Renal lecture

nephron and glomerulus

glomerulus and tubules

creatinine

end product of protein metabolism

• adult:  5-25mg/dl
• elderly:  May be slightly higher

• breakdown of skeletal muscle
• good measure of GFR
• more sensitive indicator of kidney disease

• adult:  0.5-1.5 mg/dL
• elderly:  decreased due to muscle loss

24 hour urine collection to check GFR

• obtain physician order
• keep on ice
• discard the first void of the morning, then start the collection
• if miss a voiding, must start over
• midway through will have a serum creatinine drawn

urine clearance:  1-2g/24 hours

how fast kidneys filter wastes and fluids

125 mL/min to 200 mL/min

• sudden, reversible kidney function loss
• may be almost complete
• occurs in hours or days
• can resolve itself or go into chronic renal failure

• dyspnea
• tachycardia
• neck vein distention
• moist crackles in lungs
• generalized edema
• appear acutely ill
• lethargic
• dry mm
• HA
• seizures
• twitching
• decreased UOP

diabetes

HTN

caused by volume depletion

ex:  hemorrhage, GI bleed, HF, sepsis, vasodilation, MI

due to some sort of ischemia or necrosis

ex:  drugs, dyes,

due to obstruction

ex:  BPH, tumors, stones, blood clots, strictures

• initiation
• oliguria
• diuressis
• recovery

from time of insult to when oliguria occurs

<400-500 mL/day

• lab values increase
• decreased renal function
• lasts about 10-20 days

< 50mL in 24 hours

• gradual ^ in UOP
• lab values stop increasing

kidneys start to work again

• lab values return to normal
• GFR is 1-3% reduced and not really noticeable to pt
• lasts about 3-12 months

• restore fluid balance
• provide nutritional therapy
• medication regimen

• lab monitoring
• accurate I/O
• restrictions
• dialysis may be needed

• provide ^ carbohydrate diet
• limit Na+ and K+

• temporary management (Insulin, Ca+ gluconate)
• diuretics
• cardiac medications

protects the heart

• helps lower K+ via the "gut"
• can cause diarrhea

high biological protein diet

ex:  eggs, meat

low protein, high carb diet

• decreased PR
• widened QRS
• peaked T

daily treatments:  I/O, daily wt, assessment, monitor labs, ASEPSIS!!!, complication prevention

prevention and support

education:  dietary (fluid restrictions), fluid imbalance

1

progressive, nonreversible

body fails to maintain the fluid and electrolyte balance

• edema
• engorged neck veins
• HTN
• HF

• pruritis
• uremic frost
• thin hair
• brittle nails

• hiccups
• constipation
• diarrhea
• anorexia
• metallic taste

• weakness
• inability to concentrate
• msucle twitching
• seizures
• asterixis

flapping of hands

• give information in writing
• repeat teaching
• teach in small increments due to inability to concentrate
• make sure family present

• crackles
• SOB
• thick tenacious sputum

• muscle cramps
• muscle loss
• bone pain
• foot drop

• body changes
• grieving stages (anger, depressed)

• stage 1
• stage 2
• stage 3
• stage 4
• stage 5

• no symptoms
• *GFR > or = to 90 mL/min
• higher than normal levels of creatinine or urea in the blood
• blood or protein in urine
• evidence of kidney damage in an MRI, CT, US, contrast XR

• no symtoms
• *GFR is = to 60-89 mL/min
• care is viligant o reduce risk factors for kidney disease

• *GFR is 30-59 mL/min
• moderate, chronic kidney disease
• care is focused to slow progression of disease through diet and increased vigilance to avoid hypoperfusion, toxins, and other risk factors
• *start having s/s
• *should start seeing nephrologist

• *GFR is 15-29 mL/min
• likely to develop complications of kidney disease such as HTN, anemia, bone disease, heart disease, and other CV diseases
• *s/s:  nausea, taste changes, uremic breath, loss of appetite, difficulty in concentrating, nerve problems
• *will probably begin thinking about dialysis, probably get dialysis access so it has time to heal

treatment, NOT A CURE!

