Renal Flashcards
What are some History-basic renal questions?
- Have you ever had any kidney problem?
- Have you ever had kidney stones?
- Have you had changes in bowel or bladder function in the last year?
- Has your appetite for food changed in the last year? (Voluntary avoidance of foods having a high protein content is a subtle sign of renal disease.)
- Have you ever had kidney failure, dialysis, or more than two kidney infections?
What are some type and degree of Renal Dysfunction?
What are some Co-morbidities?
- Type and degree of impairment
–Chronic Kidney Disease (CKD) =GFR less 60ml/min/1.73m2 for 3 months
–Chronic Renal Failure (CRF) =15ml/min/1.73m2
–ESRD=loss of renal function for 3 months or more (Diabetes accounts for half of cases & HTN for one fourth. Polycystic 10%-genetic autosomal dominant)
–Acute Kidney Injury-Sudden dec. function/UO
- Co-morbidities: CV disease, HTN, & electrolyte issues
What are somethings to note about Pre-Operative Evaluation of the patient with Renal Failure?
- Acute renal failure pts. requiring surgery are VERY ill (post –operative complication or trauma)
- Chronic renal failure often present for AV fistula creation or revision
What do you want to assess when you do a review of systems in a pt with renal failure?
Assess for issues related to:
- Uremia
- Dialysis
- Intermittent hemodialysis (AV fistula)
- Continuous peritoneal dialysis (implanted catheter)
In what situation is Dialysis required?
- Oliguria
- Fluid overload
- Hyperkalemia
- Severe acidosis
- Metabolic encephalopathy
- Pericarditis
- Coagulopathy
- Refractory GI symptoms
- Drug toxicity
What is Hemodialysis and what do you need?
- Diffusion of solutes between the blood and the dialysis solution remove metabolic wastes and restore buffers to the blood
- Need vascular access
–AV fistula = cephalic vein anastomosed to radial artery
–Jugular or femoral vein for emergency access
What are 6 important things about pre-operative dialysis?
- Optimization, optimization, optimization!
- Dialysis should occur day of surgery or day before surgery
- Review dialysis flowsheet if available
- Amount of fluid “taken off”
- Pre and post dialysis weights compare with day of surgery weight
- Note POST dialysis chemistry! Serum K < 5.5 mEq/L
What is the general rule about medication and dialysis?
- General rule: scheduled doses of drugs are administered after dialysis
- Low-molecular weight, water soluble, non protein bound drugs are readily cleared by dialysis
What should the Neuro Assessment consist of with Renal Failure?
- Uremic Encephalopathy
1. Asterixis
2. Myoclonus
3. Lethargy
4. Confusion
5. Seizures
6. Coma - Autonomic Neuropathy
- Peripheral Neuropathy
What are some components of a Neuro Assessment S/P Dialysis?
- Disequilibrium syndrome (dialysis related) transient CNS disturbance after rapid decrease in ECF osmolality compared with ICF osmolality
- Dementia
What can be seen with a Hematological Assessment in Renal Failure?
- Anemia typical Hgb = 6-8 g/dL
1. Decreased erythropoietin production
2. Decreased RBC production & cell life span
3. GI blood loss, hemodilution, bone marrow suppression
4. Excess PTH replaces bone marrow with fibrous tissue - Most patients tolerate the anemia well (exception CAD)
1. Increased 2,3- DPG (diphosphoglycerate)
2. Metabolic acidosis also favors rightward shift - Impaired platelets (qualitative) – prolonged bleeding time
1. Decreased plt factor III activity
2. Decreased adhesiveness & aggregation - Impaired WBC function – infections
- Release of defective von Willebrand factor
- Dialysis = Residual anticoagulation VS promotion of hypercoagulable state
- Hypocomplementemia with dialysis
Why is asceptic technique important?
- Infection common cause of death
- Care with ETT- prone to pulmonary infection
- IVs, Line insertion
What can you see with a cardiovascular assessment in renal failure?
- ↑ Cardiac output–compensation for ↓ O2 carrying capacity
- HTN – Na retention, renin-angiotensin activation
- Left ventricular hypertrophy common
- CHF with pulmonary edema after limits of compensation reached
- Deposition of calcium - in the conduction system & on the heart valves
- Arrhythmias – electrolyte imbalances
- Uremic pericarditis – can be asymptomatic, chest pain, tamponade, usually secondary to inadequate dialysis
- Accelerated CAD, PVD
What needs to be assessed regarding fluid balance in renal failure?
