1. Justine Willman Med, MSN, RN 2014
Renal System
Justine Willman Med, MSN, RN
2014

3. Kidney Anatomy
Protected by ribs but vulnerable if you receive a direct blow to the back
Encased in 3 tissue layers
Inner is the -renal capsule- thin membrane that helps seal the kidneys and prevent infections from spreading into renal tissue
Adipose capsule- this tissue cushions and holds the kidneys in place
Renal fascia - outer membrane also surrounds adrenal glands

4. Kidney Kidneys filter 45 gallons of blood a day
Nephrons are the functioning unit where filtering occurs
Glomerulus – capillary clusters that are the filtering unit of the nephron, covered by Bowman’s capsule
Tubule – collecting channel in nephron that converts fluid to urine as it goes to the pelvis of the kidney

5. Renal Failure Partial or complete impairment of kidney function
Acute & chronic
Partial or complete impairment of kidney function
Inability to excrete metabolic waste products, and water as well as functional disturbances of all body functions.

6. Acute Renal Failure (ARF)
Rapid onset- rapid symptoms
Rapid loss of renal function with progressive increase of BUN and Creatinine
Potentially reversible
Medical care: find and treat the cause to promote kidney health
Clients will be defined as being in either oliguric or non oliguric ARF
Oliguria is defined as urine output < 400 ml/day, therefore, if output does not drop this low, the client is classified as having non oliguric ARF

7. Prerenal: Any reduction in blood flow to the kidney
Prerenal: Any reduction in blood flow to the kidney. This reduction takes place prior to the blood flow of the kidney. i.e. MI, shock, sepsis, code arrest, etc %
Intrarenal: Direct damage such as a renal toxic antibiotic, IV contrast dye, renal infection, renal inflammation causing low blood flow within the kidney %
Postrenal: Least common and is the result of injury below the kidney; tumor, etc., usually enlarged prostate, Less than 5%
There are 3 ways in which acute renal failure can occur. See the above visual for locations/causes 1, 2 & 3

8. Close to 50% of acute renal failure clients do not experience oliguria
Almost half of those in acute renal failure (ARF) will go into the Oliguric Phase and will follow an expected sequence to recovery.
1. Oliguric Phase
2. Diuretic Phase
3. Recovery Phase
Those in acute renal failure who do NOT have a drop in urine output <400 mL in 24 hour (oliguria) will not go through the above phases and have a better chance at full recovery.
1. Oliguria
Urine output <400 ml/day
Occurs 1-7 days after event
Usually last days, but can also last for months
The longer it lasts the poorer the prognosis
Close to 50% of acute renal failure clients do not experience oliguria

9. Oliguria Presentation
As the nurse consider your immediate concerns during this phase. Priorities, actions, delegation, etc.
Oliguria presentation includes
Decrease urinary output < 400mL/24h
Fluid volume excess and electrolyte imbalances
( K+ Na+ Phos, BUN, Creatinine & bicarbonate)
As a result of these imbalances
Metabolic acidosis can set in
Anemia may occur
Neurological changes: seizure, stupor, coma
Possible nausea leading to vomiting
Respiratory complications (pulmonary edema)

10. Interventions – Oliguric Phase
As the nurse, think of where the fluid is going in ARF.
Interventions are focusing on the complications as the result of low urine output.
Monitor blood pressure (BP)
Restrict fluid intake
Limit IV fluids when giving the required IV medications
Monitor for fluid overload – lungs & cardiac focus
Daily weight
Daily, or as ordered, electrolyte monitoring and replacement
Dialysis as ordered

11. 2. Diuretic Phase – follows the Oliguric phase
As the nurse, predict the possible complications as a result of this phase. Since the client starts to diurese at this time, interventions will focus on:
Prompt IV fluid replacement to avoid hypotension
K+ replacement due to new onset diuresis
Monitoring of BP, neuro, cardiac status & electrolytes
Daily weights
Dialysis as ordered
During the diuretic phase, the kidneys recover the ability to excrete wastes but not to concentrate urine
Watch for hypovolemia, hypotension, low Na+, low K+, and dehydration
Urine output increases to 1-3 liters/day & can last from 1-3 weeks before progressing to the Recovery Phase

12. 3. Recovery Phase – follows the Diuretic phase
Glomerular filtration rate increases
BUN and Creatinine decrease. This phase can last 1-2 weeks  12 months
As the nurse, understand that reduction or stopping of IV fluids may be needed for stabilization of blood pressure.
Continue to monitor K+ and for symptoms of imbalance
Monitoring of BP, neuro, cardiac status & electrolytes
Daily weights
Overall outcome for this ARF depends on client overall health, severity of renal disease & the number and types of systematic complications.
Outcome is best if the client never falls into the Oliguric phase to begin

