ACUTE RENAL FAILURE CHRONIC RENAL FAILURE

OBJECTIVES Identify normal functioning of the kidney and laboratory tests that assess kidney function Define renal failure Discuss the causes of acute renal failure and compare those with chronic renal failure Compare prerenal, intrarenal and postrenal conditions Identify the alterations seen in patients, explaining why they exist Identify nursing measures appropriate to the alterations

NORMAL KIDNEY FUNCTION What does the kidney do in terms of? wastes and water balance? Acid base balance? Controlling BP? Controlling anemia?

RENAL FAILURE DEFINED Kidneys no longer function properly Kidneys unable to excrete waste kidneys cannot concentrate urine Kidneys cannot conserve electrolytes

HORMONES WHICH INFLUENCE THE KIDNEY ALDOSTERONE Produced: Action: RENIN/ANGIOTENSIN

HORMONES WHICH INFLUENCE THE KIDNEY ANTIDIURETIC HORMONE Produced: Action: ERYTHROPOIETIN (EPO)

IDENTIFYING THE THREE PRIMARY RENAL FUNCTIONS GLOMERULAR FILTRATION:glucose, amino acids, creatinine, urea, phosphates, uric acid GLOMERULAR REABSORPTION:bicarbonate, phosphates, sulfates, 65% of Na and water, glucose, K, amino acids, H ions, urea GLORMERULAR SECRETION: hydrogen and potassium, remove acids (hydrogen) to maintain appropriate acid base balance, potassium, urea

ASSESSMENTS OF RENAL FUNCTION u/a: negative for glucose, protein, blood, leukocytes, nitrites, ketones Specific gravity: measures concentration of the urine; normal values: 1.010-1.025 Urine osmolality: normal 300-900 mOsm/ kg/24 Serum creatinine: 0.6-1.2mg/dl BUN: 7-18mg/dl BUN to creatinine ratio: about 10:1

DIAGNOSTIC ASSESSMENTS CONTINUED STANDARD FOR RENAL FUNCTION: assess glomerular filtration rate (GFR) Norm for this assessment is the creatinine clearance test done over 24 hours: normal rate is 80-125ml/min

DEFINITIONS OLIGURIA: urine output is less than 30 ml/hr ANURIA: no urinary output NORMAL URINARY OUTPUT: 1500-1800ml/day

CAUSES OF ACUTE RENAL FAILURE PRERENAL or factors external to the kidney which interferes with renal perfusion (55% cases of ARF) INTRARENAL: conditions that cause direct damage to renal tissue (35-40% cases of ARF) POSTRENAL: mechanical obstruction in the urinary tract (5% cases of ARF)

CAUSES OF RENAL FAILURE CONTINUED Multiple problems may exist at same time AGING

RENAL FAILURE DEFINED To define renal failure ask yourself: How is the kidney functioning with regard to? Excreting nitrogenous wastes Concentrating urine Conserving electrolytes

PROBLEMS FOR PATIENT Retention of metabolic wastes Imbalance of fluid and electrolytes Alterations of sensorium

3 phases of acute renal failure Oliguria Diuresis Recovery

OLIGURIC PHASE (lasts 10-14 days) Urinary changes Fluid volume excess Metabolic acidosis Sodium balance Potassium excretion

OLIGURIC PHASE (lasts 10-14 days)continued Hematologic disorders Calcium deficit and phosphate excess Waste product accumulation Neurologic disorders

DIURETIC PHASE (lasts 1-3 wks) Gradual increase of urine output as a result of osmotic diuresis Why does this happen? What is the state of nephron? Can the kidney excrete wastes? Can the kidney concentrate urine? What would we see in the patient during this stage?

RECOVERY PHASE When does this begin? Do all patients recover?

GOALS OF TREATMENT Restore renal function Identify cause Eliminate cause

MAINTAINING FLUID AND ELECTROLYTE BALANCE How do we assess fluid excess? How can we control fluid intake? What physical assessments would be done? What would you expect to see? What laboratory tests would be used to assess client status?

NURSING CARE FOR: Elevated serum phosphate: Hypocalcemia: Hypermagnesemia: Hypovolemia: Fluid retention: diuretics: Hypertension: Metabolic acidosis:

TREATING HYPERKALEMIA Regular insulin IV Sodium bicarbonate Calcium gluconate IV Dialysis Kayexalate Dietary restriction

DIET FOR ACUTE RENAL FAILURE dietary protein calories K and phosphorus Na Fe Limit dietary protein to 1 Gm per kg of body weight: minimize protein breakdown and to prevent accumulation of byproducts of protein metabolism High calorie diet to promote good nutrition Restrict foods and fluids high in K and phosphorus: K intake is resricted to 40-60 mEq/day; such as bananas, citrus fruits and juices, coffee Foods high in phosphorus include milk and milk products, whole grains, dried beans and peas, nuts and seeds, organ meats, meat and fish, colas, chocolate and some types of baking powder. Restrict Na to 2 Gm a day Fe supplements for anemia. This occurs as a result of decrease in erythropoietin production

CHRONIC RENAL FAILURE DEFINED Progressive deterioration in renal function resulting in fatal uremia (excess of urea and other nitrogenous wastes in the blood) Irreversible destruction of nephrons Called ESRD (end stage renal disease) Dialysis or transplant

