Renal Flashcards
1
Q
In a patient with renal disease, what would you want to ask them regarding dialysis?
A
- When they had dialysis? Yesterday or today?
- Preferred is day before
- If Dialysis is day of surgery→ may be hypokalemic, dry and might need bolus
- Review dialysis flowsheet.
- How much fluid taken off
- Pre and post dialysis weights compare with day of sx weight
- Neuro assessment
- Assess for disequilibrium syndrome
- Transient CNS disturbance after rapid decrease in ECF osmolality compared with ICF
- Dementia- long term
- Assess for disequilibrium syndrome
- What type of dialysis do they have done?
2
Q
What tests would you want to obtain in the renal patient who has just had dialysis?
A
- Note post dialysis chemistry
- Serum K <5.5meQ/L
- BMP
3
Q
What are some diagnostic tests you can use to assess for pulmonary changes in a patient with renal disease?
A
- Increased pulmonary extravascular water→ interstitial edema= widened alveolar/arterial o2 gradient (when uremic/further away from dialysis)
- CXR” butterfly wings”
- Secondary to increased permeability of alveolar capillary membrane
- Edema with normal pulmonary capillary pressures
- Renal pt with have increased mV to compensate for metabolic acidosis
- From lab Tests at back of ppt:
- CXR
- Fluid status
- Presence of HTN related CV disease
- Pericardial effusion
- Uremic pneumonitis
- ABG
- Hypoxia
- acid /base status; especially if dypnea noted on exam
- CXR
4
Q
What are some CV changes noted on assessment of renal failure patient?
A
-
Increased CO
- Compensation for decreased o2 carrying capacity
-
HTN
- Na retention, RAAS activation→ SNS activity released around hemodialysis
- Keep BP 20% of norm
- Na retention, RAAS activation→ SNS activity released around hemodialysis
- LVH common
- CHF with pulmonary edema after limits of compensation reached
-
Deposition of calcium
- In conduction system
- Heart valves
- Make stenotic, less compliant
- Makes retrograde flow→ ECHO
- Arrhythmias- electrolyte imbalances
-
Uremic pericarditis
- Can be asymptomatic; secondary to inadequate dialysis
- CP- not always MI
- tamponade→ inflammation worse
- Inquire about CP, recent exercise intolerance change
- Can be asymptomatic; secondary to inadequate dialysis
- Accelerated CAD, PVD,- stroke and MI risk
5
Q
What are some cardiac tests you might want on a renal patient?
A
- EKG
- hyper/hypokalemia
- Hypocalcemia
- Ischemia
- Conduction blocks
- LVH
- ECHO
- Ventricular EF
- HYpertrophy
- Wall motion abnormalities
- Pericardial fluid
6
Q
What are some lab abnormalities you can expect in a renal patient?
A
- Assess adequacy of dialysis
- Metabolic acidosis with high anion gap
- Hyponatremia- dilutional issue
-
Hypocalcemia
- Check ionized Ca-> can impact BP
- Hypoalbuminemia→ impact with warfarin, highly protein bound drugs
-
Hyperkalemia
- Hypokalemia with dialysis
-
Hypermagnesemia
- Not problem unless you give exogenous Mg→ impairs NM weakness
- Hyperglycemia
7
Q
What are some examples of renal functions tests?
A
-
GFR- parallels nephron function
- BUN (10-20 mg/dL)
- Plasma creatinine (0.7-1.5 mg/dL)
- GFR can decrease 50% without rise in Cr
- Not accurate indicator of fxn esp in elderly- low muscle mass and low clearance
-
Creatinine clearance (110-150mL/min)
-
Gold standard to estimate GFR
- Normal 100-120 mL/min
- Decreased renal reseve 60-100 mL/min
- Mild renal impairment= 40-60 mL/min
- Moderate insufficiency= 25-40 mL/min← start to see symptoms
- Renal failure <25 mLmin
- ESRD < 10 mL/min- need dialysis
-
Gold standard to estimate GFR
-
Renal tubular function- how well kidneys are concentrating urin
- Urine specific graviety (1.003-1.030)
- Urine oxmolarity (38-140 mOsm/L)
8
Q
What are some hyperkalemia treatments if renal patient is symptomatic or >6.5 mEq/L?
