AKI and CKD PDF

Acute Kidney Injury & Chronic Kidney Disease Cate Enstrom DNP, AGACNP-BC, CNE HEHI Objectives Discuss causes, clinical manifestations, treatment, and nursing considerations for acute kidney injury and chronic kidney disease ...

Acute Kidney Injury & Chronic Kidney Disease Cate Enstrom DNP, AGACNP-BC, CNE HEHI Objectives Discuss causes, clinical manifestations, treatment, and nursing considerations for acute kidney injury and chronic kidney disease  KIDNEY FAILURE Acute Kidney Injury (AKI) Chronic Kidney Disease Acute Kidney Injury (AKI) Sudden cessation of renal function that occurs when blood flow to kidneys is significantly compromised Determined by urine output and serum creatinine Oliguria: 100-400ml Types Prerenal Intrarenal Postrenal Sequence of AKI CKD ESRD Happy kidney Diagnosis AKI: Serum creatinine > 1.3mg/dL Urine output Less than 0.5mg/kg/hr (30ml/hr) RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification Types of AKI Prerenal Volume depletion and reduced blood flow to kidneys Intrarenal Direct damage to the kidneys Postrenal Obstruction in structures leaving the kidney  WE DEMAND BLOOD Prerenal AKI FLOW Decreased blood pressure will reduce blood flow to kidney and glomerulus will not be able to properly function Common causes Hypovolemia Acute blood loss Dehydration (diarrhea, vomiting) Hypoperfusion (hypotension) Heart failure (decreased cardiac output) Acute myocardial infarction Renal Blood flow Intrarenal AKI Causes Hypoxic injury Renal artery or vein stenosis or thrombosis Hypertensive emergency Chemical Nephrotoxins: antibiotics, contrast dye, alcohol, medications Immunologic Infection (pyelo), vasculitis, glomerulonephritis Nephrotoxic Medications Antibiotics Antivirals Antihypertensives Cancer medication Anti-rejection medications Pain medication (NSAIDS) Psychiatric medications Postrenal AKI Obstruction impeding urine flow from kidney to urethra Stones, tumors BPH, urethral strictures Hydronephrosis Renal swelling due to urine build up from post- obstruction Nephrostomy Tube Types of AKI Signs of AKI Elevated serum creatinine and decreased urine output Determining the type of AKI will help identify the underlying problem and guide treatment What this looks like: Morning labs show creatinine 1.9 (from 0.8) and urine output is only 100ml/hr What now? Low Urine Output and Elevated Creatinine ► Prerenal Prerenal ̶ Increase PO intake or fluid What is their fluid status? bolus Dehydrated? GI losses: N/V? ̶ Prevent underlying fluid losses Perfusion issues: heart failure, hypotension? (treat diarrhea or vomiting) Intrarenal ̶ Treat heart failure Are they on any medications that are nephrotoxic? ► Intrarenal Postrenal ̶ Stop nephrotoxic medication History of kidney stones or enlarged prostate? ̶ Autoimmune: steroids ► Postrenal ̶ Remove obstruction ̶ Placement of stents or nephrostomy tubes Management of AKI Nursing care Identify and assist with correcting underlying cause Monitor vital signs and telemetry Monitor fluid intake and output Monitor for signs of volume overload Obtain daily weights Review laboratory values BUN, SCr, electrolytes, H/H Electrolyte management Diet: renal (low potassium, phosphate, fluid restriction) Nutrition consult Treatment of AKI Thoughtful fluid balance Fluid replacement if perfusion compromised Diuretics to promote increased filtration of blood by kidney Electrolyte management Possible dialysis Intermittent CRRT v. HD Dialysis – Renal Replacement Therapy Hemodialysis CRRT Health Promotion and Disease Prevention Appropriate hydration (2L) Consider patients with fluid restriction Stop smoking, active lifestyle, healthy meals Caution with NSAIDS and other nephrotoxic medications Contrast dye Control diabetes and hypertension to prevent complications Take all antibiotics as prescribed for infections  Renal Outcomes After Episode of AKI Risk factors: -Age -CKD status -Comorbidities (HTN, DM) Chronic Kidney Disease (CKD) Long-term, irreversible loss of kidney function due to kidney damage Chronic, progressive Etiologies AKI that did not recovery Long withstanding damage to kidneys Hypertension, diabetes Risk Factors for CKD Age Decreased functioning nephrons, decreased GFR) AKI DM Nephrotoxic medications HTN Autoimmune disorder (SLE) Polycystic kidney disease Pyelonephritis Renal artery stenosis Regions and Countries Where CKD is top 10 cause of life lost in 2013 Why HTN and DM Lead to CKD Diagnosis Estimating GFR (normal is 90-120 mL/min/1.73m2) Using a filtration marker like serum creatinine Testing urine for presence of albumin or protein Effect of Kidney Function on Essential Homeostatic Process Clinical Findings of CKD Maybe free of manifestations except during periods of stress Symptoms more apparent has kidney dysfunction progresses Nausea, depression, fatigue, lethargy, involuntary leg movements Symptoms mostly related to volume overload Neuro: Lethargy, slurred speech, tremors or jerky movements (sodium) CV: Fluid overload (JVD, edema), HTN, HF, peaked T waves (hyperkalemia) Resp: Tachypnea, crackles/rales Renal: Decreased or no urine output, proteinuria MS: Pathological fractures Heme: Anemia, fatigue Complications and Treatment CKD Testing – Identify underlying cause and complications Laboratory testing Electrolytes (BMP, Mg, Phos), CBC, ABG Imaging Detect disease processes, obstruction and arterial deficits Ultrasound, KUB, CT, MRI Contrast considerations Diagnostics Cystoscopy Retrograde pyelography Kidney biopsy Treatment of CKD Nursing considerations Monitor I+O, weights, vital signs, and telemetry Assess vascular access or peritoneal dialysis insertion sites Enforce/educate dietary restrictions (limited electrolytes, high carbs, mod-high fat) Mouth and skin care Medications Diuretics Potassium eliminator: sodium polystyrene (kayexalate) Epoetin alfa: stimulates production of RBC Ferrous sulfate: iron supplement Phosphate-binders: calcium or sevelamer ESRD – End-Stage Renal Disease Requires dialysis Hemodialysis (MWF or TTS) Peritoneal dialysis Kidney transplantation Dialysis Fistulas Reliable regular access created surgically Nursing implications Assess patency Feel the thrill, listen to the bruit No blood pressures Risk of bleeding and infection Dialysis Indications Toxins Fluid overload Electrolyte abnormalities Uremia Nursing considerations Bleeding Hypotension Electrolyte abnormalities Infection AV Fistulas Peritoneal Dialysis Fill abdomen with dialysate fluid Peritoneum as exchange membrane Advantages Done at home Gentle fluid shifts Risks Infection: peritonitis