Kidneys

• form urine - glomerular filtration, reabsorption, excretion
• erythropoietin - increase RBC to increase O2 carrying capacity (in response to tissue hypoxia)
• regulate BP - RAA - renin secreted by afferent arterioles in response to decreased BP
• electrolyte balance
• H2O balance - ADH
• pH balance - H+/HCO3- secretion/reabsorption if too acidi/alkaline
• activate vitamin D - stimulated by PTH in response to low blood calcium > calciferol (absorbs Ca/PO4 from small intestine)

• BP forces plasma, small proteins out of glomeruli into Bowman's capsule > renal filtrate
• GFR: amount of fluid filtered/filtrate formed per minute - 100-125mL/min
• increased BP in glomeruli (60 mmHg)

recovery and return of useful materials from filtrate to circulation via peritubular capillaries

• waste products actively secreted into filtrate
• ammonia, creatinine, medications
• H+ secreted/reabsorbed to maintain blood pH
• excess potassium secreted

ureters > bladder > urethra

• 1-2L per 24 hours
• straw or amber colored
• clear vs cloudy
• ***specific gravity: 1.010-1.025***
• --<1.010: DI, overhydration, renal disease, potassium deficit (dilute)
• -->1.025: dehydration, fever, DM, vomiting, DHR (concentrated)
• pH: 4.6-8.0 - influenced by diet, meds (chemo is acidic > bladder hemorrhage > CBI to neutralize)
• 95% H2O, 5% nitrogenous waste (urea, creatinine, uric acid)

• decreased nephrons
• decreased GFR r/t decreased renal blood flow s/t arteriosclerosis
• decreased bladder size
• decreased detrusor muscle tone > increased frequency, PVR (s/b < 150, >150/250 = straight cath)
• increased UTIs
• decreased ability to concentrate urine
• increased r/f dehydration r/t decreased ability to compensate for salt intake
• decreased potassium excretion r/t decreased aldosterone levels
• fluid/electrolyte imbalances
• decreased drug clearance

• congenital malformation
• polycystic kidney disease
• glomerular disorders (nephrotic syndrome)
• renal failure

• formation of fluid filled cysts, massive kidney enlargement
• hereditary
• two forms: autosomal dominant and autosomal recessive
• autosomal dominant - adults
• autosomal recessive - children

• renal cysts affect nephron
• fill, enlarge, multiply
• affect medulla and cortex
• cause fibrosis and scarring

• slow progression
• flank pain
• kidney concentration problems:
• --hematuria - microscopic or gross
• --proteinuria
• --polyuria
• --nocturia
• UTIs, renal calculi - cysts block normal drainage
• HTN - RAA
• enlarged, palpable kidneys
• renal insufficiency > CKD > ESRD

• renal ultrasound
• CT scan
• genetic testing

• supportive management
• avoid nephrotoxins - mycins, oral antidiabetics
• manage/avoid HTN
• avoid UTIs, lithiasis - fluid intake 2000 - 2500 mL
• hemodialysis > renal transplant

• excess fluid volume r/t impaired renal function
• grieving r/t loss of kidney function
• readiness for enhanced knowledge
• risk for ineffective coping

• affect structure and function of glomerulus
• disrupts glomerular filtration
• capillary membrane more permeable to plasma proteins, blood cells > hematuria, proteinuria, edema
• decreased plasma proteins > increased filtrate > RAA stimulation > vasoconstriction, decreased GFR
• decreased GFR > HTN, azotemia (increased waste products [urea] in blood), oliguria (< 400mL for 24 hours)

• hematuria r/t permeable membranes
• proteinuria r/t permeable membranes
• Na, H2O retention r/t increased aldosterone s/t RAA
• cola colored urine
• ***periorbital edema, dependent edema***
• HTN
• fatigue
• anorexia
• N&V

• inflammation of glomerular capillary membrane
• caused by beta hemolytic strep infection
• circulating immune complexes become trapped in glomerular membrane
• tx: antibiotics, bed rest

• rare autoimmune disorder
• formation of antibodies to glomerular basement membrane
• tx: immunosuppression, plasmapheresis (remove antibody/antigen complex)

• group of clinical findings
• s/t malignancy, HTN, infection
• --proteinuria
• --hypoalbuminemia r/t protein loss in urine
• --hyperlipidemia r/t liver compensation for decreased proteins
• --edema
• risk for clotting, DVT, PE (decreased clotting factors)
• tx: ACE inhibitors, low sodium diet (1 to 2 g daily), moderate, complete proteins

• diabetic neuropathy - 40% of DM patients, leading cause of CKD
• lupus nephritis

• identify underlying disease process, preserve kidney function
• throat/skin culture, ASO titer - strep
• ESR - autoimmune
• KUB - kidney, ureter, bladder xray - enlarged kidneys (acute), small kidneys (late chronic)
• kidney scan - perfusion
• **biopsy - most reliable to determine type, prognosis, tx

