NSG210 Hinkle Ch. 48: Management of Patients with Kidney Disorders

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 48, pp. 1554-1602 (textbooks/HINKLE_MS_CH48.pdf, also in textbooks/exam04/). Week 13 reading (elimination and GU disorders: renal cancer); Exam 4 content. Numbering note: the Week 13 syllabus lists “Ch. 49” (16th edition); kidney disorders is Ch. 48 in the 15th edition (see nsg210-textbook-chapter-crosswalk). Normal values and diagnostics are in nsg210-hinkle-ch47-kidney-urinary-assessment.

Learning Outcomes

1. Describe key factors in the development of kidney disorders.
2. Explain pathophysiology, manifestations, and medical and nursing management of kidney disorders.
3. Differentiate causes and nursing management of CKD and AKI.
4. Compare renal replacement therapies: hemodialysis, peritoneal dialysis, CRRT, transplantation.
5. Identify nursing management of the hospitalized patient on dialysis.
6. Develop a postoperative plan of care for kidney surgery and transplantation.

Key Terms

• AKI: rapid loss of renal function (formerly acute renal failure). ATN: AKI with tubular damage
• Acute nephritic syndrome: glomerular inflammation
• Anuria under 50 mL/24 h; oliguria under 400 mL/24 h or under 0.5 mL/kg/h over 6 h; polyuria: excessive urine
• AV fistula: surgical artery-to-vein connection for dialysis access. AV graft: graft material connecting artery and vein
• Azotemia: excess nitrogenous wastes in blood. Uremia: excess urea and nitrogenous wastes
• CKD: kidney damage or decreased GFR for 3 months or more. ESKD: final stage needing RRT
• CAPD: manual PD exchanges through the day. CCPD: cycler does exchanges, usually overnight
• CRRT: blood circulated through a hemofilter continuously for unstable patients
• Dialysate: electrolyte solution. Dialyzer: artificial kidney (semipermeable membrane). Effluent: drained PD fluid. Exchange: fill, dwell, drain
• Diffusion: solutes from high to low concentration. Osmosis: water toward higher solute concentration. Ultrafiltration: water removed by pressure gradient
• Glomerulonephritis: glomerular capillary inflammation. Interstitial nephritis: inflammation in renal tissue. Nephrosclerosis: hardening of renal arteries
• Nephrotic syndrome: increased glomerular permeability with massive proteinuria
• Nephrotoxic: toxic to kidney tissue. Peritonitis: inflammation of peritoneum
• Urinary casts: proteins secreted by damaged tubules

I. Fluid and Electrolyte Imbalances in Kidney Disorders

• Daily weight is more accurate than I&O. Quality and Safety Alert: 1 kg gain equals 1 L retained fluid.
• Table 48-1 highlights:
  • Fluid deficit: acute weight loss over 5 percent, poor turgor, dry mucosa, oliguria, high Hct, BUN up out of proportion to creatinine, hypothermia: fluid challenge, replacement.
  • Fluid excess: acute weight gain 5 percent or more, edema, crackles, dyspnea, low BUN and Hct, JVD: fluid and sodium restriction, diuretics, dialysis.
  • Hyponatremia: nausea, malaise, lethargy, headache, cramps, seizures. Hypernatremia: dry sticky mucosa, thirst, fever, restlessness, disorientation.
  • Hypokalemia: anorexia, distention, ileus, weakness, ECG changes. Hyperkalemia: diarrhea, colic, nausea, irritability, weakness, ECG changes: restrict, diuretics, IV glucose and insulin, sodium bicarbonate, cation-exchange resin, calcium gluconate, dialysis.
  • Hypocalcemia: cramps, stridor, carpopedal spasm, hyperreflexia, tetany, Chvostek and Trousseau, perioral tingling. Hypercalcemia: bone and flank pain, weakness, depressed reflexes, constipation, confusion, polyuria.
  • Metabolic acidosis: headache, confusion, drowsiness, deep rapid respirations, warm flushed skin: bicarbonate, dialysis.
  • Hypermagnesemia: flushing, warmth, drowsiness, depressed reflexes, respiratory depression, cardiac arrest: calcium gluconate, ventilation, dialysis.
• Older adults: less able to respond to acute changes; atypical signs; fluid deficit leads to falls, drug toxicity, constipation, infections, delirium, seizures.

II. Chronic Kidney Disease

A. Overview

• About 15 percent of US adults (37 million; 1 in 7); 9 of 10 unaware. Most die of cardiovascular events before reaching ESKD.
• Diabetes and hypertension cause about 70 percent; diabetes is the leading cause of RRT. Also glomerulonephritis, pyelonephritis, polycystic and congenital disease, renal cancer. Risk factors: CVD, diabetes, hypertension, obesity.

B. Stages (Chart 48-1; normal GFR 125 mL/min/1.73 m2)

| Stage | GFR | Description | |—|—|—| | 1 | 90 or more | Damage with normal or increased GFR | | 2 | 60-89 | Mild decrease | | 3 | 30-59 | Moderate decrease | | 4 | 15-29 | Severe decrease | | 5 | under 15 | ESKD; RRT required |

C. Manifestations and Management

• Rising creatinine; anemia (low erythropoietin), metabolic acidosis, calcium and phosphorus abnormalities herald CKD; then fluid retention, edema, heart failure, harder-to-control hypertension.
• Management: treat cause; BP under 125-130/80; control cardiovascular risk, glucose, anemia; stop smoking; weight loss, exercise; less salt and alcohol; avoid nephrotoxins; early referral for RRT.
• Older adults: fewer nephrons; more comorbidities; many medications; prevent dehydration during testing or new diuretics.

