urine output, creatinine, medication levels, and signs of infection or rejection.
NCLEX tip= A sudden increase in serum creatinine or decrease in urine output after kidney transplantation should raise concern for possible rejection or graft dysfunction. Notify the transplant team and anticipate further evaluation.
-Most important nursing priority: Protect the transplanted kidney by preventing infection, ensuring medication adherence, and monitoring kidney function closely.