AKI CKD

Question 1

What is the most accurate indicator of fluid loss or gain?

Answer 1

Weight

Question 2

I kg of weight gain =

Answer 2

1000 mL

Question 3

Acute Kidney Injury

Answer 3

It is a rapid loss of renal function r/t damage to the kidneys
Depending on severity and duration a wide range of life-threatening complications can occur:
Fluid & electrolyte imbalances
Metabolic acidosis
Goal of care:
Minimize complications
Reduce cause of injury
Prevent long term loss of renal function
Criteria for AKI
50% or greater increase in serum creatinine above baseline
Urine volume may be normal or changes may occur:
Oliguria, anuria, Nonoliguria

Question 4

AKI Causes:

Answer 4

Causes of AKI that reduce blood flow to the kidney and impair kidney function:
Hypovolemia
Hypotension
Reduced cardiac output
Heart failure
Obstruction of kidney or lower urinary tract
Tumor
Blood clot
Kidney stone (not very common causes)
Bilateral obstruction of the renal arteries or veins

Question 5

AKI Classifications

Answer 5

5 point classification system:
RIFLE- Risk, Injury, Failure, Loss , ESKD
Severity:
Risk, Injury, Failure
Outcomes: Loss, ESKD

Question 6

Fluid Volume Deficit:

Answer 6

Manifestation:Acute weight loss ≥5%, decreased skin turgor, dry mucous membranes, oliguria or anuria, increased hematocrit, BUN level increased out of proportion to creatinine level, hypothermia
Management: Fluid challenge, fluid replacement orally or parenterally

Question 7

Fluid Volume Excess

Answer 7

Manifestations: Acute weight gain ≥5%, edema, crackles, shortness of breath, decreased BUN, decreased hematocrit, distended neck veins
Management: Fluid and sodium restriction, diuretic agents, dialysis

Question 8

Hyponatremia

Answer 8

Manifestation: Nausea, malaise, lethargy, headache, abdominal cramps, apprehension, seizures
Management:
Diet, normal saline or hypertonic saline solutions

Question 9

Hypernatremia

Answer 9

Manifestations: Dry, sticky mucous membranes, thirst, rough dry tongue, fever, restlessness, weakness, disorientation
Management: Fluids, diuretic agents, dietary restriction

Question 10

Hypokalemia

Answer 10

Anorexia, abdominal distention, paralytic ileus, muscle weakness, ECG changes, dysrhythmias

Management: Diet, oral or parenteral potassium replacement therapy

Question 11

Hyperkalemia

Answer 11

Diarrhea, colic, nausea, irritability, muscle weakness, ECG changes
Management:
Dietary restriction, diuretics, IV glucose, insulin and sodium bicarbonate, cation-exchange resin, calcium gluconate, dialysis

Question 12

Hypocalcemia

Answer 12

Manifestations: Abdominal and muscle cramps, stridor, carpopedal spasm, hyperactive reflexes, tetany, positive Chvostek or Trousseau sign, tingling of fingers and around mouth, ECG changes
Management: Diet, oral or parenteral calcium salt replacement

Question 13

Hypercalcemia

Answer 13

Deep bone pain, flank pain, muscle weakness, depressed deep tendon reflexes, constipation, nausea and vomiting, confusion, impaired memory, polyuria, polydipsia, ECG changes
Management: Fluid replacement, etidronate, pamidronate, mithramycin, calcitonin, glucocorticoids, phosphate salts

Question 14

metabolic acidosis

Answer 14

Headache, confusion, drowsiness, increased respiratory rate and depth, nausea and vomiting, warm flushed skin
management:
Bicarbonate replacement, dialysis

Question 15

metabolic alkalosis

Answer 15

Depressed respirations, muscle hypertonicity, dizziness, tingling of fingers and toes
Management:
Fluid replacement if volume depleted; ensure adequate chloride

Question 16

hypoalbuminemia

Answer 16

Chronic weight loss, emotional depression, pallor, fatigue, soft flabby muscles
Management:
Diet, dietary supplements, hyperalimentation, albumin

Question 17

hypomagnesemia

Answer 17

Dysphagia, muscle cramps, hyperactive reflexes, tetany, positive Chvostek or Trousseau sign, tingling of fingers, dysrhythmias, vertigo
management:

