Acute Renal Failure/ Acute Kidney Injury Flashcards
1
Q
Goal of Acute kidney injury (AKI)
A
Minimize long term loss of renal function, prevent chronic kidney failure
2
Q
Mgmt of AKI
A
- Replace renal function temporarily
- Minimize potentially lethal complications
- reduce potential causes of increased kidney injury
3
Q
Common pt with AKI
A
Pts who are hospitalized or in outpatient settings
4
Q
Acute kidney injury
A
- Occurring for under 7 days
- Rapid loss of renal function due to dmg to kidneys
- High mortality rate
5
Q
Criteria for AKI
A
- 50+% increase in serum creatinine above baseline
- Urine volume: Normal or changes
- Non-oliguria
- Oligura
- Anuria
6
Q
Normal urine output
A
1 mg/kg/hr
30 ml/hr is minimum
7
Q
Nonoliguric
A
Normal, greater than 800ml/day urine output
8
Q
Oliguria
A
Less than 0.5 ml/kg/hr of urine output
9
Q
Anuria
A
Less than 50 ml per day of urine output
10
Q
Normal creatinine
A
Depends on the hospital
* 0.8-1.2
* 0.6-1.4
11
Q
Is AKI reversible
A
Yes
12
Q
Reversible causes of AKI
A
- Hypovolemia
- Hypotension
- Reduced CO
- HF
- Obstruction of kidney or lower urinary tract by tumor, blood clot or kidney stone
- Bilateral obstruction of renal arteries or veins
13
Q
First organ to be damaged if there is issues in the body
A
Kidneys , 25% of CO goes to the kidneys
14
Q
First sign of AKI
A
Reduced urine output
15
Q
Risk factors for AKI/ARF
A
- Major surgery
- Major trauma
- Nephrotoxic meds (IV contrast/mycin antibiotics)
- Elderly (Decreased renal function)
16
Q
Categories of AKI: Prerenal
A
- Hypoperfusion to the kidneys
- Caused by
- HF, Decreased CO
- Bleeding
- Dehydration
- Impaired blood flow leading to hypoperfusion of kidney, decreased GFR (Renal artery stenosis)
17
Q
Common causes of AKI: Pre-renal
A
- Volume depletion, burns, hemorrhage, GI loses (Vomiting, diarrhea, NG suction)
- Hypotension and vasodilation (Sepsis, shock , anaphylaxis)
- Impaired cardiac (Cardiogenic shock, dysrhythmias, HF, MI)
18
Q
Categories of AKI: Infarenal
A
- Damage to the actual kidney
- Glomeruli or kidney tubules
19
Q
Causes of AKI: Infrarenal
A
- Acute tubular necrosis Damage to the kidney tubules
- Hemoglobinuria vs hematuria
- Rhabdomyolysis/ myoglobinuria (Trauma, crush, injuries, burns)
- Infectious processes: Acute glomerulonephritis, acute pyelonephritis
20
Q
Hemoglobinuria vs hematuria
A
- Slight differences but for the purposes for this exam, it’s just blood in the urine
21
Q
Types of kidney injury
A
Prerenal
Intrarenal
Postrenal
22
Q
Phases of AKI (IODR)
A
- Initiation: Initial insult to when oliguria occurs
- Oliguria period: Decreased urine output, can last 10-14 days
- Diuresis period
- Recovery period
23
Q
Phases of AKI: Diuresis period
A
- Gradual increase in urine output
- GRF recovers
- Renal function: Still abnormal due to uremia
- Observe for dehydration
24
Q
Phases of AKI: Recovery period
A
- Signals improvement in renal function (3-12 mo)
- Lab values return to normal level
- Permanent 1-3% reduction in GFR, not clinically significant, due to dmg
25
AKI Assessment and diagnostics findings
* Varies from scant to normal volume
* Hematuria
* Low specific gravity
* Renal sonogram/ MRI/ CT, can show anatomical differences
* BUN serum creatinine increased
* Decline in GFR, oliguria, anuria
* Hyperkalemia, may lead to dysrhythmias (VT) cardiac arrest
26
Normal specific gravity
1.010-1.025
27
Why is there hyperkalemia in AKI
Body cannot excrete it properly
28
AKI Assessment and diagnostics findings: metabolic acidosis
