CNeph(C) Nephrology Nursing cheat sheet

Each kidney contains ~1 million nephrons; nephron = glomerulus + tubule; filtration begins at glomerular capillary barrier (fenestrated endothelium, basement membrane, podocyte slit diaphragms).

Normal GFR ~125 mL/min/1.73 m²; GFR = (glomerular hydrostatic pressure − Bowman's space pressure − oncotic pressure) × filtration coefficient.

Proximal tubule reabsorbs ~65% of filtered Na+, water, and nearly all glucose/amino acids; loop of Henle generates medullary osmotic gradient via Na+-K+-2Cl− cotransporter.

Juxtaglomerular apparatus (macula densa + granular cells) regulates renin release in response to low NaCl delivery or reduced renal perfusion pressure.

Kidney endocrine functions: erythropoietin (RBC production), 1α-hydroxylation of 25-OH vitamin D (calcitriol), and renin-angiotensin-aldosterone system.

Acid-base: kidneys reabsorb ~99% of filtered bicarbonate (mostly proximal) and excrete H+ as titratable acid and ammonium; CKD causes metabolic acidosis with elevated anion gap.

CKD progression: nephron loss → compensatory hyperfiltration → glomerular hypertension and sclerosis → further nephron loss (Brenner hypothesis).

Podocyte injury causes proteinuria; nephrotic-range proteinuria >3.5 g/day with hypoalbuminemia, edema, hyperlipidemia.

CKD defined as kidney damage or GFR <60 mL/min/1.73 m² for >3 months; stages G1–G5 based on GFR, with albuminuria category A1–A3.

eGFR formulas: CKD-EPI creatinine (2021 race-free), cystatin C, or combined; confirm with measured creatinine clearance or nuclear GFR when needed.

Monitor CKD complications: anemia (Hb, iron studies), CKD-MBD (Ca, PO4, PTH, 25-OH vitamin D), acidosis (bicarbonate), hyperkalemia, volume status.

Blood pressure target generally <120 mmHg systolic (per KDIGO 2021) when tolerated; use ACE inhibitor or ARB for albuminuric CKD.

SGLT2 inhibitors reduce CKD progression and cardiovascular events in albuminuric CKD; finerenone reduces progression in diabetic CKD with albuminuria.

Nephrology referral: eGFR <30, rapidly declining GFR, albuminuria A3, persistent hyperkalemia, recurrent stones, hereditary kidney disease.

Dialysis initiation considered when symptoms (uremia, volume overload, refractory hyperkalemia/acidosis) or eGFR ~5–10; not solely based on a GFR threshold.

Vaccination (influenza, pneumococcal, hepatitis B, COVID-19) and avoidance of nephrotoxins (NSAIDs, contrast) are core CKD management.

KDIGO AKI criteria: SCr rise ≥0.3 mg/dL within 48 h, or ≥1.5× baseline within 7 days, or urine output <0.5 mL/kg/h for 6 h.

AKI stages 1–3 by SCr and urine output; stage 3 includes SCr ≥3× baseline, SCr ≥4.0 mg/dL, or urine output <0.3 mL/kg/h for ≥24 h or anuria ≥12 h.

Prerenal AKI: BUN/Cr ratio >20, FENa <1%, bland urine sediment; responds to volume repletion. Intrinsic: FENa >2%, muddy brown casts.

Postrenal AKI: obstructive uropathy; assess with bladder scan and renal ultrasound; relieve obstruction promptly (catheter, nephrostomy, stent).

Rhabdomyolysis: CK >5× upper limit, myoglobinuria, hyperkalemia, hyperphosphatemia, hypocalcemia; treat with aggressive IV fluids.

Contrast-associated AKI: risk with eGFR <30, diabetes, dehydration; use lowest contrast volume, iso-osmolar/low-osmolar agent, and pre/post hydration.

CRRT indications in ICU: hemodynamic instability, fluid overload, hypercatabolism; modalities include CVVH, CVVHD, CVVHDF with typical effluent 20–25 mL/kg/h.

Drug dosing in AKI: adjust renally cleared medications; monitor levels of vancomycin, aminoglycosides, and other nephrotoxins.

AV fistula preferred access: rule of 6s (flow >600 mL/min, diameter >6 mm, depth <6 mm); maturation 6–8 weeks; cannulate using rope-ladder or buttonhole technique.

