Chapter 48

Fluid and Electrolyte Disturbances
- Table 48-1: Review of associated disturbances in kidney disorders.
Gerontological Considerations
- Atypical and nonspecific signs and symptoms of altered renal function in older adults.
- Risks include fluid and electrolyte imbalances.
Monitoring Tools
- Daily weights: Most accurate indicator of fluid loss or gain.
- Intake and output (I&O) monitoring.

Definition
- A prolonged state of acute inflammation primarily caused by hypertension (HTN) and diabetes mellitus (DM).
- Staged progression from Stage 1 to Stage 5.
- Chart 48-1 illustrates the stages of CKD, measuring increased creatinine levels, anemia, fluid retention, and electrolyte abnormalities.
- Associated complications include difficulty managing heart failure (HF) and hypertension.
Clinical Manifestations
- Increased creatinine levels.
- Symptoms include anemia, fluid retention, and various electrolyte imbalances.
Management
- Control blood pressure, with a target of maintaining levels below $125-130/80$ mmHg.
- Manage hyperglycemia effectively to control diabetes.
- Treat anemia and ensure early referrals for the initiation of renal replacement therapy (RRT).
- Educate patients on lifestyle changes such as smoking cessation, weight loss, regular exercise, and reducing alcohol and salt intake.

Definition
- Hardening of renal arteries, primarily related to prolonged hypertension or diabetes or as part of the aging process.
- Gradually elevates blood urea nitrogen (BUN)/creatinine with mild proteinuria.
Risk Factors
- Predominantly affects African Americans and individuals with uncontrolled hypertension or underlying CKD.
Types
- Acute hypertensive nephrosclerosis vs. benign nephrosclerosis.
Clinical Assessment
- Early stages often asymptomatic.
- Urine may contain proteins and casts, while later stages progress to CKD symptoms.
Management
- Implement antihypertensive therapy; ACE inhibitors can significantly reduce incidence.

Definition
- Diseases that destroy the kidney glomeruli.
- Terms typically used to describe glomerular disease:
- Primary: Disease primarily in glomeruli.
- Secondary: Glomerular diseases resulting from systemic diseases.
- Idiopathic: Unknown cause.
- Acute: Occurs over days or weeks.
- Chronic: Occurs over months or years.
- Rapidly progressing: Constant and rapid renal function loss, improved recovery chances with early diagnosis.
- Diffuse: Involves all glomeruli.
- Focal: Involves some glomeruli.
- Segmental: Involves portions of individual glomeruli.
- Membranous: Evidence of thickened glomerular capillary walls.
- Proliferative: Increasing number of glomerular cells.

Definition
- A type of acute glomerulonephritis characterized by symptoms including:
- Hematuria
- Edema
- Azotemia
- Proteinuria
- Hypertension.
Clinical Management
- Symptom management strategies include dietary modifications.
- Potential use of antibiotics, corticosteroids, and immunosuppressants where appropriate.
Monitoring
- Intake and output, daily weight, fluid and dietary restrictions.
- Monitor for further signs and symptoms of kidney disease.

Etiology
- Can result from repeated episodes of acute nephrotic syndrome, hypertension, nephrosclerosis, hyperlipidemia (HLD), and chronic tubulointerstitial injury.
- Kidneys may shrink to as little as 1/5th of normal size.
Symptoms
- Asymptomatic for long periods but may include:
- Weight loss
- Increased irritability
- Nocturia
- Headaches, dizziness, digestive disturbances.
Laboratory Findings
- Urine tests showing fixed specific gravity, casts, proteinuria, electrolyte imbalances, and hypoalbuminemia.
Management
- Control hypertension and regularly monitor weight.
- Prescribe diuretics as needed and suggest dietary modifications.
- Advise avoidance of nephrotoxic drugs.
- Ongoing assessment for fluid and electrolyte imbalances and cardiac/neurological disruptions.
- Educate patients about self-care practices.

Definition
- Characterized by increased glomerular permeability, resulting in massive proteinuria.
Clinical Manifestations
- Symptoms include edema, irritability, headache, malaise, and significant proteinuria.
Diagnostic Measures
- 24-hour urine collection and needle biopsy of the kidney.
Management
- Treat underlying causes, administer diuretics, ACE inhibitors, and lipid-lowering agents.
- Restrict sodium intake and ensure patient education on medication and dietary adherence.

Definition
- A genetic disorder characterized by the growth of numerous fluid-filled cysts in the kidneys, leading to significant kidney enlargement.
Clinical Manifestations
- Symptoms include:
- Hematuria
- Hypertension
- Renal calculi
- Urinary tract infections (UTI)
- Abdominal fullness and flank pain.
Diagnostics
- Assessment may include family history, abdominal palpation, kidney ultrasound, and genetic testing.
Management
- Currently, there is no cure; however, treatments like Tolvaptan may slow kidney function decline.
- Focus on blood pressure control, pain management, and antibiotics as needed.

Risk Factors
- Tobacco use, increased BMI in men, and being of African American descent.
Clinical Manifestations
- Often asymptomatic but may present with:
- Hematuria
- Flank pain
- Abdominal or flank mass.
Diagnostic Procedures
- Approaches include IV urography, cystoscopic examination, renal angiogram, and ultrasonography.
Medical Management
- Treatment may require nephrectomy, renal artery embolization, minimally invasive technologies, and pharmacological therapies.

Pharmacologic Management
- Includes the use of immunotherapy agents and monitoring for infection post-operatively.
Post-operative Care
- Ensure proper analgesia, position the patient for comfort, encourage use of incentive spirometry, deep breathing exercises, and provide education for patients and families regarding recovery and care.