Diet, oral or parenteral magnesium replacement therapy

Question 18

hypermagnesemia

Answer 18

Facial flushing, nausea and vomiting, sensation of warmth, drowsiness, depressed deep tendon reflexes, muscle weakness, respiratory depression, cardiac arrest
management:
Calcium gluconate, mechanical ventilation, dialysis
– causes prolonged PR interval, increased QRS duration, and prolonged QT interval. Can cause complete heart block or cardiac arrest
Calcium gluconate – displaces and neutralizes the effects of magnesium in the body

Question 19

hypophosphatemia

Answer 19

Deep bone pain, flank pain, muscle weakness and pain, paresthesia, apprehension, confusion, seizures
Management:
Diet, oral or parenteral phosphorus supplementation therapy

Question 20

AKI life threatening complications

Answer 20

Fluid & electrolyte imbalances
Metabolic acidosis

Question 21

Criteria for AKI

Answer 21

Criteria for AKI
50% or greater increase in serum creatinine above baseline
Urine volume may be normal or changes may occur:
Oliguria, anuria, Nonoliguria

Question 22

AKI Causes

Answer 22

Hypovolemia
Hypotension
Reduced cardiac output
Heart failure
Obstruction of kidney or lower urinary tract
Tumor
Blood clot
Kidney stone (not very common causes)
Bilateral obstruction of the renal arteries or veins

Question 23

AKI classification

Answer 23

RIFLE – Risk, Injury, Failure, Loss, ESKD
(used to identify kidney injury and improve outcomes for patients)

Question 24

R- RIsk

Answer 24

Increased serum creatinine 1.5 x baseline or GFR decreased greater than or equal to 25%
0.5 mL/kg/hr for 6 hours

Question 25

I (injury)

Answer 25

Increased serum creatnine 2 x baseline or GFR decreased greater than or equal to 50% 0.5 mL/kg/hr for 12 hours

Question 26

F (failure)

Answer 26

Increased serum creatnine 3x baseline or GFR decreased greater than or equal to 75% or serum creatnine greater or equal to 354 mmol/L with an acute rise of at least 44 mmol/L or < o.3 mL/kg/hr for 24 hours or anuria for 12 hours

Question 27

L (loss)

Answer 27

Persistent actute kidney injury = complete loss of kidney function > 4 weeks

Question 28

E (ESKD)

Answer 28

ESKD > 3 months

Question 29

Pre renal

Answer 29

Hypoperfusion Sudden and severe shock or interruption of blood flow to the kidneys from severe injury of illness Hypoperfusion resulting from - Volume depletion - Hemorrhage - GI loss (vomiting, diarrhea, NG suctioning) - Renal loss (diuretics) - Burns - Impaired cardiac efficiency (hypotension) - Heart failure - Dysrhythmias - MI - Cardiogenic shock - Vasodilation - Anaphylaxis - Sepsis - Antihypertensive medications causing vasodilation - Stenosis of the renal arteries

Question 30

Gerontologic Considerations:

Answer 30

They may develop atypical signs and symptoms * Fluid deficit can lead to  Constipation  Falls  Medication toxicity  Urinary or respiratory tract infections  Delirium, seizures  Delayed wound healing Recognition in this older group can be hampered by underlying chronic conditions, or just mistaken with the aging process

Question 31

Hyperkalemia Treatment explained

Answer 31

Insulin helps drive potassium back into the cells Glucose facilitates this process and prevents hypoglycemia with this treatment NaBicarb – helps move potassium back into the cells from the blood Calcium gluconate to prevent arrhythmias Cation resins bind potassium in the gut and send it into the GI tract Chvostek sign – twitch of facial muscles when gently tapping the cheek Trousseau sign – adduction of the thumb, flexion of the wrist Etidronate and pamidronate – slows bone formation and breakdown in the body

Question 32

Protein deficit

Answer 32

Hyperalimentation – iv administration of nutrients

Question 33

Creatnine and Urine lab values

Answer 33

Normal value of creatinine is < 1mg/dL Oliguria – less than 0.5 ml/kg/hr (the production of abnormally small amounts of urine) Anuria – less than 50 ml/day (failure of kidneys to produce urine) Non-oliguria – greater than 800 ml/day (a well-maintained urine output)

Question 34

Intra-renal

Answer 34

Intra-renal (damage caused by) ATN (acute tubular necrosis) characteristics: - Intratubular obstruction - Tubular back leak (abnormal reabsorption and decreased urine outflow) - Vasoconstriction - Glomerular permeability - These result in GFR decreasing, progressive azotemia (increase in BUN and creatinine), and fluid/electrolyte imbalances Causes of Intra renal failure: - CKD - Hypertension - Diabetes - Cirrhosis - Prolonged ischemia - Trauma, burns, crush injuries - Infectious processes: acute glomerulonephritis, acute polynephritis - Nephrotoxic agents: certain antibiotics (gentamycin, tobramycin), lead, mercury, NSAIDs, radiopaque contrast agents, solvents and chemicals (arsenic) Acute glomerulonephritis Acute pyelonephritis

