1. Chapter 34 Acute Renal Failure and Chronic Kidney Disease

2. 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 nonrenal origin

3. Types of Renal Failure Acute renal failure Abrupt in onset
Often reversible if recognized early and treated appropriately
Chronic kidney disease
End result of irreparable damage to the kidneys
Develops slowly, usually over the course of a number of years

4. 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

5. Postrenal Causes of Acute Renal Failure
Bilateral ureteral obstruction
Bladder outlet obstruction

6. 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

7. Phases of Acute Tubular Necrosis
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

8. Question
Congestive heart failure would be a(n) ________________ cause of renal failure.
Prerenal
Intrarenal
Postrenal

9. Answer Prerenal: The causative factor is “before” the kidney.
Intrarenal
Postrenal

10. 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)

11. Common Causes of Chronic Kidney 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. Definition and Classification
K/DOQI of the NKF published clinical practice guidelines for CKD.
Guidelines use the GFR to classify CKD into five stages

13. Stages of Chronic Kidney Disease
Damage with normal or increased GFR
Mild reduction of GFR to 60–89 mL/min/1.73 m2
Moderate reduction of GFR to 30–59 mL/min/1.73 m2
Severe reduction in GFR to 15–29 mL/min/1.73 m2
Kidney failure with a GFR < 15 mL/min/1.73 m2 , with a need for renal replacement therapy

14. 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

15. Target Populations Comprising Persons With Chronic Kidney Disease
Persons with chronic renal insufficiency
Persons with CKD being treated with hemodialysis
Persons with CKD being treated with peritoneal dialysis
Renal transplant recipients

16. Question A GFR of _____________ best describes renal failure.
60–89 mL/min/1.73 m2
30–59 mL/min/1.73 m2
15–29 mL/min/1.73 m2
<15 mL/min/1.73 m2

17. Answer 60–89 mL/min/1.73 m2 30–59 mL/min/1.73 m2 15–29 mL/min/1.73 m2
<15 mL/min/1.73 m2 : This level is the result of significantly decreased renal filtration and is the cut-off point of renal failure.

18. Factors Determining the Manifestations of Renal Failure
The extent of renal function present
Coexisting disease conditions
The type of renal replacement therapy the person is receiving

19. 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

20. 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 by regenerating bicarbonate.

21. Hematologic Disorders Accompanying Renal Failure
Anemia
Coagulopathies

22. Cardiovascular Disorders Accompanying Renal Failure
Hypertension
Heart disease
Pericarditis

23. 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
Result of less protein-bound drugs
Increased intermediates of drug metabolism
Alterations in dosage may be required.

24. Treatment of Renal Failure
Medical management
Dialysis
Hemodialysis
Peritoneal dialysis
Transplantation

25. Treatment of Renal Failure (cont.)
Dietary management
Protein
Carbohydrates, fat, calories
Potassium
Sodium and fluid intake

26. 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

27. CKD in the Elderly Normal decrease in GFR with age
Increased detrimental effects of nephrotoxic drugs
Greater incidence of cerebrovascular, cardiovascular, and skeletal system effects

28. Treatment Options for Chronic Renal Failure in the Elderly and Children
Hemodialysis
Peritoneal dialysis
Transplantation

29. Question
Which of the following alterations may affect drug efficacy in a patient with CKD?
Loss of K+
Alteration in pH
Loss of albumin
Increased Ca2+

30. Answer Loss of K+ Alteration in pH
Loss of albumin: Loss of albumin will result in altered drug metabolism via increased intermediates and faster action.
Increased Ca2+