* Associated with decreased serum CO2 (Form of compensation)
* Decreased PH levels
29
AKI Assessment and diagnostics findings: Blood Phosphates
May be elevated, coming from nutrition
30
AKI Assessment and diagnostics findings: Calcium
* May be low due to decreased absorption of Ca in the intestine and due to increased blood phosphate
31
AKI Assessment and diagnostics findings: Anemia
* Erythropoietin is produced in the kidney, in AKI it is not produced leading to a decrease in WBC
32
If Ca increases what happens to P and Mg
* P decreases
* Mg increases
Ca and P are inversely related
33
Factors that influence mortality AKI
* Increased age
* Comorbid conditions (**Diabetes and HTN**)
* Pre-existing kidney and vascular diseases
* Resp failure
34
Best way to treat AKI
prevention
35
Preventing AKI: Renal function
* Continually assess renal function (urine output, lab values)
36
Preventing AKI: Critically ill pts
* monitor central venous and art pressures, hourly urine outputs to detect early onset of kidney disease
37
Preventing AKI: Sepsis
* Know S+S
* Wounds , burns and treat infections promptly
* Prevent and treat shock promptly, blood and fluid replacement
| Goes for both septic and hypovolemic
38
Preventing AKI: Hydration
* **Maintain hydration** in pt at risk for dehydration, including before during and after surgery
39
Preventing AKI: Meds/nephrotoxic agents
Identify **nephrotixic agents**/ enviromental toxins
* **Radiocontrast dye**
* Can use N-acetylcystine and bi carb to help mgmt
* Pre hydration with saline
* NSAIDS are number one cause
* Monitor kidney function before and after initiating med therapy with nephrotoxic meds
40
Preventing AKI: Neoplastic disorders
* Neoplastic disorders or disorders of the metabolism
* Gout
* Chemo
41
Preventing AKI: Skeletal muscle injuries
* Crash injuries
* Compartment syndrome
Increased risk of renal injury
42
Preventing AKI: Heat
* Pt with heat induced illness
* Heat stroke, heat exhaustion
43
Radiocontrast dye
* Major cause of hospital aquired AKI
* Diagnostic studies that require fluid restriction and contrast agents
* Older pts are more suceptible
Not an absolute contraindication in those with renal impairment, can premedicate and alot of caution
44
Preventing AKI: Cath
Meticulous cath care, preventing ascending infections and discontinue cath asap
45
Preventing AKI: BP
Treat hypotension promptly
46
Nephrotoxic meds
* **NSAIDS**
* **Mycin/ micin**
* Aminoglycosides
* gentamicin
* Tobramycin
* Colistimethate
* Polymyxin
* Amphotericin
* Vancomycin
* amikacin
* cyclosporin
| Mycins are huge
47
Medical mgmt of AKI: Goals and guidelines
* Objective is to restore normal chem balance and prevent complications until repair of tissue and restoration of renal function occur
* Eliminate underlying cause
* Maintain fluid balance
* **Avoid fluid excesses**
* RRT as indicated (dialysis)
48
Med mgmt of AKI: Prerenal:
OPtimizing renal perfusion
* IV Fluids or blood products
* Don't wanna cause fluid excess tho
49
Medical mgmt of AKI: Prerenal:
OPtimizing renal perfusion
* IV Fluids or blood products
* Don't wanna cause fluid excess tho
* Fluid challenge, diuretics dopamine, calcium channel blockers
50
Medical mgmt of AKI: Post renal
Relieving the obstruction (Kidney stone)
51
Medical mgmt of AKI: Infrarenal
* Removal of causative agents
* Prompt treatment of shock and infection
* Treat rhabdomyolysis in crush injury, compartment syndrome, heat induced illness
* Myoglobin in the urine (Myoglobinuria)
