ARF/CRF/Renal Transplant Flashcards

Question

AKI Labs: Blood

Answer 1

- High BUN, creatinine, potassium, phosphorus, magnesium - Low calcium - Sodium can be high, low, or normal

Answer 2

- pH (low or WNL) - Low Bicarbonate - Low PaCO2 * * Metabolic Acidosis - cannot eliminate daily metabolic load of acid-type substances produced by normal metabolic processes

Answer 3

1. Nephrotoxic medications 2. Chronic use of NSAIDs 3. Radiocontrast induced neuropathy (CIN)

Answer 4

1. Aminoglycosides 2. Colistimethane 3. Polymyxin B 4. Amphotericin B 5. Vancomycin 6. Cyclosporine

Answer 5

1. Gentamycin 2. Tobramycin 3. Amikacin

Answer 6

Chronic use of NSAIDs may cause interstitial nephritis and papillary necrosis. High risk patients are those with heart failure or cirrhosis with ascites are at high risk for NSAID-induced renal failure

Answer 7

Major cause of AKI. Anyone who has a baseline creatinine level of greater than 2 mg/dL is considered high risk.

Answer 8

Administration of N-acetylcysteine and sodium bicarbonate before and after procedures reduces risk, but pre-hydration with saline is considered the most effective way to prevent CIN

Answer 9

1. Eliminate the underlying cause 2. Avoiding fluid excess 3. Providing renal replacement therapy * * Depending on the location of the AKI, depends on the management of treatment

Answer 10

Treated by optimizing renal perfusion

Answer 11

Treated by getting rid of the obstruction

Answer 12

1. Supportive therapy 2. Removal of causative agents 3. Aggressive management of pre and post renal failure 4. Avoiding associated risks

Answer 13

1. Maintaining fluid balance 2. Assess for SOB, tachycardia, distended neck veins, crackles, pulmonary edema, presacral and pretibial edema 3. Administer dialysis

Answer 14

Circulating blood through a dialyzer to remove waste products from the blood and restores chemical and electrolyte imbalance ** Passes the patient's blood through a semipermeable membrane to perform filtering and excretion functions of the kidney

Answer 15

Uses the peritoneal membrane to exchange fluid and solute

Answer 16

Circulating blood through the dialyzer continuously 24 hours a day to remove waste

Answer 17

1. Mannitol 2. Furosemide (loop diuretic) 3. Albumin (given if hypovolemic due to hypoproteinemia) 4. Normal saline, LR 5. Fresh frozen plasma

Answer 18

1. Irritability 2. Abdominal cramping 3. Diarrhea 4. Generalize muscle weakness 5. EKG changes (tall or peaked T waves) 6. Dysrhythmias

Answer 19

``` Polystyrene sulfonate (if stable) - PO or rectally ``` Dextrose 50%, insulin (regular), calcium - IV

Answer 20

1. Aminoglycosides 2. Digoxin 3. Phenytoin 4. ACE inhibitor 5. Magnesium containing agents

Answer 21

AKI causes extreme nutritional deficits, due to nausea and vomiting contributing to poor dietary intake ** Nutritional support is based on the underlying cause of AKI

Answer 22

``` At first... 1. High carbohydrate 2. Low protein 3. Low potassium 4. Low phosphorus After diuretic phase... 1. High protein 2. High calories ```

Answer 23

When a patient has sustained enough kidney damage to require renal replacement therapy on a permanent basis, the patient has moved into the end stage kidney disease or chronic kidney disease

Answer 24

As renal function declines, the end products of protein metabolism are retained in the blood. Uremia develops and adversely affects every body system. The greater the build-up of waste, the more prominent the symptoms. ** Tends to progress more rapidly in patients who excrete a considerable amount of protein or have elevated blood pressure than those who do not.

