A.

ACUTE MANAGEMENT ISSUES

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*Medical Management
Eliminating underlying cause
Maintaining fluid balance
Avoiding fluid excesses
When indicated, providing renal replacement therapy
For Prerenal azotemia, it is treated by optimizing renal perfusion, whereas
postrenal failure is treated by relieving the obstruction.
Intrarenal azotemia is treated with supportive therapy, with removal of
causative agents, aggressive management of prerenal and postrenal
failure, and avoidance of associated risk factors.
*Nutritional Therapy
Replacement of dietary proteins
Potassium or Phosphorus restriction (e.g., bananas, citrus fruits and juices,
coffee)
Following the diuretic phase, the patient is placed on high-protein, highcalorie diet and is encouraged to resume activities gradually.
*Nursing Management
Monitor complications
Participates in emergency treatment of fluid and electrolyte imbalances
Assesses the patients progress and response to treatment
Provides physical and emotional support
Keeps family members informed about the patients condition , helps
them understand the treatments and provides psychological support

B. DIALYSIS
Acute or urgent dialysis is indicated when there is a high and increasing level of
serum potassium, fluid overload, or impending pulmonary edema; increasing
acidosis; pericarditis and advanced uraemia. It also used to remove medications or
toxins (poisoning or medication overdose) from the blood or for oedema that does
not respond to other treatment, hepatic coma, hyperkalaemia, hypercalcemia,
hypertension, and uraemia.
Types of dialysis
1.) Hemodialysis
- Used for patient who are acutely ill and require short-term dialysis for
days to weeks until kidney function resumes and for patients with
advanced CKD and ESKD who require long-term or permanent renal
replacement therapy
- Done 3x a week with an average duration of 3-5 hours
- Objective: to extract toxic nitrogenous substances from the blood and to
remove excess fluid

vascular accesses:

Arteriovenous fistula joining an artery to a vein.

- This access will need time (2-3 months) to mature before it can be used.
As the AVF matures, the venous segment dilates due to the increased
blood flow coming directly from the artery
Arteriovenous graft created by subcutaneously interposing a synthetic graft
material between an artery and vein
- Usually placed in the arm but may also be placed in thigh or chest wall
- Complications: stenosis, infection, and thrombosis

2.) Continuous Renal Replacement Therapies (CRRT)

for patients with acute or chronic renal failure who are too clinically
unstable for traditional hemodialysis, with fluid overload secondary to
oliguric renal failure, and whose kidneys cannot handle their acutely high
metabolic or nutritional needs
Continuous venovenous hemofiltration
- Solute clearance occurs by convection
- No dialysate is used
- Intravenous replacement fluid is provided to replace the excess volume
that is being removed and replenish desired solutes, can be administered
either prefilter of postfilter
- Effective method of solute removal and indicated for uremia or severe
acidosis or electrolyte imbalance with or without fluid overload
- Major advantage: solutes can be removed in large quantities, maintaining
a net zero or even a positive fluid balance

Continuous venovenous hemodialysis

- Employs diffusion to replace renal function
- Dialysate is run through the filter at 1-2 L/hr.
- This results in a urea clearance of 17-34 mL/min
- One can further increase the clearance of urea by combining ultrafiltration
with the continuous hemodialysis
- Effective for removal of small to medium sized molecules

3.) Peritoneal Dialysis

Goals: to remove toxic substances and metabolic wastes and to reestablish normal fluid and electrolyte balance
Treatment of choice for patients with renal failure who are unable or
willing to undergo hemodialysis or kidney transplantation
Patients with diabetes or cardiovascular disease, many older patients, and
those who may be at risk for adverse effects of systemic heparin are likely
candidates

Approaches:
Acute intermittent peritoneal dialysis
- Indications: uremic signs and symptoms: (nausea, vomiting, fatigue,
altered mental status), fluid overload, acidosis, and hyperkalemia
- Permits a more gradual change in patients fluid volume status and in
waste product removal
- Exchange times range from 30 minutes to 2 hours
Continuous ambulatory peritoneal dialysis
- Performed at home by the patient or a trained caregiver who is usually a
family member
- Procedure allows the patient reasonable freedom and control of daily
activities but requires a serious commitment to be successful
- Less extreme fluctuations in patients laboratory values because the
dialysis is constantly in progress
- Performs exchanges 4 or 5 times a day, 24 hours a day, 7 days a week
Continuous Cyclic Peritoneal Dialysis
- Uses a machine called cycler to provide the fluid exchanges.
- The peritoneal catheter is connected to cycler machine every evening ,
usually just before the patient goes to sleep for the night
- Has a lower infection rate because there are fewer opportunities for
contamination with bag changes and tubing disconnections
- Allows patient to be free from exchanges throughout the day, making it
possible to engage in work and activities of daily living more freely