Renal Replacement Therapy Flashcards
CKD: Causes
happens slowly overtime usually secondary to other diseases like:
- DM
- HTN
- heart disease
- family hx
- age
- race
CKD: Labs
BUN
Creatinine
GFR
Urinalysis (to test for protein and blood)
CKD and Calcitriol
in CKD, kidneys don’t release calcitriol (hormone that causes absorption of calcium) > musculoskeletal issues over time
low calcitriol creates imbalance of calcium in the blood > parathyroid hormone pulls calcium from bones into blood
CKD and Calcium/Phosphorous
kidneys responsible for filtering phosphorous
when they are unable to do so, phosphorous contributes to pulling out of calcium from bones > musculoskeletal issues over time
indirect relationship: if calcium goes up, then phosphorous goes down
GFR
normal: >60
CKD: Stages
Stage 1: normal or high GFR (GFR > 90) Stage 2: Mild CKD (GFR = 60-89) Stage 3A: Moderate CKD (GFR = 45-59) Stage 3B: Moderate CKD (GFR = 30-44) Stage 4: Severe CKD (GFR = 15-29) Stage 5: End Stage CKD (GFR <15)
AKI: Definition
abrupt decrease in kidney function > retention of urea and other nitrogenous waste products and in the dysregulation of extracellular volume and electrolytes
happens quickly (in a day or two)
can be secondary to something else
includes acute injury and impairment of the kidney
AKI: Causes
Sepsis: causes decrease in BP, so kidneys are not getting blood flow they need > AKI
-lots of meds given during sepsis that are hard on kidneys
Circulatory shock: low BP > low circulation to kidneys > low O2 to kidneys > AKI
Burns/Trauma: direct trauma to kidney that can cause AKI
-trauma can also cause circulatory shock effects
Cardiac Surgery especially w/ cardio-pulmonary bypass: any type of machine that introduces blood flow outside the body poses risk to organs. After surgery, it’s not uncommon to see bump in kidney function, liver function, and cognitive effects (delirium). Many meds also given during surgery > AKI
-may require dialysis after surgery
Nephrotoxic drugs: typically antibiotics (vancomycin, getromycin, etc) very hard on kidneys
Radiocontrast agents: contrast dyes are very hard on kidneys
Dehydration: ties into shock and hypovolemia (tx with fluids)
advanced age
female
black
CKD: if you already have preexisting CKD, at increased risk for AKI
Acute Kidney Injury on CKD
someone with CKD may get med that’s challenging to the kidneys and if they go into renal failure = acute kidney injury on CKD
AKI: Lab Parameters
Increase in SCr by >0.3 mg/dl w/in 48 hours
OR
increase in SCr to >1.5x baseline, which is known or presumed to have occurred w/in the prior 7 days
OR
urine volume <0.5 ml/kg/h for 6 hours
Dialysis
process of fluids and molecules moving from the blood through a semipermeable membrane and into a dialysis solution
does work of kidneys over a shorter time period on scheduled interval
two types: hemodialysis (HD) and peritoneal dialysis (PD)
Routes of Dialysis Admin
HD: via fistula or catheter
PD: relies on abdominal cavity as a space to insert clean fluid into the space
Who gets dialysis?
- varies widely
- depends on kidney function, are they making urine?