Answer 25

1. HTN 2. Diabetes 3. Chronic glomerulonephritis 4. Reoccurring pyelonephritis 5. Autoimmune disorders such as systemic lupus erythematosus 6. Arteriosclerosis 7. Urinary blockage and reflux related to frequent infections, stones, or anatomical abnormality 8. Excessive medications that are metabolized through the kidneys

Answer 26

1. Fatigue 2. Lethargy 3. Confusion 4. Burning of soles of feet 5. Restlessness of legs

Answer 27

1. Grayish-bronze in color 2. Flaky 3. Dry 4. Pruritis 5. Coarse thinning hair 6. Nails are thin and brittle 7. Uremic frost (related to increased urea)

Answer 28

1. HTN 2. Pitting edema (hands, feet, sacrum) 3. Distended neck veins 4. Hyperkalemia 5. Hyperlipidemia 6. Periorbital edema

Answer 29

1. Crackles 2. Thick, tenacious sputum 3. Uremic pneumonitis 4. Depressed cough reflex 5. Tachypnea

Answer 30

1. Ammonia breath 2. Metallic taste 3. Constipation or diarrhea 4. GI bleed

Answer 31

1. Anemia | 2. Thrombocytopenia

Answer 32

1. Infertility 2. Amenorrhea 3. Decreased libido

Answer 33

1. Muscle cramps 2. Bone fractures 3. Renal osteodystrophy

Answer 34

1. Low GFR 2. Low creatinine clearance 3. High BUN (not definitive indicator) 4. High serum creatinine (most sensitive indicator)

Answer 35

They have a reciprocal relationship. As one increases the other lowers. Because the kidney does not filter properly, there is an increase in serum phosphorus and decrease in serum calcium. This causes the release of parathormone from the parathyroid gland. However, in renal failure the body does not respond normally to the increase secretion of parathormone. The result is that calcium leaves the bone, causing disease of the bone as well as calcification of major blood vessels.

Answer 36

Because they are unable to excrete acid

Answer 37

1. Inadequate erythropoietin production 2. Shortened lifespan of RBCs 3. Nutritional deficits 4. The tendency to bleed

Answer 38

The active metabolite of Vitamin D that decreases as renal failure progresses

Answer 39

1. Calcium and phosphorus binders 2. Antihypertensive and cardiovascular agents 3. Antiseizure agents 4. Vitamins and minerals 5. Synthetic erythropoietin

Answer 40

1. Calcium carbonate 2. Calcium acetate 3. Sevelamer hydrochloride

Answer 41

This is administered if serum calcium is high or calcium-phosphorus product exceeds >55 mg/dL

Answer 42

These bind dietary phosphorus in the GI tract - Must take with meals - Do not take at the same time as digoxin (at least 2 hours apart) - High risk of hypercalcemia

Answer 43

1. Digoxin | 2. Dobutamine

Answer 44

- Used when heart failure induces renal failure or makes it worse - IV (initial dose) or PO - Take pulse (apical) before administration, hold if less than 60 bpm - Watch for toxicity (0.8-2.0 is normal range)

Answer 45

Given for EKSD to improve creatinine clearance

Answer 46

1. Phenytoin | 2. Diazepam

Answer 47

1. Folic acid and Ferrous sulfate - Administered when patient loses these due to dialysis - Take these after dialysis - Ferrous sulfate with OJ or meals - May cause dark stools - Take stool softeners with iron as it causes constipation

Answer 48

- A synthetic erythropoietin - Prevents anemia by stimulating red blood cell growth and maturation in bone marrow - IV or SC - Watch for side effects

Answer 49

Report... 1. Chest pain 2. SOB 3. HTN 4. Rapid weight gain 5. Seizures 6. Skin rash or hives 7. Edema of feet or ankles * *Can induce serious cardiovascular problems such as an MI

Answer 50

Itching | - Diphenhydramine may be given to alleviate this

Answer 51

Prevents clotting during dialysis | - Administered SC or IV

Answer 52

1. Foods that are high in sodium 2. Avoid cheese except for cream cheese 3. Avoid biscuits, whole grain breads, long grain rice 4. Avoid dried fruits

Answer 53

1. High increasing level of serum potassium 2. Fluid overload 3. Impending pulmonary edema 4. Increasing acidosis 5. Pericarditis 6. Severe confusion 7. To remove certain medications or toxins

Answer 54

1. ERSD (end stage renal disease) 2. Presence of uremic s/sx 3. Hyperkalemia 4. Fluid overload with no response to diuretics and fluid restriciton 5. General lack of well being 6. Pericardial friction rub

Answer 55

1. Arteriovenous fistulas (AVFs) | 2. Arteriovenous grafts (AVGs)

Answer 56

- Most commonly created in the forearm - It is an anastomosis between an artery and a vein (usually cephalic) - Arterial blood flow is essential to provide the rapid blood flow required for hemodialysis - Increased pressure of the arterial blood flow through the vein makes the vein dilate and become tough, making it amenable to repeated venipuncture in approximately 4-6 weeks - AVFs have the best overall patency rates and least number of complications of all vascular accesses

