renal disease&treatment

0. ★ nephrotic syndrome

• Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia (hypoproteinemia), and edema. • urine output decreases,

dark and frothy urine

• periorbital and facial edema most prominent in the morning,

leg, ankle, labial, or scrotal edema

• ascites

• weight gain

• lethargy, anorexia

• hypotension

• Monitor V/S.

• Monitor serum electrolytes levels.

• Monitor urine for USG and protein.

• Monitor I/O.

• Diuretics may be prescribed to reduce edema.

• Corticosteroid therapy is prescribed.

• Immunosuppressant therapy is prescribed.

• client education: A regular diet without added salt may be prescribed if the child is in remission; sodium and potassium are restricted during periods of massive edema. Fluids may also be restricted. High calorie, high protein.

0. uremic syndrome ([Pediatric] hemolytic uremic syndrome)

• Accumulation of nitrogenous waste products in the blood caused by the kidneys’ inability to filter out these waste products. • oliguria

• presence of protein, red blood cells, and casts in the urine

• elevated levels of urea, uric acid, potassium, and magnesium in the urine

• electrolyte imbalances

• hypertension or hypotension

• alterations in the level of consciousness

• stomatitis, nausea and vomiting, diarrhea or constipation

• Monitor V/S.

• Monitor serum electrolytes levels.

• Monitor urine for USG and protein.

• Monitor I/O.

• client education: Provide a limited but high-quality protein diet as prescribed. Provide a limited sodium, nitrogen, potassium, and phosphate diet as prescribed.

1. ★ AKI (Acute Kidney Injury)

• AKI is the rapid loss of kidney function from renal cell damage. Occurs abruptly and can be reversible. • The signs and symptoms of AKI are primarily caused by the retention of nitrogenous wastes, the retention of fluids, and the inability of the kidneys to regulate electrolytes.

• onset → oliguric phase → diuretic phase → recovery phase

• Oliguric phase: elevated Cr levels, decreased or normal USG, hyperkalemia, hypervolemia, hypocalcemia, UOP 400 ∼ 500cc/day

• Diuretic phase: a gradual decline in serum Cr levels, but still elevated, hypokalemia, hypovolemia, UOP ↑에 따른  electrolyte imbalance


Cf.) normal UOP : 1200 ∼ 1500 cc/day

핍뇨oliguria : 400cc/day ↓

무뇨 anuria : 100cc/day ↓

다뇨 polyuria:2500cc/day↑

• Monitor V/S. (especially BP)

• Monitor for altered LOC caused by uremia.

• Monitor serum electrolytes levels.

Monitor for acidosis.

• Monitor UA for USG and protein.

Monitor urine I/O, color, and characteristics.

• Monitor I/O. (hourly)

• Monitor daily weight. (An increase of 1/2 to 1 lb/day indicates fluid retention.)

• Monitor for periorbital, sacral, and peripheral edema. Monitor for signs of HF and pulmonary edema, such as restlessness, heightened anxiety, tachycardia, dyspnea, basilar lung crackles, and blood-tinged sputum; notify the HCP immediately if signs occur.

• Monitor for signs of infection.

• Administer medications as prescribed.

• Be alert to nephrotoxic medications.

• Prepare the client for dialysis if prescribed. CRRT may be used in AKI.

• Administer a prescribed diet, which is usually a low-to-moderate protein and a high-carbohydrate diet. Restrict potassium and sodium intake as prescribed based on the electrolyte level. High calorie. Fluids restriction (UOP + 500cc).

Cf.) Normal fluid intake = UOP + 1000cc


2. CKD (Chronic Kidney Disease)

• CKD is the slow, progressive, irreversible loss in kidney function. It occurs in stages and results in uremia or ESRD (End-Stage Renal Disease). • CKD affects all major body systems and requires dialysis or KT (Kidney Transplantation) to maintain life. • same as the interventions for AKD.

• Provide support to promote acceptance of chronic illness and prepare the client for long-term dialysis and KT.

• Protein restricted. Sodium and Potassium and phosphorus restricted.

• special problems in CKD

① hypertension – Caused by the failure of the kidneys to maintain BP homeostasis. • Monitor V/S.

• Maintain fluid and sodium restrictions as prescribed.

• Administer diuretics and antihypertensives as prescribed.

② hypervolemia • Avoid the administration of large amounts of IV fluids.

• Administer diuretics such as furosemide (Lasix) as prescribed.

③ hyperkalemia • Monitor V/S; an irregular HR could indicate dysrhythmias.

