Renal Failure Critically Ill[1]
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Care of the patient with renal
failure
Christina Ballejos-Campos
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Renal Failure
� severe impairment or total lack of kidney
function
� little or no excretion of metabolic wasteproducts and water
� Acute
± Sudden and reversible� Chronic
± Slow and irreversible
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Acute Renal Failure
� Abrupt decline in glomerular filtration rate
leading to:
± reduction of urine output (less than400
mL/day)
± build up of nitrogenous waste products
± inability to maintain acid-base and electrolyte
balance
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Causes of Acute Renal Failure
1. Prerenal renal failure: ± 70%
± anything that decreases blood flow to the
kidneys
ETIOLOGY
� Intravascular volume depletion (hypovolemia)
� Impaired cardiac output
� Systemic vasodilation
� Hypoperfusion, hypotension
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2. Acute Intrarenal Renal Failure
± 25% of ARF
± damage directly to the renal tissues
ETIOLOGY� *Acute Tubular Necrosis - type of ARF
± Ischemia, nephrotoxin, pigment
� Contrast dye
� Drugs
� Infection or immunologic
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3. Acute Postrenal Renal Failure
± 5%
± obstruction of urine flow that causes retrograde flow backinto the kidneys
Etiology
Obstruction
Stenosis, calculi
FunctionalPregnancy
Spinal cord injury
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Acute Renal Failure Review(3 forms by location)
� A. Prerenal ²disrupted blood flow
� B. Intrarenal ²damaged renal tissue
� C. Postrenal ²disrupted urine flow
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ARF Phases
� 1. Onset
± Time from when the insult occurs until cell
injury.
� May last hours to days
� May have reduced urine output or it may be
normal
� With prompt treatment may have noresidual damage
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Phases of ARF
� 2. Oliguric/Anuric
� Less than 400 ml urine/24hours
± Within 1- 7 days of insult ± Total support of renal function is needed
± Lasts 5 to 16 days ( or may lead to CRF)
± GFR creatinine, BUN
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Phases of ARF
� 3. Diuretic ± High output failure
± increased glomerular filtration rate and
increased urine output.
� Lasts for 7-14 days� Kidneys clearing fluid but not solutes so that the
urine osmolality is either fixed or low
� Up to 5L/day
± May become volume depleted because of the
large urine output
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Phases of ARF
� 4. Recovery
± Slow return to normal renal function
� 3 -12 months (may take years)
� 62% of patients will recover normal renal
function
� 33% of patients will have some renal
insufficiency controlled by diet and fluidvolume restrictions
� 5% of patients will need long term dialysis
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Complications of Acute Renal
Failure� Hyperkalemia
� Metabolic Acidosis
� Hypervolemia
� Infection
� Anemia
� Congestive Heart Failure
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Diagnostic tests for Acute Renal
Failure� US� CT scan
� Angiography
� UA
� Serum ± BUN, Creatinine
� Elevations in serum creatinine indicate damageto at least 50% of the nephrons
± Electrolytes
� Hyperkalemia, etc. ± ABG
� Metabolic acidosis
� Urine Creatinine
± Urine creatinine clearance is reduced thus less
creatinine appears in the urine 27
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Nursing DX
Fluid volume excess r/t impaired renalperfusion and fluid retention
� Altered nutrition: less than bodyrequirements r/t altered metabolic stateand dietary restrictions
� Impaired skin integrity r/t sites for vascular
access for peritoneal or hemodialysis� Risk for injury r/t increased K+ levels and
potential for cardiac arrhythmias
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Nursing Management of Acute
Renal Failure� Prevent
� Fluid volume restriction:
± Past 24 hour urine output + 600 mL (insensible loss)
� Dialysis (discussed later)
� Electrolyte Balance
� Medications
Especially ?
What about diuretics?
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Nutrition
� Decrease protein catabolism
� BUT they need enough calories because?
� What other restrictions?