52
Medical mgmt of AKI: Fluid balance
* Based on daily weight, CVP, Serum and urine concentrations, fluid losses, blood pressure
* Parenteral and oral intake
* Output (Urine, gastric drainage, stools, wound drainage, perspiration)
* Calculated and used as the **basis for fluid replacement** (Output)
* Consider insensible fluid loss through skin and lungs
* **Monitor for fluid excess**, preventing fluid overload
* Special care during blood transfusion as this can occur
53
S+S Fluid excess
* Dyspnea
* Tachycardia
* Distended neck veins
* Lungs, moist crackles
* Generalized edema
54
Mgmt of fluid excess: diuresis
* Mannitol
* Furosemide
55
Where to assess for generalized edema
* Pre tibial
* Pre sacral
56
Fluid challenge
* Giving a bolus of fluids and seeing the person's response, increased CVP means fluid challenge is effective
57
Treatments for AKI: Albumin
* Plasma expander, given if AKI is caused by hypovolemia
* Helps fluid stay in the blood
58
Treatments for AKI: Dialysis
* Prevents complications of AKI
* Hyperkalemia
* Metabolic acidosis
* Pericarditis
* Pulmonary edema
* Peritoneal dialysis
* Continuous renal replacement therapies (CRRT) , Used in more unstable pts
* Renal dosing of meds (ATB, ACE-I, Dig, Phenytoin)
59
Mgmt of AKI: Hyperkalemia
* K is greater than 5
* Cation exchange resins, (sodium polystyrene sulfonate (Kayexalate)), orally or retention enema
* Sorbitol + Kayexalate, K is removed through the bowel
* Retention enema, need to retain for 30 min for best results
* **If EKG changes, IV dextrose and insulin, with calcium gluconate** helps move it back into the cells
* Sodium bi carb, moves K back into cell by correcting acidosis
60
Mgmt of AKI: Severe acidosis
* Monitor ABG and bicarb levels
* Bicarb therapy or dialysis to mgmt
61
Mgmt of AKI: Elevated serum phosphate level
* Phosphate binding agents
* Calcium or lanthanum carbonate, Aka phosLo, Phos renal
* Binds to P while eating and poops it out
* Don't administer these meds while NPO because it works on the food being eaten
62
Mgmt of AKI: Nutritional
* N+V makes it hard to have adequate dietary
* Need to weigh pts daily, 0.2-0.5 kg per day
* Weight gains with hypertension= fluid retention (Crackles in lung)
* Cannot eat a lot of protein due to creatine, mainly given to maximize benefit and prevent muscle waste
* **High carb meals**
* Nutritional support depends on cause of AKI, catabolic response, dialysis ,and co morbidities
* **Restrict foods high in potassium, or phosphorus**
63
Foods high in potassium
* Banana
* Citrus
* Juices
* Coffee
64
Foods high in Phosphorus
* Whole grain bread
* Bran cereals
* Oatmeal
* Nuts
* Sunflower seeds
* Dark cola
65
Nursing problems AKI
* **Excess fluid volume** (Decreased urine output, dietary excess, retention of sodium and water)
* **Imbalanced nutrition** (Anorexia, N+V, dietary restrictions, altered oral mucous membranes)
* **Deficient knowledge** regarding condition and treatment
* **Activity intolerance** (Fatigue, anemia, retention of waste, dialysis procedure)
* **Risk for situational low self esteem** (Dependency, role changes, body image, change in sexual function )
66
Nursing mgmt of AKI: Monitoring fluid and electrolyte balance
* IV solutions based on fluid status
* Monitor **Cardiac function** and musculoskeletal status for hyperkalemia
* Urine output, edema, JVD, altered heart sounds/ breath increase difficulty in breathing
* Accurate daily weights and I+O records