Answer 57

The AVF should be placed at least 3 months before hemodialysis is initiated

Answer 58

Using 2 large gauge needles

Answer 59

1. History of severe PVD 2. Prolonged IV drug use 3. Obese women * * For these patients, synthetic grafts are best

Answer 60

- These are made up of synthetic material and form a "bridge" between the arterial and venous blood supplies - Grafts are placed beneath the skin and are surgically anastomosed between and artery and a vein - Because the grafts are made of artificial material, they are more likely to become infected and have a tendency to become thrombogenic

Answer 61

A healing time of at least 2-4 weeks is necessary to allow the graft to heal, but some centers may use it earlier

Answer 62

Two large gauge needles (14G-16G)

Answer 63

This is a graft that is created when the patient's vessels are not suitable for creation of a fistula. It is seen with diabetics and other types of compromised vascular status

Answer 64

Continuous Renal Replacement Therapy - Used in ICU when patients are too unstable for traditional dialysis - It pulls fluid off at a slower pace than traditional dialysis

Answer 65

Continuous Venovenous Hemofiltration - Used to manage acute renal failure (ARF) - Continuous slow fluid removal - Does not require arterial access

Answer 66

Continuous Venovenous Hemodialysis - Similar to CVVH - Hemodynamic effects are mild - Does not require arterial access

Answer 67

1. Failure of permanent dialysis access 2. Hypotension 3. Muscle cramps 4. Loss of blood 5. GI ulcers/GI problems 6. Dysrhythmias 7. Air embolism (rare) 8. Chest pain 9. Disequalibrium Syndrome 10. Insomnia

Answer 68

Due to the removal of fluid - hypovolemia - Decreased cardiac output - Light headedness - N/V - Seizures - Visual changes - Chest pain

Answer 69

Decrease the volume of fluid being removed and administer 0.9% NS

Answer 70

- Poorly understood; factors include hypotension, hypovolemia, high ultrafiltration rate, and use of low-sodium dialysis solution. - Cramps are more frequently seen in the first month after initiation after dialysis begins

Answer 71

Reducing the ultrafiltration rate and administering of fluids (saline, glucose, mannitol) - Hypertonic saline is not recommended since the sodium can be problematic - Hypotonic glucose administration is preferred

Answer 72

- From blood not being completely rinsed from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture - Too much heparin or clotting disorders can cause post-dialysis bleeding

Answer 73

1. Rinse back all blood 2. Monitor heparinization to avoid excess anticoagulation 3. Hold firm but not occlusive pressure on access sites

Answer 74

Related to the physiologic stress of chronic illness, medication, and related problems

Answer 75

1. H2 Blocker - Ranitidine, Famotidine 2. Proton Pump Inhibitor (PPI) - Omeprazole

Answer 76

From electrolyte and pH changes or from removal of antiarrhythmic meds during the procedure

Answer 77

A complication of dialysis believed to result from too-rapid removal of electrolytes. - It is characterized by neurological symptoms and signs attributable to cerebral edema that occurs due to fluid shifts into the brain following a relatively rapid decrease in serum and serum osmolality during hemodialysis

Answer 78

1. First dialysis treatment 2. Large increase in blood urea concentration prior to dialysis 3. Chronic kidney disease as compared to acute 4. Severe metabolic acidosis 5. Older age 6. Pediatric clients 7. Pre-existing neurologic disease 8. Conditions characterized by cerebral edema 9. Any condition that increases permeability of the blood brain barrier

Answer 79

1. Hyponatremia 2. Hepatic encephalopathy 3. Malignant hypertension

Answer 80

1. Sepsis 2. Vasculitis 3. Encephalitis 4. Meningitis

Answer 81

1. HA 2. N/V 3. Muscle cramps

Answer 82

1. Altered mental status 2. Seizures 3. Come * * Rarely death

Answer 83

1. Slower removal of fluid | 2. CRRT

Answer 84

No, it can slow the progression but not halt it. It can’t fully replace the normal metabolic and hormonal functions of the kidneys. It can ease many of the symptoms of CKD and, if started early, can prevent certain complications. However, it does not alter the accelerated rate of development of CV disease and the related high mortality rate.

