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CHAPTER 20
Kidney Disorders and Therapeutic
Management
ACUTE KIDNEY INJURY
Acute kidney injury (AKI)
 Critical illness and AKI
Longer hospital stay, more complications, and
higher mortality
Multisystem dysfunctions
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ACUTE KIDNEY INJURY (CONT.)
Definitions of AKI
 RIFLE criteria
 Acute Kidney Injury Network (AKIN) criteria
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ACUTE KIDNEY INJURY (CONT.)
Types of AKI
 Prerenal acute kidney injury
 Intrarenal acute kidney injury
 Postrenal acute kidney injury
Azotemia
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QUICK QUIZ!
Any condition that decreases blood flow, blood pressure, or kidney
perfusion before arterial blood reaches the renal artery that supplies the
kidney may be anatomically described as which kind of AKI?
A. Prerenal
B. Intrarenal
C. Postrenal
D. Both A & B
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ASSESSMENT AND DIAGNOSIS
Laboratory assessment
 Acidosis
 Blood urea nitrogen (BUN)
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ASSESSMENT AND DIAGNOSIS (CONT.)
Laboratory assessment (Cont.)
 Serum creatinine
 Creatinine clearance
 Fractional excretion of sodium (FENa)
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY
Underlying chronic kidney disease (CKD)
Older age and AKI
Heart failure and AKI
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Respiratory failure and AKI
Sepsis and AKI
Trauma and AKI
 Trauma admissions
 Rhabdomyolysis
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Contrast-induced nephrotoxic injury and AKI
 Radiopaque contrast
 Promote hydration and avoid dehydration
 Medications
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Catheter-associated urinary tract infection (CAUTI)
Hemodynamic monitoring and fluid balance
 Hemodynamic monitoring
 Daily weight
 Physical assessment
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QUICK QUIZ!
A 1-kg weight gain over 24 hours represents how many units of additional
fluid retention?
A. 10 mL
B. 100 mL
C. 1000 mL
D. 2000 mL
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Electrolyte balance
 Potassium
 Sodium
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Electrolyte balance (Cont.)
 Calcium and phosphorus
 Calcium replacement
 Dietary-phosphorus–binding medications
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Medical management
 Treatment goals
 Prevention
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Medical management (Cont.)
 Fluid resuscitation
Crystalloids
Colloids
 Fluid restriction
 Fluid removal
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Pharmacologic management
 Diuretics
Loop diuretics
Thiazide diuretics
Osmotic diuretics
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Pharmacologic management (Cont.)
 Diuretics (Cont.)
Carbonic anhydrase inhibitor diuretics
Potassium-sparing diuretics
Vaptans
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Pharmacologic management (Cont.)
 Dopamine
 Acetylcysteine
 Dietary-phosphorus binders
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Nutrition
Nursing management
 Risk factors for AKI
 Infectious complications
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AT-RISK DISEASE STATES AND ACUTE
KIDNEY INJURY (CONT.)
Nursing management (Cont.)
 Fluid balance
 Electrolyte imbalance
 Preventing anemia
Erythropoiesis-stimulating medications
 Patient education
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RENAL REPLACEMENT THERAPY:
DIALYSIS
Hemodialysis
 Hemodialyzer
 Ultrafiltration
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
Hemodialysis
(Cont.)
 Anticoagulation
 Vascular access
Temporary
vascular access
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
Permanent
vascular access
 Arteriovenous fistula
 Arteriovenous graft
 Tunneled catheters
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
Medical management
Nursing management
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
Continuous renal replacement therapy (CRRT)
 May continue over several days
 Hemofilter
 Electric roller pump
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
CRRT (Cont.)
 Continuous Renal Replacement Therapy Terminology
Diffusion
Convection
Absorption
Ultrafiltrate volume
Replacement fluid
Anticoagulation
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
CRRT (Cont.)
 Modes of continuous renal replacement
Slow continuous ultrafiltration (SCUF)
Continuous venovenous hemofiltration (CVVH)
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
Peritoneal dialysis (PD)
 Dialysate
 Infusion
 Drainage
 Dwell time
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
PD (Cont.)
 PD catheter
placement
 Infection
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RENAL REPLACEMENT THERAPY:
DIALYSIS (CONT.)
PD (Cont.)
 Medical management
 Nursing management
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SUMMARY
AKI
 AKI risk factors include sepsis, cardiac surgery, and diabetes.
 Many critically ill patients have AKI as a complication of their illness; if AKI
develops, mortality and morbidity rates increase.
 Vigorous hydration with normal saline is the most effective intervention to
prevent contrast-induced neuropathy and AKI.
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SUMMARY (CONT.)
CAUTI
 CAUTI remains a significant risk in critical illness.
 Prevention strategies include avoiding unnecessary use of urinary catheters;
insertion of urinary catheters using aseptic technique; adoption of evidencebased standards for maintenance of urinary catheters; daily clinical review of
the need for the urinary catheter and, if not needed, prompt removal.
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SUMMARY (CONT.)
Diuretics and renal replacement therapies
 Diuretics increase urine output.
 Diuretics are categorized into different groups on the basis of their
pharmacology and site of action in the nephron.
 Acute care renal replacement therapies include IHD and CRRT.
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