Question 35

Post renal

Answer 35

Post-renal: (obstruction of the urinary tract) Pressure rises in the tubules and the GFR decreases Causes: - Blood clots - Stones - Tumors - Strictures - BPH - Pregnancy

Question 36

Phases of AKI

Answer 36

-Initiation Begins with initial insult and ends when oliguria develops -Oliguria Accompanied by an increase in urea, creatinine, uric acid, organic acids, and K+ and Mg++ Urine output decreases below 400 mL in 24 hours (or 0.5 mL/kg/hr) Hyperkalemia develops -Diuresis Gradual INCREASE in urine output…glomerular filtration starts to recover Lab values stabilize and improve UOP may reach normal (or even greater than normal) levels Labs may still be abnormal Medical/Nursing mgmt. still continuing until the recovery phase -Recovery Improvement of renal function and may take from 3-12 months Labs return to normal (or clients’ baseline level) 1-3% reduction in GFR may occur; however, is not clinically significant

Question 37

AKI Phases Notes

Answer 37

Oliguria phase: - The minimum amount of urine needed to rid the body of waste products is 400 ml in 24 hours - Uremic symptoms appear first: fatigue, nausea, loss of appetite, confusion, metallic taste - Uremia is when there is an abnormally high level of waste products in the blood - The hyperkalemia develops Diuresis phase: - Still need to be monitored closely to make sure the patient doesn’t end up developing dehydration

Question 38

AKI: assessment & diagnostics

Answer 38

Urine Changes: Urinary output Urine color, clarity, odor, etc Hematuria Specific gravity decreases (one of the earliest manifestations) Decreased sodium in urine Renal sonogram, CT or MRI to determine abnormalities with anatomy BUN and creatinine increase Hyperkalemia may lead to dysrhythmias (VTACH) and cardiac arrest strict Is and Os, daily weights, foleys

Question 39

Progressive metabolic acidosis

Answer 39

r/t inability to eliminate daily acid-type substances produced in body Buffering fails Decreased serum CO2 and pH levels

Question 40

Phosphate levels increase in blood

Answer 40

decreased calcium levels in blood (decreased absorption in the intestines

Question 41

Anemia

Answer 41

r/t reduced erythropoietin production uremic GI lesions, blood loss from GI tract

Question 42

AKI Prevention

Answer 42

Continually assess renal function (urine output, laboratory values) when appropriate. Monitor central venous and arterial pressures and hourly urine output of critically ill clients to detect the onset of kidney disease as early as possible. Pay special attention to wounds, burns, and other precursors of sepsis. Prevent and treat infections promptly Infections can produce progressive kidney damage. Prevent and treat shock promptly with blood and fluid replacement. Take precautions to ensure that the appropriate blood is given to the correct client to avoid severe transfusion reactions, which can precipitate kidney disease.

Question 43

AKI Prevention II

Answer 43

Provide adequate hydration to clients at risk for dehydration, including: Before, during, and after surgery Clients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (e.g., barium enema, IV pyelograms), especially older clients who may have marginal renal reserve Clients with neoplastic disorders or disorders of metabolism (e.g., gout) and those receiving chemotherapy Clients with skeletal muscle injuries (e.g., crush injuries, compartment syndrome) Clients with heat-induced illnesses (e.g., heat stroke, heat exhaustion)

Question 44

AKI prevention III

Answer 44

To prevent infections from ascending in the urinary tract give meticulous care to clients with indwelling catheters Remove catheters as soon as possible To prevent toxic drug effects closely monitor dosage, duration of use, and blood levels of all medications metabolized or excreted by the kidneys Treat hypotension promptly

Question 45

AKI medical management

Answer 45

Eliminating underlying cause: Shock (any type); however, sepsis is most common Maintaining fluid balance Daily weights Measuring CVPs Serum and urine concentrations Fluid losses Maintaining BP Parenteral/oral intake, UOP, gastric drainage, stools, wound drainage, and perspiration are basis for fluid replacement

Question 46

AKI Medical Management II

Answer 46

Avoid fluid excesses Dyspnea, tachycardia, and JVD Crackles auscultated in lungs edema Mannitol, furosemide, or ethacrynic acid may be prescribed for diuresis IV fluids and blood / blood product transfusions For prerenal causes Dialysis to prevent complications of AKI Hyperkalemia, metabolic acidosis, pericarditis, and pulmonary edema

