Kidney Functions: A WET BED

• The kidneys main function is to maintain bodily homeostasis through various processes summarized by "A WET BED".

Acid-Base Balance

• The kidneys maintain a healthy blood pH by filtering out excess hydrogen ions which makes blood more acidic.
• Kidneys also reabsorb bicarbonate ions, which makes the blood more alkaline.

Water Balance

• Kidneys regulate fluid volume by excreting excess fluid and conserving water when dehydrated.

Erythropoietin Production

• Kidneys produce erythropoietin which stimulates red blood cell production in bone marrow when oxygen levels are low.
• Patients in end-stage renal disease or on dialysis often experience anemia due to insufficient erythropoietin production.
• These patients are often given epoetin alfa to stimulate red blood cell production.

Toxic Removal

• Kidneys filter blood to remove nitrogenous urea waste (BUN- blood urea nitrogen) and creatinine waste.
• High BUN and creatinine levels indicate impaired kidney function.

Blood Pressure Management

• Kidneys release renin when blood pressure is low, activating the RAAS system.
• The Renin-Angiotensin-Aldosterone System constricts blood vessels and helps kidneys retain salt and water, increasing blood pressure.

Electrolyte Balance

• Kidneys regulate electrolyte levels by filtering and excreting potassium and other electrolytes.

Vitamin D Activation

• Kidneys release calcitriol, the active form of vitamin D, to help the body absorb calcium from food, which is vital for bone health.
• Patients with end-stage renal disease or on dialysis often have low levels of vitamin D and calcium and are therefore given calcitriol.

Urinary Tract Infection (UTI)

• A UTI is can be defined as an infection in any part of the lower urinary tract, including the ureters, bladder, urethra, and prostate.
• Most UTIs occur in the bladder or urethra.
• Escherichia coli (E. coli) is the most common pathogen causing UTIs.

Risk Factors for UTIs:

• Being female due to a shorter urethra
• Obesity
• A compromised immune system like in diabetes, HIV, or chemotherapy
• Having catheters or stones
• Experiencing constipation or holding urine for too long
• Poor hygiene practices (wiping back to front)

Manifestations of UTIs:

• Dysuria (pain when peeing)
• Hesitancy (difficulty to pee)
• Post void dribble
• Urinary retention
• Incontinence
• Nocturia (waking up at night to pee)

UTI Diagnostics:

• First diagnostic measure is a Urine dipstick, due to the ability to provide fast results
• Positive nitrates or WBCs indicate UTI
• Urinalysis is also used in diagnostic testing through dipstick and microscopic examination of urine
• Culture and sensitivity testing may be required for more reliable results

UTI Treatment and Client Education

• Oral antibiotics are used
• Drink at least 3 L of fluid daily
• Practice daily hygiene
• Urinate every 3 to 4 hours instead of holding or when there is urgency to pee
• Urinate before and after sex
• Drinking cranberry juice can decrease the risk of infection
• Wipe front to back
• Avoid bubble baths, sitting in wet bathing suits, and wearing pantyhose.

Pyelonephritis Definition:

• An infection of the kidneys caused by bacteria traveling up from the lower urinary tract.
• It is a more severe infection that can cause kidney damage and sepsis if untreated, which is life-threatening.
• This condition usually develops from a UTI.

Pyelonephritis Manifestations:

• Fever and chills
• Nausea or vomiting
• Malaise which is a general feeling of discomfort, illness, or unease whose exact cause is difficult to identify.
• Flank pain which is pain in the side or back of the body, and costovertebral angle tenderness
• Hematuria (blood in the urine)
• WBC casts in urine

Pyelonephritis Diagnostics:

• Urine dipstick and urinalysis will be used
• Ultrasound can identify complications (kidney damage) or underlying factors (such as obstruction or abscess).
• Blood cultures are needed if urosepsis is suspected.

Pyelonephritis Treatment:

• Antibiotic therapy, using broad-spectrum antibiotics, is used.
• For mild cases of the condition, treatment will be done for 14 days at home
• Antibiotics used: Fluoroquinolones and Cephalosporins
• For severe cases, treatment will be done with IV medication in the hospital for 24-48 hours.

Glomerulonephritis Definition

• The inflammation of the glomeruli, responsible for filtering waste and excess fluid from the blood to make urine.
• It leads to a buildup of waste products and excess fluid, resulting in swelling, hypertension, and changes in urine.
• Glomerulonephritis can lead to end-stage renal disease (ESKD), requiring dialysis.