Answer 85

1. Weigh the patient before and after dialysis 2. Know the patient’s dry weight (post-dialysis) 3. Discuss with MD if any medications should be withheld until after dialysis is complete 4. Be aware of what events that occurred during the dialysis treatment 5. Measure T, P, R, BP 6. Assess for orthostatic hypotension 7. Assess the vascular access site 8. Observe for bleeding 9. Asses the patient’s LOC 10. Assess for headache, nausea, and vomiting.

Answer 86

1. No BP’s in the extremity in which the vascular access is placed 2. No venipunctures or IVs in the extremity in which the vascular access is placed 3. Palpate for thrills and auscultate for bruits q 4 hours while the patient is awake 4. Assess distal pulses and circulation 5. Elevate the affected extremity post-op 6. Encourage routine ROM 7. Assess for bleeding at needle insertion site or shunt tubing insertion sites (keep small clamps handy) 8. Instruct the patient not to carry heavy objects or anything that compresses the access site 9. Instruct the patient not to sleep on his/her body weight on the extremity in which the device is placed

Answer 87

1. Older patients 2. Diabetics 3. CV disease 4. Risk for adverse effects of heparin 5. Severe HTN 6. Heart failure 7. Pulmonary edema who do not respond well to treatment * * These are the patients who are susceptible to the rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis

Answer 88

1. Heparin (LMWH/enoxaparin) may be added to prevent fibrin formation and resultant occlusion of the peritoneal catheter 2. KCL to prevent hypokalemia 3. Antibiotics may be added to treat peritonitis 4. Regular insulin for diabetics: may receive a larger than normal dose because about 10% of the insulin binds to the wall of the dialysate container. * * All medications are added immediately before the solution is instilled. * * Aseptic technique is imperative.

Answer 89

1. Prevent patient discomfort and abdominal pain 2. To dilate the vessels of the peritoneum to increase urea clearance. 3. Solutions that are too cold cause pain, cramping, and vasoconstriction and reduce clearance. 4. Solutions that are too hot burn the peritoneum. 5. Dry heating (heating cabinet, incubator, or heating pad) is recommended. 6. Do NOT MICROWAVE!!

Answer 90

- Is the infusion, dwell, and drainage of the dialysate 1. The dialysate is infused by gravity into the peritoneal cavity via Tenckhoff 2. The tip of the catheter rests in the peritoneal cavity and has many perforations spaced along the distal end of the tubing allowing fluid to flow in and out of the catheter. A period of about 5-10 minutes is usually required to infuse 2-3L of fluid. 3. At the end of the dwell time the drain cycle begins. Drainage is usually completed in 10-30 minutes.

Answer 91

- The drainage fluid is normally colorless or straw colored and SHOULD NOT be cloudy. - Bloody drainage may be seen in the first few exchanges, but should not occur after that. - The removal of excess water during the PD exchange is achieved by using hypertonic dialysate with a high dextrose concentration. The higher the dextrose concentration the greater the osmotic gradient and the more water that will be removed. - The entire exchange should take about 30-45 minutes.

Answer 92

Used for peritoneal dialysis - a silicone rubber catheter tubing about 60cm long and has one or two Dacron cuffs on its subcutaneous and peritoneal portions. These cuffs acts as anchors and prevent the migration of microorganisms down the shaft from the skin.

Answer 93

1. Easy to learn 2. Can be done in the home setting 3. Less stressful 4. Better control of blood pressure 5. Less dietary and fluid restrictions 6. Greater freedom

Answer 94

1. Time consuming 2. Protein wasting 3. Sterile procedure 4. Weight gain 5. Peritoneum injury 6. Chronic back pain 7. Hernia development

Answer 95

1. Peritonitis 2. Leakage 3. Bleeding

Answer 96

Most common and most serious - Cloudy dialysate drainage - Diffuse abdominal pain and rebound tenderness - Signs of shock

Answer 97

1. Initially 1-3 rapid exchanges with a 1.5% dextrose solution without added medications - Washing out causes ↓’s inflammation & reduce abdominal pain. 2. The fluid is examined for cell content and Gram stain and cultures are used to identify the organism to guide treatment. 3. Antibiotics (such as aminoglycosides or cephalosporins) are added until results are available. - Antibiotic therapy will continue 10-14 days. Careful calculation of the antibiotic dosage helps prevent nephrotoxicity and further compromise renal function.

Answer 98

1. Through the catheter site may occur immediately after insertion. 2. Will stop on its own if dialysis is withheld for several days to give the exit and incision site time to heal 3. Want the patient to avoid abdominal muscle activity and straining during bowel movements

Answer 99

Leakage can be avoided by using smaller volumes (500mL) of dialysate, gradually increasing the volume up to 2-3L.

