Renal Failure Nursing Guide 2026: AKI & CKD Care
Part of the ICU Emergencies Hub — browse every related guide in one place.
This article was created with AI assistance.
Acute Kidney Injury (AKI) affects ~1 in 5 hospitalized patients and is associated with a 4–7x increase in 30-day mortality. Early recognition and nephrology consult are critical.
AKI vs CKD
| Feature | Acute Kidney Injury (AKI) | Chronic Kidney Disease (CKD) |
|---|
| Onset | Hours to days | Months to years (>3 months) |
| Creatinine | Abrupt rise from baseline | Chronically elevated; stable baseline |
| Urine output | Often oliguria (<400 mL/day) or anuria | Often preserved until late stages |
| Anemia | Not typical early | Normocytic anemia (low EPO production) |
| Bone disease | Not typical | Renal osteodystrophy (low Ca, high PO4, secondary hyperparathyroidism) |
| Uremic symptoms | Can develop rapidly if severe | Develop gradually; may be well-adapted |
| Prognosis | Often reversible if cause treated | Progressive; may end in ESRD |
KDIGO/RIFLE Criteria for AKI
| Stage | Serum Creatinine | Urine Output |
|---|
| Stage 1 | ≥1.5× baseline or ≥0.3 mg/dL increase in 48h | <0.5 mL/kg/hr for 6–12 hours |
| Stage 2 | ≥2.0× baseline | <0.5 mL/kg/hr for ≥12 hours |
| Stage 3 | ≥3.0× baseline, or Cr ≥4.0 mg/dL, or RRT initiated | <0.3 mL/kg/hr for ≥24 hours, or anuria ≥12 hours |
Causes of AKI (Pre-Renal, Renal, Post-Renal)
| Type | Mechanism | Examples | Key Indicator |
|---|
| Pre-Renal (most common) | Reduced blood flow to kidney | Dehydration, hemorrhage, heart failure, sepsis, NSAID use | BUN:Cr >20; responds to fluids; urine Na <20 |
| Intrinsic Renal | Direct kidney damage | ATN (ischemia or nephrotoxins), glomerulonephritis, contrast nephropathy | BUN:Cr ~10–15; muddy brown casts on UA; does NOT improve with fluids |
| Post-Renal (obstructive) | Blocked urine outflow | BPH, kidney stones, tumor, foley obstruction | Hydronephrosis on ultrasound; restores with relief of obstruction |
Nephrotoxic agents to avoid/minimize in AKI: NSAIDs, aminoglycosides, contrast dye (use N-acetylcysteine and hydration pre-procedure), vancomycin (monitor troughs), ACE inhibitors (reduce GFR), diuretics if volume-depleted.
Nursing Assessment
Priority Assessment Points
- Urine output: Hourly UO if oliguric; report <30 mL/hr (<0.5 mL/kg/hr) to MD
- Fluid status: Daily weight (0.5–1 kg/day gain = fluid accumulation); I&O every shift; edema assessment
- Electrolytes: K+, Na+, HCO3, phosphate — renal failure disrupts all of these
- Uremia symptoms: N/V, fatigue, altered mental status, pericardial rub (uremic pericarditis), asterixis (flapping tremor)
- BUN and creatinine trending: Rising = worsening; note baseline
- Skin: Uremic frost (late sign: white crystalline deposits from urea excretion through skin)
Uremic Signs & Symptoms
- Encephalopathy: confusion, asterixis, seizures
- Pericarditis: pleuritic chest pain, pericardial friction rub
- N/V, anorexia, metallic taste
- Pruritis (itching from uremic toxin skin deposits)
- Bleeding (uremic platelet dysfunction)
Hyperkalemia Management
Hyperkalemia is the most immediately life-threatening complication of AKI. K+ >6.5 mEq/L or any K+ with EKG changes = emergent treatment.
EKG Changes in Hyperkalemia (in order of progression)
- Peaked/tall T waves (earliest sign)
- Widened PR interval
- Wide QRS
- Sine wave pattern (pre-terminal)
- VF / asystole
Treatment Ladder
| Drug/Intervention | Mechanism | Onset | Key Points |
|---|
| Calcium gluconate 1g IV | Membrane stabilization (does NOT lower K+) | Minutes | FIRST if EKG changes; protects heart; repeat if needed |
| Regular insulin 10u IV + D50W 50 mL | Drives K+ into cells (temporary) | 15–30 min | Monitor glucose q1h; watch for hypoglycemia |
| Sodium Bicarb 50–100 mEq IV | Drives K+ into cells (alkalosis) | 15–30 min | Most effective if acidosis present |
| Albuterol nebulized 10–20 mg | Drives K+ into cells (beta-2 agonist) | 15–30 min | Synergistic with insulin |
| Kayexalate (sodium polystyrene) | Removes K+ from body via GI tract | Hours | PO or PR; slow onset; bowel necrosis risk — use with caution |
| Furosemide IV | Removes K+ via urine | Hours | Only if patient is making urine |
| Hemodialysis | Removes K+ directly from blood | During session | Definitive treatment; for severe or refractory hyperkalemia |
Fluid Management
- Pre-renal AKI: Fluid challenge (NS 500 mL bolus); expect UO to improve
- Oliguric intrinsic AKI: Careful fluid management; avoid over-hydration (lungs fill up); strict I&O
- Fluid restriction often ordered in Stage 2–3 AKI (previous output + 500 mL/day for insensible losses)
- Daily weight: 1 kg gain ≈ 1 L fluid retained
- Monitor for pulmonary edema: crackles, rising O2 requirements, orthopnea
Dialysis Nursing Essentials
Indications for Urgent Dialysis (AEIOU)
- Acidosis (severe; pH <7.1)
- Electrolytes (K+ >6.5 refractory to medical treatment)
- Ingestion/Toxin (dialyzable: methanol, ethylene glycol, lithium, aspirin)
- Overload (pulmonary edema unresponsive to diuretics)
- Uremia (pericarditis, encephalopathy, bleeding)
Access Types
- AV Fistula: Best long-term access; DO NOT take blood pressure, draw blood, or place IV in that arm
- AV Graft: Synthetic; listen for bruit, feel for thrill (both = access is patent)
- Tunneled dialysis catheter (Permcath): Temporary or bridge access; dressing changes per dialysis team
Medication Adjustments in Renal Failure
Most drugs are renally cleared. In AKI/CKD, doses must be adjusted or drugs avoided entirely. Always check before administering.
- Metformin: HOLD if GFR <30; lactic acidosis risk
- NSAIDs: AVOID in AKI/CKD — worsen renal perfusion
- Gadolinium (MRI contrast): AVOID in GFR <30 — nephrogenic systemic fibrosis risk
- Magnesium antacids (Milk of Magnesia): AVOID — hypermagnesemia in renal failure
- Potassium-sparing diuretics (spironolactone): Use with caution; risk of hyperkalemia
- ACE inhibitors/ARBs: Often held in acute AKI; long-term use beneficial in CKD but monitor K+ and Cr
NCLEX High-Yield Points
- Oliguria = <400 mL/day (<30 mL/hr); anuria = <50 mL/day
- Pre-renal AKI: BUN:Cr >20; responds to fluids; reversible
- Hyperkalemia EKG: peaked T waves → wide QRS → VF; treat with calcium gluconate FIRST if EKG changes
- Insulin + dextrose drives K+ into cells (temporary, not eliminative)
- AV fistula arm: no BP, no IV, no blood draws — ever
- Dialysis indications: AEIOU (acidosis, electrolytes, ingestion, overload, uremia)
- Metformin must be held in AKI (lactic acidosis risk)
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