7–9 Week Preparation Guide

Certifying Body: Nephrology Nursing Certification Commission (NNCC)

Exam: Certified Nephrology Nurse (CNN)

Format: 200 multiple-choice questions

Time: 4 hours (240 minutes)

Prerequisites: Active RN license + at least 3,000 hours (approximately 1.5 years full-time) of nephrology nursing practice in the preceding 3 years; baccalaureate degree recommended but not required

Cost: ~$300 for NNCC/ANNA/ASN/NKF/NOVA partner members; ~$400 for non-members (verify at nncc-exams.org)

Validity: 3 years; recertification via 45 contact hours of continuing education + 30 clinical practice hours, or re-examination

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About the Exam

The CNN is the most comprehensive nephrology nursing certification available. Unlike the CDN (which focuses primarily on dialysis), the CNN validates knowledge across the entire kidney care continuum — from early-stage chronic kidney disease (CKD) management through dialysis, transplantation, and acute kidney injury. The CNN is designed for registered nurses whose practice spans multiple areas of nephrology.

Exam Content Domains (per NNCC)

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Week-by-Week Study Plan

Weeks 1–2: Renal Anatomy, Physiology & CKD Stages 1–5

Goal: Build a strong nephrology foundation covering the full CKD continuum

Key Topics — Renal Anatomy & Physiology:

• •Kidney structure: cortex, medulla, renal pelvis; approximately 1 million nephrons per kidney
• •Nephron components: glomerulus, Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal convoluted tubule, collecting duct
• •Renal blood flow: approximately 20–25% of cardiac output (1,200 mL/min)
• •Glomerular filtration: GFR (normal approximately 120 mL/min/1.73m2), filtration membrane, filtration fraction
• •Tubular function: reabsorption and secretion mechanisms
• •Hormonal functions:
• •Erythropoietin (EPO) — stimulates RBC production in response to hypoxia
• •Renin-angiotensin-aldosterone system (RAAS) — blood pressure and volume regulation
• •Vitamin D activation (1,25-dihydroxyvitamin D / calcitriol) — calcium and bone metabolism
• •Prostaglandins — renal blood flow regulation
• •Acid-base balance: bicarbonate reabsorption, hydrogen ion excretion, ammonia production
• •Electrolyte regulation: sodium, potassium, calcium, phosphorus, magnesium

Key Topics — CKD Stages 1–5 (KDIGO Classification):

• •Stage 1: GFR ≥90 (normal or high) with evidence of kidney damage (albuminuria, structural abnormalities)
• •Stage 2: GFR 60–89 (mildly decreased) with kidney damage markers
• •Stage 3a: GFR 45–59 (mild to moderate decrease)
• •Stage 3b: GFR 30–44 (moderate to severe decrease)
• •Stage 4: GFR 15–29 (severely decreased) — prepare for renal replacement therapy
• •Stage 5: GFR <15 (kidney failure / ESKD) — dialysis or transplant
• •Causes of CKD: diabetes mellitus (leading cause), hypertension (second leading cause), glomerulonephritis, polycystic kidney disease, obstruction
• •CKD progression risk factors: proteinuria, uncontrolled hypertension, uncontrolled diabetes, smoking, NSAID use
• •Early CKD management: blood pressure targets (per KDIGO: <130/80 with proteinuria), RAAS inhibitor use, glycemic control in diabetes, dietary sodium restriction
• •Cardiovascular risk in CKD: CKD is a coronary risk equivalent; lipid management, aspirin use
• •Anemia of CKD: EPO deficiency, iron deficiency evaluation (ferritin, TSAT), ESA therapy, iron supplementation
• •CKD-MBD (Mineral and Bone Disorder): calcium, phosphorus, PTH, vitamin D management; renal osteodystrophy types
• •Metabolic acidosis: bicarbonate supplementation when serum HCO3 <22 mEq/L
• •Uremic syndrome: nausea, pruritus, fatigue, pericarditis, encephalopathy, peripheral neuropathy, platelet dysfunction

