Nephrology Module for Nurses

• Nephrology is a medical specialty that focuses on treating diseases related to the kidneys. Nephrologists
diagnose, treat, and manage acute and chronic kidney problems and diseases. The field covers normal
kidney function, kidney disease, preservation of kidney health, and treatment options including dialysis and
kidney transplantation.

• The first scientific observations of the kidney were made by Lorenzo Bellini and Marcello Malpighi in the
middle of the 17th century, but true physiological understanding of the kidney began with Carl Ludwig’s
1844 hypothesis that blood pressure forces waste fluids out of the renal capillaries into the ducts
(nephrons) of the kidney. In 1899, Ernest Starling further explained the function of the kidney by proposing
that osmotic pressures helped to concentrate the urine there; this theory was confirmed by A.N. Richards in
the 1920s.

• Urology is a field of medicine that focuses on diseases of the urinary tract and the male reproductive
tract. It is a surgical speciality that deals with diseases of the male and female urinary tract and the male
reproductive organs. The word "Urology" comes from the Greek words "ouron" meaning urine and "logia"
meaning study. Urologists may treat general diseases of the urinary tract.

• Urology is a medical field that focuses on the urin excretory system and includes the kidneys, bladder, and
related structures, as well as the male reproductive system. Urologists are doctors who specialize in
diagnosing and treating conditions like kidney stones, urinary tract infections, prostate issues, and sexual
dysfunction. They help manage both men's and women's health concerns related to these areas and can
perform surgeries when necessary, making sure your urinary and reproductive systems work as they should.
 Nephrology

Can be discussed in 3 parts

• General Nephrology

• Dialysis

• Renal Transplant
 General Nephrology - Presentation

Patients of General Nephrology usually get admitted with one or more of the following complaints:
• Abnormalities in asymptomatic patients raising the suspicion of renal disease
• Abnormal findings in patients at risk of renal disease and complications
 Invisible (microscopic) hæmaturia
 Asymptomatic proteinuria
 Abnormal constituents of urine
 Abnormal Glomerula Filtration Rate (GFR)/estimated GFR (e-GFR)
 Raised blood pressure
 Inherited disorder known to be present in the family
 Electrolyte abnormalities
• Symptomatic urinary diseases
 Dysuria
 Frequency, polyuria, nocturia
 Oliguria, anuria
 Visible (macroscopic) hæmaturia
 Loin pain
Contd....
 PRESENTATION Contd.....

• Nephrotic Syndrome: This is a term that refers to the combination of oedema, heavy proteinuria, and hypoalbuminaemia. Usually
the plasma albumin is < 3.0 g/dL, and/or the urine protein loss is > 3 g/24 hours.
• Nephritic syndrome : This term describes the combination of oedema, hypertension, glomerular haematuria, and proteinuria (not
in the ‘nephrotic’ range) with or without a reduction in GFR
• Acute Kidney Injury (AKI): It is defined as any of the following:
 an increase in serum creatinine by > 0.3 mg/dL within 48 hours
 an increase in serum creatinine to > 1.5 times baseline, which is known or presumed to have occurred within the prior 7
days
 a urine volume < 0.5 mL/kg/h for 6 hours

• Symptomatic Chronic Kidney Disease: symptoms like lack of appetite, weakness, dyspnœa, volume overload, pruritus, cognitive
decline
• The patient has a systemic disorder known to be complicated by renal involvement
 Metabolic & Inherited disorders: like Diabetes or Cystic diseases
 Malignancy itself or its treatment damaging the kidneys
 Infection of kidney and/or urinary tract or systemic infection affecting kidney injury
 Auto-immune inflammatory disorders - systemic or renal limited - affecting kidney structure and /or function
 Drug induced kidney damage or alteration in kidney function
 Pregnancy complicated by renal dysfunction
 Other system failure: like patients suffering from advanced heart and/or liver failure affecting the kidneys
 Important nursing elements in General Nephrology care