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Nutrition
� Daily calories
± 30-35 kcal/kg of body weight
Protein
1.2 -1.3 g/kg
Fat
increased (30-40% of diet)
Na restriction (prevent overhydration)
K restriction
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Prevent and Manage Complications
of Acute Renal Failure� Hyperkalemia ±leading cause of death in oliguric phase
± Electrolyte and EK G monitoring
± Treat with IV Glucose & Insulin
± Ion Exchange R esin
� MetabolicA
cidosis ± ABG
± Sodium bicarb
� Hypervolemia
± Fluid Challenge, I & O
± Diuretics ± Inotropic Agents & Pressure Monitoring
� Infection ± leading cause of death
� Anemia
� Congestive Heart Failure42
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Treatment of Acute Prerenal
Renal Failure
� Crystalloids & colloids (*may be given with loop and
osmotic diuretics if kidney functioning)
� If fluid overload (CHF)
± use *diuretics & inotropes
� With sepsis
± increase fluids & vasoconstrictors
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Treatment for Acute Intrarenal Renal
Failure
� Dialysis
� Treat complications of renal failure Hypotension or Hypertension
Electrolyte imbalances
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Treatment of Acute Postrenal Renal
Failure� R emove obstruction
± Ureteral stent
± ESWL (lithotripsy)
± Prostatectomy
± Suprapubic catheter
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Chronic Renal Failure
� Progressive reduction of functioning renal
tissue ± Remaining Kidney Can No Longer Maintain Internal Environment
� Insidiously or Acutely Post Renal Failure
� Hypertension & diabetes most common
causes
2
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4 Stages of Chronic Renal Failure
1. Diminished renal reserve (silent)
2. Renal insufficiency
3. Frank renal failure
4. Uremia (End stage renal disease ±ESRD)
3
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Stages of Chronic Renal Failure
1. Diminished Renal
Reserve
Normal BUN & Cr.
Absence of
symptoms
2. Renal Insufficiency
Depressed
Hypertension Edema
Pruritis
Polyuria
Nocturia
Low specific gravity
GFR ¼ of normal
4
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Stages of Chronic Renal Failure
� Frank Renal Failure
Azotemia
Metabolic acidosis Hyperkalemia
Hyponatremia
Hyperphosphatemia
Hypocalcemia
Severe anemia
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Stages of Chronic Renal Failure
3. Frank Renal Failure
Lethargy
Headaches Visual disturbances
Edema
Low Urine output N & V
5
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Stages of Chronic Renal Failure
� 4. Uremia (ESRD)
N & V, diarrhea GI bleeding
Mental disturbances
Convulsions
BUN, creatinine dangerously high
U.O. less than 20 ml/hr.7
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Stages of Chronic Renal Failure
� Uremia,cont.
Uremic frost
Swollen tongue
Electrolyte imbalances Hypertension
CHF
Coma, Death 8
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Complications of Chronic Renal
Failure
Metabolic Imbalances
BUN, creatinine
Altered CHO metabolism
Impaired glucose use and insulinresistance (and insulin is excreted bykidneys)
Elevated triglycerides
High insulin increases hepatic
release of triglycerides Increased VLDL, normal or low LDL
and low HDL
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Hemopoietic Complications
Anemia� Normocytic normochromic anemia d/t
erythropoietin
� Destruction of RBC
� Lack of intake
� Bleeding tendencies� impaired platelet aggregation and impaired release of
platelet factor 3
� Infection
± altered immune response
± changes in WBC functioning ± protein malnutrition, hyperglycemia, and external trauma
of needle insertions into shunts, etc.
� Cancer
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Cardiovascular Complications
� Hypertension from retained Na and increased ECF
� CHF
Respiratory Complications
� Kussmaul respiration (blow of CO2)
� Dyspnea
� Uremic lung ± depressed cough reflex with thick sputum
GI Disturbances
� Excessive Urea irritates the mucosal lining the GI system
� Mucosal ulcerations d/t ammonia
� Uremic fetor ± urine odor breath
� Stomatitis, Anorexia, n/v, all contribute to weight loss
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Nervous System Complications
�Generalized CNS depression
�lethargy, apathy, ability to concentrate,
fatigue and altered mental ability
�altered mental status clears with dialysis and
often a sign that dialysis is due
�Seizures and coma if BUN becomes very high
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Skin Disorders
�skin yellowish
� from retained urinary chromogens that
normally give urine it¶s yellow color
�Pruritis� calcium-phospate deposits on the skin
� ³Uremic frost´ (urea crystals)
� When BUN levels are extremely high
�Hair and nails tend to be dry and brittle
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Neurological� Generalized CNS depression (lethargy, apathy, ability to concentrate, fatigue and alteredmental ability.
� Altered mental status clears with dialysis, andoften this is a sign that dialysis is due.
� Seizures and coma if BUN becomes very high
� Peripheral neuropathy
± Restless Leg Syndrome or pt feels like thereare bugs crawling in their legs.
