ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE Flashcards
is a rapid loss of renal function due to damage to the kidneys and is accompanied by serum creatinine elevation and/ or reduction in urine output
Acute Kidney Injury
Potentially reversible, but has a high mortality rate
Acute Kidney Injury
Acute Kidney Injury Etiology
-Pre-renal causes
- Intrarenal causes
- Post-renal causes
-External to the kidneys
-Factors that reduce systemic circulation, causing decreased renal blood flow
-Reduced glomerular filtration
- May lead to intrarenal disease if renal ischemia is prolonged
Pre-renal Causes
Conditions that cause direct damage to kidney tissue, resulting in impaired nephron function
Intrarenal Causes
Cause obstruction of intrarenal structures by crystallizing or by causing damage to the epithelial cells of the tubules
Nephrotoxins
Blocks the tubules and causes renal vasoconstriction
Hgb and Myoglobin
Involve mechanical obstruction of urine outflow
Post-renal causes
A 5-tier system and describes the stages of AKI
RIFLE Classification
The RISK, INJURY and FAILURE describe the
SEVERITY
The LOSS and ESKD describe the
OUTCOME
Begins with the initial insults and ends when oliguria develops
Initiation Phase
4 Phases of AKI
-Initiation
-Oliguria
-Diuresis
-Recovery
It is characterized by decreased urine output (less than 400 mL/day or <0.5 mL/kg/hr)
Oliguria Phase
A phase where uremic symptoms begin to appear
Oliguria Phase
Accompanied by an increase in the serum concentration of substances usually excreted by the kidneys
Oliguria Phase
-Marked by a gradual increase in urine output
-The renal function may still be abnormal and uremic symptoms may still be present
Diuresis Phase
This phase may take 3 to 12 months and the laboratory values return to normal
Recovery Phase
In this phase, the patient MUST avoid nephrotoxic agents
Recovery Phase
The most common initial manifestation
Oliguria
Clinical Manifestations of Acute Kidney Injury (AKI)
-Oliguria
-Jugular vein distention
- Bounding pulse
- Edema
- Hypertension
- Kussmaul respirations- rapid, deep respirations
- Hyponatremia, hyperkalemia
-Elevated serum creatinine and BUN
- Neurologic changes
(fatigue)
(Seizure, stupor, coma)
( Asterixis)
Occurs within 24 hours if the _____ is the cause
ISCHEMIA
Delayed up to 1 week if the cause is _________
NEPHROTOXICITY
Clinical manifestations of AKI were flapping tremors when the wrist is extended
Asterixis
Goal of AKI for the Medical Management
Goal: Restore normal chemical balance and prevent complications until repair of renal tissue and restoration of renal function can occur.
-Treat underlying cause
- Maintaining fluid balance
- Renal Replacement therapy
A treatment of hyperkalemia that causes a shift of potassium back into the cell
HR+ D50W
A treatment of hyperkalemia that can correct the acidosis and cause a shift of potassium into cells
NaHCO3 (Sodium Bicarbonate)
A treatment of hyperkalemia that temporarily raises the threshold at which dysrhythmias occur
Calcium Gluconate
Treatment of hyperkalemia that removes potassium from the body
Kayexelate
Most effective therapy to remove potassium
Dialysis
Medical Management for Renal Replacement Therapy
-Volume Overload
-Hyperkalemia
-Metabolic acidosis
-BUN >120 mg/dl
- Significant changes in mental status
- Pericarditis, pericardial effusion, cardiac tamponade
Method of choice when rapid changes are required in a short time
Hemodialysis
Is the most immediate life-threatening imbalances seen in AKI
Hyperkalemia
Acute Kidney Injury Nursing Management
-Bed rest to reduce metabolic rate
- Assist patient to turn, cough, and take deep breaths
- Maintain asepsis on invasive lines and catheters
-Provide meticulous skin care (bathe in cool water, frequent turning, keeping skin clean and well-moisturized)
-Attend to psychosocial needs of patient and family
is an umbrella term that describes kidney damage or a decrease in the glomerular filtration rate (GFR) lasting for 3 or more months
Chronic Kidney Disease
4th leading cause of death among Filipinos
Chronic Kidney Disease
CKD risk factors are:
-Cardiovascular Disease
-Diabetes
- Hypertension
-Obesity
GFR ≥ 90 mL/min/1.73 m2
Stage 1
GFR 60-89 mL/min/1.73 m2
Stage 2
GFR 30-59 mL/min/1.73 m2
Stage 3
GFR 15-29 mL/min/1.73 m2
Stage 4
GFR <15 mL/min/1.73 m2
Stage 5
Requires a permanent renal replacement therapy
