DA

AKI, CKD, Dialysis

Chronic Kidney Disease (CKD)

Definition & Epidemiology

  • Progressive, irreversible loss of kidney function.

  • Defined as:

    • Kidney damage or

    • GFR <60 mL/min for >3 months.

  • 5 stages (mild to ESRD).

  • Affects >26 million adults in the U.S.

  • Often asymptomatic until advanced stages.

Leading Causes

  • Diabetes (50%) – #1 cause.

  • Hypertension (25%) – #2 cause.

  • Others: aging, obesity, recurrent infections, nephrotoxic drugs.

Risk Factors

  • Age >60

  • Diabetes

  • Hypertension

  • Cardiovascular disease

  • Minority ethnicity

  • Family history of CKD

  • Nephrotoxic drug use

Clinical Manifestations

CKD affects all body systems:

  • Urinary: Initially no change → oliguria → anuria with dialysis.

  • Psychological: Depression, fatigue, poor coping.

  • Fluid/Electrolyte: Na retention, K⁺ ↑, metabolic acidosis.

  • Cardiovascular: HTN, HF, dysrhythmias, pericarditis.

  • Respiratory: Kussmaul respirations, pulmonary edema.

  • GI: N/V, anorexia, GI bleeding, stomatitis.

  • Neuro: Lethargy, fatigue, confusion, neuropathy, seizures, coma (late).

  • Musculoskeletal: CKD mineral bone disorder (renal osteodystrophy, fractures).

  • Skin: Pruritus, yellow-gray discoloration, uremic frost (late, rare).

Diagnostics

  • Labs: ↑BUN/Cr, electrolyte changes, ↓GFR.

  • UA: proteinuria, hematuria, casts.

  • Imaging: US/CT for structural damage.

  • Biopsy (sometimes).

Management

  • Control underlying disease (DM, HTN).

  • Diet: Limit Na, K, phosphate; protein restriction; adequate calories.

  • Meds:

    • Diuretics (fluid overload).

    • Antihypertensives.

    • Phosphate binders (sevelamer, calcium acetate).

    • Vitamin D supplements.

    • Erythropoietin for anemia.

  • Dialysis or transplant when GFR <15.

Acute Kidney Injury (AKI)

Definition & Key Points

  • Sudden loss of kidney function (hours–days).

  • Leads to ↑BUN, ↑Cr, ↑K⁺ (azotemia).

  • May or may not have ↓urine output.

  • Potentially reversible if caught early.

Causes & Classifications

  1. Prerenal: Decreased renal blood flow.

    • Causes: hypovolemia, HF, shock, decreased CO.

    • Usually reversible if treated early.

  2. Intrarenal: Direct damage to renal tissue.

    • Causes: nephrotoxins, hemoglobin/myoglobin, ischemia, sepsis.

    • Acute Tubular Necrosis (ATN) = most common.

  3. Postrenal: Obstruction of urine outflow.

    • Causes: BPH, stones, tumors, trauma.

    • Bilateral obstruction → hydronephrosis.

Clinical Phases

  1. Oliguric Phase (1–7 days after injury, lasts 10–14 days):

    • UO <400 mL/day.

    • Fluid overload, ↑K⁺, ↑BUN/Cr, metabolic acidosis, uremic symptoms.

  2. Diuretic Phase (1–3 weeks):

    • UO 1–3 L/day (up to 5 L).

    • Risk for dehydration, hypovolemia, hypotension, electrolyte loss.

  3. Recovery Phase (up to 12 months):

    • GFR increases, labs normalize.

Diagnostics

  • Labs: ↑BUN/Cr, K⁺, phosphate; ↓Na, Ca.

  • UA: protein, casts, hematuria.

  • Imaging: US, CT, renal scan.

Management

  • Treat underlying cause.

  • Fluid restriction: 600 mL + previous 24 hr output.

  • Nutrition: Adequate calories, ↓K⁺, ↓Na, ↓phosphate, adequate protein.

  • Hyperkalemia treatment:

    • IV insulin + glucose

    • Sodium bicarb

    • Calcium gluconate

    • Kayexalate

    • Dialysis if severe

  • Dialysis indications: Fluid overload, severe hyperkalemia, metabolic acidosis, BUN >120, mental status changes.

Nursing Care

  • Daily weights, I/O, VS.

  • Monitor urine characteristics.

  • Assess for edema, JVD, lung sounds.

  • Check dialysis site for infection.

  • Neuro checks, skin/oral care.

  • Renal dosing of meds.

Dialysis

Indications

  • GFR <15 or symptomatic uremia.

  • Corrects fluid/electrolyte imbalances.

  • Removes waste products.

Types

1. Peritoneal Dialysis (PD)

  • Catheter in abdomen, dialysate in peritoneal cavity.

  • 3 Phases: Inflow → Dwell → Drain.

  • Systems: Automated PD (machine) or CAPD (manual).

  • Complications: Peritonitis, site infection, hernia, protein loss, back pain, pulmonary issues.

2. Hemodialysis (HD)

  • Requires vascular access (AV fistula/graft).

  • Thrill: vibration felt; Bruit: whooshing heard.

  • Blood is filtered through dialyzer and returned.

  • Complications: Hypotension, cramps, blood loss, hepatitis, access infection/clot.

3. Continuous Renal Replacement Therapy (CRRT)

  • Slow, continuous dialysis for unstable AKI patients.

  • Removes toxins/fluids gradually over 24 hrs.

  • Access: double-lumen catheter.

  • Not for emergencies (takes longer).

Kidney Transplant

  • Best option for ESRD.

  • <4% receive transplant; long wait times.

  • Success rate >90%.

  • Nursing management:

    • Pre/post-op care.

    • Immunosuppressive therapy (lifelong).

  • Complications: Rejection, infection, CVD, cancer, steroid side effects.

NCLEX Quick Notes

  • AKI with oliguria = risk for hyperkalemia.

  • Diuretic phase AKI = risk for hypokalemia, hyponatremia.

  • CKD = most common causes DM & HTN.

  • PD complication = peritonitis (cloudy effluent, abdominal pain).

  • AV fistula care = no BP, IVs, or blood draws in that arm.

  • First-line treatment for hyperkalemia in AKI = IV insulin + glucose.