- Fluid overload VS intravascular depletion status post dialysis/ aggressive diuretic therapy
- Body weight
- VS (orthostatic hypotension & tachycardia)
- Atrial filling pressures
What is typically seen with a pulmonary assessment in Renal Failure
- Minute ventilation increased to compensate for metabolic acidosis
- Increased pulmonary extravascular water= interstitial edema = widened alveolar/arterial O2 gradient
- “Butterfly wings” on CXR secondary to increased permeability of alveolar capillary membrane (edema even with nml pulmonary capillary pressures)
What is typically seen in an Endocrine Assessment in Renal Failure?
- Peripheral resistance to insulin = poor glucose tolerance
- Hyperparathyroidism = prone to fractures
- Abnormal lipid metabolism = accelerated atherosclerosis
- Kidneys do not degrade hormones and proteins normally = increased circulating PTH, insulin, glucagon, GH, LH, PL
What is typically seen in a GI/Liver assessment in a patient with renal disease?
- 10-30% of patients will develop GI Hemorrhage
- Anorexia
- Nausea and Vomiting
- Hypersecretion of gastric acid + delayed gastric emptying (autonomic neuropathy)
- High incidence of Hep B and C in these pts (multiple transfusions, etc.)
- Ascites with dialysis
What is the impact of renal failure on drugs?
What are some considerations of Patient’s medication?
- Effects altered due to:
–Anemia
–Decreased serum protein
–Electrolyte abnormalities
–Fluid retention
–Abnormal cell membrane activity
- Drugs ELIMINATED BY KIDNEYS UNCHANGED are CONTRAINDICATED
–Gallamine, phenobarbital, LMWH
Patient’s Medications
- Many drugs cleared by kidneys.
- LMWH cleared by kidneys and Not removed during dialysis= prolonged duration
What do you look for in a physical assessment with a renal patient?
- General impression related to fluid and electrolytes……
- How do you assess fluid status?
–VS, mucus membranes, orthostatics etc. , auscultate the lungs
What Blood test do you want to send to the lab?
What is necessary?
Note: Current laboratory tests of renal function are often nonspecific, insensitive (>50% of the nephrons must be destroyed before test results change) or impractical.
- Chem Panel
- Renal Function Test
- BUN
- Cr
- Cr clearance
- CBC
- Pulm: CSR, ABG
- Cardiac: EKG, ECHO
Whats part of a normal chem panel?
- Sodium (135-145 mEq/L)
- Potassium (3.5-5.0 mEq/L)
- Chloride (95-105 mEq/L)
- Sodium Bicarbonate (venous – 19-25 mEqL; arterial 22-26 mEq/L)
- Calcium (4.5-5.5 mEq/L)
- Phosphate (2.4-4.7 mg/dL)
- Magnesium (1.5-2.5 mEq/L)
- Serum Osmolality (280-300 mOsm)
Whats part of a normal Renal Function Test?
- GFR
–Blood Urea Nitrogen (10-20 mg/dl)
–Plasma Creatinine (0.7-1.5 mg/dl) GFR can decrease 50% w/o rise Not accurate indicator esp in elderly
–Creatinine Clearance (110-150 ml/min)
- Renal Tubular Function
–Urine Specific Gravity (1.003-1.030)
–Urine Osmolarity (38-140 mOsm/L)
Describe BUN
- BUN normal = 10-20 mg/dL
- Varies inversely w/GFR & directly w/protein catabolism
- >50mg/dl is indicative of a ↓ GFR (in patients with nml diets)
- BUN is not a sensitive index b/c urea clearance also depends on the production of urea
- BUN can be abnormal despite a normal GFR due to:
–High protein diet
–GI bleed
–Febrile illness
- The most common cause of BUN is CHF secondary to the reabsorption of BUN
Describe Plasma Cr
- Plasma Cr is a specific indicator of GFR
- 8 -17 hr lag time after a change in GFR before the ↑ Cr levels are seen.
- Suggestive [but not indicative] of Acute Renal Failure.
- Usually a 50% ↑ in plasma Cr reflects a corresponding ↓ in GFR.
- Skeletal muscle = source of Cr
- Elderly patient- Cr levels stay nml constant due to:
–↓ muscle mass and GFR
–If CR ↑ in the elderly, this may be indicative of renal failure.