• Monitor ECG; an elevated serum potassium level can cause tall & peaked T waves, flat P waves, a widened QRS complex, and a prolonged PR interval; decreased cardiac output; heart blocks; fibrillation; or asystole.

• Administer electrolyte-binding and electrolyte excreting medications such as oral or rectal sodium polystyrene sulfonate (Kayexalate). 50% dextrose and insulin may be prescribed to shift potassium into the cell. Calcium gluconate IV may be prescribed to reduce myocardial irritability from hyperkalemia, and sodium bicarbonate IV may be prescribed to correct acidosis.

• Prepare the client for dialysis.

• Provide a low-potassium diet, avoiding foods high in potassium.

④ hypermagnesemia • Monitor CNS manifestations of decreased nerve impulse transmission, such as drowsiness or lethargy.
⑤ hypocalcemia & hyperphosphatemia • It results from a high phosphorus level and the inability of the diseased kidney to activate vitamin D. The absence of vitamin D causes poor calcium absorption from the intestinal tract.
⑥ metabolic acidosis • The kidney is unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis. • Administer alkalizers such as sodium bicarbonate as prescribed.
⑦ muscle cramps • Occurs from electrolyte imbalances and the effects of uremia on peripheral nerves. • Administer electrolyte replacements and medications to control muscle cramps as prescribed.

• Administer heat and massage as prescribed.

⑧ neurological changes • Peripheral neuropathy results from the effects of uremia on peripheral nerves. • Monitor the LOC and for confusion.

• Monitor for restless leg syndrome, which is also common during dialysis treatments.

⑨ pruritus • To rid the body of excess wastes, urate crystals are excreted through the skin, causing pruritus. The deposit of urate crystals occurs in the advanced stages of kidney disease. • Provide meticulous skin care and oral hygiene.

• Avoid the use of soaps.

• Administer antihistamines and antipruritics as prescribed.

• Teach the client to keep the nails trimmed to prevent local infection from scratching.

⑩ infection • The client is at risk for infection caused by a suppressed immune system, dialysis access site, and possible malnutrition. • Provide strict asepsis during urinary catheter insertion and other invasive procedures.

• Instruct the client to avoid fatigue, which decreases body resistance.

• Instruct the client to avoid persons with infections.

• Administer antibiotics as prescribed, monitoring for nephrotoxic effects.

⑪ GI bleeding • Urea is broken down by the intestinal bacteria to ammonia; ammonia irritates the gastrointestinal mucosa, causing ulceration and bleeding. • Monitor for decreasing Hb and Hct levels. Monitor stools for occult blood.

• Instruct the client to use a soft toothbrush.

• Avoid the administration of acetylsalicylic acid (aspirin) because it is excreted by the kidneys; if administered, aspirin toxicity can occur and prolong the bleeding time.

⑫ anemia • Anemia results from the decreased secretion of erythropoietin by damages nephrons, resulting in decreased production of RBCs. • Administer epoetin alfa (Epogen, Procrit) or darbepoetin alfa (Aranesp), hematopoietic, as prescribed to promote the maturity of the RBCs.

• Administer folic acid (Vitamin B9) as prescribed.

• Administer iron orally as prescribed, but not at the same time as phosphate binders. Note that oral iron is not well absorbed by the GI tract in CKD and causes nausea and vomiting. Parenteral iron may be used if iron deficiencies persist despite folic acid or oral iron administration.

• Administer blood transfusions if prescribed. Blood transfusions are prescribed only when necessary.


3. complication of PD

① leakage around the catheter site

• Clear fluid that leaks from the catheter exit site will be noted. It takes 1 to 2 weeks following insertion of the catheter before fibroblasts and blood vessels grow into the catheter cuffs, which fix it in place and provide an extra barrier against dialysate leakage and bacterial invasion.

• Smaller amounts of dialysate need to be used.
② insufficient outflow

• The main cause of insufficient outflow is a full colon. Insufficient outflow may also be caused by catheter migration out of the peritoneal area.

• An x-ray will be prescribed.

• Administer stool softeners as prescribed.

• Maintain the drainage bag below the client’s abdomen.

• Check for kinks in the tubing.

• Change the client’s outflow position by turning the client to a side-lying position or ambulating the client.

③ abnormal outflow characteristics

• Bloody outflow after the first few exchanges indicate a vascular complication.

• Cloudy outflow indicates peritonitis.

• Brown outflow indicates bowel perforation.

• Urine-colored outflow indicates bladder perforation.

④ abdominal pain

• Peritoneal irritation during inflow commonly causes pain during the first few exchanges.

