Renal (Acute and Chronic)

Question 1

Describe 2 types of acute kidney injury

Answer 1

Prerenal- hypoperfusion of kidneys

Intrarenal-direct damage to kidneys (prolonged renal ischemia)

Postrenal= obstruction to the flow or urine

Question 2

Describe examples prerenal injury

Answer 2

Prerenal- hypoperfusion of kidneys

EX:
low blood pressure, dehydration, hypovolemia/hemorrhage, shock/sepsis, anaphylasix, cardiac efficiency reduced (heart failure, cardiogenic shock, dysrhythmias)

Question 3

Describe examples Intrarenal injury

Answer 3

Intrarenal= direct damage to kidneys (prolonged renal ischemia)
EX:
drugs, (NSAIDS, gentamycin, tobramycin, ACE inhibitors), Contrast mediums, toxins (solvents and chemicals), crush injury (results in myogloginiuria- burns), blood transfusion reaction, acute infections like acute pyelonephritis and glomerulonephritis

Question 4

Describe Post Renal injury

Answer 4

Postrenal= obstruction to the flow or urine

Ex:
Stones, tumours, enlarged prostate, strictures and blood clots

Question 5

Describe 4 phases of renal injury

Answer 5

Initiation, Oliguria, diuresis and recovery

Question 6

What is Renal Failure (Basic)

Answer 6

• Results when kidneys cannot remove the bodies metabolic wastes or perform their regulatory fx
• Substances normally eliminated in the urine accumulate in the body and disrupt endocrine fx, metb fx, lyets, and acid-bases balance
• Systemic disease

Question 7

fxs of kidney

Answer 7

Urine formation
Excretion of waste products
Regulation of electrolytes
Reabsorption of vital nutrients 
Acid base homeostasis
Control of water balance
Renal clearance
Blood pressure regulation
Hormone secretion (erythropoietin-regulation of rbc production)
Synthesis of Vitamin D to active form

Question 8

Describe phase 1 initiation

Answer 8

basically the initial insult. Watch output and labs

Question 9

Describe Oliguria Phase

Answer 9

• Rise in serum concentration of substances usually secreted by the kidneys (urea, creatinine)
• Minimum amount of urine needed to rid the body of normal metb wastes is 400 mL
• Uremic symptoms appear and life-threatening conditions such as hyperkalemia develop
• Pts can have normal amounts of urine (2L a day) but still have decreased renal fx →considered nonoliguric form and occurs with nephrotoxic damage

Question 10

Describe the diuresis phase

Answer 10

• Gradual increasing of urine output signaling GFR has started to recover
• Lab values (urea) start to decrease
• Observe closely for dehydration in this phase

Question 11

Describe the Recovery phase

Answer 11

• May take 3 to 12 months

* A permanent 1-3% reduction in GFR is common but not clinically significant

Question 12

What is Azotemia

Answer 12

Literally “urine in the blood”

Build-up of nitrogenous waste products unable to be excreted adequately by the kidneys

Question 13

Why might renal disease lead to SOB and Lethargy?

Answer 13

Kidneys produce erythropoietin which stimulates bone marrow to produce Red blood cells- in renal injury this does not happen therefore less RBCs, less hemoglobin available to carry oxygen, anemia and shortness of breath follow.

Nutritional deficiencies and tendency to bleed in
GI tract from azotemia (along with shortened lifespan of RBC) all contribute to anemia.

Lethargy can be due to anemia (as above) or also due to effects of low sodium levels, metabolic acidosis, or azotemic symptoms (brain encephalopathy)

Question 14

What is the affect of kidney failure on acid base balance?

Answer 14

Kidneys can’t excrete the extra loads of acid and they can’t reabsorb the bicarbonate
Metabolic Acidosis due to accumulation of sulfates, phosphates and uric acid may cause altered enzyme activity or cardiac and neuronal membranes by the promotion of hyperkalemia due to excess acids. High potassium, high phosphate and low bicarb levels aggravate acidosis

Question 15

What are the symptoms of Acidosis?

Answer 15

Headaches, nausea and vomiting, abdominal pain, rapid shallow respirations, low plasma bicarb (review your ABG notes and classes here), low blood ph (less than 7.35). Acidosis affects the central nervous system so this can increase neuromuscular irritability due to cellular exchange of hydrogen and K.

