1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 42 Acute Renal Injury and Chronic Kidney Disease

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Renal Failure Definition –A condition in which the kidneys fail to remove metabolic end products from the blood and regulate the fluid, electrolyte, and pH balance of the extracellular fluids Underlying causes –Renal disease –Systemic disease –Urologic defects of non-renal origin

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention and Early Diagnosis of Acute Renal Failure Assessment measures to identify persons at risk for development of acute renal failure –Those with preexisting renal insufficiency and diabetes –Elderly persons (due to the effects of aging on renal reserve)

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Renal Failure Acute Renal Failure –Abrupt in onset –Often is reversible if recognized early and treated appropriately Chronic Renal Failure –The end result of irreparable damage to the kidneys –It develops slowly, usually over the course of a number of years.

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Prerenal Cases of Acute Renal Failure Hypovolemia Decreased vascular filling Heart failure and cardiogenic shock Decreased renal perfusion due to vasoactive mediators, drugs, diagnostic agents

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Postrenal Causes of Acute Renal Failure Bilateral ureteral obstruction Bladder outlet obstruction

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Congestive heart failure would be a(n) __________ cause of renal failure. −A. prerenal −B. intrarenal −C. postrenal

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. prerenal

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intrinsic or Intrarenal Causes of Acute Renal Failure Acute tubular necrosis –Prolonged renal ischemia –Exposure to nephrotoxic drugs, metals, organic solvents –Intratubular obstruction resulting from hemoglobinuria, myoglobinuria, myeloma light chains or uric acid casts –Acute renal disease

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of ATN Onset or Initiating Phase –Lasts hours or days –The time from the onset of the precipitating event until tubular injury occurs Maintenance Phase –Characterized by a marked decrease in the GFR Recovery Phase –Period during which repair of renal tissue takes place

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Causes of Chronic Renal Disease Hypertension Diabetes Mellitus Polycystic kidney disease Obstructions of the urinary tract Glomerulonephritis Cancers Autoimmune disorders Diseases of the heart or lungs Chronic use of pain medication

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Stages of the Progression of Chronic Renal Failure Diminished renal reserve Renal insufficiency Renal failure End-stage renal disease (ESRD)

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Stages of the Progression of Chronic Renal Failure (cont.) Mild reduction of GFR to 60 to 89 mL/min/1.73 m 2 Moderate reduction of GFR to 30 to 59 mL/min/1.73 m 2 Severe reduction in GFR to 15 to 29 mL/min/1.73 m 2 Kidney failure with a GFR < 15 mL/min/1.73 m 2, with a need for renal replacement therapy

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A GFR of _____________ best describes renal failure. –A. 60 to 89 mL/min/1.73 m 2 –B. 30 to 59 mL/min/1.73 m 2 –C. 15 to 29 mL/min/1.73 m 2 –D. <15 mL/min/1.73 m 2

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. <15 mL/min/1.73 m 2 Rationale: Less than 15 mL/min/1.73 m 2 is the result of significantly decreased renal filtration and is the cut-off point of renal failure.

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Manifestations of Chronic Renal Failure Accumulation of nitrogenous wastes Alterations in water, electrolyte and acid-base balance Mineral and skeletal disorders Anemia and coagulation disorders Hypertension and alterations in cardiovascular function Gastrointestinal disorders Neurologic complications Disorders of skin integrity Immunologic disorders

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment During the Renal Insufficiency Stage of Renal Failure Using measures to retard deterioration of renal function and assist the body in managing the effects of impaired function –Treating urinary tract infections promptly –Avoiding medication with renal damaging potential –Controlling blood pressure –Controlling blood sugar in persons with diabetes –Stopping smoking

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Target Populations Comprising Persons with Chronic Renal Failure Persons with chronic renal insufficiency Persons with renal failure being treated with hemodialysis Persons with renal failure being treated with peritoneal dialysis Renal transplant recipients

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Determining the Manifestations of Renal Failure The extent of renal function that is present Coexisting disease conditions The type of renal replacement therapy that the person is receiving

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of Water, Electrolyte, and Acid–Base Balance Sodium and water balance –The kidneys function in the regulation of extracellular fluid volume. Potassium balance –Approximately 90% of potassium excretion is through the kidneys. Acid–Base balance –The kidneys normally regulate blood pH by eliminating hydrogen ions produced in metabolic processes and regenerating bicarbonate.

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Hematologic Disorders Accompanying Renal Failure Anemia Coagulopathies

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiovascular Disorders Accompanying Renal Failure Hypertension Heart disease Pericarditis

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Altered Drug Metabolism in Kidney Disease CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs. –Altered drug absorption Antacid treatment –Altered metabolism Results of less protein-bound drugs Increased intermediates of drug metabolism –Alterations in dosage may be required

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following alterations may affect drug efficacy in a patient with CKD? –A. Loss of K + –B. Alteration in pH –C. Loss of albumin –D. Increased Ca 2+

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Loss of albumin Rationale: Loss of albumin will result in altered drug metabolism via increased intermediates and faster action.

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment of Renal Failure Medical Management –Dialysis Hemodialysis Peritoneal dialysis –Transplantation

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment of Renal Failure (cont.) Dietary Management –Protein –Carbohydrates, fat, calories –Potassium –Sodium and fluid intake

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins CKD in Children Causes –Congenital malformations –Inherited disorders –Acquired diseases –Metabolic syndromes Manifestations –Severe growth impairment; –Developmental delay –Delay in sexual maturation –Bone abnormalities –Development of psychosocial problems

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins CKD in Elderly Normal decrease in the GFR with age –Increased detrimental effects of nephrotoxic drugs Greater incidence of cerebrovascular, cardiovascular, and skeletal system effects

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Options for Chronic Renal Failure in the Elderly and Children Hemodialysis Peritoneal dialysis Transplantation