Renal

Disorders
Alexis Luigi Lorenzo C. Cresencia, RN, MD
 Classification of Renal Disorders
• Obstructive Disorders
Nephrolithiasis
Ureterolithiasis
Cystolithiasis
Polycystic Kidney Disease
Renal Artery Stenosis
• Acute Kidney Injury
• Chronic Kidney Disease
 Acute Kidney Injury
• Deterioration of kidney function over hours or days resulting in the
accumulation of toxic wastes and the loss of internal homeostasis
• Damage is reversible

Epidemiology
• Community-acquired AKI is approximately 100 per 1 million
population
• Hospital-acquired AKI
 4% of hospital admissions
 20% of critical care admissions
• Mortality rate of approximately 50%
 Pathophysiology
• Normally, the kidney receives 25% of the cardiac output.
• Decrease in renal blood flow (RBF), glomerular filtration rate is depressed
• Decreased renal blood flow injures the kidney
• The kidney tries to adapt by preserving volume that would be lost due to the
decreased reabsorptive capacity of the injured tubes
• Injured renal tubular cells lose their appropriate function, further depressing the
glomerular filtration rate
• During the period of depressed renal blood flow, the kidneys are especially
vulnerable to further insults
• Recovery from AKI is first dependent on restoration of renal blood flow
 Ischemic/Prerenal Failure
- Conditions that decrease renal blood flow causing a drop in the GFR
• Volume depletion resulting from: Clinical Manifestations
• Gastrointestinal losses (vomiting, diarrhea, • Nausea
nasogastric suction) • Vomiting
• Hemorrhage
• Diarrhea
• Renal losses (diuretic agents, osmotic diuresis)
• Decreased tissue turgor
• Impaired cardiac efficiency resulting from:
• Dryness of mucous membranes
• Cardiogenic shock
• Dysrhythmias • Somnolence
• Heart failure
• Myocardial infarction
• Vasodilation resulting from:
• Anaphylaxis
• Antihypertensive medications or other medications
that cause vasodilation
• Sepsis
 Intrarenal Failure
- Result from ischemic, toxic or immunologic mechanisms; from intrinsic disease of
renal parenchyma including glomerular, tubulointerstitial, and vascular diseases
• Prolonged renal ischemia resulting from:
• Hemoglobinuria (transfusion reaction, hemolytic anemia)
• Rhabdomyolysis/myoglobinuria (trauma, crush injuries, burns)
• Pigment nephropathy (associated with the breakdown of blood cells Clinical Manifestations
containing pigments that in turn occlude kidney structures)
• Fever
• Nephrotoxic agents such as:
• Aminoglycoside antibiotics (gentamicin, tobramycin)
• Skin Rash
• Angiotensin-converting enzyme inhibitors • Edema
• Heavy metals (lead, mercury)
• Nonsteroidal anti-inflammatory drugs
• Radiopaque contrast agents
• Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
• Infectious processes such as:
• Acute glomerulonephritis
• Acute pyelonephritis
 Obstruction/Postrenal Failure
- Arise from obstruction of urine flow
• Urinary tract obstruction, including:
• Benign prostatic hyperplasia
• Blood clots
• Calculi (stones)
• Strictures
• Tumors
Clinical Manifestations
• Difficulty in voiding
• Changes in urine flow
Classifications of Acute Kidney Injury
 Phases of Acute Kidney Injury
PHASE FINDINGS SYMPTOMS
Initiation - Oliguria
Oliguria/Oliguric • Increased BUN • Drowsiness, confusion,
Inability to excrete metabolic wastes • Increased Creatinine coma
• GI Bleeding
• Asterixis
• Pericarditis
Inability to regulate electrolytes • Hyperkalemia • Cardiac dysrhythmias
• Hyponatremia • Kussmaul breathing
• Acidosis

Inability to excrete fluid loads • Fluid overload • CHF

• Pulmonary Edema
• Neck Vein Distention
• Hypertension
 Phases of Acute Kidney Injury
PHASE FINDINGS SYMPTOMS
Diuresis/Diuretic • Hypovolemia • Urine output up to
• Hyponatremia 4-5L/day
• Hypokalemia • Hypotension
• Tachycardia
• Improving mental alertness
• Weight loss
• Dry mucus membranes
• Muscle weakness
• Constipation
Recovery • Normal laboratory -
values
• Permanent 1% to 3%
GFR reduction
 Medical Management
• Correction of any reversible cause
• Prerenal Azotemia – optimize renal perfusion
• Intrarenal Azotemia – supportive therapy
• Postrenal Failure – relieving the obstruction
• Attention to and correction of underlying fluid excess or deficits
• Correction and control of biochemical imbalances—treatment of