Question 47

AKI: pharmacologic therapy

Answer 47

Hyperkalemia: EMERGENCY!!! Potassium level greater than 5 mEq/L ECG changes (tall, tented, or peaked T waves) Irritability, abdominal cramping, diarrhea, paresthesia, and generalized muscle weakness Generalized muscle weakness, slurred speech, difficulty breathing, and paralysis Treatment: Kayexalate**** Hemodynamic instability: Low BP, AMS, and/or dysrhythmia Treatment: IV Dextrose 50%, insulin, and calcium replacement to shift potassium back into cells (temporary…so, dialysis will still be needed)

Question 48

AKI pharmacologic therapy

Answer 48

Renal dosing of medications Since many meds utilize the kidneys to filter; pharmacy can adjust medications accordingly Common meds: antibiotics, digoxin, phenytoin, ACE inhibitors, and magnesium-containing agents Sodium bicarbonate: Since client is typically more acidotic, sodium bicarb may be given; however, dialysis may still be needed for long-term effect Phosphate-binding agents: Treatment of hyperphosphatemia Calcium or lanthanum carbonate decrease levels by decreasing absorption from the intestinal tract

Question 49

CKD: Chronic Kidney Disease

Answer 49

An umbrella term describing kidney damage decrease in the glomerular filtration rate (GFR) that lasts for 3 months or longer Untreated CKD can result in end-stage kidney disease (ESKD) Final stage of CKD Results in retention of uremic waste products Need for RRT (renal replacement therapy) Dialysis, or kidney transplant Damage to kidneys is thought to be caused by prolonged acute inflammation Early stages: There can be significant damage with

Question 50

CKD: Risk Factors / causes

Answer 50

Cardiovascular disease Diabetes (primary cause) More than 35% of the US population over 20 years of age has CKD Leading cause of kidney disease in patients starting renal replacement therapy Hypertension (second-leading cause) Obesity Glomerulonephritis Pyelonephritis Polycystic disorders Nephorsclerosis Hereditary disorders More than 60 Congenital disorders Renal cancers

Question 51

Stage 1 of CKD

Answer 51

Stage I: GFR > or equal to 90mL/min/1.73 m2 Kidney damage with normal or increased GFR

Question 52

Stage 2:

Answer 52

Stage II: GFR = 60-89 mL/min/1.73 m2 Mild decrease in GFR

Question 53

Stage 3:

Answer 53

Stage III: GFR = 30-59 mL/min/1.73 m2 Moderate decrease in GFR dialysis

Question 54

Stage 4:

Answer 54

Stage IV: GFR = 15-29 mL/min/1.73 m2 Severe decrease in GFR dialysis

Question 55

Stage 5:

Answer 55

Stage V: GFR < 15 mL/min/1.73 m2 End-stage kidney disease (ESKD) or chronic kidney disease dialysis

Question 56

CKD: what to expect

Answer 56

Elevated serum creatinine levels Abnormal creatinine clearance -24 hour sample Anemia Decreased erythropoietin Metabolic acidosis Abnormal calcium and phosphorus levels Fluid retention (edema and CHF) As the disease progresses: Electrolyte disturbances heart failure worsens HTN more difficult to control

Question 57

CKD: Medical Management

Answer 57

Treat underlying cause(s) Keep blood pressure BELOW 130/80 Renal replacement therapies (RRT) Early referral Prevent complications Controlling cardiovascular risk factors Treating hyperglycemia Managing anemia Smoking cessation Weight loss Exercise Reduction in salt and alcohol intake labs before and after dialysis

Question 58

Dialysis

Answer 58

Dialysis or renal replacement therapy is indicated when advanced uremia and/or serious imbalances are present. Dialysis is typically the first-line treatment vs. kidney transplantation Dialysis is divided into 2 categories: Hemodialysis Peritoneal dialysis Continuous renal replacement therapy (CRRT) is a ‘gentler’ form of dialysis that can be done in critical care settings ONLY!

Question 59

Hemodialysis

Answer 59

Hemodialysis is basically an artificial kidney Acute, chronic, ESKD Prevents death, but does not cure kidney disease A hemodialysis system consists of 3 parts: Blood delivery system Dialyzer Dialysis fluid delivery system During dialysis, blood moves from an artery through the tubing and blood chamber, then back into the body through a vein…this occurs via an AV fistula Diffusion, osmosis, ultrafiltration Heparin is given to prevent clotting during the dialysis circuit Most persons are dialyzed three times a week for 3-4 hours each time Always assess fistula sites! You don’t give heparin because it’s a part of dialyzer.