D. Nephrosclerosis

• Hardening of renal arteries from prolonged hypertension, diabetes, aging; slowly rising BUN and creatinine, mild proteinuria; major cause of CKD and ESKD. African Americans about 8 times risk of hypertension-induced ESKD.
• Acute hypertensive (patchy necrosis, fibrosis, can progress rapidly) and benign (older adults, atherosclerosis).
• Treatment: antihypertensives, especially ACE inhibitor.

III. Glomerular Diseases

• Third most common cause of stage 5 CKD. Primary (within kidney) or secondary (diabetes, lupus nephritis).
• Antigen-antibody complexes trapped in glomeruli cause inflammation; IgG in capillary walls. Manifestations: proteinuria, hematuria, decreased GFR, sodium retention, edema, hypertension.

A. Acute Nephritic Syndrome (Acute Glomerulonephritis)

• Postinfectious: group A beta-hemolytic streptococcal throat infection 2 to 3 weeks before; also impetigo, viral infections (URI, mumps, varicella, EBV, hepatitis B, HIV).
• Features: hematuria (microscopic or cola-colored; RBC casts = glomerular injury), edema, azotemia, proteinuria, hypertension; possible oliguria and AKI; elevated BUN and creatinine; anemia. Severe: headache, malaise, flank pain. Older adults: circulatory overload (dyspnea, JVD, cardiomegaly, pulmonary edema), confusion, somnolence, seizures.
• IgA nephropathy: elevated serum IgA, low-normal complement. Kidney biopsy may be needed.
• Complications: hypertensive encephalopathy (emergency), heart failure, pulmonary edema. Rapidly progressive glomerulonephritis: ESKD in weeks to months (crescents); plasma exchange, high-dose steroids, cytotoxics.
• Prognosis excellent; rarely causes CKD; dialysis if severe uremia.
• Management: corticosteroids, BP control, proteinuria control; penicillin if residual strep; protein restriction if BUN elevated; sodium restriction with hypertension, edema, heart failure.
• Nursing: liberal carbohydrates (spare protein); I&O; fluids based on losses and daily weight (insensible loss about 300 mL lungs, 500 mL skin); diuresis means improvement; proteinuria and microscopic hematuria may persist months. Teach fluid and diet restrictions; report fatigue, nausea, vomiting, anorexia, decreasing urine, any infection; follow-up BP, BUN, creatinine, urine protein.

B. Chronic Glomerulonephritis

• Repeated acute nephritis, hypertensive nephrosclerosis, hyperlipidemia, tubulointerstitial injury; secondary: SLE, Goodpasture syndrome, diabetic glomerulosclerosis. Kidneys shrink to one fifth size.
• May be silent for years; found by hypertension, elevated BUN and creatinine, proteinuria. Weight and strength loss, irritability, nocturia, headache, dizziness, GI upset. Later: yellow-gray skin, periorbital and peripheral edema, retinal changes, pallor, heart failure, crackles, peripheral neuropathy, confusion, pericarditis (friction rub, pulsus paradoxus over 10 mm Hg), pleural effusion.
• Labs: fixed specific gravity about 1.010, proteinuria, casts. With GFR under 50 mL/min: anemia, low calcium, hyperkalemia (tall tented T waves), hypoalbuminemia, high phosphorus, neuropathy, mental changes, metabolic acidosis.
• Management: sodium and water restriction, antihypertensives, daily weight, diuretics; high-biologic-value protein (eggs, meat, fish); adequate calories; treat UTIs promptly; avoid NSAIDs and IV contrast; start dialysis early.

C. Nephrotic Syndrome

• Increased glomerular permeability: proteinuria over 3.5 g/day (hallmark; normal under 150 mg/day), hypoalbuminemia, diffuse edema, hypercholesterolemia and hyperlipidemia, hypercoagulability.
• Edema: soft, pitting; periorbital, dependent, ascites. Irritability, headache, malaise.
• Complications: infection, thromboembolism (renal vein, DVT), PE, AKI (hypovolemia), accelerated atherosclerosis.
• Treatment: diuretics, ACE inhibitors (reduce proteinuria), lipid-lowering agents, sodium about 2 g/day. Teach adherence and prompt reporting of changes.

IV. Polycystic Kidney Disease (PKD)

• Genetic; fluid-filled cysts destroy nephrons; most common inherited cause of kidney failure. Also liver and pancreatic cysts, brain aneurysms, cardiovascular abnormalities.
• Autosomal dominant (90 percent): PKD1 (chromosome 16, 78 percent; ESKD at mean 54.3 years) and PKD2 (chromosome 4; slower; ESKD at 74.0). Autosomal recessive (10 percent): begins in infancy or in utero.
• Signs: hematuria, hypertension, stones, UTIs, proteinuria, abdominal fullness, flank pain; enlarged palpable kidneys. Ultrasound preferred; genetic testing if unclear.
• Treatment: no cure; tolvaptan slows decline (polyuria; rare reversible liver injury); BP control, pain management, antibiotics; RRT; genetic counseling (screen family donors).