Following elements are essential in the management of any patient suffering from kidney disease:
 Diet: Is an important and integral part of the Nephrology care. Every patient suffering from kidney ailment has some
dietary modifications particularly with respect to electrolyes, namely, sodium, potassium etc. incorporated in the
management.
 Fluid Intake: Another important aspect of Nephrology care. Fluid advice needs to be followed and monitored diligently
because both ways - less or excess - it has significant physiological and/or pathological consequences on the patients.
 Drugs: Drugs and their dosing are to be meticulously followed as they have either reduced effects or exaggerated
deletorius effects if not used as per advice.
 Urine output: Observing and measuring urine output meticulously is an important task of nursing care in Renal patients
particulary who are admitted; more so in critically ill patients.
 Blood pressure (BP): Measurement of BP as well as promptly responding to its' unusual/unexpected alteration is
necessary to avoid unfavourable outcome.
 Renal function: Renal/kidney function is measured by Glomerular Filtration Rate (GFR) which can either be measured
directly or can be estimated indirectly based on other prameters, namely, Serum Creatinine when that is called Estimated
GFR or e-GFR.
 Renal Replacement Therapy (RRT): Apart from the above elements kidney patients who are on any form of RRT other
than Kidney Transplantation (KT), namely, Hæmodialysis, or Peritoneal Dialysis, undertaking the procedure and doing it at
regular intervals is essential in the care of patients with End Stage Renal Disease (ESRD).
 Education: Patients suffering from kidney diseases need education about the disease they are suffering from as well as the
treatment they are receiving. They need to be explained and made aware of, in simple terms, the broad nature of their
illness as well as the nature of treatment they are receiving. They must also be apprised of the consequences that they may
face if they don't follow the advices. A training of life-style modifications that they need and small steps of self-care that may
help them to improve outcome of the management that they are receiving.
 NURSING ASSESSMENT
Assess for the following subjective and objective data:
• nausea and vomiting
• Loss of appetite
• fatigue and weakness
• sleep disturbances
• Increased urination (polyuria) or decreased urination
(oliguria)
• Urinating more frequently, especially at night (nocturia)
• Foamy or bubbly urine

This Photo by Unknown author is licensed under CC BY.

 NURSING ASSESSMENT
• Pale urine or dark, tea-colored urine
• Decreased mental sharpness
• Muscle twitches and cramps
• Swelling of feet and ankles
• Persistent pruritus
• Chest pain due to uremic pericarditis
• Uncontrolled hypertension
• Shortness of breath
 • Recording as well as monitoring of vital paramameters in patients of
Nephrology and responding to its' acute or chronic deviations from
the usual trend is paramount.
• Tachycardia may raise suspicion of presence of Fever - either due to
infection or inflammation - or some cardiac abnormality. Therefore, needs
attention and prompt intervention.

Nursing • Maintaining reasonable control of blood pressure (SBP: 100-150 mmHg

and/or DBP: 70-100 mmHg) with/without medicines is desireable.

Interventions • Oxygen saturation (SpO2) is a measurement of how much oxygen ones

blood is carrying as a percentage of the maximum it could carry. For a
and Actions healthy individual, the normal SpO2 should be between 96% to 99%. It
should menaintained that way with/without Oxygen.

• Monitor and manage blood sugar which should be best maintained

between 100 & 150 mg/dL. Keeping blood sugar in the optimal range in a
diabetic can help prevent incidences of hypoglycæmia.

• Fluid retention from improper glomerular filtration may lead to collection

of fluids in different parts of the body causing embarrassment of the
adjacent organs such as Heart, Lung etc resulting in compromise of the
functioning of those organs leading to consequential signs and symptoms.
 CKD
staging
Chronic kidney disease
is defined by the
presence of kidney
damage or decreased
kidney function for at
least three months or
above, irrespective of
the cause
 Renal Replacement Therapy (RRT)
Usually when a patient's GFR/eGFR is reduced to 10 or less and /or he/she develops any of the following sign(s) or a combinationof
them, namely,
 advanced symptomatic uræmia
 resistant hyperkalæmia
 resistant metabolic acidosis
it becomes necessary to initiate some form of RRT, namely,
 Hæmodialysis
 Peritoneal Dialysis
 Renal Transplantation (Pre-emptive Transplant): Discussed in detail later
 Hæmodialysis (HD): Here blood is taken out from the body of a patient of renal failure through a Dialysis Access and passed
through a filter, known as Dialyzer, with the help of a machine that controls the entire process. There are different types of
Dialysis Access as well as Dialyzers which can be dealt in detail in Dialysis section
 Peritoneal Dialysis (PD): Here a special type of fluid is introduced into the peritoneal cavity through a catheter inserted
surgically under local anæsthesia in the OT. The fluid - different types of which are used - is kept inside the body for different
periods of time as per Nephrologist's advice. The fluid is drained from the peritoneal cavity after the prescribed period. This
process may be repeated number of times as per prescription of the Nephrologists depending on the cinical requirements of the
patient.