Daily Schedule (2 hours/day):

• •Week 1, Days 1–3: Renal anatomy — structures, nephron, blood flow, filtration
• •Week 1, Days 4–5: Renal physiology — hormonal functions, acid-base, electrolytes
• •Week 1, Days 6–7: Review and quiz (40 questions); reinforce with diagrams
• •Week 2, Days 1–3: CKD stages 1–5 — classification, causes, progression, risk factors
• •Week 2, Days 4–5: Early CKD management — BP targets, anemia, CKD-MBD, acidosis
• •Week 2, Days 6–7: Review and quiz (40 questions)

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Weeks 3–4: Hemodialysis — Principles, Access, Procedures & Complications

Goal: Master hemodialysis concepts and clinical procedures

Key Topics — Principles of Hemodialysis:

• •Diffusion: solute movement from high to low concentration across semipermeable membrane (removes BUN, creatinine, potassium, phosphate)
• •Ultrafiltration: fluid removal driven by transmembrane pressure (TMP)
• •Convection (hemodiafiltration): combined diffusive and convective clearance for middle molecules
• •Osmosis: water movement from low to high solute concentration
• •Dialysate composition: sodium (135–145 mEq/L), potassium (0–3 mEq/L), calcium (2.5–3.5 mEq/L), bicarbonate (30–40 mEq/L), glucose (100–200 mg/dL)
• •Kt/V and URR (Urea Reduction Ratio) — adequacy measures: target Kt/V ≥1.2 or URR ≥65%
• •Clearance concepts: small molecules (urea, creatinine) vs. middle molecules (beta-2 microglobulin)

Key Topics — Vascular Access:

• •AV Fistula (AVF): preferred access; artery-to-vein anastomosis; matures in 4–6 weeks; lowest complication rate; assess with thrill/bruit
• •AV Graft (AVG): synthetic conduit (ePTFE); can use in 2–4 weeks; higher infection and thrombosis rate than AVF
• •Central Venous Catheter (CVC): temporary or tunneled; highest infection risk
• •Tunneled (e.g., Permcath, Hickman) — long-term use
• •Non-tunneled — temporary (<3 weeks)
• •Access assessment: thrill (palpation), bruit (auscultation); inspect for redness, swelling, drainage, aneurysm, pseudoaneurysm
• •Cannulation techniques: rope-ladder, buttonhole, area (not recommended)
• •Access complications: infection, thrombosis, stenosis, steal syndrome, aneurysm/pseudoaneurysm, hematoma
• •Fistula First / Catheter Last initiative

Key Topics — Hemodialysis Procedure:

• •Pre-dialysis assessment: weight, vital signs, access site, edema, lung sounds, interdialytic weight gain (IDWG)
• •Machine setup: priming, testing, alarm settings
• •Treatment parameters: blood flow rate (typically 300–450 mL/min), dialysate flow rate (500–800 mL/min), treatment time (typically 3–4 hours), heparin dose
• •Intradialytic monitoring: vital signs every 30–60 minutes, monitoring for complications
• •Post-dialysis: assessment, needle removal, hemostasis, weight, vital signs

Key Topics — Hemodialysis Complications:

• •Hypotension (most common): causes (excess ultrafiltration, low dialysate sodium, food intake, antihypertensives, cardiac dysfunction); treatment (Trendelenburg, normal saline bolus, reduce UF rate, stop UF)
• •Muscle cramps: related to volume depletion, low sodium; treatment (saline, hypertonic saline, reduce UF)
• •Disequilibrium syndrome: caused by rapid solute removal; headache, nausea, confusion, seizures; prevention (slower first treatment, shorter time, lower blood flow)
• •Hemolysis: machine malfunction, hypotonic dialysate; red/Porter wine–colored blood in lines
• •Air embolism: air in blood line; immediately clamp, position on left side with Trendelenburg, give O2
• •Pyrogenic reaction: contaminated dialysate; fever, chills, hypotension
• •Anaphylaxis/anaphylactoid reaction: hypersensitivity to dialyzer membrane or sterilant (ethylene oxide)