TERMS ASSOCIATED WITH CHRONIC RENAL FAILURE Azotemia: collection of nitrogenous wastes in blood Uremia: azotemia Uremic syndrome: systemic clinical and laboratory manifestations of ESRD

Alterations: Chronic Renal Failure Metabolic Disturbances: elevated BUN, creatinine, hyponatremia, hyperkalemia, metabolic acidosis, hypocalcemia, hyperphosphatemia Reproductive Disturbances: For woman: menstrual irregularities, amenorrhea, infertility, decreased libido For men: impotence, reduced sperm motility Integumentary Disturbances: pruritus,dry,hair brittle, nails thin, UREMIC FROST: white/yellow crystals of urate on skin

ALTERATIONS OF CHRONIC RENAL FAILURE CONTINUED Gastrointestinal Disturbances: Anorexia, N&V, metallic taste in mouth, breath smells like ammonia, stomatitis, ulcers/GI bleeding, constipation Neurological Distrubances: uremic encephalopathy progresses to seizures & coma CHF: from increased workload on heart from anemia, hypertension and fluid overload Uremic pericarditis: pericardium becomes inflammed from toxins

ALTERATIONS OF CHRONIC RENAL FAILURE CONTINUED Respiratory: breath smells like urine: uremic fetor or uremic halitosis Metabolic acidosis: see tachypnea (increased rate) and hyperpnea (increased depth) indicates worsening metabolic acidosis See Kussmaul respirations extreme hyperventilation

NURSING CARE FOR PT WITH CHRONIC RENAL FAILURE FOR ANEMIA: FOR HYPOCALCEMIA FOR FLUID RETENTION AND HYPERTENSION FOR SKIN ITCHING

DIETARY RESTRICTIONS FOR CHRONIC RENAL FAILURE calorie protein Na K calcium Phosphorus Magnesium

DIALYSIS: peritoneal and hemodialysis

PERITONEAL DIALYSIS Diffusion of solute molecules through a semi-permeable membrane passing from the side of higher concentration to that of lower concentration Fluids passing through the semi-permeable membrane via osmosis Renal Failure pt has dialysis to remove waste products and to maintain life until kidney function can be restored Dialysis indicated for high levels of K and fluid overload

PERITONEAL DIALYSIS Sterile dialyzing fluid is introduced into the peritoneal cavity Peritoneum is an inert semipermeable membrane The dialyzing solution promotes osmosis leading to diuresis Urea and creatinine are removed

NURSING CARE OF PT ON PERITONEAL DIALYSIS Baseline VS and wgt Assess for fluid overload Maintain highly accurate inflow and outflow records When PD starts the outflow may be bloody or blood tinged This clears within a week/two Effluent should be clear and light yellow

Nursing care during PD Drainage bag is lower than the client’s abdomen to enhance gravity drainage Avoid kinking or twisting, ensure clamps are open Reposition client to stimulate inflow or outflow Sitting/standing/coughing: increases intraabdominal pressure

COMPLICATIONS OF PERITONEAL DIALYSIS Respiratory difficulties Hypotension Infection: peritonitis: see cloudy or opaque dialysate outflow (effluent), fever, abdominal tenderness, pain, malaise, N&V Hypo-albuminemia Bowel perforation: Bladder perforation: Catheter may get clogged

COMPLICATION OF PD: Fibrin Clot formation Milking the tubing Xray

COMPLICATION OF PD: LEAKAGE Dialysate leakage See with obese, diabetic, older clients, those on long term steroids

HEMODIALYSIS Process by which the uremic toxins and accumulated waste products are removed from the blood

HEMODIALYSIS CONTINUED A synthetic semi-permeable membrane replaces the renal glomeruli and tubules and acts as a filter for the impaired kidneys Must have 3 times/week for 4 hours per treatment for rest of life

Access to pt’s circulation via: AV shunt (less common): external silastic tubing placed in an adjacent artery and vein AV Fistula: internal access using pts own vessels (artery and vein) AV Graft: internal access using a foreign material

COMPLICATIONS Hemodialysis vascular access BLEEDING INFECTION CLOTTING

Assessment during Hemodialysis Assess for disequilibrium reaction CAUSE: due to rapid decrease in fluid volume and BUN levels Change in urea levels can cause cerebral edema and increased intracranial pressure Neurologic complications: HA, N&V, restlessness, decreased LOC, seizures, coma, death PREVENTION: starting HD for short periods with low blood flows

Nursing care pre dialysis Vasoactive drugs which cause hypotension are held until after treatment CHECK WITH MD ABOUT WHICH DRUGS TO BE HELD Know pt’s BP predialysis

Post dialysis nursing care BP and wgt Hypotension Temperature may also be elevated: If client has a fever Bleeding risk:

KIDNEY TRANSPLANT Involves transplanting a kidney from a living donor or human cadaver to a recipient who has end-stage renal disease and requires dialysis to live

POSTOPERATIVE CONCERNS AFTER TRANSPLANT major concern is rejection Drugs given to suppress immunologic reactions: Imuran, prednisone, cyclosporin (Cyclosporin A) Next concern is infection

NRSG CARE POST KIDNEY TRANSPLANT TO DETECT REJECTION: Assess for increased temp, pain or tenderness over grafted kidney Assess for decrease in urine output, edema, sudden wgt gain Assess for rise in serum creatinine and BUN values