AV graft: matures in 2–4 weeks; higher infection and thrombosis risk than fistula; PTFE most common material.

Central venous catheter: non-tunneled for acute, tunneled cuffed for long-term; lowest blood flow, highest infection risk; use only when AV access not available.

Dialysis prescription: blood flow 300–500 mL/min, dialysate flow 500–800 mL/min, duration 3–4 h, 3×/week; target Kt/V ≥1.2 per session (spKt/V) or ≥1.4 for better clearance.

Dialyzer membranes: low-flux vs high-flux; high-flux needed for middle-molecule clearance; biocompatible synthetic membranes (polysulfone) reduce complement activation.

Complications: hypotension (most common), muscle cramps, disequilibrium syndrome (cerebral edema from rapid urea removal), air embolism, hemolysis, access infection.

Anticoagulation: unfractionated heparin bolus + maintenance; monitor ACT or aPTT; alternatives include citrate, low-molecular-weight heparin, or saline flushes for high bleeding risk.

Water treatment: reverse osmosis, deionization, carbon filtration; monitor for chlorine/chloramine and bacterial/endotoxin contamination.

Peritoneal membrane surface area ~1–2 m²; dialysis occurs via diffusion and convection (ultrafiltration) across capillary and peritoneal barriers.

PD modalities: continuous ambulatory PD (CAPD, 4 exchanges/day), continuous cycling PD (CCPD), nocturnal intermittent PD (NIPD), tidal PD.

Prescription components: fill volume (typically 1.5–2.5 L), dwell time, number of exchanges, dextrose concentration (1.5%, 2.5%, 4.25%).

Peritoneal equilibration test (PET) classifies transport: high, high-average, low-average, low; guides dwell time and dextrose concentration.

Peritonitis: cloudy effluent, abdominal pain, fever; cell count >100 WBC/mm³ with >50% neutrophils; culture and intraperitoneal antibiotics; remove catheter if refractory.

Exit-site care: daily cleansing, avoid trauma, monitor for erythema, drainage, tenderness; exit-site infection increases peritonitis risk.

Ultrafiltration failure: high transporter status, catheter malfunction, leaks; assess with PET and consider modality change.

Contraindications: recent abdominal surgery, hernias, severe malnutrition, active abdominal infection, severe back problems.

ABO blood group compatibility and HLA matching (A, B, DR) determine allocation; crossmatch prevents hyperacute rejection.

Immunosuppression: induction (basiliximab, antithymocyte globulin) + maintenance (calcineurin inhibitor, antimetabolite, corticosteroid).

Calcineurin inhibitors (tacrolimus, cyclosporine) require therapeutic drug monitoring; tacrolimus trough 5–10 ng/mL typical; nephrotoxic and cause hypertension, hyperkalemia, tremor.

Rejection types: hyperacute (minutes–hours, preformed antibodies), acute (days–months, cellular or antibody-mediated), chronic (months–years, interstitial fibrosis/tubular atrophy).

Post-transplant complications: delayed graft function, infection (CMV, BK virus, PJP), malignancy (skin cancer, PTLD), cardiovascular disease, bone disease.

BK virus nephropathy: monitor urine/serum BK PCR; reduce immunosuppression; can cause graft loss.

Living donor evaluation: medical, psychosocial, and genetic assessment; long-term follow-up for donor kidney function and hypertension.

Patient education: medication adherence, infection prevention, sun protection, hydration, and reporting fever or decreased urine output.

Renal drug dosing: adjust for GFR using Cockcroft-Gault or CKD-EPI; loading dose unchanged, maintenance dose reduced or interval extended.

Nephrotoxic drugs: NSAIDs, aminoglycosides, amphotericin B, vancomycin, contrast media, calcineurin inhibitors, cisplatin; monitor renal function.

ACE inhibitors/ARBs: reduce intraglomerular pressure and proteinuria; monitor K+ and SCr; hold during acute illness (sick-day rules).

Diuretics: loop diuretics (furosemide) act on Na+-K+-2Cl− cotransporter in thick ascending limb; thiazides less effective at eGFR <30; monitor electrolytes.

Phosphate binders: calcium carbonate/acetate (take with meals), sevelamer (non-calcium), lanthanum; avoid hypercalcemia with calcium-based binders.