Daily Schedule (2–3 hours/day):

• •Week 3, Days 1–3: Hemodialysis principles — diffusion, ultrafiltration, clearance, adequacy
• •Week 3, Days 4–5: Vascular access — types, assessment, cannulation, complications
• •Week 3, Days 6–7: Review and quiz (50 questions)
• •Week 4, Days 1–3: HD procedure — machine, parameters, pre/intra/post monitoring
• •Week 4, Days 4–5: HD complications — recognition, prevention, treatment
• •Week 4, Days 6–7: Review and quiz (50 questions); case studies

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Weeks 5–6: Peritoneal Dialysis, Transplantation & Acute Therapies

Goal: Cover PD, transplant, and AKI — domains unique to the CNN (not on the CDN)

Key Topics — Peritoneal Dialysis (PD):

• •Principle: peritoneum acts as natural semipermeable membrane; dialysate infused into peritoneal cavity
• •Types:
• •CAPD (Continuous Ambulatory PD): manual exchanges, 4–5 exchanges/day, dwell 4–6 hours
• •APD (Automated PD / CCPD): cycler machine at night; typically 3–5 cycles
• •IPD (Intermittent PD): in-center, intermittent treatments
• •PD catheter: Tenckhoff catheter (most common); surgically placed
• •PD solutions: dextrose-based (1.5%, 2.5%, 4.25%) or icodextrin; contain sodium, calcium, magnesium, chloride, lactate/bicarbonate
• •PD adequacy: Kt/V ≥1.7/week (peritoneal + residual renal)
• •PD complications:
• •Peritonitis: cloudy effluent, abdominal pain, fever; diagnosis >100 WBC/μL with >50% PMNs; treatment (intraperitoneal antibiotics)
• •Exit site infection, tunnel infection, catheter malfunction, leaks, hernias
• •Encapsulating peritoneal sclerosis (EPS): rare, serious late complication

Key Topics — Renal Transplantation:

• •Donor types: living related, living unrelated, deceased (brain death, donation after cardiac death)
• •Evaluation process: immunologic compatibility (HLA typing, crossmatch, PRA), psychosocial evaluation, cardiovascular and infection screening
• •Immunosuppression:
• •Induction: basiliximab (Simulect), thymoglobulin, alemtuzumab
• •Maintenance: calcineurin inhibitors (tacrolimus, cyclosporine), mycophenolate mofetil (CellCept), azathioprine, corticosteroids, mTOR inhibitors (sirolimus, everolimus)
• •Target drug levels and monitoring
• •Rejection types:
• •Hyperacute: minutes to hours; antibody-mediated; graft removal required
• •Acute: days to months; cellular or antibody-mediated; treatable with pulse steroids, thymoglobulin
• •Chronic: months to years; gradual decline in function; difficult to reverse
• •Post-transplant complications: infection (CMV, BK virus, PJP), malignancy (skin cancer, PTLD), cardiovascular disease, diabetes (new-onset diabetes after transplant / NODAT), graft dysfunction
• •Long-term monitoring: serial creatinine, proteinuria, drug levels, BK viral load, CMV viral load

Key Topics — Acute Kidney Injury (AKI):

• •AKI classification: KDIGO criteria based on serum creatinine rise and urine output decrease
• •Prerenal causes: volume depletion, heart failure, hepatorenal syndrome, sepsis, nephrotoxins
• •Intrinsic renal causes: acute tubular necrosis (ATN — most common), glomerulonephritis, interstitial nephritis, vasculitis
• •Postrenal causes: obstruction (BPH, stones, tumors, catheter kinking)
• •AKI management: fluid resuscitation, nephrotoxin avoidance, dose adjust medications, renal replacement therapy if indicated
• •Continuous Renal Replacement Therapy (CRRT): CVVH, CVVHD, CVVHDF — used in hemodynamically unstable ICU patients
• •Sustained Low-Efficiency Dialysis (SLED): hybrid therapy for AKI in ICU