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Psychological changes
�Fatigue, lethargy
�Personality and behavioral changes
�Grief
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Nursing Diagnoses
Renal Failure� Fluid Volume Deficit/Fluid Volume Excess
� Altered Nutrition: Less Than Body
Requirements
� Risk Of Impaired Skin Integrity Related to
Poor Nutrition/Edema And Pruritus
� AnxietyR
elated to Unknown Outcome of Disease
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Medical Goals of
ChronicR
enal Failure� Preservation of Renal Function
� Delay of Need for Dialysis or Transplant
� Improvement of Body Chemistry� Alleviation of Extrarenal Effects
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Management for CRF ±
Conservative
� Correct ECF (overload or deficit)
� Nutrition
� Adjust drug dosages ± Digoxin
± Aminoglycosides
± NEVER meperidine
± Avoid NSAIDS
� Medications
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� Hyperkalemia
±Diet
± IV glucose and Insulin, SodiumBicarb
± Kayexalate if good GI function
� Hypertension
±Na and fluid restriction
±Antihypertensives
Loop diuretic, beta antagonist, ACEinhibitor
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� Phosphate intake limited (<1000 mg/day)
� Calcium based phosphate binders
- Calcium Carbonate (Tums) and
Calcium acetate (PhosLo).- Given with food***
� NON calcium phosphorous binder
- sevelamer (Renegal)
� Lower phosphate before treating low calciumand giving Vit D
� Watch for hypercalcemia
� May need Vitamin D ± calcitrol
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� Anemia ± erythropoietin (Epogen)
� May take 2- 3 wks
� Increases HTN
± Oral iron supplements and Folic acid
� (1 mg or more) are given daily
� NOT same time as phosphate binders
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Nutrition
� Protein restriction (high biologic protein) ± some renal function & not on dialysis
� a low protein (.6-.8g/kg/day), low phosphorus diet
± on hemodialysis
� protein intake increased to 1.2-1.3g/kg/day ± on peritoneal dialysis
� protein intake at least 1.2g/kg/day
� High calorie intake will prevent proteincatabolism ± High CHO (100g) and fats
� Fluid restriction- same as with ARF 600 mLover yesterday¶s losses
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High Biological Value (HBV)
Protein
� sources that are easily assimilated into
body tissue
± EGGS
± fish
± beef
± poultry
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� Na restriction
± depends on degree of renal failure (2-4 g)
± avoid foods known to be high in Na
� K+ restriction
± depends on degree of renal failure and
whether on dialysis.
± (see table 45-8 on pg. 1224).
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Treatment for Renal Failure
Hemodialysis
Peritoneal Dialysis
Continuous Renal ReplacementTherapy (CRRT)
Kidney Transplantation
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Dialysis
� Process used to remove fluid and waste
products when kidneys fail
� Types ± 1. Hemodialysis (HD)
± 2. Peritoneal (PD)
± 3. Continuous renal replacement therapy
(CRRT)
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General Principles of Dialysis
� 1. Diffusion-
± movement of solutes from an area of higher
concentration to an area of lesser concentration.
� 2. Osmosis- ± movement of fluid from an area of lesser to an area of
greater concentration of solutes.
� 3. Ultrafiltration-
± water and fluid removal from an area of increasedpressure to an area of decreased pressure
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1. Hemodialysis
� Blood shunted from thebody through tubinginto a dialysis machinewhich cleans the blood
using a ³Dialyzer´ or ³Artificial Kidney´.
� Solutes and wasteproducts removed bythe principles of
osmosis, diffusion andultrafiltration
� Performed 2-3 x/wk for 3- 4 hrs
HEMODIALYSIS MACHINE
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Requires Vascular Accessa) AV Shunt
b) AV Fistula
c) AV Graft
d) Vascath
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Access to Patient¶s blood stream
� a) Shunt
± external device connecting
radial artery and vein in the
forearm for the purpose of
attachment to a dialysismachine
� Complications: Infection,
Bleeding
� Rarely used except for
continuous renal
replacement therapy
(CRRT)
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b) Internal Arteriovenous Fistula
(AVF)
� internal fistula that
creates an anastamosis
between an artery and a
vein
� Most commonly in the
forearm
� Native -- Need healthy
vessels
� 4- 6 wks to mature
� Accessed with two large
gauge needles
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c) Arteriovenous Graft (AVG)
� created using asynthetic material that
is self-healing
� Used in patients who
have poor vessels
(hypertension, D.M.)
� Graft matures usually
2- 4 wks� Complications: > clots,
infection, steal
syndrome
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Nursing Care
� 1. ³Thrill´- nurse must check for a vibrationover the area of anastamosis each shift.
� 2. ³Bruit´- nurse must listen with a
stethoscope for an audible swish.� *Report loss of either stat to physician
� Teach patient how to check for ³Thrill´
before going home.� Can eat double their usual protein (since
urea & creatinine excreted)
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d) VAS Catheter
� Temporary vascular access
when quick or short term
use is expected.
� A large bore catheter (14-
16) is placed in subclavian,
internal jugular or femoral
vein.
� Catheter has a double
lumen (blue and red), onefor blood removal and one
for blood return
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Care of Double-lumen catheter
� Never flush or draw blood from thiscatheter for any reason!
� Each ³tail´ contains 1500u of heparinplaced there by dialysis nurse toprevent clotting off of vessels.
� No blood draws or B/P from that arm.
� If removed- apply pressure withsandbags for long time to preventhemorrhage.