Whatever may be the form of RRT, the process needs to be repeated at regular intervals and must not be skipped at all
without explicit doctor's advice to that effect.
• No prick, specially in the cephalic vein, on non-dominant hand in renal patient.
• Assess the need for dialysis
• Note down the access for dialysis if present; eg.
 Temporary Dialysis Access/Catheter like
 Double Lumened Cathere in Right/Left Internal Jugular Vein (IJV) or Sub-clavian Vein or
Femoral Vein
 Chronic Dialysis Access/Catheter, namely,
 Tunnelled Cuffed Catheter (TCC)
 Left/Right Radio-cephalic (Radial)/Brachio-cephalic Arterio-Venous (AV) fistula or
 AV Graft
New access for patient who are being initiated on hemodialysis or due to failure of previous access
• Proper care of dialysis access to avoid any Catheter related blood stream infection.
• Be alert to any nephrotoxic drugs that patient is getting
• Emergency dialysis in case of fluid overload, severe metabolic acidosis, hyperkalemia, uremic
encephalopathy
 Kidney Biopsy
 The percutaneous renal biopsy is now a routine and essential diagnostic tool guiding diagnosis and prognosis of
Renal Diseases.
 Indications for native renal biopsy
 Nephrotic syndrome (except children)
 Acute kidney failure without clear cause
 Chronic kidney impairment especially with proteinuria and/or haematuria
 Non-nephrotic proteinuria
 Microscopic haematuria
 Systemic diseases with abnormal function and/or heavy proteinuria
 Diagnosis of Graft dysfunction

 Safety conditions for renal biopsy

◆ Haemoglobin must preferably be > 9 g/dL
◆ Platelets ≥ 100,000 × 109/L
◆ Prothrombin (PT) and activated partial thromboplastin time (aPPT) < 1.2 × control
◆ Blood pressure < 160/95 mmHg
 Kidney Biopsy Contd....

 Consent must be taken before the procedure but counselling should be offered as early as possible.
 The possible complications and their incidence should be provided. These would include the following:
• Mild to moderate back/loin pain which usually settles with simple analgesia such as Paracetamol
• Visible haematuria (up to 5%) which usually clears spontaneously within 24 hours
• Local bleeding always occurs but is usually minor
• self-limiting; more severe bleeding requiring transfusion (~ 1%)
• Bleeding requiring angiographic intervention (≤ 0.5%)
 Biopsies are generally performed under ultrasound guidance using a disposable Tru-Cut® needle or biopsy gun
which can be of different length and gauge.
 Choice of needle gauge (G) is a matter of personal preference; it is customary to use a 16-G needle for native
and 18-G for transplant biopsies
 Either kidney may be biopsied, but the left kidney is usually more convenient as it is usually lower so access to
the pole is easier. The patient lies prone on one or two firm pillows and the operator first determines the
optimum entry site with ultrasound and in which phase of respiration the biopsy will best be performed, aiming
for the lower pole through the cortex. The skin is sterilized, sterile gel applied, and the probe covered with a
sterile sheath. Local anæsthetic is administered and then, using a spinal (21-G) needle, more local anaesthetic is
delivered down to the capsule of the kidney. The biopsy needle is then advanced to the renal capsule under
ultra_x0002_sound visualization, the patient stops breathing as the device is fired and immediately removed,
after which the patient can breathe normally. Generally two passes are made to obtain two cores of tissue.
 Kidney Biopsy Contd....

Immediate post-procedure care of the patient who has undergone kidney biopsy
• Complete bed rest for next 24 hours,
• Check pulse and BP
 Every 15 minutes for first 2 hours (post procedure),
 Then, every 30 minutes for next 2 hours,
 Then every 60 minutes for next 20 hours
• Hypotension if present or increasing inform Nephrology Register/Consultant
• Observe urine colour to exclude hæmaturia. Hæmaturia, if increasing, inform Nephrology Register/Consultant.
 Dyselectrolytæmia

Electrolytes are important constituents of the body.

They perform some critical functions in the working of the body as a whole as well as in various metabolic
activities that take place within it. They help various organs to function optimally and play their individual
roles in metabolism.
Therefore, maintaining their concentration in serum and in tissues are essential in smooth functioning of the
body as a whole and specific organs in particular.
Kidneys plays an important role in the metabolism of some of the electrolytes themselves. For example, Na+, K+,
Ca2+, PO4 , Cl - , HCO3-, etc.
Consequently, in Renal falure of any varity, the homeostasis of the above mentioned electrolytes are often
jeopardized and they lead to abnormal functioning of the organs resulting in signs and symptoms some of
which are life threatening. Sometimes they may occur as a result of treatment itself that the patient is receiving.
The serum concentrations of all these electrolytes must always be maintained within normal range. Any
deviation - high or low - from those values must promptly be brought to the notice of the senior nursing staff
and the doctors concerned.
One such situation is Hyperkalæmia (↑ K+). Serum K+ must preferably be maintained between 3.5 to 4.5 mEq/L
in renal patients.
Similar is the situations in case of other electrlytes as well.
Renal transplant
 Introduction