V. Renal Cancer

• About 4.2 percent of cancers; rising (incidental imaging). Risk (Chart 48-3): African American race, antihypertensive medications including diuretics, genetics, hypertension, male, obesity, industrial chemicals (cadmium, herbicides, trichloroethylene), smoking.
• 90 percent renal cell carcinoma; 70 to 80 percent clear cell (proximal tubule); 10 percent papillary. Metastases (lungs, nodes, brain, bone, liver) in 30 percent at diagnosis. Over 50 percent found incidentally.
• 5-year survival: 92 percent local, 65 percent regional, 12 percent distant.
• Signs (only 10 percent): hematuria, pain, flank mass. First sign usually painless hematuria (intermittent microscopic or continuous gross). Dull back pain; colicky pain if clots pass. Metastatic symptoms: weight loss, fatigue, anemia.
• Diagnosis: IV urography, cystoscopy, angiography, ultrasound, CT, MRI (watch for dehydration and anxiety).
• Treatment: radical nephrectomy (kidney, adrenal, perinephric fat, Gerota fascia, nodes) or nephron-sparing partial nephrectomy (bilateral tumors, single kidney, small tumors, CKD risk); open, laparoscopic, robotic. Renal artery embolization (postinfarction syndrome 2-3 days: flank and abdominal pain, fever, GI symptoms: parenteral analgesics, acetaminophen, antiemetics, NPO, IV fluids). Radiofrequency, cryo-, or microwave ablation. Immunotherapy, targeted therapy, antiangiogenics, checkpoint inhibitors (IL-2 and interferon largely replaced); chemotherapy rarely helps; radiation for palliation.
• Nursing: catheters and drains; frequent analgesia; turn, cough, incentive spirometry; infection monitoring with immunotherapy; teach incision care, activity, lifting, driving; report fever, dyspnea, wound drainage, hematuria, leg pain or swelling; fluids, stool softeners; yearly exam and chest x-ray (late metastases common); renal function checks.

VI. Acute Kidney Injury

A. Definition and Classification

• Rapid loss of function; criterion: serum creatinine up 50 percent or more over baseline (normal under 1 mg/dL). Urine may be nonoliguric (over 800 mL/day), oliguric, or anuric.
• RIFLE (Table 48-2):
  • Risk: creatinine 1.5 x baseline or GFR down over 25 percent; urine under 0.5 mL/kg/h for 6 h.
  • Injury: creatinine 2 x or GFR down over 50 percent; under 0.5 mL/kg/h for 12 h.
  • Failure: creatinine 3 x or GFR down over 75 percent (or creatinine over 354 micromol/L with acute rise of 44 or more); under 0.3 mL/kg/h for 24 h or anuria 12 h.
  • Loss: persistent AKI over 4 weeks. ESKD: over 3 months.
• COVID-19: 7 percent of hospitalized patients in one study developed AKI; higher ICU admission and mortality.

B. Categories (Chart 48-4)

• Prerenal (60 to 70 percent): hypoperfusion: volume depletion (GI losses, hemorrhage, diuretics, burns), poor cardiac output (arrhythmias, cardiogenic shock, heart failure, MI), vasodilation (sepsis, anaphylaxis, antihypertensives).
• Intrarenal: parenchymal damage; ATN most common: prolonged ischemia; pigment nephropathy (hemoglobinuria from transfusion reaction, rhabdomyolysis/myoglobinuria from crush injuries and burns); nephrotoxins (aminoglycosides gentamicin and tobramycin, ACE inhibitors, heavy metals, NSAIDs, contrast, ethylene glycol, carbon tetrachloride, arsenic); acute glomerulonephritis, pyelonephritis.
• Postrenal: obstruction: BPH, clots, stones, strictures, tumors, pregnancy.
• Table 48-3: prerenal: BUN:creatinine ratio over 20:1, low urine output, urine sodium under 20 mEq/L, normal sediment with few hyaline casts, urine osmolality high (to 500), specific gravity high. Intrarenal: urine sodium over 40 mEq/L, abnormal casts and debris, urine osmolality about 350 (like serum), low-normal specific gravity. Postrenal: variable; may have sudden anuria.

C. Phases

1. Initiation: from insult until oliguria.
2. Oliguria: rising urea, creatinine, uric acid, phosphorus, potassium, magnesium; minimum urine to clear wastes about 400 mL/24 h; uremic symptoms and hyperkalemia appear; may last 10 to 14 days.
3. Diuresis: gradual increase in urine; labs stabilize then fall; function still abnormal; watch for dehydration.
4. Recovery: 3 to 12 months; permanent 1 to 3 percent GFR loss usually insignificant.
   • Nonoliguric form (1-2 L/day) mainly after nephrotoxins, burns, trauma.

D. Manifestations and Diagnosis

• Critically ill, lethargic; drowsiness, headache, twitching, seizures.
• Urine: scanty to normal; hematuria; low specific gravity; inability to concentrate is an early sign of tubular damage.
• Renal ultrasound or noncontrast CT. BUN rises with catabolism, perfusion, protein intake; creatinine tracks glomerular damage.
• Hyperkalemia (protein catabolism, diet, GI blood, transfusions, IV fluids, potassium penicillin, acidosis shift): arrhythmias, VT, arrest.
• Metabolic acidosis (low CO2 and pH), high phosphorus, low calcium, anemia (low erythropoietin, GI bleeding, short RBC life).

