Nephrologic Disorders

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Renal Failure
1.Admit to:
2.Diagnosis: Renal failure
3.Condition:
4.Vital Signs: q8h. Call physician if QRS complex
>0.14 sec; urine output <20 cc/hr; BP >160/90, <90/-
60; P >120, <50; R>25, <10; T >38.5 C.
5.Allergies: Avoid magnesium containing antacids, salt
substitutes, NSAIDS. Discontinue phosphate or
potassium supplements.
6.Activity: Bed rest.
7.Nursing: Daily weights, inputs and outputs, chart
urine output. If no urine output for 4h, in-and-out
catheterize. Guaiac stools.
8.Diet: Renal diet of high biologic value protein of 0.6-
0.8 g/kg, sodium 2 g, potassium 1 mEq/kg, and at
least 35 kcal/kg of nonprotein calories. In oliguric
patients, daily fluid intake should be restricted to less
than 1 L after volume has been normalized.
9.IV Fluids: D5W at TKO.
10. Special Medications:
-Consider fluid challenge (to rule out pre-renal azo-
temia if not fluid overloaded) with 500-1000 mL NS IV
over 30 min. In acute renal failure, in-and-out
catheterize and check postvoid residual to rule out
obstruction.
-Furosemide (Lasix) 80-320 mg IV bolus over 10-60
min, double the dose if no response after 2 hours to
total max 1000 mg/24h, or furosemide 1000 mg in
250 mL D5W at 20-40 mg/hr continuous IV infusion
OR
-Torsemide (Demadex) 20-40 mg IV bolus over 5-10
min, double the dose up to max 200 mg/day OR
-Bumetanide (Bumex) 1-2 mg IV bolus over 1-20 min;
double the dose if no response in 1-2 h to total max
10 mg/day.
-Metolazone (Zaroxolyn) 5-10 mg PO (max 20 mg/24h
30 min before a loop diuretic.
-Hyperkalemia is treated with sodium polystyrene
sulfonate (Kayexalate), 15-30 gm PO/NG/PR q4-6h.
-Hyperphosphatemia is controlled with calcium acetate
(PhosLo), 2-3 tabs with meals.
-Metabolic acidosis is treated with sodium bicarbonate
to maintain the serum pH >7.2 and the bicarbonate
level >20 mEq/L. 1-2 amps (50-100 mEq) IV push,
followed by infusion of 2-3 amps in 1000 mL of D5W
at 150 mL/hr.
-Adjust all medications to creatinine clearance, and
remove potassium phosphate and magnesium from
IV. Avoid NSAIDs and nephrotoxic drugs.
11. Extras: CXR, ECG, renal ultrasound, nephrology
and dietetics consults.
12. Labs: CBC, platelets, SMA 7&12, creatinine, BUN,
potassium, magnesium, phosphate, calcium, uric aci
osmolality, ESR, INR/PTT, ANA.
Urine specific gravity, UA with micro, urine C&S; 1st AM
spot urine electrolytes, eosinophils, creatinine, pH,
osmolality; Wright's stain, urine electrophoresis. 24h
urine protein, creatinine, sodium.
Nephrolithiasis
1.Admit to:
2.Diagnosis: Nephrolithiasis
3.Condition:
4.Vital Signs: q8h. Call physician if urine output <30
cc/hr; BP >160/90, <90/60; T >38.5 C.
5.Activity: Up ad lib.
6.Nursing: Strain urine, measure inputs and outputs.
Place Foley if no urine for 4 hours.
7.Diet: Regular, push oral fluids.
8.IV Fluids: IV D5 ½ NS at 100-125 cc/hr (maintain
urine output of 80 mL/h).
9.Special Medications:
-Cefazolin (Ancef) 1-2 gm IV q8h
-Meperidine (Demerol) 75-100 mg and hydroxyzine
25 mg IM/IV q2-4h prn pain OR
-Butorphanol (Stadol) 0.5-2 mg IV q3-4h.
-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-
6h PO prn pain OR
-Oxycodone/acetaminophen (Percocet) 1 tab q6h pr
pain OR
-Acetaminophen with codeine (Tylenol 3) 1-2 tabs P
q3-4h prn pain.
-Ketorolac (Toradol) 10 mg PO q4-6h prn pain, or 30
60 mg IV/IM then 15-30 mg IV/IM q6h (max 5
days).
-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.
11. Extras: Intravenous pyelogram, KUB, CXR, ECG.
12. Labs: CBC, SMA 6 and 12, calcium, uric acid,
phosphorous, UA with micro, urine C&S, urine pH,
INR/PTT. Urine cystine (nitroprusside test), send
stones for X-ray crystallography. 24 hour urine
collection for uric acid, calcium, creatinine.
