ALTERED ELIMINATION- MULTI From glomerulus -> Bowman’s capsule ->

SYSTEM PROBLEM proximal convoluted tubule -> loop of

henly -> distal convoluted tubules ->
FLUID
collecting duct
Renal
System:
Anatomy and Physiology:

Kidneys – two small, but mighty bean-

shaped organs that remove excess fluid
and waste products from the body. (R-
kidney is lower than L-kidney because
of liver)

Layers:

Filtration -> reabsorption ->

secretion -> excretion
Inner to
outer: REABSORPTION
Renal medulla, renal cortex, renal
capsule, adipose capsule (perirenal fat), PCT – Na, Cl, K, glucose, amino acids,
renal fascia, pararenal fat urea, bicarbonate. H2O
Renal LOH – (descending: h2o; ascending: Na,
protection: Cl, K)
Capsule – tough fibrous connective tissue DCT – Na, Cl, K, Mg, Ca,
layer that covers the outside of each Bicarbonate
kidney. (Composed primarily of collagen CD – Na, Cl, Urea,
H2o
and elastin) SECRETION
Perirenal
fat PCT – Creatinine, drugs, H
Fascia – wraps around the whole kidney to
the vena cava DCT – H, K
NOTE: HOW MANY LITERS OF BLOOD
DOES KIDNEY FILTER EACH DAY: 142L URINE – 95% h2o, nitrogenous waste,
OF BLOOD (but only 2L becomes urine) ions, metabolites, wbc and rbc (low
levels)
Urine RENAL ASSESSMENT:
Formation:
 “Kidneys filter and remove” Hyponatremia (<130) – usually
asymptomatic
Obvious signs – gross Treatment: increase by 0.5 mEq/hr (if
hematuria (blood in urine), complaints of seizures
flank pain is present = increase by 2.4 mEq/hr)
Signs require more assessment – CHEM-8 (Potassium [K+]) – 3.5-5
edema, Hypertension, Signs and mEq/L
symptoms or uremia Special role for: muscle contraction,
creatinine, abnormal urinalysis results fluid balance, nerve transmission
Silent (asymptomatic) signs –
Check: https://youtu.be/LJai9zjFnTs for
Elevated serum
chem-8
(Read more on acute kidney injury
(AKI) or acute renal failure (ARF) or
chronic renal disease) Test for liver
Early identification = function
Safety  CMP – Comprehensive Metabolic Panel
- Monitoring and screening of pt’s
-
kidney function can identify
- Test for Alkaline Phosphate, AST, ALT,
problems earlier and allow for
Bilirubin, Total protein, albumin
intervention to slow the progression
of kidney disease
- When disease or damage is
discovered, additional testing is a
priority to determine the degree of
damage and/or progression
DIAGNOSTIC EXAMS

Metabolic Panels – assess electrolytes,

kidney function, and liver function

2 Types:

 BMP – Basic Metabolic Panel

- Test for electrolytes and kidney
function
(chem 8)

CHEM-8 (Sodium [Na+]) – 135-145 mEq/L

- Maintain serum osmolality

- H2o/ion shifts
- Higher concentration in blood vs.
cells

Hypernatremia (>145-150)

Treatment: correct water balance = lower

by
0.5-1 mEq/L
 URINALY
SIS
- Is a commonly ordered panel of test
on a urine sample
- Gross inspection = color and
turbidity
- Dipstick = specific gravity, pH,
glucose, Heme, Protein, Leukocyte
esterase, Nitrites, Ketones,
Bilirubin
- Microscopy = WBCs, RBCs,
bacteria, crystals, casts
SG fixed at 1.010 regardless of
dehydration or excessive hydration
 advanced kidney
failure
urine pH – 4.5-8.0
when kidneys are functioning normally:
excrete more H+ in acidemia (lower pH <5)
excrete less H+ in alkalemia (higher pH 7-8)
 helpful in diagnosing tubular
acidosis
 monitoring urine alkalinization
 differentiation of different types of
kidney stones
Glucose