E. Prevention (Chart 48-5)

• Mortality 10 to 80 percent. Monitor renal function, CVP, arterial pressure, hourly urine in critically ill; watch wounds and burns (sepsis); treat infection and shock promptly; hydrate before, during, after surgery and contrast studies (especially older adults); hydrate patients at risk of tumor lysis, crush injuries, heat illness; meticulous catheter care and early removal; monitor dosage, duration, and drug levels of renally cleared drugs (aminoglycosides, polymyxin B, amphotericin B, vancomycin, amikacin, cyclosporine, tacrolimus).
• Chronic NSAIDs: interstitial nephritis, papillary necrosis (higher risk with heart failure, cirrhosis with ascites).
• Contrast-induced AKI: major hospital-acquired cause; highest risk with CKD, dehydration, coronary interventions; prehydration with IV normal saline is most effective; N-acetylcysteine no longer recommended.
• Older adults: about half of hospital AKI is over 60; dehydration (low thirst, bed rest, no water access, confusion); bowel prep and fasting.

F. Medical Management

• Remove cause; prerenal: restore perfusion (fluids, blood, albumin if hypoproteinemic); postrenal: relieve obstruction; intrarenal: supportive; treat shock and infection; rhabdomyolysis care.
• Fluid balance: daily weight, CVP, I&O including insensible loss; fluid excess signs: dyspnea, tachycardia, JVD, crackles, edema (presacral, pretibial). Loop diuretics (furosemide, bumetanide) without consensus.
• Dialysis for hyperkalemia, acidosis, pericarditis, pulmonary edema.
• Hyperkalemia (over 5.0 mEq/L; tall peaked T waves; irritability, cramps, diarrhea, paresthesia, weakness, slurred speech, paralysis): sodium polystyrene sulfonate orally or retention enema (onset over 6 hours; not for emergent ECG changes; sorbitol may be added; rectal balloon catheter; cleansing enema afterward); with ECG changes give IV dextrose 50 percent, insulin, calcium (temporary shift into cells; arrange emergent dialysis; check glucose for hypoglycemia).
• Adjust doses of renally cleared drugs (aminoglycosides, digoxin, phenytoin, ACE inhibitors, magnesium products).
• Severe acidosis: ABGs, bicarbonate, dialysis. High phosphorus: phosphate binders (calcium or lanthanum carbonate).
• Nutrition: weigh daily (expected loss 0.2 to 0.5 kg/day if catabolic; gain or no loss suggests fluid retention); high-carbohydrate (protein sparing); restrict sodium, potassium, phosphorus (bananas, citrus, dairy); after diuretic phase high-protein, high-calorie diet.

G. Nursing Management

• Monitor electrolytes, cardiac and musculoskeletal signs of hyperkalemia. Quality and Safety Alert: screen all IV fluids, food, and medications for potassium.
• Fluid status: smallest IV volumes; I&O, edema, JVD, heart and breath sounds, daily weight; report deterioration.
• Reduce metabolic rate: prevent and treat fever and infection.
• Pulmonary: turn, cough, deep breathe.
• Infection: asepsis; avoid indwelling catheters when possible.
• Skin: cool baths, turning, moisturize, trim nails (uremic pruritus).
• Psychosocial support; encourage family to touch and talk to the patient.

VII. End-Stage Kidney Disease

A. Overview

• Stage 5 needing permanent RRT. 2017: new ESKD started 86.9 percent HD, 10.1 percent PD, 2.9 percent preemptive transplant; one third had little or no prior nephrology care. Prevalent: 62.7 percent HD (98 percent in-center), 7.1 percent PD, 29.9 percent transplant. Policy push toward home dialysis and transplant.
• Uremia affects every system; progresses faster with heavy proteinuria and hypertension. Cardiovascular disease is the leading cause of death.

B. Manifestations (Chart 48-6)

• Neurologic: weakness, fatigue, confusion, disorientation, poor concentration, tremors, asterixis, seizures, restless legs, burning soles, behavior changes.
• Integumentary: gray-bronze skin, dry flaky skin, pruritus, ecchymosis, purpura, thin brittle nails, coarse thin hair.
• Cardiovascular: hypertension, pitting edema, periorbital edema, JVD, hyperkalemia, hyperlipidemia, pericarditis, friction rub, effusion, tamponade.
• Pulmonary: crackles, thick sputum, depressed cough, pleuritic pain, dyspnea, tachypnea, Kussmaul respirations, uremic pneumonitis.
• GI: uremic fetor (ammonia breath), metallic taste, mouth ulcers and bleeding, anorexia, nausea, vomiting, hiccups, constipation or diarrhea, GI bleeding.
• Hematologic: anemia, thrombocytopenia.
• Reproductive: amenorrhea, testicular atrophy, infertility, decreased libido.
• Musculoskeletal: cramps, weakness, bone pain, fractures, foot drop, renal osteodystrophy.