Hypercalcemia
1.Admit to:
2.Diagnosis: Hypercalcemia
3.Condition:
4.Vital Signs: q4h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C; or tetan
or any abnormal mental status.
5.Activity: Encourage ambulation; up in chair at other
times.
6.Nursing: Seizure precautions, measure inputs and
outputs.
7.Diet: Restrict dietary calcium to 400 mg/d, push PO
fluids.
8.Special Medications:
-1-2 L of 0.9% saline over 1-4 hours until no longer
hypotensive, then saline diuresis with 0.9% saline
infused at 125 cc/h AND
-Furosemide (Lasix) 20-80 mg IV q4-12h. Maintain
urine output of 200 mL/h; monitor serum sodium,
potassium, magnesium.
-Calcitonin (Calcimar) 4-8 IU/kg IM q12h or SQ q6-
12h.
-Etidronate (Didronel) 7.5 mg/kg/day in 250 mL of
normal saline IV infusion over 2 hours. May repeat
in 3 days.
-Pamidronate (Aredia) 60 mg in 500 mL of NS infuse
over 4 hours or 90 mg in 1 liter of NS infused over
24 hours x one dose.
9.Extras: CXR, ECG, mammogram.
10. Labs: Total and ionized calcium, parathyroid
hormone, SMA 7&12, phosphate, Mg, alkaline
phosphatase, prostate specific antigen and
carcinoembryonic antigen. 24h urine calcium, phos-
phate.
Hypocalcemia
1.Admit to:
2.Diagnosis: Hypocalcemia
3.Condition:
4.Vital Signs: q4h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C; or any
abnormal mental status.
5.Activity: Up ad lib
6.Nursing: I and O.
7.Diet: No added salt diet.
8.Special Medications:
Symptomatic Hypocalcemia:
-Calcium chloride, 10% (270 mg calcium/10 mL vial),
give 5-10 mL slowly over 10 min or dilute in 50-100
mL of D5W and infuse over 20 min, repeat q20-30
min if symptomatic, or hourly if asymptomatic.
Correct hyperphosphatemia before hypocalcemia
OR
-Calcium gluconate, 20 mL of 10% solution IV (2
vials)(90 mg elemental calcium/10 mL vial) infused
over 10-15 min, followed by infusion of 60 mL of
calcium gluconate in 500 cc of D5W (1 mg/mL) at
0.5-2.0 mg/kg/h.
Chronic Hypocalcemia:
-Calcium carbonate with vitamin D (Oscal-D) 1-2 tab
PO tid OR
-Calcium carbonate (Oscal) 1-2 tab PO tid OR
-Calcium citrate (Citracal) 1 tab PO q8h or Extra
strength Tums 1-2 tabs PO with meals.
-Vitamin D2 (Ergocalciferol) 1 tab PO qd.
-Calcitriol (Rocaltrol) 0.25 mcg PO qd, titrate up to
0.5-2.0 mcg qid.
-Docusate sodium (Colace) 1 tab PO bid.
9.Extras: CXR, ECG.
10. Labs: SMA 7&12, phosphate, Mg. 24h urine
calcium, potassium, phosphate, magnesium.
Hyperkalemia
1.Admit to:
2.Diagnosis: Hyperkalemia
3.Condition:
4.Vital Signs: q4h. Call physician if QRS complex
>0.14 sec or BP >160/90, <90/60; P >120, <50;
R>25, <10; T >38.5 C.
5.Activity: Bed rest; up in chair as tolerated.
6.Nursing: Inputs and outputs. Chart QRS complex
width q1h.
7.Diet: Regular, no salt substitutes.
8.IV Fluids: D5NS at 125 cc/h
9.Special Medications:
-Discontinue ACE inhibitors, angiotensin II receptor
blockers, beta-blockers, potassium sparing
diuretics.
-Calcium gluconate (10% solution) 10-30 mL IV over
2-5 min; second dose may be given in 5 min.
Contraindicated if digoxin toxicity is suspected.
Keep 10 mL vial of calcium gluconate at bedside
for emergent use.
-Sodium bicarbonate 1 amp (50 mEq) IV over 5 min
(give after calcium in separate IV).
-Regular insulin 10 units IV push with 1 ampule of
50% glucose IV push.
-Kayexalate 30-45 gm premixed in sorbitol solution
PO/NG/PR now and q3-4h prn.
-Furosemide 40-80 mg IV, repeat prn.
-Consider emergent dialysis if cardiac complications
or renal failure.
10. Extras: ECG.
11. Labs: CBC, platelets, SMA7, magnesium, calcium,
SMA-12. UA, urine specific gravity, urine sodium, pH,
24h urine potassium, creatinine.