• Warm the dialysate before administration, using a special dialysate warmer pad.
⑤ peritonitis • fever

• abdominal pain, nausea, vomiting

• cloudy outflow: an early sign

• Avoid infections by maintaining meticulous sterile technique when connecting and disconnecting PD solution bags and when caring for the catheter insertion site. Prevent the catheter insertion site dressing from becoming wet during the care of the client or the dialysis procedure; change the dressing if wet or solid. Follow the institutional procedure for connecting and disconnecting PD solution bags, which may include scrubbing the connection sites with an antiseptic solution.

• If peritonitis is suspected, obtain a sample for C&S of the outflow to determine the infective organism.

• Administer antibiotics as prescribed.


4. complication of HD

① air embolus

• introduction of air into the circulatory system

• dyspnea, tachypnea

• hypotension

• chest pain

• Stop the HD.

• Turn the client on the left side, with the head down. This position is used to try to prevent the air from traveling as a bolus to the lungs by trapping it on the right side of the heart.

• Notify the HCP.

• Monitor V/S.

• Administer oxygen.

• Document the event, actions taken, and the client’s response.

② disequilibrium syndrome

• A rapid change in the composition of the extracellular fluid occurs during hemodialysis. Solutes are removed from the blood faster than from the CSF and brain. The fluid is pulled into the brain, causing cerebral edema.

• hypertension

• headache, nausea, vomiting

• restlessness, agitation, confusion, seizure

• Stop the HD.

• Notify the HCP.

• Reduce environmental stimuli.

• Prepare to administer hypertonic saline solution IV, albumin, or mannitol if prescribed.

③ encephalopathy

• An aluminum toxicity from dialysate water sources containing aluminum.


5. pyelonephritis

• Pyelonephritis is an inflammation of the renal pelvis and the parenchyma, commonly caused by bacterial invasion. Escherichia coli is the most common causative bacterial organism.

• Chronic pyelonephritis causes contraction of the kidney and dysfunction of the nephrons, which are replaced by scar tissue.

• flank pain on the affected side,

CVAT (CostoVertebrarl Angle Tenderness)

• fever, tachycardia, nausea

• dysuria, frequency and urgency,

cloudy, bloody, or foul-smelling urine,

increased WBCs in the urine

• Monitor V/S.

• Monitor I/O. Ensure that output is a minimum of 1500mL/1day.

• Monitor characteristics of urine.

• Encourage fluid intake up to 3000mL/day to reduce fever and prevent dehydration.

• Daily weights at the same time of day, using the same scale and wearing the same clothing.

• Instruct the client on a high-calorie, low-protein diet.

• Encourage adequate rest.

• Provide warm, moist compresses to the flank area to help relieve pain.

• Encourage the client to take warm baths for pain relief.

• Administer antibiotics, urinary antiseptics, analgesics, antipyretics, and antiemetics as prescribed.


6. glomerulonephritis

• Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus, Inflammation of the glomeruli results from an antigen-antibody reaction produced by an infection elsewhere in the body.

• cause: antecedent group A β-hemolytic streptococcal infection of the pharynx or skin, history of pharyngitis or tonsillitis 2 to 3 weeks before symptoms

Cf. ) rheumatic fever

• edema; an early sign

• flank pain

• hypertension

• dysuria, frequency and urgency,

cloudy, bloody, or foul-smelling urine,

increased WBCs in the urine,

proteinuria that produces persistent and excessive foam in the urine

• azotemia

increased BUN and Cr level,

increased ASO titer (Anti-Streptolysin O titer), used to diagnose disorders caused by streptococcal infections

• Monitor V/S.

• Monitor I/O.

• Monitor characteristics of urine.

• Daily weights at the same time of day, using the same scale and wearing the same clothing.

• Diet restrictions of sodium depending on the stage and severity of the disease. Potassium may be restricted during periods of oliguria.

• Limit activity. Provide safety measures.

• Administer antibiotics, diuretics, and antihypertensives as prescribed.


7. polycystic kidney disease

• Cyst formation and hypertrophy of the kidneys, which leads to cystic rupture, infection, the formation of scar tissue, and damaged nephrons. • often asymptomatic

• flank pain

• increased abdominal girth, palpable abdominal masses

• fever, hypertension

• recurrent UTI, calculi

• Monitor for gross hematuria, which indicates cyst rupture.


8. hydronephrosis

• Hydronephrosis is the distention of the renal pelvis and calices caused by an obstruction of normal urine flow. • flank pain

• hypertension

• Prepare the client for insertion of a nephrostomy tube or a surgical procedure to relieve the obstruction if prescribed.


9. kidney tumor