C. Assessment Findings

• GFR and creatinine clearance fall; creatinine and BUN rise (creatinine more sensitive; BUN affected by protein, catabolism, TPN, steroids).
• Sodium and water retention (edema, heart failure, hypertension, RAAS) or sodium wasting (hypotension).
• Metabolic acidosis (cannot excrete ammonia or reabsorb bicarbonate).
• Anemia: low erythropoietin, short RBC life, deficiencies, GI bleeding: fatigue, angina, dyspnea.
• Calcium-phosphorus: high phosphorus, low calcium, PTH rises, bone loses calcium; less active vitamin D; renal osteodystrophy; vascular calcification.

D. Complications

• Hyperkalemia; pericarditis, effusion, tamponade; hypertension; anemia; bone disease and metastatic and vascular calcification.

E. Medical Management

• Phosphate binders: calcium carbonate or calcium acetate (hypercalcemia risk); sevelamer if calcium high or calcium-phosphorus product over 55 mg/dL; take with the first bite of food. Calcium and vitamin D; calcimimetics.
• Antihypertensives, volume control; heart failure: fluid restriction, low-sodium diet, diuretics, inotropes, dialysis. Acidosis usually asymptomatic; bicarbonate or dialysis if symptomatic.
• Erythropoiesis-stimulating agents (recombinant erythropoietin) IV or subcut 1 to 3 times weekly; target Hgb 10 to 11 g/dL; Hgb rises in 2 to 6 weeks (not for urgent anemia). Adverse: hypertension (especially early), access clotting, seizures, cardiovascular events, iron depletion. Check iron studies first; IV iron (iron sucrose, ferric gluconate); rule out folate and B12 deficiency; adjust heparin for dialysis; caution with uncontrolled hypertension.
• Nutrition (renal dietitian): protein 1.2 g/kg/day on HD, 1.2 to 1.3 on PD, high biologic value; fluid about 1000 mL/day for anuric HD patients (individualized to urine output) with interdialytic weight gain under 4 percent of dry weight; restrict potassium and sodium; adequate calories; vitamin B and C supplement after dialysis (water-soluble vitamins lost).

F. Nursing Management (Chart 48-7)

• Fluid: daily weight, I&O, turgor, edema, JVD, VS, respiratory effort; restrict fluid as prescribed; identify hidden fluid sources (medications, IV, foods); frequent oral hygiene for thirst.
• Nutrition: renal dietitian; food preferences within limits; high-biologic-value protein; high-calorie, low-phosphorus, low-sodium, low-potassium snacks; do not give medications right before meals (except phosphate binders with first bite); written food lists; pleasant meals; watch for low albumin, edema, poor healing.
• Knowledge: explain at patient’s readiness; written information.
• Activity: fatigue, anemia, depression; alternate rest and activity; rest after dialysis.
• Coping and sexuality: discuss role and lifestyle changes; alternative sexual expression; social work, psychiatry.
• Hyperkalemia: notify at or approaching over 5.5 mEq/L; watch weakness, diarrhea, tall tented T waves, widened QRS.
• Pericarditis: fever, chest pain, friction rub; every 4 hours check for pulsus paradoxus over 10 mm Hg, hypotension, weak pulses, altered LOC, JVD; echocardiogram; emergency pericardiocentesis or pericardial window for tamponade.
• Hypertension: BP, antihypertensives, diet and fluid adherence; report vision changes, headaches, edema, seizures.
• Anemia: monitor RBC, Hgb, Hct; iron, folic acid, ESA, multivitamins; avoid unnecessary blood draws; prevent bleeding (no vigorous nose blowing, contact sports; soft toothbrush); transfusion if symptomatic.
• Bone: binders, calcium, vitamin D, calcimimetics; monitor calcium, phosphorus, iPTH; exercise.
• Teaching: check access patency; no venipuncture or BP on access arm; report worsening uremia (nausea, vomiting, urine change, metallic taste, ammonia breath), hyperkalemia signs (weakness, diarrhea, cramps), access problems (clotting, infection).
• Older adults: fastest growing CKD group; symptoms masked; HD and PD both effective; conservative and palliative care for those who decline RRT; selected older transplant recipients live longer than those on dialysis.

VIII. Renal Replacement Therapy: Dialysis

A. Indications

• Acute or urgent: rising potassium, fluid overload or impending pulmonary edema, worsening acidosis, pericarditis, advanced uremia, toxin or drug removal, refractory edema or hypertension.
• Chronic: uremic symptoms (nausea, vomiting, anorexia, lethargy, confusion), hyperkalemia, fluid overload unresponsive to diuretics, lack of well-being. Pericardial friction rub (uremic pericarditis) is an urgent indication.
• Preemptive living-donor transplant gives longer graft survival than transplant after dialysis starts.

