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Following the implementation of citrate anticoagulation for continuous renal replacement therapy, we evaluate its first year of use and compare it to the previously used heparin, to assess whether our patients benefit from the recently reported advantages of citrate. We retrospectively analysed 2 years of data to compare the safety and efficacy of citrate versus heparin. The results have shown that 43 patients received continuous renal replacement therapy with heparin, 37 patients with citrate. We found no significant difference in metabolic control of pH, urea and creatinine after 72 h. Filters anticoagulated with citrate had significantly longer median lifespan (33 h vs 17 h; p ¼ 0.001), shorter downtime (0 h vs 5 h; p ¼ 0.015) and less filter sets per patient day (0.37 vs 0.67; p ¼ 0.002). Filters anticoagulated with heparin were commonly interrupted due to clotting (50% vs 16.4%), whereas filters anticoagulated with citrate were often stopped electively (53.4% vs 24.6%). Patients on heparin filters had significantly higher APPTs, some at potentially dangerous levels (>180 s), whilst patients on citrate filters had significantly higher levels of bicarbonate. Therefore, we conclude that citrate is superior in terms of safety and efficacy, with longer filter lifespan. It has become our first line anticoagulant for continuous renal replacement therapy.

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The aim of this chapter is to provide nurses with the knowledge to be able to assess, manage, and care for people with the renal disorders chronic kidney disease (CKD) and acute kidney injury (AKI) in an evidence-based and person-centred way. In recent years, AKI has replaced the term ‘acute renal failure’. The chapter will provide a comprehensive overview of the causes, risk factors, and impact of CKD and AKI, before exploring best practice to deliver care, as well as to prevent further progression of these conditions. Nursing assessments and priorities are highlighted throughout, and further nursing management of some of the symptoms and common health problems associated with CKD and AKI can be found in Chapters 6, 9, 15, and 19, respectively. Chronic kidney disease (CKD) is the gradual and usually permanent loss of some kidney function over time (Department of Health, 2007). In CKD, the damage and decline in renal function usually occurs over years, and in early stages can go undetected (Department of Health, 2005a). CKD has rapidly moved up the healthcare agenda in recent years, primarily because of the links with cardiovascular risk, and with a shift in focus away from the treatment of established renal failure towards the detection and prevention of CKD in primary care (O’Donohue, 2009). Glomerular filtration rate (GFR) is an indicator of renal function and is the rate at which blood flows through, and is ‘filtered’ by, the kidney; a normal GFR is approximately 125 ml/min. CKD is classified into five stages according to an estimated glomerular filtration rate (eGFR) and, in the milder stages, further evidence of renal damage such as proteinuria and haematuria. This classification holds regardless of the underlying cause of kidney damage. The understanding of GFR is pivotal to caring for patients with renal disorders. Monitoring, management, and referral of the patient in the earlier stages of CKD became much clearer following the publication of the National Clinical Guidelines for the Management of Adults with Chronic Kidney Disease in Primary and Secondary Care (NICE, 2008a). Many people with stage 3 CKD, unless they have proteinuria, diabetes, or other comorbidity such as cardiovascular disease, have a good prognosis and can be managed in primary care (Andrews, 2008).

This chapter addresses the fundamental nursing role of managing hydration. Water is a basic nutrient and is essential to sustaining human life. In the developed world, we often take for granted the basic commodity of clean and plentiful water, but in other parts of the world water can have a profound effect on human health, in both the reduction and the transmission of disease (World Health Organization, 2011). For health, body water and electrolytes must be maintained within a limited range of tolerances. For nurses working in acute or primary care settings anywhere in the world, it is important to have a clear understanding of fluid and electrolyte homeostasis to assess haemodynamic status, to anticipate and recognize deterioration in status, and to implement appropriate corrective interventions. Developing knowledge and associated skills around this topic will be facilitated by reflecting upon your clinical experiences as a student or as a qualified nurse, and your ability to link theory and practice. Your basic foundation of knowledge should include an understanding of how fluid is gained and lost from the body, the distribution of water between different compartments within the body, the processes by which fluid and electrolytes move between the intracellular and extracellular environments (Pocock and Richards, 2009; Cowen and Ugboma, 2011), and knowledge of the different types of intravenous replacement fluid (Endacott et al., 2009: 249–73). Equally important is an insight into the use of criteria such as clinical/ outcome indicators and benchmarking, what to use on what occasions, and how to use such tools to your best advantage. Armed with this knowledge, you will be well equipped to assess each patient’s needs and to make clinical decisions about the most appropriate evidence-based nursing interventions to be used. The state of water balance within the body is principally maintained by the osmoreceptors in the hypothalamus. These are best described as ‘sensors’ that detect the osmolarity (concentration) of the blood to stimulate or suppress the thirst mechanism, as well as regulate the amount of antidiuretic hormone (ADH) released by the posterior pituitary gland. When a person is becoming dehydrated, the thirst centre will be stimulated and usually he or she will seek fluid to rehydrate him or herself.