- consider comorbidities, they will more quickly progress to dialysis : CKD, DM, HF
complications of uremia’s require HD ASAP:
- encephalopathy
- neuropathies
- hyperkalemia
- pericarditis
- accelerated HTN
HD
via catheter in large vein (jugular, femoral, subclavian)
*won’t see peripheral catheter b/c there aren’t large enough veins in the arms to support it
AV fistula: take part of vein and hook it up to artery which allows for high blood flow that we need in order to pull out high volumes of blood and return them to get circulated through body quickly
-evaluate for thrill/bruit
AV grafts exist as well
HERO graft
HD: Schedule
M/W/F
Tue/Thurs/Sat
HD: Complications
hypotension
hypoglycemia
HERO Graft
- less common
- used when vein you need to use is very brittle
- man-made graft, tube allows for high blood flow needed for dialysis without having to go through older brittle veins
PD
- catheter is inserted into the anterior abdominal wall
- can be done at home
- same osmosis concept except smaller amounts over longer period of time
- most popular time for exchanges is during sleeping, allows for several exchanges to occur
- can do it throughout day, but need to take breaks for 1-2 hours
- less common and more difficult for a person to be a candidate for b/c
PD: Complication
Site infection: aseptic technique, wash with soap and water
Peritonitis: secondary to infection, can get irritation or infection of peritoneal cavity. There is possibility of bacteria being inserted at every exchange
Hernias: when fluid is dwelling in abdominal cavity, it puts compression on other organs, increases amount of pressure in abdomen for amount of time > increase risk of hernia
Protein loss: common in HD and PD, occurs as natural process of fluid going in and out, sometimes protein gets pulled in and out
Pulmonary issues: occur as result of pushing fluid into abdomen > putting pressure on diaphragm > puts pressure on lungs (can see atelectasis, possible pneumothorax)
CRRT/CVVH
- only done in ICU in hospital
- more gentle dialysis for those we are hemodynamically unstable and cannot tolerate HD tx
- SBP = 80 or MAP = 50
-done through HD catheter (not fistula or abdomen
- requires specialized nurse trained to manage the machine
- monitoring does not require HD nurse but requires training
-not on bed rest
CRRT/CVVH: Nursing Considerations
- infection
- monitor hemodynamics since they are hemodynamically unstable
- closely monitor electrolytes and correct imbalances
Kidney Transplant
required when severe AKI becomes a chronic issue or CKD
patient prep includes evaluation of psychosocial state, mental health, physical health
can have live donor or deceased donor kidney
UNOS point system includes severity of disease and persons compliance
laparoscopic or open approach
Kidney Transplant: Post-Op Care
- prioritize fluid and electrolyte balance
- large amounts of urine is expected b/c new kidney is ready to work and body has a lot of waste that needs to be filtered
- avoid dehydration (look for low UO, hypovolemia (high HR, low BP))
- may need dialysis after surgery if kidney needs a little extra support and not immediately taking
Rejection Types
Hyperacute
Acute
Chronic
Rejection: Hyperacute
occurs w/in 24 hours
pre-existing antibodies present and body that receives new kidney starts attacking new kidney
no tx > organ removed > person goes back on list
rare
d/t error in testing/matching of kidneys
Rejection: Acute
occurs in first 6 months
started by pt’s lymphocytes and body attacks kidney
common
presents as flu-like symptoms (achy, fever, chills, general malaise)
tx w/ steroids and immunosuppression
SE of tx:
- from steroids = hyperglycemia, mood changes, irritability, sleep changes,
- immunosuppression
Rejection: Chronic
months/years after transplant
irreversible
presents as flu-like symptoms (achy, fever, chills, general malaise)
d/t repeated episodes of acute rejection, that they recovered from but didn’t return to state they were at before
tx = supportive therapy such as dialysis
Immunosuppresants
Mycophenolate mofetil (cellcept): given in immediate period post op -SE: achy, flu-like
Tacrolimus and cyclosporine: long term anti-rejection meds
Corticosteroids
Monoclonal antibodies (flu-like symptoms can occur) Polyclonal antibodies
GVHD
graft vs. host disease
rare compared to rejection
donor tissue rejects the recipient tissue (donor T-cell’s attack recipient cells)
occurs 7-30 days after transplant
s/sx :
- skin: patches/loss of pigmentation
- liver: failure
- GI: issues w/ digestion/absorption
- s/sx of infection (making it difficult to figure out where it’s coming from)
Tx: immunosuppression to remove donor T-cells but SE is that it also removes recipient T-cells putting them at higher risk for infection themselves