B. Hemodialysis

• Short-term for AKI; long-term for ESKD (62.7 percent). Usually 3 times a week, 3 to 4 hours; prevents death but does not cure or replace endocrine functions.
• Principles: diffusion (toxins into dialysate), osmosis, ultrafiltration (negative pressure; most efficient water removal); bicarbonate bath buffers acid; heparin prevents circuit clotting. High-flux dialyzers (500-550 mL/min) shorten treatment and need less heparin.
• Vascular access:
  • Temporary: double-lumen noncuffed catheter in internal jugular or femoral vein (subclavian avoided: stenosis); risks: hematoma, bleeding, pneumothorax, infection, thrombosis.
  • Tunneled cuffed internal jugular catheter: longer term; infection and sepsis still common.
  • AV fistula: preferred permanent access; artery to vein (forearm); matures at least 3 months; hand exercises (squeeze rubber ball); 14- to 16-gauge needles; longest life.
  • AV graft: when vessels unsuitable (diabetes); arm, thigh, chest; stenosis, infection, thrombosis common.
  • Assess current access for bruit and thrill.
  • Quality and Safety Alert: access failure causes many admissions; limb alert band or sign: no lab draws, IVs, or BP on access arm.
• Complications: cardiovascular disease (leading cause of death); worsened anemia (blood loss); gastric ulcers; metallic taste, nausea; malnutrition; bone pain and fractures; vascular calcification; itching from phosphorus; sleep problems. During treatment: dyspnea between treatments, hypotension (nausea, vomiting, diaphoresis, tachycardia, dizziness), muscle cramps late in treatment, exsanguination if lines separate, arrhythmias, air embolism (rare), chest pain, dialysis disequilibrium (cerebral fluid shift: headache, nausea, vomiting, restlessness, decreased LOC, seizures; with BUN over 150; prevent with short, low-flow treatments).
• COVID-19: HD patients at higher risk; fewer typical symptoms (fever, cough), more ICU care and death.
• Nursing: monitor patient, dialyzer, and bath for clotting, air embolism, fluid removal problems, hypotension, cramping, vomiting, blood leaks, access problems.
• Medications: water-soluble drugs are removed by dialysis; adjust timing; many once-daily drugs (and antihypertensives on dialysis days) given after dialysis to avoid hypotension.
• Diet: protein 1.2 g/kg ideal weight, high biologic value; sodium 2 g/day; fluid 1000 to 1500 mL/day individualized; interdialytic gain under 4 percent dry weight; potassium per residual function. Avoid judgmental tones about dietary indiscretion.
• Psychosocial: financial and job issues, sexual dysfunction, depression, fear of dying; screen for depression (PHQ-9, Beck); resilience; respect informed decision to stop dialysis after depression ruled out; advance directives; palliative care.
• Teaching (Chart 48-10): short 10- to 15-minute sessions (uremia shortens attention); medication schedule on dialysis vs nondialysis days; access care; diet and fluid; dry weight and self-weighing.
• Home HD: about 2 percent; motivated patient plus trained caregiver; assess home (electrical, plumbing, storage); periodic home visits; lowers COVID exposure.

C. Continuous Renal Replacement Therapy

• For unstable patients, fluid overload with oliguria, or high metabolic needs; hemofilter; often in ICU without dialysis staff.
• CVVH: double-lumen venous catheter, pump, continuous ultrafiltration; mild hemodynamic effects.
• CVVHD: adds dialysate for solute (toxin) removal by concentration gradient.

D. Peritoneal Dialysis

• Peritoneum is the semipermeable membrane; diffusion (clearance) and osmosis (ultrafiltration via high-glucose dialysate). Slower changes: good for diabetes, cardiovascular disease, older adults, heparin risk, refractory hypertension or heart failure. Under 8 percent of ESKD patients.
• Chart 48-11: advantages (no machine, more control, more liberal diet and fluids, better Hct and BP, no needles); disadvantages (7 days a week; protein and potassium losses, so increase intake). Indications: willing and able, strong support, HD access problems, bridge to transplant, diabetic ESKD. Contraindications: adhesions, systemic inflammatory disease, chronic back pain or disc disease, severe arthritis or poor hand strength (though blind or limited patients can learn).
• Preparation: dialysate concentration and additives (heparin to prevent fibrin, potassium chloride to prevent hypokalemia, antibiotics for peritonitis; insulin rarely); pharmacist adds medications under laminar flow in hospital. Warm dialysate to body temperature with dry heat only (heating cabinet, incubator, heating pad); never water bath (bacteria) or microwave (burns peritoneum). Prime tubing to remove air.
• Catheter insertion: consent; baseline VS, weight, electrolytes; exit site on nondominant side; empty bladder and bowel first (prevent puncture); prophylactic antibiotic. Silicone catheter with two Dacron cuffs; 5- to 10-cm subcutaneous tunnel protects against infection.
• Exchange: fill (2 to 3 L over about 10 minutes by gravity), dwell, drain (20 to 30 minutes by gravity). Effluent normally colorless or straw-colored, not cloudy; pink or bloody in first few exchanges after insertion is expected. Overly long dwells allow reabsorption. Dextrose 1.5, 2.5, 4.25 percent in 1000 to 3000 mL; higher dextrose removes more water.
• Complications:
  • Peritonitis: most common and serious; first sign is cloudy effluent; then diffuse abdominal pain, rebound tenderness, hypotension, shock. Effluent WBC over 100 (after at least 2-hour dwell) with over 50 percent neutrophils: broad-spectrum intraperitoneal antibiotics (aminoglycosides or cephalosporins) for 14 to 21 days; large protein loss.
  • Leakage: wait at least 2 weeks after insertion before use; hold dialysis several days; avoid bending, lifting over 5 lb, straining; start with small volumes (500 mL) and increase to 2000 to 3000 mL.
  • Bleeding: bloody effluent in menstruating women and after new catheter; usually stops in 1 to 2 days; heparin and frequent exchanges prevent clotting.
  • Long-term: hypertriglyceridemia, cardiovascular disease, hernias, worsened hiatal hernia and hemorrhoids, low back pain, anorexia, sweet taste; mechanical drainage problems (fibrin, clots, constipation).
• Acute intermittent PD: for unstable patients or late referrals; for example hourly: 10-minute fill, 30-minute dwell, 20-minute drain. Flow sheet of each exchange, VS, weight, I&O, cumulative balance; daily weight (document dwell or no dwell).
• Quality and Safety Alert: if PD fluid does not drain, turn side to side, sit or stand, raise HOB; check for kinks, closed clamps, air lock; never manipulate the catheter.
• Asepsis: hand hygiene and mask for anyone within 6 feet during connection or disconnection; clean technique for exit site at home, sterile in hospital.
• CAPD: 4 to 5 exchanges daily, 7 days a week; closed Y-set; more stable lab values.
• CCPD: cycler overnight; alarms; lowest infection rate; free days.
• Psychosocial: body image (catheter, larger waist), sexuality (catheter, cycler in bedroom), feeling overwhelmed.
• Teaching (Chart 48-12): 5 days to 2 weeks; high protein (1.2 to 1.3 g/kg/day), low phosphorus, more fiber (constipation impedes flow); may gain 3 to 5 lb in first month (limit carbohydrates); potassium and fluid restriction usually not needed (lose 1 to 2 L extra fluid daily); exit site care; aseptic exchange; record keeping; sterile fluid samples.