Hypokalemia
1.Admit to:
2.Diagnosis: Hypokalemia
3.Condition:
4.Vital Signs: Vitals, urine output q4h. Call physician if
BP >160/90, <90/60; P>120, <50; R>25, <10; T
>38.5 C.
5.Activity: Bed rest; up in chair as tolerated.
6.Nursing: Inputs and outputs
7.Diet: Regular
8.Special Medications:
Acute Therapy:
-KCL 20-40 mEq in 100 cc saline infused IVPB over 2
hours; or add 40-80 mEq to 1 liter of IV fluid and
infuse over 4-8 hours.
-KCL elixir 40 mEq PO tid (in addition to IV); max total
dose 100-200 mEq/d (3 mEq/kg/d).
Chronic Therapy:
-Micro-K 10 mEq tabs 2-3 tabs PO tid after meals (40-
100 mEq/d) OR
-K-Dur 20 mEq tabs 1 PO bid-tid.
Hypokalemia with metabolic acidosis:
-Potassium citrate 15-30 mL in juice PO qid after
meals (1 mEq/mL).
-Potassium gluconate 15 mL in juice PO qid after
meals (20 mEq/15 mL).
9. Extras: ECG, dietetics consult.
10. Labs: CBC, magnesium, SMA 7&12. UA, urine Na,
Hypermagnesemia
1.Admit to:
2.Diagnosis: Hypermagnesemia
3.Condition:
4.Vital Signs: q6h. Call physician if QRS >0.14 sec.
5.Activity: Up ad lib
6.Nursing: Inputs and outputs, daily weights.
7.Diet: Regular
8.Special Medications:
-Saline diuresis 0.9% saline infused at 100-200 cc/h
to replace urine loss AND
-Calcium chloride, 1-3 gm added to saline (10%
solution; 1 gm per 10 mL amp) to run at 1 gm/hr
AND
-Furosemide (Lasix) 20-40 mg IV q4-6h as needed.
-Magnesium of >9.0  mEq/L requires stat
hemodialysis because of risk of respiratory failure.
9. Extras: ECG
10. Labs: Magnesium, calcium, SMA 7&12, creatinine.
24 hour urine magnesium, creatinine.
Hypomagnesemia
1.Admit to:
2.Diagnosis: Hypomagnesemia
3.Condition:
4.Vital Signs: q6h
5.Activity: Up ad lib
6.Diet: Regular
7.Special Medications:
-Magnesium sulfate 4-6 gm in 500 mL D5W IV at 1
gm/hr. Hold if no patellar reflex. (Estimation of Mg
deficit = 0.2 x kg weight x desired increase in Mg
concentration; give deficit over 2-3d) OR
-Magnesium sulfate (severe hypomagnesemia <1.0)
1-2 gm (2-4 mL of 50% solution) IV over 15 min,
OR
-Magnesium chloride (Slow-Mag) 65-130 mg (1-2
tabs) PO tid-qid (64 mg or 5.3 mEq/tab) OR
-Milk of magnesia 5 mL PO qd-qid.
8. Extras: ECG
9. Labs: Magnesium, calcium, SMA 7&12. Urine Mg,
electrolytes, 24h urine magnesium, creatinine.
Hypernatremia
1.Admit to:
2.Diagnosis: Hypernatremia
3.Condition:
4.Vital Signs: q2-8h. Call physician if BP >160/90, <7-
0/50; P >140, <50; R>25, <10; T >38.5 C.
5.Activity: Bed rest; up in chair as tolerated.
6.Nursing: Inputs and outputs, daily weights.
7.Diet: No added salt. Push oral fluids.
8.Special Medications:
Hypernatremia with Hypovolemia:
If volume depleted, give 1-2 L NS IV over 1-3 hours
until not orthostatic, then give D5W IV to replace
half of body water deficit over first 24hours
(correct sodium at 1 mEq/L/h), then remaining
deficit over next 1-2 days.
Body water deficit (L) =  0.6(weight kg)([Na serum]-
140)
             140
Hypernatremia with ECF Volume Excess:
-Furosemide 40-80 mg IV or PO qd-bid.
-Salt poor albumin (25%) 50-100 mL bid-tid x 48-72
h.
Hypernatremia with Diabetes Insipidus:
-D5W to correct body water deficit (see above).
-Pitressin 5-10 U IM/IV q6h or desmopressin
(DDAVP) 4 mcg IV/SQ q12h; keep urine specific
gravity >1.010.
9. Extras: CXR, ECG.
10. Labs: SMA 7&12, serum osmolality, liver panel,
ADH, plasma renin activity. UA, urine specific gravity.
Urine osmolality, Na, 24h urine K, creatinine.