Causes and Types of Glomerulonephritis

• It often occurs after an infection.
• Acute glomerulonephritis has a sudden onset, can be temporary, and is reversible .
• Chronic glomerulonephritis has a slow, progressive onset (20-30 years) and can lead to irreversible renal failure.

Glomerulonephritis Risk Factors:

• Recent infection, especially streptococcal (strep throat), most common 1-6 weeks post-infection, skin, or upper respiratory tract.
• HIV, Hepatitis B, or Hepatitis C
• Immune diseases, leads to damaged and scarred glomeruli, such as Lupus and Scleroderma (hardened skin).
• Vasculitis (inflamed blood vessels) and diabetic neuropathy
• Hypertension (HTN)

Glomerulonephritis Manifestations:

• Periorbital edema which is the first sign
• Generalized edema and hypertension
• Oliguria (low urine output) and hematuria (red to brown color)
• Proteinuria (too much protein in urine) characterized by foamy urine.
• Other indicators: High RBCs, High BUN/Creatinine

Glomerulonephritis Diagnostics:

• Urinalysis: High RBCs and protein
• Blood test: High BUN & creatinine
• Renal biopsy (kidney biopsy): done to diagnose and determine cause & treatment, gold standard if diagnosis is unclear.

Glomerulonephritis Treatment:

• Antibiotics are used for symptom and underlying cause treatment
• Control HTN with Antihypertensives
• For edema, diuretics are used with decreased sodium and fluid intake

Glomerulonephritis Nursing Care:

• Conserve client energy through fluid restriction
• Administer antibiotics as prescribed
• Monitor BP, respiratory status, fluid, and electrolytes
• Diet changes which include reduced salt and phosphorus intake

Renal Cancer Definition:

• Abnormal cells begin to grow uncontrollably in the kidneys, forming a tumor.

Renal Cancer Risk Factors:

• Occurs more in men than women;
• Cigarette smoking and asbestos exposure
• Obesity and HTN
• Those with a first degree relative known with the condition are at risk

Renal Manifestations depend on size and location of the tumor:

• Anemia indicated by decreased HgB/Hct
• Increased or decreased levels when testing the ESR
• Increased Calcium
• Hematuria, indicated by the presence of blood, in urine
• Pain in the flank or hip

Renal Cancer Diagnostics:

• CT scan: Assesses the size & location of the tumor
• Ultrasound: Creates waves to create an image and detects tumors in kidneys
• Angiography: Shows the blood vessels in kidneys
• Biopsy: Provides a small tissue to confirm cancer cells are present

Renal Cancer Treatment:

• Partial nephrectomy (standard treatment): Removal of part of the kidney for small tumors
• Radical nephrectomy: Removal of the entire kidney, often used for larger tumors
• Chemotherapy & radiation: Aim to kill remaining cancer cells
• Unresectable metastatic tumors (can't have surgery), Ablation, Biological response modifiers (BRMs), and Targeted therapy can be used;

Renal Cancer Nursing Care:

• Educate on preventative measures:
  • Stop smoking
  • Maintain healthy weight
  • Control BP
  • Reduce exposure to toxins
  • Avoid NSAIDs (nephrotoxic) and contrast dye (damage kidneys)
• Monitor urine output and kidney labs: BUN, Creatinine, Urinalysis, To assess renal function of unaffected kidney

Bladder Cancer

• More common in women
• The number one risk factor is cigarette smoking

Bladder Cancer Manifestations

• Hematuria (blood in the urine)
• Dysuria, frequency, and urgency may be present with a UTI or obstruction

Diagnostics for Bladder Cancer:

• Urine test to check for cancer or atypical cells, and bladder tumor antigens
• Biopsy to confirm presence of cancer cells
• Also used: CT scan, ultrasound, or MRI

Treatment for Bladder Cancer:

• Surgery which includes Transurethral resection of the bladder tumor (TURBT) and the Removal of abnormal skin lesions
• Segmental (partial) cystectomy, which is the removal of large tumors in one area of bladder wall and margin of normal tissue
• Radical cystectomy (reconstruction): Surgery which includes removal of surrounding tissue, or muscle for large, invasive tumors. Includes urinary diversion, to divert ureters to another location and Postoperative care
• Additional treatment includes radiation and chemotherapy
• Intravesical therapy (Bacillus Calmette-Guerin): Chemotherapy medication is put directly into the bladder through catheter
  • Must restrict fluids for 4 hours prior to infusion and increase fluid intake after infusion
  • Educate client there may be bladder irritation and hematuria after infusion
  • Retained for 2 hours; client must change position every 15 minutes and must do weekly intervals for 6-12 weeks.