A
- Calcium gluconate 10%; 10-20 mL IV
- MOA- antagonizes K effect on cardiac muscle
- Onset- immediate
- Duration- brief
- s/e- avoid with dig therapy
- Sodium bicarb 50-100 mEq IV
- MOA- shift K into cell
- Onset prompt
- Duration short
- S/E Na overload
- Glucose 50 mL of 50% soluntion + 10 units regular insulin
- MOA- shift K into cells
- Onset prompt
- Duration short
- S/E Hyperglycemia and hypoclycemia
- Dialysis
- MOA- remove K from body
- Onset- immediate
- S/E- need vascular access
- Ion exchange resin (Kayexalate)
- MOA- remove K from body
- Onset 1-2 hours
- S/E - Na overload
9
Q
What are some hemetologic considerations for a patient with renal failure?
A
-
Anemia typical 6-8 g/dL
- decreased erythropoietin produciton
- decreased RBC rpoduction and cell life span
- GI blood loss, hemodilution, bone marrow suppression
- EXCESS PTH- replaces bone marrow with fibrous tissue
- difficulty producing RBC
- Most patients tolerate the anemia well (Except for CAD pt)
- increased 2,3 DPG
- shift oxygen disassociation curve to right
- metabolic acidosis also favors rightward shift
- avoid giving blood tx bc they tolerate it well
- increased 2,3 DPG
-
Impaired paltelets - prolonged bleeding time–> normal PLT count but not fx well
- decreased plt factor III activity (inhibited)
- decreased/defected von willebrane factor
- Decreased adhesiveness and aggregation
- order type and cross- see in fridge if bleeding sx
- decreased plt factor III activity (inhibited)
-
Impaired WBC function- infection
- 25% die each year and 1/2 from infection
- Release of defective von willebrand factor
- dialysis=- residual anticoagulation vs promotion of hypercoaguable state
- heparin admin
- hypocomplementemia with dialysis- lower levels of compliment
10
Q
What impact does renal failure have on drug pharmacokinetics and dynamics?
A
- Effects altered due to
- Anemia
- Decreased serum protein
- Electrolyte abnormalities
- Lithium ARB, ACE, digoxin (high K)
- Fluid retention
- Vd change→ more space for water soluble drugs to distribute (change dosing)
- Abnormal cell membrane activity
- Drugs eliminated by kidneys unchanged are contraindicated
- Morphine- can’t clear active metabolites→ respiratory depression
- Contraindicated: gallamine, phenobarbital, LMWH
- Call pharmacist to assess for antibiotic needed if on dialysis (GFR b/w 10-25)
- LMWH- not removed well by dialysis- risk of bleeding increased further
11
Q
What should you assess for in the review of systems in the patient with renal failure?
A
- Uremia
- Metabolize proteins→ breakdown→ ammonia→ liver converts ammonia to urea→ rely on kidneys to remove urea
- Dialysis- Required in the following situations (CAPE OF HD (G))
- Coagulopathy
- Severe acidosis
- Pericarditis
- Metabolic encephalopathy
- Oliguria
- Fluid overload
- Hyperkalemia
- Drug toxicity
- Refractory GI symptoms
12
Q
In what situations might dialysis be indicated prior to surgery?
A
Required in the following situations
- Oliguria
- Fluid overload
- Hyperkalemia
- Severe acidosis
- Metabolic encephalopathy
- Pericarditis
- Coagulopathy
- Refractory GI symptoms
- Drug toxicity
13
Q
What are some types and degrees of renal impairment?
A
- Chronic kidney disease
- GFR <60 mL/min/ 1.73 m2 for 3 months
- <25 mL/min–> see s/s Of uremia
- Chronic renal failure= 15 mL/min/1.73m2
- ESRD= loss of renal fucntion for 3 or more months
- DM accounts for half cases
- HTN counts 1/4
- Acute kidney injury
- sudden decrease in function/UOP
14
Q
What is an important consideration for patient that may be eventually needing dialysis d/t renal failure?
A
Avoid IV on non dominant arm–> preserve for fistula
Jugular and femoral vein for emergency access
15
Q
What are some neurological assessment considerations in patient with renal failure?
A
- Uremic encephalopathy
- Asterixis
- Myoclonus
- lethargy
- confusion
- seizures
- coma <– bolded need dialysis!
- Autonomic neuropathy- difficult to control BP
- more sensitive to VA, epdiural
- not as responsive to ephedrine
- need aline
- Peripheral neuropathy