• *<15 mL/min
• s/s:  loss of appetite, N/V, HA, being tired, being unable to concentrate, itching, making little or no urine, swelling (especially around the eyes and ankles), muscle cramps, tingling in hands or feet, changes in skin colo, increased skin pigmentation
• *have to intervene or pt will die

FYI:  may be referred to as ESRD

• ARF
• reversible
• survival is fluid electrolyte monitoring
• may be caused by meds, trauma, MI, HF, renal obstruction

• CRF
• nonreversible
• survivial means lifetime dialysis or transplant
• may be caused by

• progressive cutaneous necrosis that often occurs in about 1% of CKD/ESRD
• happens distally in toes, fingers, glans penis, abd, trunk, buttocks
• calcium deposits line the vessels (like having rocks in the blood)
• rare, often fatal (80%)
• ?

• goal:  maintain kidney function for as long as possible by treating underlying conditions
• pharmacological
• nutrition
• dialysis  *treatment, NOT A CURE!
• kidney transplant *treatment, NOT A CURE!

TUMS

• epogen
• procrit

can take 3 wks - 1 mth to start working

reglan

blood pressure meds

• low in K+
• low in Ph
• low in Na+
• encourage positive foods
• avoid saying "don't eat this or that..."

rice, spaghetti, oatmeal, cream of wheat, peach, grape, apple, lemons, helly, unsalted pretzels, soaked potatoes, mushroom

grapes, apples, pineapple, cranberry, strawberry, pasta, broths, soy milk, lettuce, cabbage, green beans

some lean meats, applesauce, figs, pears, plum, tea, coffee, alcohol, lamb, veal, turkey, lollipops, caramel

• assess, assess, assess to prevent complications
• teach, teach, teach to increase independence
• promote, promote, promote responsible f/u and self-care
• support, support, support self-esteem, self-care, independence

• normal kidney function decreases w/ age
• glomerular filtration decreases altering lab values
• watch for dehydration
• mental assessment is difficult due to already changes/atrophy
• dx, tx may be delayed due to masking symptoms
• conservative measure may be used

• HD (hemodialysis)
• PD  (peritoneal dialysis)

• vascular access
• running circuit
• dialyzer and dialysate
• blood flow rate
• continuous renal replacement therapy (CRRT)
• pre-lab and dry wt
• diet
• schedules

• Tenckhoff access
• continuous ambulatory peritoneal dialysis (CAPD)
• continuous cyclic peritoneal dialysis (CCPD)
• diet
• activites/schedules

• CRRT
• continuous renal replacement therapy

peritoneal

• catheters
• temporary access
• subclavian, jugular, femoral
• can be used immediately
• high infection rates
• high clotting rates
• severeal months use
• tessio catheter
• upper chest near collar bone
• SC device

• direct connection between pt's artery and vein
• goal is an AV fistula
• last the longest
• less prone to infection
• placed in non-dominant FA
• allowed 14 days to mature and can be used in a few months

• indirect conncetion of vein and artery though an artificial synthetic tube
• usually placed in upper FA
• can be placed in upper arm and thigh
• clots and easier to become infected (foreign body)
• artegraft access in 10 days

• blood does not flow to hand
• hand becomes cold, pale
• decreased pulse distal to fistula or graft
• painful distal to fistula or graft

feel the thrill, hear a bruit

graft

• used in ARF and CRF in pt not stable for hemodialysis
• need a double lumen venous access
• "this tx tries to emulate the normal function of the kidneys.  It is slow and continuous."

