Renal System Overview and Assessment

Renal System

GFR: 90 or above is normal, less than 60 for 3 months indicates CKD, less than 15 is kidney failure
BUN: 10-20 is normal, levels greater than 4 indicate serious impairment
Creatinine: 0.5-1.2 is normal, greater than 2 indicates "dead kidney"
Creatinine Clearance Test: 24-hour urine test, discard the first urine, collect all urine for 24 hours, keep refrigerated/on ice, avoid strenuous exercise. Collect last urine as close to finish time as possible. Document age, weight, height, and current medications.
BUN to Creatinine Ratio: 10-20 is normal. High BUN with normal creatinine suggests dehydration. Hydration (PO/IV) treats.
Hypoalbuminemia: Normal level is 3.5-5.5
Urine Uric Acid: 250-750 mg/24 hours is normal.

Assessment & Interventions

Hydration Status: Assess mucus membranes, skin turgor, Input and output (I&O).
Fluid I&O: Monitor daily, along with weights.
Muscle Tone/Strength: Assess
Cardiac Status: Monitor and look for changes in cardiac and respiratory status. Monitor neurologic status.
Interventions: Monitor I&O, daily weights, skin. Monitor cardiac, respiratory, and neurologic status, note changes.
Epoetin (Epogen, Procrit): Given when Hemoglobin (HGB) is less than 10. Assess renal function tests (RFT), I&O, and blood pressure (BP). May be mixed with normal saline (NS) & benzyl alcohol to reduce injection site pain.

ACE Inhibitors & ARBs

ACE Inhibitors (-pril): Prescribed for hypertension (HTN), but can damage the kidneys. Enhances the effects of thiazide diuretics.
ARBs (-sartan): Prescribed for HTN, but can damage the kidneys.

Electrolytes

Sodium: 135-145 mEq/L is normal. AKI & CKD can cause hyponatremia. Dietary sources include cheese, seafood, table salt, processed foods, and ketchup.
Potassium: 3.5-5 mEq/L is normal. Hypokalemia (low potassium) may occur. Dietary sources include organ meats, bananas, avocados, spinach, and salt substitutes. Hyperkalemia (high potassium): administer IV insulin immediately followed by D50 and Kayexalate, if needed.
Calcium: 9-11 mg/dL is normal, AKI/CKD affect vitamin D which affects calcium absorption . Dietary sources include milk, yogurt, cheese, figs, and ice cream. Take vitamin D with calcium supplements.

Metabolic Acidosis

Metabolic Acidosis: Resulting from inadequate bicarbonate production; AKI/CKD causes it. Bicarbonate drip is needed if level is lower than 7.2
Dialysis: Used as a treatment option if needed

Renal Diseases

Polycystic Kidney Disease (PKD): Fluid-filled cysts in kidneys. Inherited disorder that damages glomerular and tubular membranes.
Acute Kidney Injury (AKI): Lasts less than 3 months. Causes include hemorrhage, trauma, dehydration, and myocardial infarction (MI).
Chronic Kidney Disease (CKD): Progressive, irreversible loss of kidney function over months/years. azotemia (build-up of nitrogenous waste) can lead to uremia (azotemia with symptoms, ex: metallic taste, uremic frost)
Stages of CKD: CKD 1-3, then discuss treatment/dialysis in stages 4-5.
Treatment/interventions: Manage fluids & electrolytes and/or modify diet. Monitor complications.
Medications: Digoxin for decreased stroke volume (monitor dig toxicity), Ferrous sulfate for anemia, Calcium carbonate to prevent osteodystrophy (abnormal bone growth due to decreased calcium due to decreased vitamin D)

Peritoneal Dialysis

Description: Catheter placed in peritoneum; dialysate is introduced and flushed. Dialysis is completed in the peritoneum.
Nursing Care: Aseptic technique, monitor vitals, weights, I&O, catheter, dressing, site. Never push catheter in. Turn patient.

Hemodialysis

Description: Blood is removed via vascular access, passed through a filter, and returned to the patient.
Vascular Access: AV fistula (artery and vein joined in forearm), AV graft, or central line (not ideal and placed emergently).

Liver

Function: Filters and detoxifies, Protein production, metabolism of steroid hormones.
ALT (Alanine Aminotransferase): 4-36 is normal.
AST (Aspartate Aminotransferase): 8-33 is normal, elevated levels suggest damage.
Bilirubin: 0-1 (typically less than 1)
Alkaline Phosphatase: 30-120
Albumin: 3.5-5
PT/INR: PT: 11-13.5 seconds; INR: 0.8-1.1 are normal
CMP: Aldosterone regulates sodium and potassium by reabsorbing or excreting these electrolytes
Impaired Protein Metabolism: Decreased production of albumin (edema) and clotting factors (bleeding).
Bile Production: Essential for lipid and fat-soluble vitamin absorption; unconjugated bilirubin buildup.
Filtering Ability: Buildup of toxins (ammonia, drugs) due to poor filtering ability.
Steroid Hormone Metabolism: Impairment affects male and female hormones (males: gynecomastia and testicular atrophy; females: irregular menses)
Glucose Metabolism: Creates unstable glucose levels,
Cirrhosis: Liver shrinks & hardens (scar tissue). s/s include, RUQ pain, jaundice, altered mental status, increased bleeding, weight loss.
Jaundice: Yellowing of skin and eyes. Blood and clotting factors are trapped in liver, leading to a buildup of bilirubin.
Portal Hypertension: Increased pressure due to obstruction of blood flow; causes splenomegaly, varices, ascites, and hepatic encephalopathy.
Splenomegaly: Enlarged spleen.
Ascites: Fluid accumulation in the abdomen. Leads to shortness of breath.
Paracentesis: Fluid drain from peritoneal cavity (insert catheter).
Spontaneous Peritonitis: Ascites fluid infection. Signs include sudden fever, abdominal discomfort, worsening ascites, worsening HE.
Neomycin: Intestinal antiseptic, avoid with renal disease.
Rifaximin: Non-systemic antibiotic, eliminates ammonia-producing bacteria.
Hepatic Encephalopathy (HE): Liver unable to filter toxins; leads to ammonia buildup. AMS, asterixis, and fetor hepaticus (musty breath) are symptoms.
Lactulose: Promotes ammonia excretion. Monitor potassium (K+) levels.
Hepatitis: Inflammation of liver, risk factors include male-to-male sex, contaminated water/undercooked foods, IV drug use, HIV infection
Liver Biopsy: Tissue sample taken post-incision.