Renal failure part 1

Evert organ system affected with renal function loss, Acute kidney injury (AKI) most common in acute care, Chronic kidney disease (CKD) most common in community, Both types can lead to dialysis, Graudal decline=CKD, Suddne decline=AKI, Can occur simultaneously; Acute on chronic kidney disease

Rapid, sudden decline in kidney function affecting: -Elimination of metabolic wastes -Fluid & electrolyte balance -Acid-base balance, Occurs over hours to days, Often reversible, Sometimes AKI needs dialysis emergently

BUN, Creatinine, BUN/Creatinine ratio

10-20 mg/dL

Males: 0.6-1.2 mg/dL, Females: 0.5 - 1.1 mg/dL, If someone’s serum Cr doubles in value (regardless of it being in range or not) this means there has been a 50% reduction in glomular filtration

6-25

Dehydration (give fluids)

Increase in serum Cr by 0.3 mg/dL or more within 48 hours or, Increase in serum Cr to 1.5 or more from baseline (over 7 days), Urine volume < 0.5 mL/kg/he for 6 hours

Hypotension-even short episodes= kidney dmg., Shock- hypotension, Cardiac surgery, Sepsis- massive vasodilation, PRolongs mechinacl ventilation- stress on lungs, DM, HTN, CKD, Liver disease, Elderly

Prerenal, Intrinsic, Postrenal

Source outside the kidney, leading TO the kidney, Impaired renal perfusion, Cardiac failure, Sepsis, Blood loss, Dehydration, Vascular occlusion

Occurse inside kidney, Renal cortex/medulla, Glomerulonephritis Small vessel vasculitis Acute tubular necrosis:, :Toxins, :Drugs, :Prolonged hypotension, Intertsitial nephritis -, -Drugs, -Toxins, -Inflammatory disease, -Infection

Unrine outflow obstruction, Urinary calculi, Retroperitoneal fibrosis, Benigin prostatic enlargement (BPH), Prostates cancer, Cervical cancer, Urethreal stricture/valves, Meatal stenosis/phimosis

Decreases renal perfusion, Causes anything that reduces blood flow into the kidneys:, :Hypovolemia: hemorrhage, burns, GI losses, :Hypotension from ↓ cardiac output: massive PE, MI, :Hypotension from vasodilation: septic shock, anaphylaxis, anesthesia administration, hepatorenal syndrome, :Renal vasoconstriction: NSAIDS

Ok great thinks. Still gonna be asystole after this 😭

Damage occurs inside kidney tissues • Acute tubular necrosis (damage to kidney tubules), Most common causes:, Blood clots in renal vessels, Pyelonephrtitis, Lupus (immune reaction causing glomerulonephritis, Contrast media, Nephrotoxic medications: many abx, NSAIDS, chemotherapy, Tumors

Tubular epithelial cells have a high metabolic rate, Most vulnerable to ischemic injury

Urine outflow obstruction :Causes, :Tumors, :Kidney stones, :Strictures, BPH, Urethral obstructions

Ok awesomeee thanks

In-hospital complication associated with shock, surgery, & heart conditions, 20% of hospitalized patients experience AKI, 60% of ICU patients, Higher risk: Eldrly, CKD patients, diabetics, 95% of nephrology consults are for AKI

Low urine output, Decreased systolic BP, decreased pulse pressure, orthostatic hypotension, Thirst (later sign), Rising blood osmolarity (more particles less fluid)

Oral fluids (if not restricted), IV fluids, Monitor lab values, I&O measurement, Daily weights, Report oliguria promptly

50% of hospitalized AKI patients are >60 years of age, Why?, :Dehydration decrease thirst recognition decreased mobility/access to fluids confusion, Polypharmacy, Complications of surgery

Onset initial phase, Oliguric phase, Diuretic phase, Recovery phase

Time between the kidney injury and reduction in kidney function, Lasts hours to days, Nursing goal:minimize subsequent injury, Recoginze: -hypotension -nephrotoxic meds, Treatment: Fluid bolus, diuretics (only recommended for volume overload) med changes (BP meds may be stoppped for now too prevent hypotension)

Urine output <400 ml/24hrs, Usually begins 1-7 days after injury, Typically lasts 10-14 days (can last months), Longer durations in this phase have poor outcomes

^BUN, ^Cr, ⬇️GFR, Fluid overload, Weight gain, Low urine output, HTN, Kyperkalemia, Hyponatremia, Metabolic Acidosis

ACE-i, ARB, Fluid restriction

Hyponatremia: Fluid restriction, Hyperkalemia(HK): Kayexalate, HK: Lokelma, HK: Insulin & d50 protocol

Fluid restriction -Yesterdays output +500ml (need to know), Diuretics (^renal blood flow and &diurese fluid/ electrolytes

Urine production increases, Nephrons have regained the ability to excrete urea, Result is osmotic diuresis, 1-3L per day but can be >5L, BUN, serum Cr, acid base, & electrolytes will improve

Hypotension, Hyponatremia, Hypokalemia, Weight loss, Neuro symptoms, Hypovolemia, TX: manage hypotension, TX: replace fluids/electrolytes

Kidnes regain ability to maintain metabolic waste, BUN and serum Cr return to baseline, Takes several week, may continue for up to a year, Kidneys may never fully recover: may have mild, chronic elevations in BUN and Cr, Some patients will progress to CKD and need lifelong management

Risk factors (family hx, urinary symptoms, patterns)?, Urinary changes/issues?, Surgery/trauma, transfusions, allergic reactions?, Recent contrast media?

Past urinary obstructions, CKD, DM,, Long-term HTN, PVD, HIV, Liver disease etc, Immune mediated AKI (acute glomerulonephritis) requires assessment for recen illness (flu, colds, gastroenteritis)

Abx, NSAIDS etc., Any condition that causes hypoperfusion/volume depletion

Assess catheter (if present) & output q1hr after surgery, Monitor for oliguria, Daily weight (same time, same clothes, same scale), Azotemia, Fluid overload: crackles, confusion, S3, edema, ^RR, dyspnea hypoxia, Monitor VS to catch hypoperfusion and hypoxemia early:, :MAP<65 mm Hg, :Tachycardia, :Thready pulses, :Decreased cognition, : Spo2<88%

Blood tests: ↑BUN, ↑Cr, ↑K+, ↑Phosphorus, ↓Calcium, Imaging: US, CT (without contrast), MRI, KUB, Nuclear Med MAG3 study, Renal scan, cystoscopy or retrograde pyelogram, Other diagnostics: Kidney biopsy Manage hypo & hypertension post- procedure (BLEEDING!)

If hypovolemia or hypotension, then volume repletion -Fluid chalange (bolus): 500-1000 ml NS over 1 hour, Drug dosage adjustments may be required, May need to discontinue nephrotoxic medications, ACE-I and ARBS can contribute to AKI (can be renoprotective over time)

Register dietician, PRotien may be restricted even with non- dialysis pts (try not restric protien if we don’t have to but is hard for kidneys to filter), Protien, sodium, potassium restrictions with dialysis, Fluid restriction for dialysis: urine volume +500 ml, Monitor caloric intake, Oral supplements, enteral nutrition, TPN, etc.

Hemodialysis, CRRT (continuous renal replacement therapy), Peritoneal dialysis, Symptomatic uremia: pericarditis, neuropathy, decreased cognition, Severe metabolic acidosis: pH<7.1, Rapidly rising serum potassium >6.5 med/L, Fluid overload reduction tissue perfusion