E. Hospitalized Patient on Dialysis

• Protect access: no BP or blood draws on access arm; no constricting dressings, restraints, jewelry; check bruit and thrill every 8 to 12 hours (absence = clotting; risk with infection or hypotension); watch HD catheter site for infection; access used only for dialysis except emergencies (dialysis nurse cannulates; withdraw catheter dwell volume first).
• IV therapy: slowest possible rate. Quality and Safety Alert: rapid IV fluid causes pulmonary edema.
• Uremia worsens faster with steroids, TPN, infection, bleeding, surgery; may need daily dialysis.
• Cardiac and respiratory: crackles, moist cough, frothy blood-tinged sputum (pulmonary edema); pericarditis (substernal pain, low fever, friction rub, pulsus paradoxus); effusion (rub disappears, muffled heart sounds, low-voltage ECG); tamponade (narrow pulse pressure, inaudible heart sounds, crushing chest pain, dyspnea, hypotension) needs emergent pericardial window.
• Electrolytes: check all IV solutions and medications; give transfusions during HD when possible; hypoalbuminemia = malnutrition.
• Discomfort: pruritus (antihistamines like diphenhydramine; bath oils, superfatted soap, lotions, short nails); neuropathy pain; adjust doses.
• BP: often multiple antihypertensives; held before and given after dialysis.
• Infection: impaired phagocytosis, low WBC, anemia, platelet dysfunction, anticoagulants: high infection and bleeding risk.
• PD catheter site: daily or 3-4 times weekly cleaning with liquid soap and water during shower; do not submerge in bathwater; keep catheter secure.
• Do not attribute every symptom to kidney disease; support decisions about continuing dialysis.

IX. Kidney Surgery

• Preop: evaluate renal function; encourage fluids unless contraindicated; antibiotics with caution (nephrotoxic); coagulation studies; reassure that one healthy kidney maintains normal function.
• Approaches: flank, lumbar, thoracoabdominal (painful), laparoscopic (less pain, faster recovery); nephrostomy or other drains.
• Postop complications: hemorrhage and shock (chief risks; highly vascular organ), abdominal distention and paralytic ileus (NG decompression; oral fluids after flatus), infection, thromboembolism (low-dose heparin), pneumonia, fluid imbalance.
• Nursing (Chart 48-13): respiratory (pain on inspiration causes splinting: analgesics, splint incision, turn, incentive spirometer, early ambulation; RR 12 to 18); circulation (VS, skin, urine output, incision and drains); pain before and after analgesics; urinary drainage (report decreased or absent drainage: obstruction; closed sterile system; irrigate only as prescribed, gently with sterile saline; protect stents and ureteral catheters; anchor tubing; fluids 6 to 8 glasses daily); fluids (daily weight within 2-3 lb of baseline, infusion pump, heart and lung sounds every shift).
• Bleeding signs: fatigue, dyspnea, urine under 400 mL/24 h; late: cool skin, flat neck veins, LOC change.
• Fluid excess signs: weight gain, pedal edema, urine under 400 mL/day; treat with restriction, furosemide, or dialysis.
• DVT: anti-embolism stockings, leg exercises, anticoagulants.
• Teaching: drainage system care (teach-back), prevent obstruction, infection, DVT, atelectasis, pneumonia.