Daily Schedule (2–3 hours/day):

• •Week 5, Days 1–3: Peritoneal dialysis — types, solutions, procedure, adequacy
• •Week 5, Days 4–5: PD complications — peritonitis, catheter issues
• •Week 5, Days 6–7: Review and quiz (50 questions)
• •Week 6, Days 1–3: Transplantation — donor types, immunosuppression, rejection
• •Week 6, Days 4–5: AKI — classification, causes, CRRT, SLED
• •Week 6, Days 6–7: Review and quiz (50 questions)

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Weeks 7–8: Pharmacology, Nutrition, Lab Values & Professional Issues

Goal: Complete all remaining content areas

Key Topics — Nephrology Pharmacology:

• •Erythropoiesis-Stimulating Agents (ESAs): epoetin alfa (Procrit/Epogen), darbepoetin (Aranesp); target Hgb 10–11.5 g/dL; monitor for hypertension, thrombosis; black box warning for cardiovascular risk
• •Iron supplementation: IV iron preferred in HD (iron sucrose, ferric gluconate, ferumoxytol); oral iron for non-dialysis CKD; target ferritin 200–500 ng/mL, TSAT 20–50%
• •Phosphate binders:
• •Calcium-based: calcium carbonate, calcium acetate (take with meals)
• •Non-calcium: sevelamer (Renvela), lanthanum (Fosrenol), sucroferric oxyhydroxide (Velphoro)
• •Aluminum-based: rarely used due to toxicity risk
• •Vitamin D:
• •Active: calcitriol (Rocaltrol), paricalcitol (Zemplar), doxercalciferol
• •Nutritional: ergocalciferol, cholecalciferol for early CKD
• •Antihypertensives: ACE inhibitors, ARBs (renoprotective; monitor potassium and creatinine), beta-blockers, CCBs, diuretics
• •Heparin: unfractionated heparin for HD anticoagulation; low-molecular-weight heparin in some settings; monitor ACT or PTT
• •Immunosuppressants (transplant): tacrolimus, cyclosporine, mycophenolate, azathioprine, sirolimus, everolimus, corticosteroids
• •Glucose-lowering agents in CKD: insulin dose adjustments, metformin contraindicated in advanced CKD, SGLT2 inhibitors (renoprotective in CKD)

Key Topics — Renal Nutrition:

• •Protein: 1.0–1.2 g/kg/day on dialysis (higher than general population); 0.6–0.8 g/kg/day in pre-dialysis CKD (with dietitian supervision)
• •Potassium restriction: typically <2–3 g/day on dialysis; monitoring in CKD stages 4–5
• •Phosphorus restriction: <800–1000 mg/day; phosphate binders with meals
• •Sodium restriction: <2 g/day (1500 mg for hypertension)
• •Fluid restriction: based on urine output and IDWG; typically 1–1.5 L/day for anuric dialysis patients
• •Calcium: avoid excess calcium-based binders; monitor for calcium-phosphorus product (<55)

Key Topics — Key Lab Values for CNN:

• •BUN: 10–20 mg/dL (pre-dialysis typically elevated)
• •Creatinine: 0.6–1.2 mg/dL (elevated in CKD)
• •GFR: estimated via CKD-EPI equation; normal approximately 120 mL/min/1.73m2
• •Potassium: 3.5–5.0 mEq/L (hyperkalemia is dangerous in ESKD)
• •Calcium: 8.5–10.5 mg/dL (corrected for albumin)
• •Phosphorus: 3.0–4.5 mg/dL (typically elevated in ESKD)
• •Intact PTH: 150–600 pg/mL (target in dialysis patients per KDOQI/KDIGO)
• •Albumin: goal ≥4.0 g/dL (nutritional marker; goal ≥3.5 minimum)
• •Hemoglobin: target 10–11.5 g/dL on ESA therapy
• •TSAT: 20–50%; Ferritin: 200–500 ng/mL
• •Kt/V: ≥1.2 (HD), ≥1.7/week (PD); URR: ≥65%
• •Bicarbonate: ≥22 mEq/L (metabolic acidosis management)
• •BK viral load and CMV viral load (post-transplant monitoring)
• •Tacrolimus/cyclosporine trough levels (transplant drug monitoring)