- glucose in urine is called glucosuria

(if severe, can lead to osmotic
Gross Inspection
diuresis and dehydration)
Color – can be influenced by medical
Heme
conditions, medications, and ingested food.
RED – medical conditions: bleeding - dipstick highly sensitive for
Orange – Hyperbilirubinemia (Liver disease); hemoglobin
rifampin - also detects myoglobin
Detectable Heme
Brown/Black – If severe = red/orange urine is - Hematuria
Protein
concentrated enough
Green – UTIs, methylene blue, ingestion of blue dyes - Most sensitive for albumin
Purple – infected urinary catheters
White – Hypercalciuria, chyluria Detectable protein

Turbidity – how cloudy a urine is - Glomerular disease

- Overflow proteinuria
- May indicate the presence of UTI;
- Post-renal
do not base the turbidity for the proteinuria
presence or absence of UTI
DIPSTICK Leukocyte Esterase and Nitrites
- Assessment of contents of - Used to aid in diagnosis of UTIs
urine - Leukocyte esterase = qualitative measure
Specific gravity (n= 1.001-1.035) of WBC in urine
- density of urine/density of - Nitrites detect enterobacteriacae
water
Usually around 1.010
SG closer to 1.001 = urine more dilute than
normal (excessive hydration, diabetes
insipidus)
SG closes to 1.035 = dehydration
(SIADH, impaired perfusion or CHF)
 Ketones Contraindication: depends of renal function
Detectable Ketones  Renal failure (cannot excrete contrast
- Ketoacidosis (diabetic, alcoholic, Contrast Media:
starvation )
- Ketogenic diet  Water-soluble Non-ionic LOCM
(350- 370mgl/ml). Average
BLOOD TESTS volume of 50mL
Creatinine  Multiple myeloma
– chemical waste of muscle  Elevated creatinine levels (>200)
metabolism  Risk of severe contrast media reaction
- Assess renal (kidney) function  Pregnancy
- Inversely proportional to GFR Preparation:
Impaired kidney =inc. creatinine
 Bowel preparation (use laxatives 2 days
GFR (glomerular filtration rate) – a more specific before exam )
measure of CKD (chronic kidney disease)  Fluid restriction (avoid fluids 2-3 hrs
eGFR (estimated GFR) before exam)
 Empty bladder
GFR > 60 = normal
GFR < 60 = may indicate kidney disease
GFR < 15 = medically defined as kidney failure Technique:
 Patient is placed supine
Note: In calculation of CFR:  Contrast media injected in MEDIAN
- Creatinine level must be stable CUBITAL VEIN
- Not as accurate in AKI or dialysis When not to use compression
- Not valid for pts <18 yrs old
 Suspected renal calculi
IVU (Intravenous Urography)
 Suspected abdominal aorta
- Radiological investigation of the urinary
aneurysm
tract following injection of water- soluble
 Pain
contrast media (contrast media
 Recent surgery
administered in the vein of the arm)
 Trauma
Indication:

 Hematuria, suspected renal calculi, Alternatives for

suspected transitional cell carcinoma, compression
 High dose contrast
suspected ureteric obstruction, flank
media
pain
 Trendelenburg position
Aftercare:

 Cannula is removed and pressure

applied to prevent bleeding
 Pt. is advised to drink sufficient
water
Complications:

 Contrast media
reactions
 Burning sensation in
arm
Special Considerations:
Causes:
 Emergency IVU – no bowel PRERENAL – dec. pressure and/or blood tokidneys /
preparation and fluid restriction; inc. any problems in perfusion
contrast media amt. to compensate - Dec. cardiac output: Cardiac
ACUTE KIDNEY INJURY (AKI)
problems
 Abrupt loss of kidney function
- Shock
 Retention of urea
- Dehydration/diuresis/diarrhea/
 Dysregulation of extracellular volume
hemorrhage
Oliguria - <500mL urine output in 24h - 3rd spacing: cirrhosis ->splanchnic
Anuria <100mL urine output in 24h (essentially vasodilation
not producing urine) - Artery obstruction
- Drugs: ACEi/ARB; NSAIDs
 High mortality rates
INTRARENAL –Direct damage to kidneys
- Glomerular
- Tubular
- Tubulointerstitial:
- Vascular drugs
POSTRENAL – obstruction of urine flow
- Calculi
- Malignancy
- BPH
- Urethral strictures