Question 60

Before Dialysis

Answer 60

Before Dialysis: Assess Fluid status Weigh (current & previous) Vital signs Assess Fistula (shunt) Feel a thrill (vibration) Hear a bruit (swooshing

Question 61

Hemodialysis deadly complication

Answer 61

Deadly complication – DDS (dialysis disequilibrium syndrome) Restless & disoriented Vomiting Headache Priority action: Stop or slow infusion, & report to provider (can happen during or after hemodialysis)

Question 62

Hemodialysis Hold meds:

Answer 62

A (ACE & ARBS) Lisinopril, Losartan B (Beta blockers) Atenolol, metoprolol C Ca Channel Blockers Nifedipine, Verapamil, Diltiazem D Diuretics Furosemide, Hydrochlorothiazide D Dilators Nitroglycerin

Question 63

Hemodialysis washed out meds

Answer 63

Washed out Antibiotics Digoxin Water soluble vitamins (B, C, & folic acid)

Question 64

Hemodialysis Monitor for

Answer 64

Monitor for: Infection Bleeding Feel a thrill

Question 65

Hemodialysis the 5Ps

Answer 65

The 5 P’s Pale skin “pallor” Paresthesia (numbness or tingling) Pulses diminished Poor capillary refill Pain (distal to shunt) First 2 P’s are serious and need to be addressed quickly (they can loose their fistula, or worse, their extremeties

Question 66

Hemodialysis Teaching: Nos

Answer 66

NO Nos No restrictive clothing or jewelry No BP on affected arm No sleeping on arm No cream or lotions (infections) No lifting over 5 lbs. (no purse)

Question 67

AV Fistula

Answer 67

Best choice for hemodialysis made by connecting an artery to a vein optimal blood flow lowest chance of infection

Question 68

Goals of peritoneal dialysis

Answer 68

Goals of PD are to remove toxic substances and metabolic wastes to reestablish normal fluid and electrolyte balance

Question 69

Peritoneal Dialysis- Treatment of choice for

Answer 69

Treatment of choice for clients with kidney disease who are unable or unwilling to undergo hemodialysis or kidney transplantation

Question 70

A typical candidate for PD:

Answer 70

Diabetes Cardiovascular disease Those at risk for adverse effects from systemic heparin Clients with other conditions that haven’t been responsive to hemodialysis, will sometimes do well with PD.

Question 71

What happens during peritoneal dialysis?

Answer 71

A sterile dextrose dialysate fluid is introduced into the peritoneal cavity via an abdominal catheter Once this solution is in the peritoneal cavity, uremic toxins begin to be cleared from blood.

Question 72

Peritoneal Dialysis Advantages

Answer 72

More freedom More control over daily activities A more liberal diet (less fluid restrictions) Improve BP control

Question 73

Peritoneal Dialysis Disadvantages

Answer 73

7 days a week Need to increase protein & K+ in diet

Question 74

Peritoneal Dialysis Indications

Answer 74

Willingness, motivation & ability to do Strong support (family & community) Problems with HD (failing access devices, severe HTN, severe anemia, post dialysis HA HTN, uremia, and hyperglycemia easier to manage with PD

Question 75

Peritoneal Dialysis Contraindications

Answer 75

Adhesions from previous surgery Chronic back pain or disc disease Severe arthritis or poor hand strength

Question 76

Parameters and Acronyms for peritoneal dialysis

Answer 76

Acute intermittent peritoneal dialysis Not indicated for long term Usually someone who requires immediate dialysis (referred late in stage of CKD) CAPD Continuous ambulatory peritoneal dialysis Done during the day CCPD Continuous cyclic peritoneal dialysis Done at night while you sleep All PD involves a series of exchanges: Installation of dialysate (by gravity) Dwell time Drainage of fluid (by gravity

Question 77

CRRT: Continuous replacement therapy

Answer 77

ONLY DONE IN ICU- patient is very unstable Dialysis that is carried out continuously instead of over 3-4 hours, as in traditional hemodialysis cases Benefits: Can be initiated quickly Do not affect hemodynamics as often as traditional hemodialysis Used in critical care units Indicated for clients who have acute or chronic kidney disease in the following cases: Too clinically unstable for traditional hemodialysis Fluid overload secondary to oliguric kidney disease Client with kidneys that cannot handle acutely high metabolic or nutritional needs