Renal Failure- Acute Kidney Injury (AKI), Chronic Kidney Disease (CKD)

Definition/Etiology:

• Renal Failure – Caused by acute and/or chronic conditions
• AKI
  • Definition -Acute kidney injury, also known as acute renal failure, is when the kidneys stop working over the period of a few hours or a few days.
    • Cause Pre/Intra/Post renal
    • Sudden onset & usually reversible
• CKD – Gradual Loss
  • Definition – Chronic kidney disease includes conditions that damage the kidneys and decrease their ability to effectively filter waste products from the blood. Chronic kidney disease (CKD) develops slowly over time.
    • Cause – uncontrolled hypertension and diabetes mellitus
    • Slow onset & rarely reversible

Pathophysiology:

• Acute Renal Failure (AKI)
  • Pre-Renal (Decreased blood flow)
    • Low BP, Sepsis, etc
  • Intrarenal (Direct Injury to kidney)
    • Vancomycin, Contrast Dye, etc
  • Post-Renal (Decreased outflow)
    • Prostate disease, Stones
• Chronic Renal Failure
  • No stages, rather persistent impairment of kidney function that results renal fibrosis
  • Leads to ESRD & Dialysis

Noticing: Assessment & Recognizing Cues:

• AKI – symptoms are sudden/severe and are easily recognized
  • History of acute illness or toxic medication
  • ↑ HR & ↑ BP
  • Oliguria
    • 50 – 400 ml/day
  • Edema in lower extremities
• CKD – symptoms develop slowly and are easily mistaken for other conditions
  • History of HTN/DM
  • Vitals normalized
  • Anuria
    • Less than 50ml/day
  • Periorbital Edema
  • Chronic changes
    • Grey Skin – toxins
    • Anemic signs/sx

Interpreting: Analyzing & Planning:

• Labs
  • Bun/Creatinine – AKI specific
    • 20/1.3
  • Glomerular filtration rate (GFR) – CKD specific
    • 90
  • Potassium
    • High in both
  • Calcium
    • CKD = Low related to ↓D levels
  • Hemoglobin
    • erythropoietin
  • UA – Protein & Blood
• Diagnostics
  • ABD Xray – Renal Stones
  • Renal Ultrasound
    • AKI – Normal/Enlarged Kidney
    • CKD – Small Shrunken Kidney
  • 12 Lead
    • Arrhythmias
  • CXR
    • Pleural Effusion
    • Uremic Pericardial Congestion

Responding: Patient Interventions & Taking Action:

• Pharmacological Interventions
  • Withhold Nephrotoxic drugs
  • Fluids vs Diuretics
    • Is the patient Oliguric?
    • Do they need Kidneys flushed?
  • Epoetin alfa = synthetic erythropoietin
  • Hyperkalemia
    • Insulin/Glucose
    • Calcium gluconate ↑K + Arrhythmia
  • Flomax – Prostate
• Non-Pharmacological Interventions
  • Daily Weight
  • Foley
    • Goal = ↑ 400 ml/24 hours
  • Dialysis
    • Short vs long term

Reflecting: Evaluating Patient Outcomes:

• Monitor KCL Levels
  • Hyperkalemia → EKG changes (peaked T waves, flat P, wide QRS, blocks, asystole)
  • Continuous cardiac monitoring
  • Low potassium diet
  • Potassium lowering medications
• Immediate Dialysis
  • Severe Hyperkalemia
  • Acidosis
  • Uremic Pericarditis
  • Encephalopathy

Linchpins (Key Points):

• Notice AKI or CKD = Renal Failure
  • Is this acute or a chronic issue? Patient’s will present a little differently, especially labs.
• Interpret
  • Labs & Imaging
    • Is there something we can immediately fix?
• Respond
  • KCL Interventions
• Reflect
  • KCL & Dialysis Watch