PRERENAL vs INTRARENAL/RENAL
MANAGEMENTS FOR AKI:
 Labs: Creatinine, BUN, eGFR Goals:
1. Treat the cause
2. Manage the effects (symptoms)
 Patient is having retention (fluids
and metabolic waste products) –
Renal replacement
RENAL REPLACEMENT TYPES:
- Hemodialysis (1) most common
- Peritoneal Dialysis – associated w/ CKD
- CRRT – for critically ill patients
Hemodialysis:
BEFORE:
Check BP – due to removal of fluids, BP
is usually low ( a normal or higher than
normal is acceptable )
Monitor Labs (BUN)
Weight – how big is the fluid loss
Dialysis site – check for bleeding (if
soaked ang pads); check for bruits
and thrills (if absent, vessels not
patent or presence of clots)
Hold Medications: Anti-hypertensives and diuretics
(lowers BP)
Antibiotics, Water-soluble
vitamins
(eliminated during dialysis, usik)
DURING:
Disequilibrium syndrome – Patient may
experience headache; rapid removal of
fluids in the body causes shifting in the
brain.
NOTE: patients may experience
SEIZURES
 Hypertension/Hypotension – due
to rapid removal of fluid
mngt:
Hypotension - lay pt.reverse trendelenberg
flat in bed,
Hypertension – raise head of the pt
DURING
(Cont.)
 Give supplemental vitamins (but
usually AFTER) – the problem if
given during, vitamins can still be
eliminated.
Peritoneal Dialysis – patient is usually stable;
almost never given to AKI (because it is usually
SLOW)
AKI Medications: – manages the symptoms
Diuretic – offer symptomatic relief but
s
Furosemide – both no effect on the disease itself
 Inotropic Agents dopamine and dobutamine
if given together, inc.
contraction of heart and inc. renal
function
- Dopamine (1st choice)
- Dobutamine (2nd choice)
NOTE: Titrated (Order: “Start
dobutamine premixed 500mcg/250mL
@15cc/hr with the following titrations:
titrate at increments/decrements of
5cc/hr for BP above or below
120mmHg every 15 mins)
- If BP is less than 120, inc. the
dose
- If BP is higher than 120, dec. the
dose
 Recent 2 medications that shows SHOCK
positive effects for AKI: COMMON INTERVENTIONS
 ANP (hormone) – improve kidney  1st = O2 (Airway)
function; stimulate excretion of Na and H2 - intubate due to possible acidosis, dec.
O LOC (impending respiratory failure)
 Norepinephrine (vasoconstriction)
though it causes– vasoconstriction, it - check ABG before intubation sedate the pt.
improves kidney function - If patient is conscious =before intubation
(cardio safe = ketamine )
EMERGENCY DIALYSIS: Possible reasons for pts w/ AKI  FLUIDS (may be contraindicated
 Hyperkalemia – due to cardiac effects for other types of shock)
Immediately give fluids during
(may cause death of the pt) - hypovolemic shock
 Pulmonary edema
 Profound acidosis NOTE: DO NOT GIVE FLUIDS FOR PT
UNDERGOING CARDIOGENIC SHOCK
 Severe uremia – BUN-Creatinine
; For any
ratio inc. (n=10:1), if 30,40,50:1, it
type of shock (anaphylactic or septic),
is now a problem
fluids may be given
NOTE: Watch out for(during dehydration
diuretic phase) - Safest is ISOTONIC (Plain NSS, lactated ringers)
CHRONIC KIDNEY DISEASE - IV – large bore needles (to prepare for the
possibility of blood transfusion,
Kidney damage many side drips in a single line
 pathological
abnormalities NOTE: If suspected cardiogenic but there
 Clinical Markers of kidney is no problem in L ventricles – FLUID
damage:
Proteinuria CHALLENGE – give 250mL/min to check
- >150 mg of proteinuria per day for status )
- >30 mg of albuminuria per day
o Glomerular hematuria  Medications
- Dysmorphic RBCs or RBC casts - Vasopressors – to increase the BP
o Imaging - Inotrope – for cardiogenic shock
- Polycystic kidneys s
- Hydronephrosis Anaphylactic Shock – Epinephrine,
- Small kidneys with thinned cortices corticosteroids, and
immunosuppressants (cyclosporin
ESRD: Common Causes Septic Shock – Empiric antibiotics
 DM nephropathy
 Hypertension
 AKI - (broad spectrum); can also use
narrow spectrum (depends on
common microbes in a specific
area that caused the septic shock)
 IDENTIFY AND TREAT THE CAUSE