ACUTE & CHRONIC

KIDNEY INJURY
Cooper/Burian/Pearson
Renal Physiology
Functions of the Kidney
Regulation of water/fluid balance
Regulation of electrolytes
Regulation of acid-base balance
Regulation of blood pressure
Excretion of metabolic waste products & drug
metabolites
Production of hormones
Assessment of Renal
Function
BUN (Blood Urea Nitrogen)
Creatinine
BUN: Creatinine Ratio Normal 10:1 to 20:1
GFR (Glomerular Filtration Ratio)
Urine Analysis
Urine Culture
Additional Signs of Kidney
Dysfunction
Low urine output
Fluid overload
SOB, Chest pain
Electrolyte imbalances
Azotemia (nitrogen in the blood)
Uremia (urine in blood)
Phases of Acute Renal Failure

Initiating Phase or Onset

Urine output < 0.5 ml/kg/hr
Oliguric (Anuric) Phase
Urine Output 100-400 ml/day
Diuretic Phase
Urine Output > 400ml day
Recovery Phase
GFR returns to 70-80% of normal
Acute Renal Failure (ARF)

3 Causes:
Post-renal
Pre-renal
Intra-renal
Acute Renal Failure (ARF)
Pre-renal Failure

Kidney is structurally and functionally normal

Causes?
Elevated BUN, normal creatinine, elevated ratio
Management of Pre-renal
Failure
Determine & treat cause of hypoperfusion
i.e. sepsis, GI bleed, blockage, etc.
Volume replacement
NS Goal CVP=12 and MAP >70
Pressors or inotropes if required
Monitor for overload
Renal artery obstruction requires intervention
Angioplasty
Stent placement
Intra-renal Failure

Renal tubules and basement membranes are

damaged
Causes?
Elevated BUN &
Creatinine,
normal ratio
Additional Management of
Pre & Intra-renal Failure
Adjust medications
avoid nephrotoxic agents, renal dosing
Adjust diet
renal diet (low protein, PO4, Ca, Na, K)
Administer diuretics
Loop-Furosemide, Torsemide (monitor for low K, Ca)
Thiazides-Hydrochlorothiazide (monitor for low K, high Ca)
Potassium sparing-Spironolactone (monitor for high K, low Na)
Osmotic- Mannitol (monitor for low K, Na)
Manage electrolyte abnormalities
Consider dialysis or CRRT
Post-renal Failure

Resolves rapidly with

removal of obstruction
Causes?
Management?
Elevated BUN,
Creatinine & ratio
Acute Kidney Injury vs.
Chronic Kidney Disease

Acute Chronic
Causes Causes
Phases Phases
Management Management
Concerns Concerns
Stages of Chronic Kidney
Disease
Electrolyte Imbalances &
Treatments
Severe Acidosis
Treatment?
Hypocalcemia
Treatment?
Hyperphosphatemia
Treatment?
Hyperkalemia
Treatment?
Effects of Hyperkalemia on
Electrocardiogram
Indications for Dialysis

Hyperkalemia (> 6.5 or >7.0)

Severe metabolic acidosis (<7.0)
Symptomatic fluid overload
Azotemia (BUN>100)
Symptomatic Uremia
Toxic overdoses
ESRD (Stage V CKD)
Basic function of Dialysis
Dialysis Filters
Types of Access Peritoneal Dialysis Access

AV Fistula

Vas Cath

AV Graft
Types of Dialysis

Hemodialysis (acute or long term)

Short, frequent but intermittent treatments
Risk for disequilibrium syndrome
Peritoneal Dialysis (long term)
Slower dialysis, simple equipment
Risk for infection
CRRT (Continuous Renal Replacement Therapy
24 hour, continuous treatment
For patients that are hemodynamically unstable
Requires ICU level 1:1 nursing
https://youtu.be/0EqN1EAf0B4
Nursing Management

Hemodialysis
Fluid balance goal determined by nephrologist
Monitor VS and volume status during removal
Hold medications that may be cleared during dialysis
Draw labs, administer blood or EPOGEN (epoetin alfa)
CRRT
Maintain patency of the system, heparin or citrate
Determine hourly fluid needs and hourly filtration rate
Close monitoring of VS, hemodynamics and I/O, frequent labs
Monitor for bleeding, infection, issues with machine
CRRT

https://youtu.be/dVwH7
TdoEc4
Questions

Of the following patients in an intensive care unit, the nurse

identifies which patient as being at highest risk for the
development of acute kidney injury with a prerenal cause? A
patient who is:
1. Experiencing acute status asthmaticus
2. Being treated for hypertension following a cerebral vascular
accident
3. In skeletal traction following a motor vehicle accident
4. Post-operative from a ruptured abdominal aortic aneurysm
Questions

A patient in the intensive care unit is reported to be in the

oliguric phase of intrinsic renal failure, which is reflected by:
1. Urine output of less then 400 mL/day
2. BUN and creatinine that may begin to increase slightly
3. Urinary output of up to 5 liters of urine each day
4. Abnormal laboratory values that can last from 6 months to
a year in duration
Questions

A nurse plans to administer to a patient a fluid challenge for

the purpose of establishing normal renal perfusion. What
does this treatment involve?
1. Infusing 250 mL of 0.9% sodium chloride over 1 hour
2. Administering albumin intravenously, followed by
furosemide
3. Infusing 500 mL of normal saline over a 30-minute period
4. Giving twice the amount of IV fluid each hour compared to
urinary output
Questions

What will the nurse do when caring for a patient with an

atrioventricular fistula in the forearm for hemodialysis?
1. Percuss the fistula for presence of a bruit each shift
2. Take the blood pressure in the unaffected arm
3. Position the patient so there is pressure on the access area
4. Flush the fistula with heparin every shift
Questions

The intensive care nurse is reviewing a patient's chart to find

the most accurate indicator of fluid volume status, which is:
1. Intake and output
2. Daily weights
3. Hematocrit level
4. Systolic blood pressure
Questions

The critical care nurse is providing a training session on the

principles of renal replacement therapies. When discussing
how solutes move across a semipermeable membrane from a
higher to lower concentration, the nurse is describing:
1. Ultrafiltration
2. Diffusion
3. Active transport
4. Osmosis