hyperkalemia
• Restoration/maintenance of blood pressure
• Maintenance of nutrition
• Initiation of hemodialysis, peritoneal dialysis, or continuous renal
replacement therapies for patients with progressive azotemia
 Nursing Management
Monitoring and Managing Hyperkalemia
1. Evaluate for hyperkalemia correlated with ECG changes
2. Administration of sodium bicarbonate or glucose and
insulin
3. Administer cation exchange resin (sodium polystyrene
sulfonate [Kayexalate, given as retention enema])
4. WOF cardiac dysrhythmias (cardiac arrest) and congestive
heart failure
5. Control potassium balance
6. Prepare for dialysis
 Nursing Management
Providing Electrolyte Replacement
• Acidosis: sodium bicarbonate
• Hyperphosphatemia: aluminum or calcium antacids
Monitoring for Gastrointestinal Bleeding
• Examine all stools for blood
• Administer H2-receptor antagonist (cimetidine or ranitidine) and/or
antacids as prophylaxis
• Prepare for endoscopy in case bleeding occurs
 Nursing Management
Correcting Fluid Volume Deficits or Overload
• WOF signs and symptoms of hypovolemia (dehydration) or
hypervolemia
Hypovolemia: poor skin turgor, dryness of mucous membranes,
hypotension, tachycardia
Hypervolemia: dyspnea, tachycardia, distended neck veins, crackles,
peripheral edema, pulmonary edema
• Monitor urinary output and urine specific gravity; measure intake
and output
• Monitor serum and urine electrolyte concentrations.
• Weigh patient daily; expected weight loss is 0.25-0.5 kg (1/2-1 lb.
daily)
• Provide skin care
 Nursing Management
Maintain rest/activity balance
• Provide assistance in ADLs
• Maintain strict bedrest in the acute phase
Prevent injury
• Keep side rails elevated and pad side rails if necessary
• Protect patient from bleeding
• WOF mental status changes
• Employ seizure precaution
 Nursing Management
Prevent infection
• Always maintain aseptic technique
• Isolate patient from anyone with infection
• Turn weak or immobile patients frequently
• Provide meticulous skin care
• Promote measures to relieve pruritus
Improving Nutritional Status
• Employ moderate protein restriction during oliguric phase
• Offer high-carbohydrate feedings
• Restrict foods and fluids containing potassium and phosphorus (bananas, citrus
fruits/juices, coffee)
• Encourage a high-protein, high-caloric diet after diuretic phase
 Chronic Kidney Disease
• Gradual and progressive loss of the ability of the kidneys to excrete
wastes, concentrate urine, and conserve electrolytes which fatally
ends in uremia
• Damage is irreversible
Causes:
• Chronic systemic diseases (DM, hypertension)
• Polycystic Kidney Disease
• Long standing obstruction
• Chronic glomerulonephritis
• Obstructive Uropathy
• Interstitial nephritis
• Recurrent infections
 Pathophysiology
• Some of the nephrons (including the glomeruli and tubules) are thought to remain
intact while others are destroyed
• The intact nephrons hypertrophy and produce an increased volume of filtrate with
increased tubular reabsorption despite a decreased glomerular filtration rate(GFR)
• This adaptive method permits the kidney function until about three fourths of the
nephrons are destroyed
• The solute load then becomes greater than can be reabsorbed, producing an
osmotic diuresis with polyuria and thirst
• As more nephrons are destroyed, oliguria occurs with retention of waste products
 Stages of Chronic Kidney Disease
• Decreased Renal Reserve (renal
impairment)
GFR 40%-50% of normal
BUN and creatinine normal
Asymptomatic
• Renal Insufficiency
GFR 20%-40% normal
BUN and creatinine begins to rise
Mild anemia, mild azotemia
Polyuria, nocturia
• Renal Failure
GFR 10%-20% of normal
BUN and creatinine increase
Anemia, azotemia, metabolic acidosis
Polyuria, nocturia
• End-stage renal disease
 GFR <10% of normal
 BUN and creatinine severely
increased
 Anemia, azotemia, metabolic
acidosis, bleeding
 Oliguria
 Signs of CHF
 Hypocalcemia,
hyperphosphatemia,
hyperkalemia, hyponatremia
 Fractures, joint pains
 Signs of renal failure
 Uremia
 Infertility, amenorrhea
 Clinical Manifestations
Initial symptoms may include the following: • Muscle twitching or cramps
• Unintentional weight loss • Seizures
• Nausea, vomiting • Uremic frost - deposits of white crystals in and on