Answer 100

1. May be occasionally, but most often seen in young menstruating women. 2. Hypertonic fluid pulls blood from the uterus through the opening of the fallopian tubes and into the peritoneal cavity 3. Common during the first few exchanges after a new catheter insertion 4. Invariably, bleeding stops in 1-2 days and requires no specific intervention 5. May need more frequent exchanges during this time to prevent obstruction from blood clots

Answer 101

1. Hypertriglyceridemia 2. Increased BP (leading to L ventricular hypertrophy) 3. CV disease 4. Abdominal hernias 5. Low back discomfort 6. Anorexia 7. Constant sweet taste (related to the glucose absorption) 8. Clots in the peritoneal catheter

Answer 102

1. Observe for s/sx of infection 2. Strict I/O must be observed at all times 3. Cardiac/respiratory assessment must be conducted frequently 4. Pericarditis may result from build-up of uremic toxins 5. Monitor for substernal chest pain, low grade fever, pericardial friction rub, pulsus paradoxus (a decrease in BP of more than 10mmHg during inspiration)

Answer 103

1. Advanced, uncorrectable cardiac disease (transplant worsens these symptoms) 2. Metastatic cancer 3. Chronic infection 4. Severe psychological problems (alcoholism, chemical dependency) 5. GI disorders, such as PUD and diverticulosis (will consider for transplant, but need to resolve these issues d/t large doses of steroids after transplant can worsen symptoms)

Answer 104

1. Patients with a recent history of cancer –treated with dialysis d/t shortage of donor organs & limited life expectancy. In addition, drugs that are used post-transplant increase the risk of cancer. If more than 2-5 years have passed since eradication of the cancer, patient will be considered for transplant. 2. Diabetes Mellitus and other endocrine problems—can receive a transplant, but will require intense observation, 3. Most patients with ESKD are considered

Answer 105

1. Living donors (relative or non-relative) | 2. Non-heart beating donors (NHBD)

Answer 106

1. Declared dead by cardiopulmonary criteria 2. Removed (harvested) immediately post-death who have previously consented for organ donation 3. If immediate removal must be delayed, kidney is preserved by infusing a cool preservation solution into the abdominal aorta after death is declared & surgery can be performed.

Answer 107

Size is seldom a problem in adults - if transplanted from child, the kidney will become larger to meet adult needs within a few months

Answer 108

- Highest renal graft survival (90%) - Donor ages: usually 18-65 yrs - There is certain physical criteria that donor must meet such as absence of systemic infection, no history of CA, No HTN or kidney disease, and adequate renal function. - Donor must express a clear understanding of the surgery and the willingness to give up a kidney.

Answer 109

- Pre Op education is very important. Patient must understand that he/she will be on anti-rejection meds for the rest of their life - Potential complications include GI bleed and renal insufficiency

Answer 110

1. Will be placed on non-diseased side with diseased kidney side up. 2. Opposite trunk area is flexed to increase exposure. 3. Removal of 11th and 12th rib is done to better access the kidney 4. Surgeon will remove kidney, tumor, renal artery, renal vein, and fascia. Adrenal gland is left intact. (Drain will be placed prior to closure.) **Radical nephrectomy is when local and regional lymph nodes are removed.

Answer 111

1. Monitor for hemorrhage, adrenal insufficiency, and kidney functioning 2. Inspect for abdominal distention 3. Monitor BP 4. Monitor Urine output 5. Monitor HCT/HGB 6. Monitor VS q 4 and PRN 7. Daily weights 8. Have patient TCDB; incentive spirometer x10 q1 hour 9. Pain management

Answer 112

Functional kidney is expected to provide adequate renal function, but may take days or weeks. - Assess urine output for the first 24 hrs. post op. - Acceptable is 30-50mL/hr - Output of < 30mL you should suspect decreased renal blood flow * * The sooner the kidney starts working, the better the prognosis.

Answer 113

Opioid analgesics (common) hydromorphone and morphine administered parentally

Answer 114

Prevent infection, management of adrenal insufficiency. - Monitor q 8 hrs and PRN for manifestations of systemic infection or local wound infection. - Adrenal insufficiency: although only one is affected, may not be able to secrete sufficient glucocorticoids immediately after surgery - steroid replacement may be needed.