Acute Kidney Injury and Chronic Kidney Disease Deep Dive

Loretta Swift

Hi everyone! Welcome to another episode of NSG4052 Renal. I’m Loretta Swift, and with me as always is James A. Bond. Today, we’re deep diving into—what else?—renal failure. You know, I remember when I was a brand new nurse, the whole idea of a kidney “failing” sounded so catastrophic… and honestly, it is. But it’s also more complex than just a switch flipping off.

James A. Bond

Absolutely, Loretta. And hello from across the pond, everyone. Renal failure is all about the kidneys losing their knack for doing the basic jobs: excreting waste, keeping the fluids and electrolytes in a delicate dance, the acid-base thing—we’ll unpack all of that. Whether it’s partial or total, when kidney function drops, nothing in the body escapes. Honestly, the impact is systemic and, well, it’s life-changing for patients and their families. And it can be acute—something that sneaks up or hits suddenly, as with infection or surgery—or chronic, which unfortunately is progressive and doesn’t reverse.

Loretta Swift

Yeah, and you know, one thing that stuck with me—I’ll never forget my very first patient in total renal failure. The family made all the difference; they learned, they adapted, and it just reinforced how this isn’t a condition only for the person in the bed. It shakes up the entire household, jobs, food at the dinner table, everything. And acute kidney injury—AKI—sometimes gets better, sometimes not. Chronic kidney disease? That’s a whole journey, and not an easy one. Let’s walk through what happens and what we, as nurses, really watch for.

James A. Bond

So, let’s break down AKI. There are three main types: prerenal, intrarenal, and postrenal. You might remember those from class. Prerenal is all about the plumbing before the kidney—say, severe dehydration, heart failure, hypovolemia. Basically, not enough blood gets to the kidney. It accounts for, what, around sixty percent of cases, Loretta?

Loretta Swift

Yeah, I always remember it as “before the kidney,” like a traffic jam upstream. And older adults? Double risk with chronic hypertension, volume depletion, even over-the-counter NSAID use—think aspirin or ibuprofen. I had a lady whose only issue was too many “headache pills.” That alone triggered her AKI when she got the flu.

James A. Bond

Spot on. Then, intrarenal—direct hit to the nephrons themselves. That could be ischemia from prolonged low oxygen, nephrotoxic drugs like IV contrast, or diseases like glomerulonephritis. I’ll never forget a patient post-angiogram… contrast dye did a number on him. After surgery, his creatinine shot up. It’s why we have to flag kidney function before these procedures, especially in elderly folks who might already have one foot in CKD.

Loretta Swift

And postrenal is a bit rarer—less than ten percent—but dramatic. Think blockages: BPH, kidney stones, strictures, tumors. Or even trauma. If that urine can’t leave, it backs up. I once had a guy with bilateral stones—hydro-nephrosis in both kidneys. You fix the blockage quick, and sometimes you can turn things around; if not, the damage can stick around for good.

James A. Bond

Let’s not forget risk factors: besides the usual suspects, things like ongoing hypovolemia, repeated admissions—just being in the hospital and exposed to nephrotoxins. And with older adults, every additional med is another gamble. Spotting the risk early makes a world of difference.

Loretta Swift

So, AKI isn’t just one long decline—it’s got stages. First up is the oliguric phase—less than 400 milliliters of urine per day, often within a week of injury. Your patient may be puffy, hypertensive, and showing all the signs. For example, case J.K.—a construction worker, fell off a roof, a mess of trauma and blood loss. He started passing less and less urine—classic oliguria. Fatigued, high BUN and creatinine, his blood pressure was sky high. That’s the oliguric phase: not enough pee, metabolic acidosis, hyperkalemia, risk of serious complications.

James A. Bond

Exactly. Then, after the oliguric phase, the kidneys sometimes go into a kind of overdrive: the diuretic phase. Urine output suddenly jumps—sometimes two liters or more overnight. And it can be a surprise. But it’s not always good news straight away. The kidneys might excrete water, but not concentrate urine yet, risking dehydration, hypotension, and electrolyte loss—hyponatremia, especially. You’ve gotta watch vitals closely and replace fluids carefully.

Loretta Swift

Right, and after that, recovery phase. You see the labs normalize, GFR rises, BUN and creatinine trend down. But in the elderly, or with major complications, sometimes recovery isn’t total. I’ve had patients who hovered at early CKD for months. These phases—oliguric, diuretic, recovery—they really help you gauge how things are progressing. And the labs! I’m always quizzing my students: Tell me what’s happening to BUN, creatinine, GFR, potassium. AKI changes them all—watch for big swings in those values.

James A. Bond

Diagnosing AKI, compared to, say, a simple UTI, is a bit more involved. You’ll rely on everything: serum creatinine, BUN, checking urine output, urinalysis for casts or protein. A renal ultrasound is king for ruling out obstructions, while CT might be next, but, and this is a biggie—contrast is a no-go if possible. In some cases, a biopsy is the gold standard, especially if we can’t pin down the cause, but that’s not for everyone.