End-Stage Kidney Disease (ESKD)
Progression is faster in those with significant proteinuria or hypertension
End-Stage Kidney Disease (ESKD)
A syndrome in which kidney function declines to the point that symptoms may develop in multiple body systems
Uremia
Clinical Manifestations in Metabolic (Waster product Accumulation)
-Elevated serum creatinine
-Elevated BUN
-Nausea and vomiting
-Lethargy
-Fatigue
-Impaired thought process
-Headaches
Clinical Manifestations in Metabolic (Altered CHO metabolism)
-CKD causes insulin resistance
-Hyperglycemia
-Hyperinsulinemia
Cause to elevate triglycerides
Hyperinsulinemia
Due to the conversion of urea back to ammonia
Stomatitis and GI bleeding
Yellow-bronze pigmentation of skin due to elevated serum levels of urochrome
Sallow complexion
Brain tissue damage due to elevated levels of urea and nitrogenous waste
Renal Encephalopathy
Renal Encephalopathy clinical manifestations
-Vomiting
-Emotional volatility
-Decreased cognitive function
-Confusion
-Stupor
-Coma
Due to the accumulation of urate in the skin
Uremic Frost
Decreased libido, impotence, and infertility are due to
Hormonal Imbalance
Severe anemia is due to
Due to the inability of the kidneys to secrete erythropoietin
Clinical Manifestations related to fluid, electrolyte and acid-base balance
-Edema (due to water retention)
- Hyperkalemia (due to the inability of the kidneys to excrete potassium)
- Hypermagnesemia
-Sodium disturbance (due to the inability of kidneys to regulate sodium balance)
-Metabolic acidosis (due to inability of kidneys to buffer hydrogen, regenerate bicarbonate, and excrete metabolic wastes
Demineralization from slow bone turnover and defective mineralization of newly formed bone
Osteomalacia
Decalcification of the bone and replacement of bone tissue with fibrous tissue
Osteitis fibrosa
1+ protein on standard dipstick testing two or more times over a 3- month period
Persistent proteinuria
Done to detect any obstructions and to determine the size of the kidneys
UTZ of kidneys
May provide a definitive diagnosis
Kidney Biopsy
Medical Management for hyperkalemia
-Low potassium diet
- IV glucose with insulin or IV calcium gluconate
-Kayexelate, PO or Enema
Medical Management for hypertension
- Target BP less than 130/80 mm Hg for patients with CKD and 125/75 mm Hg for patients with significant proteinuria
Medical Management for metabolic acidosis
Sodium bicarbonate
Medical Management for CKD-MBD
Phospate Binders
-Calcium based: Calcium carbonate (Caltrate)
-Non-calcium based: sevelamer carbonate
-Administered with each meals
Side Effects: Constipation
Calcium carbonate mechanism of action
Binds with phosphate in bowel and excreted in stool
Medical Management for persistent hypocalcemia
Calcium and Vitamin D supplements
Exogenous erythropoietin
Epoetin alfa (Epogen) IV/SQ
Increase in hematocrit and hemoglobin may not be seen for 2 to 3 weeks
Epoetin alfa (Epogen)
Side effect of Epoetin alfa (Epogen)
Iron deficiency
Contraindication of Epoetin alfa (Epogen)
Hypertension
Medical Management for Dyslipidemia
HMG-CoA Reductase Inhibitors
The drug of choice is atorvastatin (lipitor)
Has minimal clearance and has a lesser chance of causing myopathy
Atorvastatin (Lipitor)
The breakdown products of dietary and tissue proteins accumulate rapidly in the blood when there is impaired renal clearance
Protein Restriction
Are those that are complete proteins and supply the essential amino acids necessary for growth and cell repair
High-biologic value proteins
Medical Management for Nutritional Therapy
High Calorie, low sodium, low potassium, low phosphate
Prevents wasting
Carbohydrates and fat
Prevents further water retention and edema (may vary from 2 to 4 grams per day)
Low sodium
helps resolve the hyperkalemia
Low potassium
To prevent hyperphosphatemia
Low phosphate
The high sodium foods are
Processed meats and cheese
Canned foods
Soy sauce
Salad dressings
The high phosphate foods
-Meat
-Dairy Products (milk, ice cream, cheese, yoghurt)
-Foods containing dairy products (pudding)
Nursing Management (Maintain fluid and electrolyte balance)
-Weigh the patient daily
-Measure and record I and O
- Assess presence and extent of edema
- Auscultate for breath sounds (rales and crackles) indicate for pulmonary edema
- Restrict fluids, as ordered
-Monitor vital signs
- Avoid OTC medications
