AKI
Acute Kidney Injury Diagnosis Criteria
1.5 increase from baseline drawn in last 7 days
urine volume less than 0.5 mL/kg/hr for 6 hours (30 mL)
Stages of CKD
Stage I - GFR = normal
Stage II - GFR = 60-90
Stage III - 45-59/30-44 - may see proteinuria
Stage IV - 15-29 - dialysis indicated
Stage V - (ESRD) GFR = <15
caring interventions for HD access
assess client's distal pulses and circulation
check for bruit and thrill (every 4 hours)
avoid BP, IVs, and venipuncture of affected extremity
elevate after surgery
watch for thrombosis, infection, and steal syndrome
hemoglobin considerations with CKD/ESRD
erythropoietin isn't formed by kidneys so can expect a decrease in Hgb. expect to give blood transfusion, epoetin alpha, iron supplement, and folic acid supplement.
This medication can be given to improve blood flow to kidneys in polycystic kidney disease
Tolvaptan - through vasopressin suppressing mechanism and slows kidney volume growth
Types of AKI
Pre-renal: kidneys are not getting enough fluid
Intra-renal: damage to the kidneys itself caused by inflammatory or immunologic process
Post-renal:obstruction of urine flow out because of blockage
Importance of Potassium in CKD
CKD often causes hyperkalemia. This can cause peaked T waves (K+ around 6-7) and pt needs to be on tele. ST elevation (around 7-8) and Wide QRS (>8).
Treatment - identify foods that have potassium (oranges, tomatoes, salt subs, bananas, potatoes, avocados strawberries, leafy greens). IV calcium gluconate, IV 50% dextrose + reg insulin, kayexalate to decrease K+.
list indications for dialysis
systemic uremia - pericarditis, perfusion, N/V
persistent hyperkalemia
severe metabolic acidosis (pH < 7.1)
fluid overload compromising tissue perfusion
AKI r/t drug toxins
ESRD
what is a normal creatinine level?
female: 0.5 - 1.1
male: 0.6 - 1.2
examples of nephrotoxic medications
ACEIs, ARBs, NSAIDs, diuretics, metformin
Stages of AKI
Stage 1: risk (Creatinine 1.5-1.9 times baseline; urine output <0.5 mL/kg/hr for 6-12 hrs)
Stage 2: in it (Creatinine 2.0-2.9 times baseline; urine output <0.5 mL/kg/hr for >12 hrs)
Stage 3: failure (Creatinine 3.0 times baseline; anuria > 12 hrs)
what medications are used in CKD to improve cardiac output?
ACE inhibitors - slow progression of CKD
CC Blockers - improve GFR and blood flow in kidneys
what are the 3 phases of PD?
Drain - used and saturated solution is drained gravity into draining bag
Fill - infusion, 1-2L of dialysate into peritonea, space (10-20 mins)
Dwell - diasylate stays in bag for 4-6 hrs
What are the Potassium Restrictions for uremia, HD, and PD?
uremia = 60-70 mEq/day
HD = limit to 70 mEq/day
PD = no restrictions
what is dialysis disequilibrium syndrome (DDS)?
a neurological state that can occur at initiation of dialysis - specifically new dialysis. watch for restlessness, disorientation, N/V, HA.
if occurs, stop dialysis and notify provider.
hydrate before and after administration
1 mL/kg/hr x 12 hrs or 3 mL/kg/1 hr (PRE)
3 mL/kg/hr x 6 hrs (POST)
goal is UOP = 150 mL/hr post
what can you give with food to help prevent high phosphorus in CKD patients?
phosphate binders - calcium acetate, calcium carbonate, lanthanum carbonate, sevelamer
for calcium depletion - give vitamin D, calcitriol, paricaltcitol, doxercalciferol
what medications should be held before dialysis
antihypertensives (ACE, ARBs, BB, CC Blockers); antibiotics (Vanc and Genatmicin); Digoxin; Vitamins B, C, and folic acid); Heparin (give during dialysis); anticonvulsants; antiviral
what state is the body at risk for becoming with CKD or ESRD?
metabolic acidosis
low pH, low HCO3, low PaCO2 (trying to compensate) - holding onto H+
ammonia and bicarb can excrete H+
what is an accumulation of nitrogen-based waste in blood called?
azotemia
uremia = azotemia with symptoms
what are the phases of AKI?
oliguric phase - kidneys are not working. UOP less than 400
diuretic phase - kidneys starting to work but can't concentrate urine (dumping phase)
recovery phase = urine output normalizes BUN/Cr return to normal
what are some assessment findings in CKD?
lethargy, FVO, anemia, osteodystrophy, hypertension, neuropathy, uremic halitosis, metabolic acidosis
increased BUN/Creatinine, potassium, sodium (later CKD), phosphate, magnesium
decreased GFR, calcium, Hgb/Hct, albumin, Creatinine clearance
administer normal saline bolus - experiencing hyponatremia.
what are decreased albumin treatments in CKD?
uremia = 0.55-.80 g/kg/day
HD = 1.0-1.5 g/kg/day
PD = 1.2- 1.5 g/kg/day - calc question on test
what are the rejection signs of a renal transplant?
hyperacute - can be within first 48 hours (within minutes) will see signs of increase in temp, BP, and pain at transplant site. treatment = removal
acute - within days to weeks after surgery. will see signs of oliguria/anuria, temperature, htn, enlarged tender kidney (mimics AKI). treatment = increased immunosuppressive drugs
chronic - within months to years. presents like CKD and progress until failure. treatment = conservative management and dialysis.