Chronic Kidney Disease (CKD) Definition:

• The kidneys gradually lose their ability to function properly over time.
• It defines a progressive, irreversible kidney disease.
• Kidneys lose more function, and waste can build up in the body, leading to serious health problems, including:
  • Inability to function properly, excrete waste, concentrate urine, and conserve electrolytes.

Risk factors for CKD:

• acute kidney injury (AKI) and diabetes mellitus
• chronic glomerulonephritis and Nephrotoxic medications:
  • NSAIDs
  • Gentamicin
  • Chemicals
• Also includes: HTN, autoimmune disorders, Polycystic kidney disease, Renal artery stenosis, Recurrent severe infections

Stages of CKD are defined by:

• Stage 1. Minimal kidney damage with normal or elevated GFR, GFR ≥ 90
• Stage 2. Mild kidney damage with mildly decreased GFR, 60-89
• Stage 3. Moderate kidney damage with moderate decrease in GFR (more manifestations show), 30-59
• Stage 4. Severe kidney damage with severe decrease in GFR, 15-29
• Stage 5. Kidney failure, < 15, dialysis is needed

Manifestations of CKD are often related to fluid volume overload:

Metabolic, Diagnostics and Treatment of CKD

• BUN and creatinine increase as GFR decreases
• Hyperkalemia
  • May cause fatal dysrhythmias when K reaches 7-8 (normal 3.5-5)
• Hyperglycemia
  • Caused by impaired glucose metabolism
• Urinalysis
  • Hematuria, proteinuria (1st sign of kidney damage), and decrease in specific gravity (more diluted pee)
• Blood test:
  • Increased BUN and creatinine
  • Decreased sodium and calcium and Increased electrolytes
  • Decreased Hgb and Hct Due to loss of erythropoietin in CKD
• Treatment:
  • Calcium gluconate and insulin help stabilize the heart and shift K into cells for Hyperkalemia
  • Kayexalate will help poop out K
  • Furosemide will assist in peeing out the K
  • Epoetin alfa is used to stimulate production of RBCs
• Renal Diet:
• Fresh fruits & vegetables
• Low potassium & phosphorus
• Moderate amount of protein

Goals of CKD management include:

• Preserve existing kidney function
• Reduce risks of cardiovascular disease
• Prevent complications
• Provide patient comfort

Dialysis Definition:

Defines a treatment that helps remove waste, excess fluids, and toxins from blood when kidneys are no longer working properly (supports, but doesn't cure)

• Indicated when GFR < 15
• Aids in can be used to treat drug overdose
• Two types of dialysis exits:
• Hemodialysis (HD)
• Peritoneal dialysis (PD)

Hemodialysis:

• The patients blood is taken from the body and filtered through a dialyzer, where waste and excess fluids are removed.
• The cleaned blood is then returned to the body.
• A type of AVF (arteriovenous fistula) is inserted to allow blood to be removed and returned during treatment Surgical connection made between an artery and vein (fistula)
• Lasts longer than grafts and have fewer complications
• Requires 3 months to heal before dialysis. Synthetic tube (made out of plastic) surgically placed between the artery and the vein
• used when AVF isn’t possible (due to small veins)
• is able to be used more quickly than an AVF and Nursing care for AVF/grafts

Nursing care for AVF/grafts: Assessment is done for a palpable thrill (woosh sound) to indicate proper blood flow and patency Blood pressure should not be taken on the arm in which it is inserted

Complications associated:

• Hypotension

• Muscle cramps

• Blood loss

• Hepatitis

• Special fluid is put into the abdomen, where it absorbs waste and extra fluid from the blood through the lining of the abdomen (peritoneum). After a few hours, the fluid is drained out

• Catheter is placed into the belly, is used to fill the abdomen with special dialysis fluid (dialysate). Automated: machine does most of the work, when sleeping with cycle programmed Continuous: the 2L exchange of peritoneal diaslsate 4x daily CRRT (continuous renal replacement therapy): done in the ICU for severe kidney failure and is a continuous process that runs 24 hours a day

Postoperative care includes:

• to monitor renal function with more the 30 nL/hr output. -HCT and administer anti rejection medications