Daily Schedule (2–3 hours/day):

• •Week 7, Days 1–3: Pharmacology — ESAs, iron, phosphate binders, vitamin D, antihypertensives
• •Week 7, Days 4–5: Transplant pharmacology; renal nutrition
• •Week 7, Days 6–7: Review and quiz (50 questions)
• •Week 8, Days 1–2: Lab values — interpretation, target ranges, nursing implications
• •Week 8, Days 3–4: Professional issues — CMS regulations, quality measures, patient education, ethics
• •Week 8, Days 5–6: Full-length practice exam #1; review incorrect answers
• •Week 8, Day 7: Rest

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Week 9: Comprehensive Review & Practice Exams

Goal: Achieve exam readiness through targeted review and full-length practice exams

Daily Schedule:

• •Days 1–2: Review weakest domains based on practice exam results
• •Day 3: Full-length practice exam #2; review
• •Day 4: Targeted review — transplantation, AKI, CRRT (CNN-specific domains)
• •Day 5: Full-length practice exam #3; review
• •Day 6: Final review — key lab values, pharmacology flashcards, access types, complications
• •Day 7: REST. You are ready.

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Test-Taking Tips

1. Patient safety first — in emergency situations, choose the intervention that protects the patient
2. The CNN is broader than the CDN — expect questions on early CKD management, transplant, AKI, and CRRT that the CDN does not cover
3. Know your KDIGO guidelines — CKD staging, blood pressure targets, anemia management, CKD-MBD management, and AKI classification are heavily tested
4. Transplant is a major CNN domain — know immunosuppression drugs, rejection types, and post-transplant complications
5. Lab value interpretation — know target ranges for dialysis patients (which differ from general population norms)
6. Pharmacology is high-yield — know drug classes, purposes, key side effects, and monitoring parameters
7. AKI vs CKD differentiation — know how to distinguish acute from chronic kidney injury and appropriate management
8. CRRT knowledge — know the different modalities (CVVH, CVVHD, CVVHDF) and when each is used
9. Time management — 200 questions in 4 hours = 1.2 minutes per question
10. Do not second-guess unless you clearly misread the question

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Recommended Resources

Primary:

• •NNCC CNN Candidate Handbook and Exam Content Outline (nncc-exams.org)
• •Core Curriculum for Nephrology Nursing — American Nephrology Nurses Association (ANNA)
• •Nephrology Nursing Standards of Practice and Standards of Professional Performance — ANNA

Supplementary:

• •Nephrology and Dialysis Therapy — Daugirdas, Blake, Ing (Handbook of Dialysis, 5th ed)
• •Brenner and Rector’s The Kidney — for in-depth renal physiology
• •Transplantation — Danovitch (Handbook of Kidney Transplantation)
• •KDIGO Clinical Practice Guidelines (kdigo.org — free)
• •ANNA Clinical Practice Guidelines

Free Resources:

• •KDIGO Guidelines (kdigo.org) — CKD, AKI, transplant guidelines
• •CMS Conditions for Coverage for ESRD Facilities
• •National Kidney Foundation KDOQI Guidelines
• •ANNA educational webinars and resources (annanurse.org)
• •Fresenius Medical Care and DaVita patient/staff education materials

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Sources

• •Nephrology Nursing Certification Commission (NNCC) — nncc-exams.org
• •NNCC CNN Examination Content Outline
• •American Nephrology Nurses Association (ANNA) — annanurse.org
• •KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guidelines
• •National Kidney Foundation KDOQI Guidelines
• •CMS Conditions for Coverage for ESRD Facilities (42 CFR Part 494)
• •Daugirdas, J.T. et al. Handbook of Dialysis, 5th Edition
• •Danovitch, G.M. Handbook of Kidney Transplantation