Causes of High Creatinine (Nursing)

00:00 So I know we have six but let's start with the most common.

00:03 I want to start with chronic kidney disease.

00:06 Now your kidneys are meant to filter things from your blood put them into the urine so they can leave your body but in chronic kidney disease the kidney itself is damaged.

00:16 So we can't remove in filter creatinine and other ways products like we need it to to stay healthy.

00:23 So a patient with chronic kidney disease will have higher levels of serum creatinine.

00:30 When we think about atherosclerosis you generally think about your heart, right? Chest pain.

00:37 But the problem is the same when the vessels that supply any organ in your body are compromised and you're not getting enough volume of blood to that organ that organ is going to suffer if we're talking about atherosclerosis in your heart you're going to have an MI or heart attack if we're talking about your kidneys we call that renal artery stenosis.

01:00 It just refers to the vessels that supply the kidneys.

01:03 So when these vessels narrow and it happens progressively over time, it causes a reduction in the amount of blood flow that's getting to those kidneys.

01:12 So with the kidneys, the vessels become tighter and tighter and tighter look at the graphic there.

01:18 That's to help you remember that you can see blood flow in one vessel is pretty well free-flowing.

01:24 But in the one that's got atherosclerosis or renal arterial sclerosis.

01:28 You can tell that that blood supply is Significantly diminished.

01:33 See when that happens when you have reduced renal blood flow.

01:37 It has a huge impact on the kidneys less blood flow means those nephrons become damaged.

01:43 And those are the ones that help, how's the units that filter the blood.

01:48 So we're talking about acute versus chronic.

01:51 Now, we're talking about chronic changes that happen in the body.

01:54 Renal artery stenosis happens over a period of time.

01:58 It's Progressive.

01:59 Chronic renal disease also happens over a period of time.

02:04 An acute episode is something that hopefully if we can resolve the underlying cause we can reverse it.

02:10 But chronic has happened over a period of time a number of insults to the kidney and it's much harder to treat.

02:17 Now here's one thing I want you to remember when the kidneys receive low blood flow, they act like the flow is because of dehydration.

02:25 So they try to pump up your heart rate, try to get that blood pressure going up higher which ends up causing more problems for the kidney.

02:33 So what's meant to be a compensatory mechanism short term if your body has experienced progressive changes over a longer period of time it can actually do more damage to your kidney.

02:44 So you'll notice patients with chronic kidney disease generally have hypertension have to do a lot of medication treatments to try to bring that down within a more normal range.

02:54 Now, what about the impact of RAS and creatinine? Well, here's something that's really applicable in the clinical setting creatinine Rises less quickly than urea nitrogen.

03:05 So you would expect to see a rise in your BUN probably before you would see one in the creatinine of equal levels.

03:13 So the concentration of creatinine only becomes abnormal one about half or more of the nephrons have stopped functioning.

03:20 Okay, that's really important.

03:22 Please make sure you write that down because people can have chronic kidney disease and not even be aware of it and before it gets picked up.

03:30 If they're not getting regular Health Care, they may have lost over half of their nephrons in their kidneys because of the progression of chronic renal disease.

03:39 So that's a very important patient education point.

03:42 That's why physicals on a regular basis are so important.

03:46 So before we move on from here, what are the two things I want you to take away.

03:50 Well creatinine rises less quickly than BUN and the second one the creatinine as a way to help you quantify how slow it goes sometimes over half of the nephrons have been destroyed before you'll see that change in their creatinine.

04:08 Now the GFR is the glomerular filtration rate and that's how much blood goes through your glomeruli each minute.

04:15 Now take a look at our picture see right there up in the corner.

04:18 You can see the glomeruli is that little tangle of capillaries surrounding that is Bowman's capsule.

04:25 That's a little round cup that's surrounded it.

04:27 Then you've got, all the tubules and then it exit out of the body.

04:32 So when we're talking about the GFR, we're talking about how much blood can pass through that glomeruli and each minute.

04:40 So what do you think the impact would be of renal artery stenosis and creatinine? Well, we've got less blood going through and remember that concentration of creatinine only gets up normal when a lot of these units are damaged.

04:55 So they're not functioning and very well at all.

04:58 So you're going to see that creatinine rise slowly.

05:01 Okay now we've looked at chronic kidney disease.

05:04 Let's look at something a little more acute, kidney obstruction.

05:09 So anything that blocks or impedes the flow of urine can impair the kidneys ability to function.

05:16 Take a look at that picture.

05:18 So you see we've got two kidneys there right, but one of them definitely does not look like the other.

05:24 Look at that kidneys, it's all swollen up. And knobbly that's because that's called hydronephrosis that means that the urine is filling that kidney and overfilling that kidney, that's why the term hydronephrosis So how does that happen with the kidney obstruction will notice that it's only happening with one kidney in our picture.

05:46 That's because it's all about the placement wherever the obstruction is urine is going to be blocked upstream from there.

05:53 So in this example, it's just in one side and one kidney, but I want you to make sure you have that term, Hydronephrosis, right? You see it there on your slide and take that graphic with you, that picture of that gnarly kidney is because it's all swollen up because of the obstruction.

06:14 Okay now, I've got a question for you.

06:17 I want you to think about what you seen in clinicals, what are some examples of things in patients that could block the flow of urine like that.

06:25 One is mostly a male condition and one is only a male condition.

06:31 Right, the enlarged prostate is definitely only a male condition kidney stones tend to happen more often in males too but females have more than their share.

06:42 So keep in mind we've talked about chronic kidney disease causing high creatinine.

06:46 We talked about kidney obstruction anything that blocks the exit of that creatinine from the body is also going to give us an elevation in your serum creatinine.

06:55 Now dehydration.