X. Kidney Transplantation

• Treatment of choice for selected ESKD patients; not a cure; elective, not emergency. Over 103,000 waiting. Annual cost about $34,084 vs about $88,750 for in-center HD.
• Living (related or unrelated) or deceased donor (“cadaveric” no longer used); well-matched living donor transplants do best. Organ donor cards; paired exchanges and chains.
• Recipient contraindications: recent cancer, active or chronic infection (HIV, hepatitis B, C), severe irreversible extrarenal disease, BMI over 35, active substance use, inability to consent, active psychiatric disease, nonadherence. Donors excluded for hypertension, diabetes, or anything threatening the remaining kidney; donor coercion excluded.
• Native kidneys usually left (except large or infected polycystic kidneys). Graft in iliac fossa; renal artery to iliac artery, renal vein to iliac vein, ureter to bladder. Urine production in OR is a key early indicator (deceased donor).
• Preop: metabolic state near normal; free of infection (including dental); tissue and blood typing, antibody screening; psychosocial evaluation; HD before surgery; PD dwell drained before OR.
• Rejection: hyperacute (within 24 hours; antibody-mediated; remove kidney), acute (3 to 14 days or weeks; rising creatinine; later fever, graft tenderness, malaise, oliguria; treat with immunosuppression), chronic (years). Biopsy most reliable for diagnosis.
• Immunosuppression lifelong; 90 to 95 percent of grafts work at 1 year. Avoid grapefruit and grapefruit juice. Risks: nephrotoxicity, hypertension, hyperlipidemia, hirsutism, tremors, blood dyscrasias, cataracts, gingival hyperplasia, cancers.
• Table 48-4: tacrolimus (nephrotoxicity, hyperkalemia, tremors, hypertension; levels); cyclosporine (nephrotoxicity, hirsutism, gingival hyperplasia; give with food at same time daily; swallow whole; no grapefruit; limit sun; levels); sirolimus (give 4 hours after oral cyclosporine); mycophenolate (GI upset, diarrhea; with food); belatacept (IV; not if EBV seronegative); everolimus (watch pulmonary status; no live vaccines; do not crush).
• Nursing: assess for rejection (oliguria, edema, fever, rising BP, weight gain, graft swelling or tenderness; with cyclosporine maybe only a rise in creatinine); infection (monitor WBC and platelets; chills, fever, tachycardia, tachypnea; frequent urine cultures; culture catheter tips; no fresh flowers; hand hygiene; most infections in first month); urine output hourly (living related kidney may produce large dilute volumes; deceased donor kidney may have ATN with no function for 2 to 3 weeks; HD may be needed); H2 blockers or PPIs (steroid GI bleeding); antifungal mouth rinses; watch for adrenal insufficiency; psychological support. Living donor often has more pain than recipient.
• Teaching: lifelong immunosuppression; report decreased urine, weight gain, malaise, fever, respiratory distress, graft tenderness, anxiety, depression, BP changes; tell all providers including dentist; avoid contact sports; daily weight and urine measurement; close follow-up (once or twice weekly at first); cardiovascular disease is the main cause of death; higher cancer risk; health screening.
• COVID-19: higher risk; immunosuppression often reduced.

XI. Renal Trauma

• Blunt (motor vehicle crashes, falls, assaults, sports) or penetrating (gunshot 86 percent, stab 14 percent). Associated rib or lumbar transverse process fractures. Not wearing seat belts increases risk.
• Blunt categories: contusion (subcapsular bruise), minor laceration (cortex), major laceration (into medulla, maybe collecting system), vascular injury (artery or vein tear).
• Kidneys get half of abdominal aorta flow: even small lacerations can bleed massively; most patients arrive in shock.
• Best indicator: hematuria (gross or microscopic) with injury history; degree of hematuria does not match degree of injury. Pain, renal colic (clots), flank mass, ecchymosis, flank or abdominal wounds.
• Management: control bleeding, pain, infection; save all urine for RBC analysis; serial Hgb and Hct (falling = hemorrhage); watch for oliguria and shock; palpate and mark flank mass outline to track expansion; contrast CT when stable; check for other abdominal injuries.
• Contusion with microscopic hematuria and normal CT: outpatient. Gross hematuria or minor laceration: bed rest until hematuria clears; antibiotics for hematoma or urinoma; low-grade fever as clot absorbs.
• Major lacerations: surgery, angioembolization, or conservative care; sudden change = hemorrhage, rapid surgery; vascular injury: immediate exploration, aggressive fluids, possible nephrectomy.
• Complications: rebleeding, perinephric abscess, sepsis, urine extravasation, fistula (early); stones, infection, cysts, aneurysms, loss of function, late hypertension.
• Nursing: frequent assessment for flank and abdominal pain, spasm, swelling; teach incision care, fluids; report fever, hematuria, flank pain, decreasing function; restrict activity about 1 month (delayed bleeding); monitor BP; follow-up renal function; medical ID after nephrectomy.

High-Yield Numbers

Priority Nursing Actions and Red Flags

• Daily weight is the best fluid indicator.
• Hyperkalemia (peaked T waves, weakness): IV calcium, insulin with dextrose, then dialysis; screen everything for potassium.
• Prevent contrast AKI: IV normal saline prehydration; hold nephrotoxins.
• Pericardial friction rub in ESKD: urgent dialysis indication; watch for tamponade.
• Access arm: no BP, IV, or blood draw; check thrill and bruit; absent thrill = clot.
• Give antihypertensives after dialysis; phosphate binders with the first bite of food.
• PD: cloudy effluent = peritonitis; warm with dry heat only; mask and hand hygiene for connections; never manipulate a catheter that will not drain.
• Dialysis disequilibrium: headache, restlessness, seizures in early high-BUN dialysis.
• Post kidney surgery: hemorrhage and shock; absent drain output = obstruction.
• Transplant: rising creatinine may be the only sign of rejection; infection signs; no grapefruit.
• Renal trauma: serial Hgb/Hct, mark flank mass, save urine.

Medications

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• INDEX