Erythropoiesis-stimulating agents (epoetin, darbepoetin): target Hb 10–11.5 g/dL; risks include hypertension, stroke, thrombosis; ensure iron repletion first.

Potassium binders: patiromer, sodium zirconium cyclosilicate lower K+; monitor for hypokalemia and GI effects.

Immunosuppressant interactions: azathioprine with allopurinol causes severe myelosuppression; tacrolimus/cyclosporine interact with CYP3A4 inhibitors/inducers.

CKD protein intake: 0.6–0.8 g/kg/day for non-dialysis CKD; 1.0–1.2 g/kg/day for hemodialysis; 1.0–1.2 g/kg/day for peritoneal dialysis.

Fluid restriction: individualized; typical 500–1000 mL/day plus urine output for oliguric patients; monitor weight gain between dialysis sessions (<2 kg/day or <4–5 kg inter-dialytic).

Sodium restriction: <2 g/day (≈5 g salt) to control hypertension and fluid overload; avoid processed foods.

Potassium restriction: 2–3 g/day for hyperkalemia; avoid high-K foods (bananas, oranges, potatoes, tomatoes, salt substitutes).

Phosphate restriction: 800–1000 mg/day; limit dairy, cola, processed foods; binders with meals.

Hyperkalemia management: calcium gluconate for cardiac protection, insulin+glucose, beta-agonists, sodium bicarbonate, potassium binders, dialysis for refractory cases.

Hyponatremia: assess volume status; treat symptomatic with hypertonic saline; correct slowly (≤8–10 mEq/L/day) to avoid osmotic demyelination.

Malnutrition screening: use subjective global assessment (SGA) or MIS; monitor albumin, prealbumin, weight, and dietary intake.

Hand hygiene is the single most effective infection control measure; use alcohol-based hand rub or soap and water.

Vascular access infection prevention: catheter exit-site care, sterile dressing changes, chlorhexidine skin antisepsis, avoid unnecessary catheter use.

Hemodialysis catheter-related bloodstream infection (CRBSI): suspect with fever, chills, hypotension; obtain blood cultures from catheter and peripheral; treat with antibiotics and consider catheter removal.

Peritonitis prevention: mask and sterile technique during exchanges, hand hygiene, exit-site care, avoid constipation.

Standard precautions: gloves, gowns, eye protection for splash risk; transmission-based precautions for MRSA, VRE, C. difficile, and other resistant organisms.

Hepatitis B and C: vaccinate against HBV; screen dialysis patients monthly for HBsAg and quarterly for anti-HCV; isolate HBsAg-positive patients in dedicated areas.

Tuberculosis screening: annual PPD or IGRA for dialysis patients; isolate suspected active TB.

Dialysis water and dialysate: monitor bacterial and endotoxin levels; use ultrapure dialysate to reduce inflammatory response.

Self-management education includes medication adherence, diet, fluid restriction, symptom monitoring, and vascular access care.

Teach-back method confirms patient understanding; use plain language and culturally appropriate materials.

Depression and anxiety are common in CKD; screen with PHQ-9 or GAD-7; refer to mental health services.

Sexual dysfunction and fertility concerns: address with patients; CKD affects libido, erectile function, and pregnancy planning.

Advance care planning: discuss goals of care, dialysis withdrawal, palliative care, and hospice options early.

Financial and social support: social work referral for transportation, insurance, medication costs, and caregiver support.

Dialysis modality education: explain hemodialysis, peritoneal dialysis, and transplant options; include home dialysis training.

Vaccination education: influenza annually, pneumococcal, hepatitis B, COVID-19, and others per guidelines.

Informed consent: discuss benefits, risks, alternatives, and consequences; document consent for dialysis, procedures, and research.

Patient autonomy: respect refusal of treatment; assess decision-making capacity; involve family as appropriate.

Confidentiality: protect PHI per HIPAA; share only on need-to-know basis; secure electronic and paper records.

Advocacy: nurses advocate for patient safety, pain management, and access to care; report unsafe practices.

Medication safety: use two patient identifiers, barcode scanning, and reconciliation; report adverse drug events.

Dialysis safety: verify dialyzer reuse, water quality, machine alarms, and emergency protocols; conduct fire and disaster drills.

Professional boundaries: avoid dual relationships; maintain competence through continuing education and certification.

End-of-life care: honor advance directives; provide palliative care; discuss dialysis withdrawal with ethics consultation when needed.