Acute Kidney Injury

Chapter 47

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Acute Kidney Injury
Etiology and Pathophysiology
Prerenal
Causes are factors external to the
kidneys that reduce renal blood flow
Severe dehydration, heart failure, CO
Decreases glomerular filtration rate
Causes oliguria
Autoregulatory mechanisms attempt
to preserve blood flow

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Etiology and Pathophysiology
Intrarenal
Causes include conditions that cause
direct damage to kidney tissue
Results from
Prolonged ischemia
Nephrotoxins
Hemoglobin released from hemolyzed
RBCs
Myoglobin released from necrotic muscle
cells

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Etiology and Pathophysiology
Intrarenal
Acute tubular necrosis (ATN)
Results from ischemia, nephrotoxins, or
sepsis
Severe ischemia causes disruption in
basement membrane
Nephrotoxic agents cause necrosis of
tubular epithelial cells
Potentially reversible

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Etiology and Pathophysiology
Postrenal
Causes include
Benign prostatic hyperplasia
Prostate cancer
Calculi
Trauma
Extrarenal tumors

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Clinical Manifestations
RIFLE classification
Risk (R)
Injury (I)
Failure (F)
Loss (L)
End-stage kidney disease (E)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Clinical Manifestations
Oliguric phase
Urinary changes
Urinary output less than 400 mL/day
Occurs within 1 to 7 days after injury
Lasts 10 to 14 days
Urinalysis may show casts, RBCs, WBCs

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Clinical Manifestations
Oliguric phase
Fluid volume
Hypovolemia may exacerbate AKI
With decreased urine output, fluid retention
occurs
Neck veins distended
Bounding pulse
Edema
Hypertension
Fluid overload can lead to heart failure,
pulmonary edema, and pericardial and
pleural effusions

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

 Acute Kidney Injury
Clinical Manifestations
Oliguric phase
Metabolic acidosis
Serum bicarbonate level decreases
Severe acidosis develops
Kussmaul respirations
Sodium balance
Increased excretion of sodium
Hyponatremia can lead to cerebral edema
Potassium excess
Usually asymptomatic
ECG changes

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Clinical Manifestations
Oliguric phase
Hematologic disorders
Leukocytosis
Waste product accumulation
Elevated BUN and serum creatinine levels
Neurologic disorders
Fatigue and difficulty concentrating
Seizures, stupor, coma

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Clinical Manifestations
Diuretic phase
Daily urine output is 1 to 3 L
May reach 5 L or more
Monitor for hyponatremia,
hypokalemia, and dehydration
Recovery phase
May take up to 12 months for kidney
function to stabilize

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Diagnostic studies
Thorough history
Serum creatinine
Urinalysis
Kidney ultrasonography
Renal scan
Computed tomography (CT) scan
Renal biopsy

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Diagnostic studies
Contraindicated
Magnetic resonance imaging (MRI)
Magnetic resonance angiography (MRA)
with gadolinium contrast medium
Nephrogenic systemic fibrosis
Contrast-induced nephropathy (CIN)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Collaborative care
Primary goals
Eliminate the cause
Manage signs and symptoms
Prevent complications

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Collaborative care
Ensure adequate intravascular volume
and cardiac output
Force fluids
Loop diuretics (e.g., furosemide [Lasix])
Osmotic diuretics (e.g., mannitol)
Closely monitor fluid intake during
oliguric phase

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Collaborative care
Hyperkalemia
Insulin and sodium bicarbonate
Calcium carbonate
Sodium polystyrene sulfonate
(Kayexalate)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

 Acute Kidney Injury
Collaborative care
Indications for renal replacement
therapy (RRT)
Volume overload
Elevated serum potassium level
Metabolic acidosis
BUN level higher than 120 mg/dL
(43 mmol/L)
Significant change in mental status
Pericarditis, pericardial effusion, or cardiac
tamponade
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Acute Kidney Injury
Collaborative care
Renal replacement therapy (RRT)
Peritoneal dialysis (PD)
Intermittent hemodialysis (HD)
Continuous renal replacement therapy
(CRRT)
Cannulation of artery and vein

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Acute Kidney Injury
Collaborative care
Nutritional therapy
Maintain adequate caloric intake
Restrict sodium
Increase dietary fat
Enteral nutrition

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing assessment
Measure vital signs
Measure fluid intake and output
Examine urine
Assess general appearance
Observe dialysis access site

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing assessment
Mental status and level of
consciousness
Oral mucosa
Lung sounds
Heart rhythm
Laboratory values
Diagnostic test results

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing diagnoses
Excess fluid volume
Risk for infection
Fatigue
Anxiety
Potential complication: dysrhythmia

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Planning
The patient with AKI will
Completely recover without any loss of
kidney function
Maintain normal fluid and electrolyte
balance
Have decreased anxiety
Comply with and understand the need for
careful follow-up care

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing implementation
Health promotion
Identify and monitor populations at high
risk
Control exposure to nephrotoxic drugs
and industrial chemicals
Prevent prolonged episodes of
hypotension and hypovolemia

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing implementation
Health promotion
Monitor intake and output
Monitor electrolyte balance
Measure daily weight
Replace significant fluid losses
Provide aggressive diuretic therapy for
fluid overload
Use nephrotoxic drugs sparingly

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing implementation
Acute intervention
Accurate intake and output measurements
Daily weights
Assessment for signs of hypervolemia or
hypovolemia
Meticulous aseptic technique
Careful administration of nephrotoxic drugs
Skin care measures
Mouth care

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing implementation
Ambulatory and home care
Regulate protein and potassium intake
Follow-up care
Teaching
Appropriate referrals

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Management
Acute Kidney Injury
Nursing implementation
Evaluation
The expected outcomes are that the
patient with AKI will
Regain and maintain normal fluid and
electrolyte balance
Comply with the treatment regimen
Experience no untoward complications
Have complete recovery

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Gerontologic Considerations
Acute Kidney Injury
More susceptible to AKI
Polypharmacy
Hypotension
Diuretic therapy
Aminoglycoside therapy
Obstructive disorders
Surgery
Infection

Copyright 2014 by Mosby, an imprint of Elsevier Inc.