• need surgical permanent access (Tenckhoff)
• 2-3 wks to heal
• prevent trauma and infection

• peritoneum is very vascular
• osmosis for removing water and fluid
• diffusion for removing particles
• CAPD: long dwells, daytime, QID
• CCPD: short dwells, night, 8 hrs, cycler required

• results from cerebral fluid shift
• H/a, n/v, restlessness, decrease loc, seizures

• avoid dialysis
• improve well-being by not having to have to go to dialysis or have accesses taht clot or need to be changed
• more freedom
• able to lead more of a normal life
• cost

• someone w/ 2 healthy kidneys gives up a kidney to help anyone
• can be anonymous if chosen by donor

wanting to give a kidney to someone who is noncompatable so find someone who is a match

"you pat my back and i'll pat yours"

• compatibility testing
• diagnostic testing
• dental exam and cleaning
• psychological evaluation
• hemodialysis the day before if already been on dialysis
• must be free from infection
• permits
• nursing must do peroperative teaching to include NPO, TCDB, pain control

no

• goal:  maintain homeostasis until new kidney is functioning
• recognize signs of rejection
• prevent infections
• mointor urinary function
• address psychological concerns
• prevent complications
• early ambulation
• watch for side effects of immunosuppressant therapy

immunosuppresant therapy lowers immune system and increases risk of infection

• immuran?
• antibiotics
• cellcept?

rejection and failure can occur from within 24 hours (hyperacute), within 3-14 days (acute), or after years (chronic)

• oliguria
• edema
• fever
• increased B/P
• wt gain
• swelling or tenderness over surgical site

• shaking
• chills
• fever
• tachycardia
• tachypnea

• teach LIFE TIME f/u is necessary
• teach drug regimen
• review s/s of infection and rejection
• avoid contact sports
• teach to inform all healthcare teams of transplant (ex:  dentist)

90% of potassium is excreted by the kidneys

3.5-5.3mKg/l

• abominal cramps
• twitching
• tingling
• slow pulse
• peak T and Wide QRS and disappearing P wave
• cardiac arrrest

• dizziness
• hypotension
• n/v/d
• muscle weakness
• leg crampts
• decreased perastalsis
• polyuria
• depressed ST flat or inverted T wave

• maintains body fluids
• conduction of neurmuscular activity
• regulates acid/base balance

135-145 meq/L

• restless
• flushed
• sticky membranes
• rough dry tounge
• fast pulse
• thirsty
• htn

• apprehension
• anxiety
• muscular twitching
• weakness
• h/a
• confusion tachycardia
• hypotension

maintains body fluid balance and acid base balance

95-105 mEq/l

• weakness
• deep rapid breathing
• lethargy

• slow shallow breathing
• hyperactivity of the nervous system
• hypotension

negative

4.5-8.0 with an avg of 6

• restlessness
• confusion
• sweet smelling breath

normally not present

1.005-1.030

determines urine concentration

• 50-1200 mOsm/kg/H2O
• avg is 200-800

the end product of protein metabolism

• 5-25mg/dl
• (elderly may be slightly higher)

• decreased urine output
• fast pulse
• decreased BP
• increased resp
• high protein diet

• low protein diet
• high carb
• continuous dextrose infusion

• breakdown of skeletal muscle
• good measure of GFR
• more sensitive indicator of kidney disease

• 0.5-1.5mg/dl
• in elderly it is decreased due to muscle loss

• dehydration
• hypovolemia

people with small muscle mass / amputations/ muscle disease usually have low creatinine levels

24 hour urine collection to check GFR

• 1-2g/24 hours
• it is decreased in elderly and females

strenuous exercise

how fast kidneys filter wastes and fluid

125ml/min- 200ml/min

• combines with calcium for bones/teeth strength
• maintenance of acid base
• promotion of nerve/muscle activity

• 2.5-4.5mg/dl
• in elderly it is slightly lower

• tetany
• decreased renal output

• anorexia
• bone and muscle pain

• found in bones/teeth
• necessary for nerve impulses and myocardial contration
• strengthens capillary membranes
• cuases blood to clot by converting prothrombin to thrombin

9-11mg/dl

• lethargy
• h/a
• weakness
• muscle flaccidity
• heart blocks
• anorexia
• n/v
• digitalis toxicity
• thiazide diuretics

• tetany
• twithcing
• tremors
• laryngeal spasms
• numbness and tingling
• prolonged ST and lengthened QT intervals

used to transport Na and K across the cell membrane

1.5-2.5meq/L

• flushing
• increased sweating
• peak t wave and wide qrs
• diminished reflexes
• hypotesnive
• sedation
• muscle weakness