06:57 BUN in creatinine can both be elevated in dehydration.

07:01 So see here's what happens.

07:02 She become really really dehydrated.

07:04 That means your blood pressure drops.

07:06 Then you don't have good perfusion to your kidneys that leads to acute kidney injury.

07:12 Remember, we've got a chance to fix the acute kidney injury, but with the acute kidney injury comes the elevated creatinine levels because the kidney can't function the way it was intended.

07:23 So if I can just rehydrate this person, if I can figure out a way to get fluids back into them appropriately, we can resolve the acute kidney injury in most cases.

07:32 So the key is if your patient is dehydrated we want to safely re-administer fluids to get them back to homeostasis or to fluid volume balance.

07:43 If we can't resolve that acute kidney injury immediately.

07:47 We might need to look at pursuing temporary dialysis therapy to try to prevent the damage that can happen in an AKI event.

07:56 Now let's look at high levels of dietary protein.

07:58 This one is not so common, in your practice you may or may not see this but dietary protein, maybe someone who's really engaged in eating a lot of meat or protein.

08:11 Why does protein play such a role? Remember red meat is the muscle tissue of the animal.

08:16 Now it naturally has creatinine.

08:18 So cooking the meat causes the creatine to break down into creatinine.

08:23 So when a person eats the meat their creatinine levels can go up.

08:27 Now you've got to eat a lot of meat, okay? This isn't just one burger and you're going to see a shoot up in your creatinine, but dietary proteins and cooked meats contain creatinine.

08:41 So there is a diet that is popular with some people called the carnivore diet depending on how much red meat there is and how well their kidneys are functioning, This could be problematic.

08:50 So eating higher than recommended levels of protein or comments can elevate creatinine levels.

08:57 Often times people who are into bodybuilding without proper medical assistance as they're going through that regimen, can also end up with elevated creatinine levels because they're taking massive amounts of supplements and protein.

09:11 Now remember cooked red meats can be problematic.

09:14 But again, you're going to have to balance that out and be under a physician's care and a dietitians advice and guidance to make sure you can balance your protein intake with your body's ability to process it.

09:26 Now our fifth one is intense exercise.

09:29 I don't mean walking from the couch to the TV or to the kitchen.

09:33 That's not what we're talking about.

09:34 I'm talking about hardcore long-term Marathon Ironman kind of thing, because remember creatinine is present in your muscles and helps produce energy.

09:45 We just talked about eating that creatinine and red meat but creatinine in your own muscles is what helps your muscles produce energy to do intense things.

09:54 If you do, extremely rigorous exercise that can also increase your creatinine levels because your muscle breakdown is increasing with that intense activity.

10:03 Now our last one number six.

10:05 There's actually certain medications.

10:08 Pretty much anything that can go wrong in your body, medication can sometimes cause it as an unintended adverse effect.

10:15 So some of these drugs may increase your creatinine levels temporarily without actually causing kidney damage.

10:21 So make sure when you're caring for a patient and their elevated levels come back.

10:26 You see are they on any of the medications that you see here.

10:31 Now some of these are pretty common.

10:32 Look at that in H2 antagonist.

10:34 We take that for stomach acid, NSAIDs, people take that over the counter.

10:39 You can also take it after some really intense exercise if you're hurting.

10:42 Certain chemotherapy drugs, cephalosporin or other antibiotics.

10:47 The point is you can't memorize this list because there's just not that much real estate in your brain, but I do want you to have filed the way for an elevated creatinine level you want to make sure you thought through these six categories and have a basic understanding of how they impact your patients lab work.

11:05 So we've looked at those six possible causes of a high creatinine.

11:10 I also don't want you to overlook the possible causes of acute kidney injury.

11:15 Remember we've grouped them into three categories prerenal, intrarenal and postrenal.

11:22 Prerenal being anything leading up to the kidneys, which would include decreased renal perfusion and an increased protein breakdown in the body.

11:30 So we're talking about delivery to the kidney being a prerenal cause so if I have decreased renal perfusion from things like dehydration, blood loss, shock, maybe a heart that's not pumping as well as it should and CHF that's a prerenal cause because I'm not delivering enough blood to the kidneys.

11:49 Now if I have increased protein breakdown, what I'm delivering in the body is overwhelming to the body.

11:57 So increased protein breakdown comes from something like a GI bleed because blood has hemoglobin and hemoglobin is a protein could also happen from a crush injury, from burns, from corticosteroids.

12:10 So you can have some extra challenges with increased protein.

12:14 But the first category is prerenal that's talking about what is being delivered to the kidney.

12:21 Intrarenal is within the kidney, intra-renal.

12:25 This means I've got something going on due to nephrotoxicity.

12:29 So you've got severe hypertension.

12:32 I have glomerulonephritis, maybe some tubular necrosis.

12:35 Those are really impressive words, but don't get lost in those.

12:39 Just stop for a minute and think what we've got going pre renal what's being delivered not enough blood or way too much protein in the body.

12:49 Intrarenal something that's damage the kidney.

12:52 So I've ingested something that just killed the tissue, I have really severe hypertension and that was just blowing through the kidneys and damage them for some reason diabetes, glomerulonephritis, those are all things that you're familiar with and interacting with your patients, but know that they directly damage the kidney itself.

13:14 Now last is post renal, right? That's after we're talking about some type of obstruction the most common things you would see would be something like you've got a kidney stone which happen to anybody and they are excruciatingly.

13:28 Trust me, those people are not exaggerating their pain.

13:31 It's horrible.

13:32 Or maybe even a male's problem with the prostate that's over growing and causing blockage that way.

13:37 So always be on the lookout for acute kidney injury the earlier you catch it the quicker we can intervene and do something so it doesn't turn into chronic kidney disease.