• BUN - increased r/t azotemia
• serum creatinine - increased r/t decreased renal function (> 4 = serious)
• creatinine clearance - amt cleared in one minute - decreased
• serum albumin - decreased r/t proteinuria
• serum electrolytes - hyper except calcium
• RBC - decreased r/t decreased erythropoietin levels
• urine creatinine - decreased
• urine protein - increased
• urine RBC - increased
• GFR - decreased (normal > 60)
• "elevated potassium, phosphorus, decreased protein, pee pee"

• antibiotics if infectious
• immunosuppressive therapy if autoimmune
• oral glucocorticoids if autoimmune
• ACE inhibitors - renal protective, decrease BP
• antihypertensives - limit kidney damage

• goal: maintain renal function, prevent complications, promote healing
• fluid volume excess - restrict fluids
• fatigue
• ineffective protection
• ineffective role performance
• pain
• ineffective breathing patterns
• anticipatory grieving

• presence of kidney damage for 3+ months (GFR < 20)
• diffuse bilateral kidney disease with progressive destruction and scarring of whole nephron
• caused by
• --diabetes
• --HTN
• --pre-existing glomerular nephritis

• depends on underlying disorder
• gradual loss of entire nephron unit
• hypertrophy of remaining nephrons > increased glomerular capillary flow and pressure
• more solute particles filtered to compensate for lost renal mass
• increased demand cause scarring on remaining nephrons
• decreased renal reserve > renal insufficiency > renal failure > ESRD

• GFR 50% of normal
• normal BUN
• slightly elevated creat
• asymptomatic

• GFR 20-50%
• mild azotemia
• increased BUN

• GFR < 20%
• sharp increase in BUN/creat

• GFR < 5%
• renal replacement therapy

• "urine in the blood" - build up of waste - severe azotemia
• nausea, apathy, weakness, fatigue, confusion

• impaired ability to regulate fluids, electrolytes, acid/base
• early stage: Na/H2O not conserved > dehydration, polyuria, nocturia, dilute urine
• late state: Na/H2O retained > FVE
• hyperkalemia - muscle weakness, paresthesia, EKG changes (when GFR < 5)
• hyperphosphatemia - excretion impaired
• hypermagnesemia - avoid antacids
• hypocalcemia - reduced calcium absorption r/t impaired vitamin D activation
• H+ excretion, bicarb production impaired - metabolic acidosis - Kussmaul respirations

• accelerated atherosclerosis
• HTN r/t FVE, increase RAA, vascular resistance
• HF r/t FVE
• decreased contractility r/t acidosis
• hyperlipidemia

• anemia r/t decreased erythropoietin, decreased life span s/t toxins in blood
• impaired platelet function

• increased r/f infection - impaired inflammation and immune response r/t toxins
• suppressed fever

• anorexia
• N&V
• hiccups
• uremic fetor - urine breath

• central and peripheral changes r/t uremia
• AMS, fatigue, insomnia
• restless legs, paresthesias r/t hypocalcemia

• hyperphosphatemia, hypocalcemia stimulate PTH > renal osteodystrophy (renal rickets) - softened bones, decreased bone mass
• bone tenderness, pain, muscle weakness
• Trousseau's, Chvostek's

• glucose intolerance
• high triglycerides

• uremic frost - crystals on skin from urea
• pallor r/t anemia
• yellow hue r/t retained metabolites

• urinalysis - specific gravity (low d/t impaired tubular secretion, reabsorption, concentration)
• urine culture - UTIs
• BUN - 20-50 = mild azotemia, 100+ = severe azotemia, 200+ = uremic sx
• serum creatinine > 4 = serious renal impairment
• eGFR - stage disease
• Na - normal to low d/t H2O retention
• K - elevated
• Phos - elevated
• Ca - decreased
• CBC - amemia, low platelets
• renal US - kidney size decreaed as nephrons destroyed
• kidney biopsy - determine underlying disease

• avoid nephrotoxic meds
• increased half-life
• avoid oral antidiabetics, NSAIDs
• ACE/ARBs - slow progression of CKD, HTN
• diuretics - reduce FV, edema, HTN, waste K
• Na bicarb/Ca bicarb - correct acidosis
• Phos-Lo - binds to phosporus to lower phosphate, normalize Ca
• High K levels - bicarb + insulin + glucose (move K back into cells)
• Kayexalate - excrete K
• folic acid/iron/vitamin D

• reduced protein - 0.6gm/kg/day
• increased carbs - 35cal/kg/day
• decreased Na and H2O as disease progresses
• decreased K - salt substitutes
• decreased phos - eggs, dairy, meat

• goals: prevent further damage, minimize toxic waste, maintain nutritional status
• ineffective renal perfusion r/t nephron destruction
• imbalanced nutrition - less r/t anorexia, N&V
• risk for infection r/t altered immunity
• disturbed body image