Hyponatremia
1.Admit to:
2.Diagnosis: Hyponatremia
3.Condition:
4.Vital Signs: q4h. Call physician if BP >160/90, <7-
0/50; P >140, <50; R>25, <10; T >38.5 C.
5.Activity: Up in chair as tolerated.
6.Nursing: Inputs and outputs, daily weights.
7.Diet: Regular diet.
8.Special Medications:
Hyponatremia with Hypervolemia and Edema (low
osmolality <280 mOsm/L, UNa <10 mmol/L:
nephrosis, heart failure, cirrhosis):
-Water restrict to 0.5-1.0 L/d.
-Furosemide 40-80 mg IV or PO qd-bid.
Hyponatremia with Normal Volume Status (low
osmolality <280 mOsm/L, UNa <10 mmol: water
intoxication; UNa >20: SIADH, diuretic-induced):
-Water restrict to 0.5-1.5 L/d.
-Conivaptan (Vaprisol) 20 mg IV over 30 minutes
once, followed by a continuous infusion of 20 mg
over 24 hours. If the response is insufficient,
increase dose to 40 mg/24 hours; max 4 days.
Hyponatremia with Hypovolemia (low osmolality <280
mOsm/L) UNa <10 mmol/L: vomiting, diarrhea, third
space/respiratory/skin loss; UNa >20 mmol/L:
diuretics, renal injury, RTA, adrenal insufficiency,
partial obstruction, salt wasting:
-If volume depleted, give 0.5-2 L of 0.9% saline over
1-2 hours until no longer hypotensive, then 0.9%
saline at 125 mL/h or 100-500 mL 3% hypertonic
saline over 4h.
Severe Symptomatic Hyponatremia:
If volume depleted, give 1-2 L of 0.9% saline (154
mEq/L) over 1-2 hours until no longer orthostatic.
Determine volume of 3% hypertonic saline (513
mEq/L) to be infused:
 Na (mEq) deficit = 0.6 x (wt kg)x(desired [Na] - actual
[Na])
  =     Sodium to be infused
     Volume of solution (L)
(mEq)     
      Number of hrs           (mEq/L in solution) x Num-
ber of hrs
-Correct half of sodium deficit intravenously over 24
hours until serum sodium is 120 mEq/L; increase
sodium by 12-20 mEq/L over 24 hours (1
mEq/L/h).
-Alternative Method: 3% saline 100-300 mL over 4-6h,
repeated as needed.
9. Extras: CXR, ECG, head/chest CT scan.
10. Labs: SMA 7&12, osmolality, triglyceride, liver panel.
UA, urine specific gravity. Urine osmolality, Na.
Hyperphosphatemia
1.Admit to:
2.Diagnosis: Hyperphosphatemia
3.Condition:
4.Vital Signs: qid
5.Activity: Up ad lib
6.Nursing: Inputs and outputs
7.Diet: Low phosphorus diet.
8.Special Medications:
Moderate Hyperphosphatemia:
-Restrict dietary phosphate to 0.7-1.0 gm/d.
-Calcium acetate (PhosLo) 1-3 tabs PO tid with meals
OR
-Aluminum hydroxide (Amphojel) 5-10 mL or 1-2
tablets PO before meals tid.
Severe Hyperphosphatemia:
-Volume expansion with 0.9% saline 1-2 L over 1-2h.
-Acetazolamide (Diamox) 500 mg PO or IV q6h.
-Consider dialysis.
9. Extras: CXR PA and LAT, ECG.
10. Labs: Phosphate, SMA 7&12, magnesium, calcium.
UA, parathyroid hormone.
Hypophosphatemia
1.Admit to:
2.Diagnosis: Hypophosphatemia
3.Condition:
4.Vital Signs: qid
5.Activity: Up ad lib
6.Nursing: Inputs and outputs.
7.Diet: Regular diet.
8.Special Medications:
Mild to Moderate Hypophosphatemia (1.0-2.2 mg/dL):
-Sodium or potassium phosphate 0.25 mMoles/kg in
150-250 mL of NS or D5W at 10 mMoles/h.
-Neutral phosphate (Nutra-Phos), 2 tab PO bid (250
mg elemental phosphorus/tab) OR
-Phospho-Soda 5 mL (129 mg phosphorus) PO bid-
tid.
Severe Hypophosphatemia (<1.0 mg/dL):
-Na or K phosphate 0.5 mMoles/kg in 250 mL D5W or
NS, IV infusion at 10 mMoles/hr OR
-Add potassium phosphate to IV solution in place of
maintenance KCL; max IV dose 7.5 mg
phosphorus/kg/6h.
9. Extras: CXR PA and LAT, ECG.
10. Labs: Phosphate, SMA 7&12, Mg, calcium, UA.