Loretta Swift

So true. And older folks? Have to be twice as careful with diagnostics—you don’t want to push them into contrast-induced nephropathy. I had an elderly patient come in for a “routine” scan—he wound up in full-blown AKI because of the dye. It was that delicate balance of working with radiology, nephrology, and pharmacy that actually saved him—everyone talked, watched his trends, and adjusted the plan together. That’s interprofessional gold.

James A. Bond

And sometimes none of that is enough. We look at when to start renal replacement therapy—RRT. The big flags are fluid overload, stubborn hyperkalemia, rising acidosis, BUN over 120, altered mental status, or pericardial problems. As for modalities: peritoneal dialysis isn’t as common in AKI, but intermittent hemodialysis or continuous renal replacement—CRRT—may be lifesavers, especially for hemodynamically unstable patients.

Loretta Swift

It all comes back to early detection, communication, and having a team that listens. That’s honestly what makes the difference, especially in our older crowd.

Loretta Swift

Alright, shifting gears to chronic kidney disease—CKD. The big difference? It’s slow, sneaky, and once you’ve lost the nephrons, they don’t come back. CKD is seriously underdiagnosed, especially in older adults. You could have a patient with a GFR under 60 for months before anybody notices. And a lot of folks don’t show symptoms until it’s advanced.

James A. Bond

Spot on, Loretta. Leading causes are diabetes and hypertension. Stage-wise, CKD goes from one to five—stage one being a normal or mildly reduced GFR, stage five is end-stage renal disease, GFR less than fifteen. I had a gentleman in the UK, years of poorly controlled type 2 diabetes, who came in for pruritus—intense, all-consuming itching. Turned out he was in advanced CKD with mineral deposits in the skin. That’s what chronic kidney failure can do—fluid overload, elevated BUN and creatinine, anemia, hyperkalemia, metabolic acidosis… it literally touches every organ system.

Loretta Swift

Absolutely. And you’ll see issues from neuro changes—fatigue, confusion—to GI symptoms, anemia from low erythropoietin, bleeding risks, bone disease, even reproductive changes. For nursing students, remember to connect elevated BUN and creatinine with declining GFR, and ask about subtle symptoms: “Have you felt itchier? More tired? Less hungry?” Sometimes those little things are the only clues CKD is getting worse.

James A. Bond

Medications are tricky in kidney disease—dosing’s a constant challenge. Many drugs, like NSAIDs or ACE inhibitors, are nephrotoxic or need renal dosing. I can’t count the number of times I’ve seen an elderly patient’s AKI worsened because they didn’t know which meds to avoid. It takes both teaching and vigilance. And with CKD, you need to think about epoetin alfa for anemia, phosphate binders for bone disease, careful use of antihypertensives.

Loretta Swift

And the diet side—oh, it gets complicated! You’ve got to adjust sodium, potassium, phosphate, and protein depending on the stage. Pre-dialysis? Low protein. On hemodialysis? Need more. Phosphate restriction means watching dairy and meats. And with so many processed foods, hidden sodium is everywhere—we literally go through food labels together, I always say, “If the sodium’s above 200mg per serving, let’s leave it on the shelf.” Fluid restriction’s another monster, especially for those used to chugging water. I teach patients tricks, like chewing gum or freezing grapes, to manage thirst without blowing their weight targets.

James A. Bond

That’s such practical advice. It’s a constant balancing act—keeping nutrition up while protecting what’s left of the kidneys. Having a dietitian on board is a must, really.

Loretta Swift

So, bringing it all together—it’s about what nurses can do for these patients, right? Key nursing diagnoses you’ll see: fluid and electrolyte imbalance, risk for infection, impaired skin integrity, anxiety, and always, always patient teaching. Teaching isn’t just about spitting out facts—it’s helping patients recognize swelling, fatigue, mood changes. “Call me if you gain two kilos in a week!” or “Let’s talk about what’s in that energy drink.”

James A. Bond

And, for those prepping for exams—here’s my favourite tip: get really clear on AKI versus CKD. Look for sudden versus gradual onset, lab patterns, and reversibility. If they ask, “Which patient is most likely to recover?”—it’s the AKI one, usually. Remember, infection is the top cause of death in AKI, but cardiovascular disease is the killer in CKD. Distinguishing those will save you points.

Loretta Swift

Exactly. And don’t forget the emotional side. Supporting patients through denial, fear, or grief is just as important as the technical stuff. Sometimes a friendly, “Hey, you’re not alone. We’ve got a plan,” means the world.

James A. Bond

Well said, Loretta. This stuff can feel overwhelming, but it’s all about breaking it down for yourself and your patients. And on that note, shall we wrap, Loretta?

Loretta Swift

Yeah, let’s leave it there for today. Thanks for tuning in to NSG4052 Renal. We’ll be back to tackle more real-world renal scenarios and keep you sharp for that next exam—or your next shift. James, always a pleasure chatting with you.

James A. Bond

The pleasure’s all mine, Loretta. Take care, everyone—until next time, stay curious and keep caring.