* Disturbances may be treated with dialysis, PD, or CRRT
67
Nursing mgmt of AKI: Reducing metabolic rate
* Bed rest
* Treat fever and infection
68
Nursing mgmt of AKI: Promoting pulmonary function
* T+P
* Cough and deep breathing
* Prevent atelectasis and respiratory tract infection
69
Nursing mgmt of AKI: Preventing infection
* Asepsis with invasive lines and cath
* Avoid indwelling urinary cath but may be required for accurate I+O
70
Nursing mgmt of AKI: Skin care
* Dry or susceptible to breakdown due to edema
* Meticulous skin care
* **excoriation and itching from deposit of irritating toxins in patients tissues**
* Bath with cool water, T/P keep skin clean and well moisturized, fingernails trimmed (Especially with excoriation)
71
Nursing mgmt of AKI: Psychosocial support
* For pt and families needing Hemodialysis (HD), peritoneal dialysis (PD) or Continuous renal replacement therapy (CRRT)
* Need to offer assistance, explanation and support
* Purpose of treatment and explained to patient and family
* High levels of anxiety and fear may necessitate repeated explanation and clarification
72
Chronic kidney disease (CKD)
* Kidney disease greater or a decreased GFR >3mo
* Untreated CKD leads to End stage kidney disease, retention of uremic wase
* Need for renal replacement therapies (RRT), dialysis or kidney transplantation
73
Risk factors for CKD
* Cardiovascular disease, diabetes, hypertension
* Lesser: Glomerulonephritis and pyelonephritis, polycystic KD, Hereditary or congenital disorders, Renal cancers
| **HTN and Diabetes are the number one**
74
Normal GFR
125 ml/min/ 1.73
75
Stage 1 CKD
GFR >90ml/min
76
Stage 2 CKD
GFR is 60-89ml/min
Mild decrease in GFR
77
Stage 3 CKD
GFR is 30-59 ml/min
Moderate decrease in GFR
78
Stage 4 CKD
GFR is 15-29 ml/min
Severe decrease in GFR
79
Stage 5 CKD
GFR is <15ml/min
ESRD or CKD
80
Clinical manifestations of CKD
* Elevated serum creatinine levels
* Anemia
* Metabolic acidosis
* Abnormalities in calcium and Phosphorus
* Fluid retention, Edema, CHF
* Electrolyte imbalance
* uncontrolled HTN
81
Assessment and diagnostic findings CKD
* S+S (HTN, Diabetes)
* PHM
* GFR
* Creatinine clearance
* Labs (CBC, CMP)
* ABG
82
Med mgmt of CKD
* Treat the underlying cause
* Keep BP < 130/80
* Early referral to dialysis if they will need later
* Prevention of complications (Control of cardio risk, treating hyperglycemia, anemia, smoking cessation, weight loss, exercise programs, reduce salt and alc)
* Identify factors that contribute to ESKD
* meds
* Diet therapy
* Dialysis
* Renal transplant
| **Goal is to maintain kidney function and homeostasis for long as poss**
83
Medical mgmt of CKD: Pharm
* Prevent or delay complications
* Phosphate binders (Phoslo, renagel, phosrenol)
* Ca with vit D support
* Antihypertensive and cardiac meds (Hyperkalemia)
* Anticonvulsant meds (Due to fluid shift, can cause hyponatremia, leading to seizures)
* Recombinant human erythropoietin (For anemia)
84
Medical mgmt of CKD: Dietary
* Carbs and fat to prevent wasting
* Vitamin supplements
* 1.2-1.3 g/kg of protein per day, preferably of biological protein (Eggs, milk, meat)
* Sodium (2-3g per day)
* Fluid allowance (500-600 ml more than daily urine output)
* Monitor diet, meds and fluids for K content
85
AKI: IODR, Oliguric phase
* Increase in serum concentration of substances that would be excreted by kidneys
* Potassium is a huge concern here as it is retained and can lead to hyperkalemia
* This phase last 10-14 days followed by diuresis phase