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Nursing Care for patient with HD
� Pre-Procedure
� Check meds to be held or given (Give
insulin and Digoxin, hold all B/P meds)
� Vital Signs
� Weigh patient, lung sounds
� Check site
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During Procedure
� Dialysis nurse is usually with patient. She/he willmonitor v.s. q 15 min.
� Hypotension is a common problem
� Patient may eat while on HD if stable
� Weigh patient (before and after)
� Lab tests
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Complications with
Hemodialysis
� 1) Hypotension ± As fluid removed
� 2) Muscle cramps
± Rapid removal of Na and H20� 3) Bleeding
± Heparin used
� 4) Hepatitis
� 5) Sepsis� 6) Disequilibrium syndrome (hypotonic soln)
± Cerebral fluid shifts
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2. Peritoneal Dialysis
Large surface of the
peritoneum is used
as asemipermeable
membrane for
performing clinical
dialysis
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Phases of PD- called an ³Exchange´
� 1) Inflow- ± prescribed amount of solution (2L of warmed,
sterile Dialysate) is infused through the catheter over 10 min.
� 2) Dwell- ± Diffusion and Osmosis occur while the solution sits
in the peritoneal cavity
± Typical ³dwell´ time is 20-30 min., but can be 8 hrsor >.
� 3) Drain- ± Fluid drained, takes 15-30 min.
± Patient may need to change position
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± Continuous Ambulatory Peritoneal
Dialysis (CAPD) ± esp pt with Diabetes
� Approx 2L dialysate 4 x/day
� Dwell times of 4 to 10 hrs
± Automated Peritoneal Dialysis (APD)
� Automated cycler times and controls the fill,
dwell and drain phases
� 4 or > exchanges/night
± May use 1 or > daytime manual the day
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Types of Peritoneal Dialysis
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Technique
� Catheter placed (usually surgically) through theanterior abdominal wall.
� A common catheter is the ³Tenckhoff´, a silicone
rubber tubing (about25
cm long) that has a cuff that anchors it and prevents migration.
� Complications of catheter insertion: ± perforation of the bladder, bowel or major blood
vessels.
� Catheter must be irrigated periodically withheparinized dialysate to keep it free of blood andfibrin.
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Nursing Care for Patient with PD
� Pre-procedure ± Assess site for any s/s of infection.
± Take baseline V.S.
� During procedure ± Assess for pain, watch V.S., watch equipment for any
leaks, etc.
� Post-procedure ± Assess amount of outflow (should match what you
put in or be a little more),
± Assess for hernias and pulmonary complications
± Watch for abnormal color of returned fluid (milky or white could indicate peritonitis)
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Complications
� 1) Exit site infection
� 2) Peritonitis
� 3) Abdominal pain/Back pain/Shoulder pain
(decrease rate)� 4) Outflow problems
� 5) Hernias
� 6) Bleeding
� 7) Pulmonary complications: atelectasis,pneumonia
� 8) Protein Loss
� 9) CHO3 and lipid abnormalities
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� 3. Continuous Renal Replacement
Therapy (CRRT)
� CAVH (Continuous arterial-venous
hemofiltration)
± Blood flows through semipermeable filter
and extracorpeal circuit
± Removes only excess fluid
� CAVHD (Continuous arteriovenoushemodialysis)
± Same as above but uses dialysate and
solute removed
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� CVVH (Continuous venous-venous
hemofiltration)
± Continuous fluid removed
� CVVHD (Continuous venous-venous
hemodialysis)
± Solutes and fluids
T t t f R l F il
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Treatment for Renal Failure
CCRT
� Nursing Interventions
± monitor I&O
± integrity of circulatory access
± monitor hemofiltration system
± prevent infection
± monitor circulation
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Kidney Transplantation
� Not enough supply for the demand for organs
± 54,000 pts awaiting cadaveric kidneytransplants about 8000 performed in 2002
± Waiting period up to 4 years� 90-95% success rate
� reverse many of the pathophysiologicchanges associated with renal failure.
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Donor Sources
� 1. Cadaver donors ± Kidneys removed after death
± can be preserved up to 72 hours.
�2. Live donors ± most often blood relatives, but can be other donors if
blood type matches.
� Method ± Laparscopic donor nephrectomy
± Traditional ³Open Nephrectomy´ used less often
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Surgical procedure
� old kidneys left inplace
� new donor kidney is
grafted into theInternal Iliac arteryand Vein
� Once blood flow isestablished to thenew kidney itbecomes firm andpink
�
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Post-op Care
** Maintenance of fluid & electrolyte balance
� Large diureses if kidney is functional(up toa 1L/hr)
� Fluid replaced mL for mL or dehydrationand shock can occur.
� Sudden decrease in urine output in early
postop period a priority concern
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Complications post-op
� Rejection (early/late)
� Infection
� Cardiovascular disease� Malignancies
� Recurrence of original renal disease
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