• tetany
• neuromuscular irritability
• muscle cramps
• tingling
• resless
• confusion
• inverted t wave

needed in cells for energy

• 70-110mg/dl
• in elderly 70-120mg/dl

• excessive thirst
• polyuria
• excessive hunger w/ weight loss
• rapid deep breathing
• kussmauls

• nervousness
• rapid pulse
• diaphoresis
• weakness
• clammy/cold skin
• confusion

• Acute
•  Reversable   
• Survival is fl and electrolyte   monitoring   
• May be caused by medications,   trauma, MI, heart failure, renal obstruction 
• chronic
•  Progressive   
• Survival means lifetime dialysis   or transplant  
• May be caused by other systemic   diseases such as DM, HTN or can be from medications

• pre-renal
• intra-renal
• post-renal

• volume depletion
• fluid loss

kidneys start to die and ischemia occurs

there is an obstruction

• hemorrhage
• gi bleed
• HF
• MI
• vasodilation

• nephrotoxic drugs
• dyes and contrast

• kidney stones
• bph
• tumors
• blood clots
• strictures

• initiation phase
• oliguria phase
• diuresis phase
• recovery phase

from the time of the insult to the oliguria phase occurs (UO less than 400-500ml/24hrs)

• lasts about 10-20 days
• lab values increase
• decreased renal function
• blood count decreases

• there is a gradual increase in urine output
• lab values stop increasing

• lasts about 3-12 months
• lab values return to normal
• GFR is 1-3% reduced and not really noticed by patient

• Stage 1- at risk for CKD
• Stage 2- mild risk for CKD
• Stage 3- moderate risk for CKD
• Stage 4- severe CKD
• Stage 5- ESRD

> = 90

60-89

30-59

15-29

15 or <

• caused by waste product build uo
• HTN
• anemia
• early bone dz
• brittle nails
• Fatigue
• fl excess
• urination changes
• kidney pain
• sleep problems

• same as stage 3 plus
• nausea
• taste changes
• uremic breath
• loss of appetite
• difficulty in concentrating
• nerve problems
• anemia
• fluid buildup
• numbness
• tingling

• kidney failure
• Loss of appetite
• n/v
• HA
• tired
• unable to concentrate
• itching
• making little or no urine
• swelling esp around eyes and ankles
• muscle cramps
• tingling in hands or feet
• changing in skin color
• increased skin pigmentation
• anemia
• resp problems

reduce risk factors for kidney dz

• Try to Keep pt in stage 3
• monitor q6months
• Monitor labs
• See a nephrologist

teaching patient regarding dialysis and either put an access in or start considering it

dialysis

• tums
• oscal
• titrolac

to prevent blood transfusions, stimulates bone marrow to produce cells

problems with diabetic gastroporesis

• to lower phosphate level
• given with the first bite of food

• high carb
• low potassium
• low sodium
• low phosphorus

• rice
• spaghetti
• oatmeal
• cream of wheat
• peach
• grape
• apples
• lemons
• jelly
• unsalted pretzels
• soaked potatoes
• mushroom

• grapes
• apples
• pineapple
• cranberry
• strawberry
• pasta
• broths
• soy milk
• lettuce
• cabbage
• green beans

• some lean meats
• applesauce
• figs
• pear
• plum
• tea
• coffee
• alcohol
• lamb
• veal
• turkey
• lollipops
• caramel

• used in ARF and CRF in pts not stable for hemodialysis
• Need a double lumen enous access
• tries to emulate the normal function of the kidneys
• slow and continuous
• Runs slow and continuous
• for Unstable patients

• has to be done qid
• patient does it during the day
• long dwell times (when fluid is in the patient)

• Direct connection of vein and artery
• Goal is a AV fistula
• Last the longest
• Less prone to infection
• Placed on non dominant forearm
• Allowed 14 days to mature and can be used in a few months

• Indirect connection of vein and artery through an artificial synthetic tube
• Usually placed in forearm.
• Can be placed in upper arm and thigh

• surgically placed
• takes 2-3 weeks to heal
• PREVENT TRAUMA, and INFECTION