13. REVIEW - Chronic Renal Failure
Chronic RF is a progressive, irreversible destruction of the nephrons of both kidneys
43% diabetic neuropathy
23% HTN
12% glomerunephritis
3% cystic kidney disease
19% “other”
Staged by level of function “glomerular filtration rate” through creatinine clearance
Normal creatinine clearance
Stage 1: increase GFR 90 or above
Stage 2: decreased GFR 60-89
Stage 3: decreased GFR 30-59
Stage 4: decreased GFR 15-29
Stage 5: GFR 45 and needs dialysis
REVIEW - Chronic Renal Failure
Partial or complete impairment of kidney function
Inability to excrete metabolic waste products, and water as well as functional disturbances of all body functions.

14. Classic Presentation of CRF
Every body system is affected due to decrease in body waste filtration – the retained substances, urea, creatinine, hormones, electrolytes, water
UREMIA- is the term used for this build up of toxins
Many client are tolerant to the toxins as it can develop slowly. In time is causes lethargy and fatigue
Oliguria is common and at times may  anuria
A 68 year old CRF client presents with the following results & assessment finding:
Serum K+ of 6.2 mEq
Serum Mg++ of 3.1 mEq/L
2 plus edema bilateral legs
Arterial blood pH of 7.32
Serum BUN of 44 mg/dL
Serum creatinine of 2.6 mg/dL
Explain the lab results
Which result would you address first?
What signs and symptoms are associated with these values?

16. As a Result of CRF Progression
HTN, CHF& pulmonary edema will set in: due to fluid retention
Diarrhea/ constipation, N/V are possible
Anemia is common, as the nurse, why do you think this is and what can be done to help?
Increase for risk of infection
Neurological changes such as seizures, lethargy, coma are common
Yellow-gray skin may occur, as the nurse, what do you think is causing this?
Pale, dry scaly skin may also begin due to anemia and decreased oils
Pruritis – is also common due to dry skin
As a Result of CRF Progression
As with any chronic disease, emotional changes, withdrawal & depression may be expected

17. Treatment & Management of Acute & Chronic
As the nurse, your focus is on the correction of extra cellular fluid overload or deficit in your client
Nutritional therapy
Dietician consult/change TPN
Decreased protein, sodium, potassium, phosphate diet
Dialysis
Fluid restriction
CA++ and phosphorous supplements
Antihypertensive meds
Decrease K+
Kaexelate as indicated & ordered
Electrolyte imbalance assessments
Treatment & Management of Acute & Chronic
Renal US/ scan or CT
BUN, Creatinine, 24 hour creatinine clearance
UA, C&S

18. Hemodialysis Basics
Dialysis is the movement of fluid and molecules across semi a permeable membrane, one compartment to another
Begins when uremia can no longer be adequately managed conservatively (diet, etc.)
With CRF, once dialysis is started, it rarely ends because CRF is progressive & irreversible
With ARF, dialysis can be temporary

19. Hemodialysis & Vessel Access
AV Fistula: Created by joining an artery to a vein
Less complications
4-6 week healing
AV Graft: A man-made tube that connects an artery to a vein
More complications (infection & thrombus)
2-4 week healing
No BPs, IVs, venipuncture in affected limb
If a person “may” be a candidate for dialysis this rule also hold true.
AV Graft
What assessments will the nurse do to determine functionality of HD fistulas & grafts?

20. Temporary or Emergency Access for Dialysis
Right or left Internal jugular, femoral or subclavian veins are used
Inter jugular vein (IJ) is most common due to the lower incidence of thrombus
Highest risk of infection with femoral and subclavian
These are considered “central lines”. As the nurse, consider the precautions and responsibilities of managing a central line catheter.

21. Peritoneal Dialysis Complications include:
Exit site infections, peritonitis, abdominal pain, outflow problems, hernias, lower back problems, bleeding, pulmonary complications

22. Complications of Hemodialysis
Decrease or increased in BP due to volume changes
Muscle cramps (rapid removal of Na+ and water)
Hepatitis: Hepatitis C most common
Sepsis
Disequilibrium syndrome: rapid changes in extracellular fluids, urea, Na+ and solute.
N/V confusion, h/a, twitching, jerking, seizures