• General ill feeling the skin
• Fatigue • Decreased sensation in the hands, feet, or other
• Headache areas
• Frequent hiccups
Additional symptoms that may be associated with
• Generalized itching (pruritus)
this disease:
Later symptoms may include the following:
• Excessive nighttime urination
• Increased or decreased urine output
• Excessive thirst
• Need to urinate at night
• Easy bruising or bleeding; • Abnormally dark or light skin
• May have blood in the vomit or in • Paleness
stools • Nail abnormalities
• Decreased alertness • Breath odor
• drowsiness, somnolence, lethargy • High blood pressure
• confusion, delirium • Loss of appetite
• coma • Agitation
 Diagnostic Findings
• Glomerular Filtration Rate – decrease
• Serum creatinine and BUN – increase
• Creatinine clearance – decrease
• Anemia – EPO
• Sodium and water retention
• Acidosis (metabolic)
• Calcium and phosphorus imbalance
• Low serum proteins, especially albumin
• Urinalysis
• KUB-UTZ
 Medical Management
Goal: Conservation of renal function and homeostasis as long as possible
• Detection and treatment of reversible causes of renal failure
• Dietary regulation – low-protein diet supplemented with essential amino acids or
their keto analogues
• Treatment of associated conditions to improve renal dynamics
- Anemia – recombinant human erythropoietin (epoetin alfa[Epogen]), a
synthetic kidney hormone, iron, Folate and Vit B12 and blood transfusion
- Acidosis – sodium bicarbonate
- Hyperkalemia – restriction of dietary potassium; administration of potassium-
binding agents
- Phosphate retention – decrease dietary phosphorus (chicken, milk, legumes,
carbonated beverages); administer phosphate-binding agents (Calcium
Carbonate/Acetate)
• Maintenance dialysis or kidney transplantation when symptoms can no longer be
controlled with conservative management.
 Nursing Management
Monitoring for potential complications
• Cardiovascular disease; congestive heart failure; pericarditis
• Hypertension
• Anemia
• Chronic metabolic acidosis
• Hyperlipidemia
• Hyperuricemia
• Renal osteodystrophy – renal bone disease, as uremia is associated
with abnormal calcium metabolism, which causes bone pathology
• Paresthesia; neurologic abnormalities
 Nursing Management
Achieving & Maintaining Fluid and Electrolyte Balance
• Assess intake and output every 8 hours.
• Weigh patient everyday.
• Assess presence and extent of edema.
• Auscultate breath sounds.
• Monitor cardiac rhythm and blood pressure every 8 hours.
• Assess level of consciousness every 8 hours.
• Encourage patient to remain within prescribed fluid restrictions.
• Encourage a diet high in carbohydrates and within prescribed
sodium, potassium and protein limits.
• Administer medications as ordered.
• Monitor for acidosis
 Nursing Management
Maintaining nutrition to conserve renal function as long as possible
• Protein should be of high biologic value, rich in essential amino
acids (dairy products, eggs, meat)
• Low-protein diet may be supplemented with essential amino acids
and vitamins
• As renal function declines, protein may be restricted
proportionately
• Protein will be increased if patient is on a dialysis program to allow
for loss of amino acids during dialysis
• Ensure high calorie intake
• Encourage intake of hard candy, jelly beans, jellies, and flavored
carbohydrates powders
• Monitor nutritional state: body weight, anthropometric
measurements, serum albumin and nitrogen balance
 Nursing Management
Prevent infection and promote skin integrity
• Use measures to produce vasoconstriction; cool environment,
removal of excessive bedding
• Provide tepid, cooling baths or cool wet dressings
• Eliminate irritants; apply emollient lotions
• Promote meticulous skin care
• Maintain good medical/surgical asepsis
• Encourage use of soft toothbrush.
• Protect confused person from injury.
• Protect person from infectious agents.
 Nursing Management
Relieving Constipation
• Encourage high-fiber diet, bearing in mind the potassium content of
some fruits and vegetables
• Commercial fiber supplements (Fierall; FiberMed) may be
prescribed
• Give stool softeners as prescribed
• Avoid laxatives and cathartics that can cause electrolyte toxicities
(compounds containing magnesium or phosphorus)