• Renal Transplant is a surgical procedure where one of the functioning kidneys from a normal individual -
called the Donor- is put either at the abdominal wall or into the abdominal cavity of a patient suffering
from End Stage Renal Disease (ESRD) - called the Recipient. It must also be noted here that the orginal
kidneys of the Kidney Transplant Recipient are usually not removed during the transplant
operation, that is, they are kept in-situ, unless there is some indication for their removal, namely,
inadequacy of space to implant the donated kidney as in Cystic Diseases of the kidneys.
• This can be of 2 varities:
 Living Donor Kidney Transplant (LDKT): where the kidney to be transplanted - called the Graft - is
operated out from a living otherwise healthy person just before it is implanted in a Recipient.
 Cadaver (Deceased) Donor Kidney Transplant (DDKT): where the kidney Graft is retrieved from a
Brain Death person which means that person's Brain-Stem Reflexes have ceased to function without
external help though his Heart continues to beat.
• Renal Transplantation is governed in our country by the Transplantation of Human Organs Act (THOA),
1994 which has subsequently been amended a number of times and in different states.
• According to the prevalent laws
Living donors are classified as either a near relative or a non near-relative donor.
(i) A near-relative (spouse, children, grandchildren, siblings, parents and grandparents) needs permission
of the doctor in-charge of the transplant center to donate his organ.
(ii) A non near-related donor needs permission of an Authorization Committee established by the state to
donate his organs.
 Nursing Evaluation of Recepient on Admission

• Identify the recipient and his donor

• Blood group of both Recipient & Donor and their matching
• Legal clearences & Documents
• Precardiac profile
• CDC & Flow-Cytometry crossmatch Reports
• Chest X-ray, ECG, 2-D Echo and CT- Angiography of pelvic vessels of the Recipients
• Pre-Anæsthetic Check-up (PAC)
• Check all necessary clinical clearances
• Identify any abnormalities in reports and inform
• Need for RRT and identification of dialysis access
• In case of temporary access note down the time the access was created and evaluate the need for
change of access before dialysis with the attending Registers or the Consultant concerned.
• In case of ABOi or HLA
sensitized renal transplant,
check whether patient had
taken injection Rituximab and
has been started on
immunosuppressant.
• Prepare for plasmapharesis
in above case
 Nursing Evaluation of Donor on Admission

• Identify the blood group and match it with that of the Recipient
• Any comorbidities
• Pre-cardiac profile
• Chest x-ray , 2D-Echo, ECG, Renal CT angiography, DTPA scan
• All necessary clinical clearances
• Urinary Pregnancy Test (UPT) in case of female Donors
 Pre-OT care of the Recipient

• To start Immunosuppression as per advice

• Pre-transplant HD/PD if advised
• To follow PAC orders
• To indent and/or administer Induction immunosuppressions, namely, Methyl-Prednisolone, Anti-
Thymocyte Globulin (ATG), and prophylactic antibiotic
• To administer morning doses of antihypertensive drugs early in the morning
• To chase and collect reports of pending investigations and communicate the reports to the on-
duty Register and/or Consultants.
 Immediate Post-Transplant Care
• ON RECEIVING IMMEDIATE VITAL MONITORING
• CHECK FOR URINE OUTPUT
• CHECK FOR DRAIN COLLECTION
• CHECK FOR OXYGEN SATURATION
• CHECK FOR ALERTNESS
• START IV FLUID AS PER THE PROTOCOL
• CHECK IF PATIENT HAS RECEIVED ANY INTRA–OP MEDICATION OR NOT
• TO INFORM ON-DUTY REGISTER/CONSULTANT IN CASE OF ANY ABNORMALITY
 COMPLICATIONS OF RENAL TRANSPLANT
 Surgical Complications:
 Hematoma : Pain At Graft Site With Increase Drain
 Urine Leak: Decrease Urine Output But Increase In Drain With Pain At Graft Site And Drain
Fluid Analysis Showing High Creatinine And Low Sodium
 Urine Obstruction: Anuria With Suprapubic Pain
 Abcess
 Lymphocele
 Medical Complications:
 Infection
 Rejection: Antibody Mediated Or Cell Mediated
 Volume Overload
 Acute Tubular Necrosis Or Acute Cortical Necrosis
 Special Elements In Post-Transplant Care in Wards

• strict fluid intake and output charting

• srtict hand hygiene and maintenance of sterility
• inform immediately in case of any deviation from usual trend of vital parameters
• inform any abnormal results to the clinicians as soon as possible
• keep tab on fluid intake and hydration
 Acknowledgement

Contribution and advice of Dr. Nikhil Pratap Yadav, senior Register Nephrology, Br. Sk Shamsul
Haque, Nursing Manager, Renal Transplant Unit, and Sr. Sumita Acharjee, Deputy Manager,
Nephrology General Ward (ACTC 3rd. floor) is acknowledged and deeply appreciated.