Renal & Urologic Problems (Chapters 45 & 46)

Differences
Acute kidney injury (AKI)
 Sudden
 Acute reduction of urine output or abrupt increase of serum creatinine
 Potentially reversible
 #1 cause of death is infection
Chronic kidney disease (CKD)
 Progressive/gradual
 GFR < 60 mL/min for 3 months
 Irreversible
 #1 cause of death is CAD

Chronic kidney disease (CKD)

 Progressive and irreversible
 CVD leads to death
 Diabetes and HTN leading causes
Stages
 Stage 1
o Normal GFR > 90
o Damage
 Stage 3
o GFR = 45
o Treatment starts
 Stage 5
o GRF < 15 mL/min
o Dialysis
o ESRD
Symptoms (pg. 1067)
 Uremia
o GRF < 15
o Renal function decrease leads to symptoms in multiple organs
 Cardiovascular
 o HTN (both cause & effect)
o HF
o PAD (vascular calcification)
o High potassium levels lead to dysrhythmias (7 – 8)
 Gastrointestinal
o Anorexia
o N/V
o GI bleeding
 Endocrine
o Hyperparathyroidism (Ca+)
o Abnormal thyroid function
 Metabolic
o Carbohydrate (CHO) intolerance
o Increased cholesterol levels
 Both related to insulin resistance
 Hematologic
o Anemia
 Decrease in erythropoietin
 Iron deficiency
 Dialysis damaging RBC
o Bleeding
 Platelet defect
o Increased infections
 Related to change in WBC function
 Neurologic
o Fatigue
o Headaches
o Sleep disturbances
o Peripheral neuropathy (RLS)
o Paresthesias
 Eyes
o Hypertension or diabetes causing retinopathy
 Skin
o Pruritus
o Ecchymosis
o Scaly skin
 Musculoskeletal
o Vascular & soft tissue calcification
o Osteomalacia
 Both from no vitamin D (to move Ca+ into bones)
 Pulmonary
 o Pulmonary edema
o Pneumonia
o Pleural effusions (pleural space between linings of lungs)

Diagnostics
 Labs (serum)
o BUN
o Cr
o GFR
o K+
 Urine
o Proteinuria
o Albuminuria
 Both show renal damage
 Renal ultrasound
Treatment
 Goals
o Preserve renal function (stages 1 – 4 / no point at stage 5)
o Decrease CVD risk
o Prevent complications
o Comfort

Interventions
 Lower K+
 Control BP
 Treat bone disease (get calcium into bones)
 Correct anemias (i.e., Epogen, iron supplements)
 Statin medication class (lower cholesterol)
 Diet
o 2g Na+
o 2g K+
o Fluid restriction (1500 – 2000 mL daily)
o Phosphate restriction (or phosphate binder medication – only if eating)
o Protein in normal levels (protein is damaging to kidneys)
 Peritoneal dialysis = Increased protein

Hyperkalemia (pg. 1063)

 Range: 3.5 – 5 mcg/L
Treatment
 K+ wasting diuretic (furosemide/Lasix)
o Stop K+ sparing diuretics (spironolactone/Aldactone)
 Stop K+ supplements (salt substitutes have K+)
 Insulin (regular)
o Causes K+ to shift into cells
o Causes hypoglycemia (watch blood glucose + treat with dextrose)
 Decrease dietary intake (know what food are high in K+)
 Hemodialysis (most effective)
o Need access (CVAD, tunneled, 2 lumens / i.e., Groshong)
 Sodium polystyrene sulfonate/Kayexalate (PO or rectal)
 Sodium Bicarbonate (causes acidosis so K+ shifts to cells)
 Patiromer/Veltassa
o Binds K+ in the gut
o Takes longer

Serum sodium (Na+) *where sodium goes, water follows*

 Serum Na+ swells = reflect the ratio of Na+ to water
 Na+ is lost through sweat, urine, & stool
o Urine loss from kidneys response to ADH
 Na+ levels can be due to:
o Water imbalance
o Na+ imbalance
o Combination both

Hypernatremia
 Can be from:
o Inadequate water intake
o Excess water loss
o Na+ gain

Renal replacement therapy

 Based on osmosis & diffusion
Hemodialysis
 Vascular, needs rapid blood flow
  AV graft
o Synthetic material
 AV fistula
o Join artery to vein directly
 Cannulate (14 or 16 gauge needles x 2)
 Nursing considerations
o Patient will have limb restriction
o Listen for bruit & feel for thrill
o Check distal blood flow
o Risk for infection, clotting, & hepatitis (B & C)
o Do not give antihypertensives or meds that will be dialyzed out before treatment
 Complications during treatment
o Hypotension
o Muscle cramps
o Blood loss

Peritoneal
 Catheter (24 in.) inserted into anterior abdominal wall
 Exchange (happens every 6 hours)
o Inflow dialysate
o Dwell 4 – 6 hours
o Drain abdomen
 Dialysate (2 – 3 L)
o Dextrose (can increase blood glucose)
 Cycler = automated peritoneal dialysis
o Happens at night
 Complications
o Exit site infection
o Peritonitis
o Low back pain (lots of fluid in abdomen)
o Hernia
o Pulmonary issues
o Bleeding/frank blood (rare)
o Protein loss
 High protein diet