Question 16

What sort of medical interventions might be required with metabolic acidosis?

Answer 16

IV infusion of sodium bicarbonate? Treat underlying cause of kidney failure- hemodialysis if interventions are ineffective.

Question 17

What are the symptoms of hyponatremia?

Why might these present in kidney failure?

Answer 17

Weakness, lethargy to coma, CNS effects (cellular edema causes cerebral edema), adb pain, muscle twitching, cramps and convulsions, N and V and diarrhea.

Patient may become dehydrated in diuresis phases which would cause loss of water and sodium from body, may also be on NA restriction in diet, or vomiting/diarrhea from metabolic acidosis all which may contribute to low NA

May also be insufficient salt in diet

Question 18

Why might kidney failure lead to hyperkalemia?

Answer 18

Kidneys decreased ability to excrete potassium and/or excessive potassium in diet. Acidosis also further increases release of K from cells into blood stream.

Question 19

Main issues of FVE?

Interventions?

Answer 19

Pulmonary edema, systemic edema, weight gain, HTN.

Strict Ins/Outs
Fluid/diet restriction (NA)
Elevate head of bed
Diuretic as ordered
Watch IV and input carefully 
Minimal dilution of IV meds
Oxygen as ordered
Weigh patient daily

Question 20

What can be done to treat hyperkalemia?

Answer 20

Medications to lower potassium = IV glucose or IV dextrose; retention enema to facilitate exchange of NA and K ions in the colon.

Correct metabolic acidosis (bicarb infusion) which further draws K out of cells and into blood stream

Hemodialysis if above medications and therapies fail to work

Question 21

What are the Risk factors of Chronic Kidney Disease

Answer 21

Diabetes (and poorly controlled) is number one risk factor
Hypertension, non-compliance with medications
Uncontrolled hyperglycemia
Heart disease
Undetected acute kidney injury

Question 22

What would you expect to find in CKD in relation to these lights?

K, NA, CA, Ph

Answer 22

K+ Potassium= high
NA= Sodium= high or low depending on stage
Ca= Calcium=low
Phosphate =high

Question 23

Describe the effects of Uremia (Renal Failure) on the systems of the body

Answer 23

Hematologic: kidneys make eryropoetin so not enough produced= low RBC count- low platelets, low hb = tired, SOB, risk of bleeding

Cardiovascular- Sodium and water retention from renin-angiotensin-aldosterone system= heart failure, pitting edema, pericarditis (irritation of pericardium due to uremic build-up of toxins) hypertension, high K can cause arrythmias

Immunologic- immunosuppressed

Neurologic- Uremia, ICP, low sodium levels can cause seizures, muscle cramps, coma

Musculoskeletal- bone disease due to retained (increased )phosphorous decreased calcium, Vit D- affected

Endocrine- thyroid and parathyroid dysfunction
Metabolic- tubular cell in kidneys malfunction and can’t rid body of accumulation of acids (phosphorous, sulpuric) therefore metabolic acidosis- patient may need bicarbonate IV

GI- affected and often results in GI bleeds (also linked to low platlets)

Dermatologic- build up of nitrogenous wastes in skin- crystals, itchiness, uremic frost

Question 24

Critical indicators that a patient requires Dialysis

Answer 24

High potassium levels
Uremic encephalopathy
Uncontrollable metabolic acidosis 
Heart failure
Total body fluid overload leading to unresponsive pulmonary edema and inability to 
restore normal fluid balance

Question 25

Complications of hemodialysis

Answer 25

Infection of venous access site and sepsis, pneumonia (common) uremic symptoms, cardiac and respiratory complications, hypertension, clotting of vascular access device, fluid volume maintenance during dialysis, pain and discomfort, patients undergoing hemodialysis often have low platelets (watch for clotting/bleeding etc) and low WBC counts (infection) and low RBC (anemia)

Question 26

Complications of peritoneal dialysis

Answer 26

Peritonitis (most serious complication usually caused by staph A., E.coli and Klebsiella), leakage, bleeding, hypertriglyceridemiaabdominal hernias, low back pain and constant sweet taste related to glucose absorption

Question 27

Priorities during acute Renal failure

Answer 27

hyperkalemia (arrythmias) is the key, Pulmonary edema is 2nd

Question 28

Interventions for Hyperkalemia

Answer 28

Kay Exalate, diuretic, dialysis