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Renal Failure

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Acute Renal Failure (ARF)

is a rapid loss of renal function

due to damage to the kidneys

Can lead to potentially fatal conditions

Including metabolic acidosis; fluid and

electrolyte imbalances

Can be seen in both outpatient andinpatient clients

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ARF

A widely accepted criterion:

!" or greater increase in serum creatinineabo#e baseline

(normal is less than $ mg%dl)

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&atients may ha#e normal or abnormal

urine output

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&athophysiology

&athogenesis is not always known

'ome cases may be re#ersible:

$hypo#olemia

hypotension

*reduced cardiac output and heart failure

+obstruction of the kidney or lower urinary tract

by tumor, blood clot, or kidney stone

bilateral obstruction of the renal arteries or

#eins

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&athophysiology

If treated and corrected before the kidneys are

permanently damaged, the increased -./and creatinine le#els, oliguria, and other signs

may be re#ersed

Renal stones are not common causes of ARF

but some types may increase its risk

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Categories

&rerenal (hypoperfusion of kidney)

Intrarenal (actual damage to kidneytissue)

&ostrenal (obstruction to urine flow)

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&rerenal ARF

0ccurs in 1!" to 2!" of cases

the result of impaired blood flow3

3that leads to hypoperfusion of the

kidney and a decrease in the 4FR

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Intrarenal ARF

the result of actual parenchymal damage tothe glomeruli or kidney tubules

Acute tubular necrosis (A5/) is the mostcommon type of intrinsic ARF

Characteristics of A5/ are:

intratubular obstructiontubular back leak

6asoconstriction

changes in glomerular permeability

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Those processes result in:

a decrease of 4FR

progressi#e a7otemia

and fluid and electrolyte imbalances

C89, 9, F, 5/, and cirrhosis can lead to

A5/

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&ostrenal ARF

.sually result from obstruction

5he pressure rises in the kidney tubulesand e#entually decreasing 4FR

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Causes of &rerenal ARF

VOLUME DEPLETO! resulting from:emorrhage

Renal losses (diuretics, osmotic diuresis)4astrointestinal losses (#omiting, diarrhea, nasogastricsuction)

MP"#ED $"#D"$ E%%$E!$& resulting from:yocardial infarctioneart failure9ysrhythmiasCardiogenic shock

V"'ODL"TO!resulting from:'epsisAnaphyla

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Causes of Intrarenal ARF

P#OLO!(ED #E!"L '$)EM" resulting from:&igment nephropathy (associated with the breakdown

of blood cells containing pigments that inturn occlude kidney structures)yoglobinuria (trauma, crush in=uries, burns)emoglobinuria (transfusion reaction, hemolytic anemia)

!EP)#OTO*$ "(E!T' such as:Aminoglycoside antibiotics (gentamicin, tobramycin)Radiopa>ue contrast agentsea#y metals (lead, mercury)'ol#ents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)

/onsteroidal anti?inflammatory drugs (/'AI9s)Angiotensin?con#erting en7yme inhibitors (AC@ inhibitors)

!%E$TOU' P#O$E''E' such as:Acute pyelonephritis

Acute glomerulonephritis

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&ostrenal ARF

U#!"#& T#"$T O+'T#U$TO!,

including:

Calculi (stones)

5umors

-enign prostatic hyperplasia

'trictures

-lood clots

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9ecreased 4FR

0bstruction4lomerular

inflammation9amage to

nephrons

9ecreased

renal

perfusion

ARF

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9@CR@A'@9

4FR

9ecreased

fluid e

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ypo

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&hases

$ Initiation period

0liguric period

* 9iuresis period+ Reco#ery period

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$ Initiation period

begins with the initial insult

and ends when oliguria de#elops

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0liguria &eriod

,-- ml. The minimum amount of urineneeded to rid the body of normal metabolicwaste products

In this phase uremic symptoms first appear andlife?threatening conditions such as hyperkalemiade#elop

/onoliguric form has enough urine output nutdecreased renal function(nephroto

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9iuresis phase

marked by a gradual increase in urine output/

which signals that glomerular filtration has started toreco#er

aboratory #alues stabili7e and e#entuallydecrease

Renal function may still be markedly abnormal

.remic symptoms may still be present

BA5C 0.5 F0R 9@9RA5I0/DDD(may increase uremic symptoms)

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reco#ery period

'ignals the impro#ement of renal function

may take * to $ months

aboratory #alues return to the patientEs normal

le#el

Although a permanent $" to *" reduction in

the 4FR is common, it is not clinically

significant

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Clinical anifestations

6ariesay include '%'< since many organs may be affected

Altered urine output

@dema or dry skin

&atient may apear critically ill and lethargic

C/' '%'< include:

9rowsinessheadache,

muscle twitching

sei7ures

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Assessment and 9iagnostic Findings

-./, Creatinine, /4A (blood and urine)

.rinalysis (hematuria, low spec gra#ity)

Inability t concentrate urine (one of earliestsigns)

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Assessment and 9iagnostic Findings

If w% prerenal a7otemia: decreased amount of

/a in the urine (less than ! m@>%) normal

urinary sediment

intrarenal a7otemia: usually ha#e urinary

sodium le#els greater than +! m@>% with

urinary casts and other cellular debris

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.ltrasound

C5 scan

RI

Creatinine clearance

'erum electrolytesC-C

A-4

@C4

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&re#enting Acute Renal Failure

$ &ro#ide ade>uate hydration to patients at riskfor dehydration including:

.-efore, during, and after surgery

.&atients undergoing intensi#e diagnosticstudies

re>uiring fluid restriction and contrast agents

.&atients with neoplastic disorders or disordersof metabolism (eg, gout) and those recei#ingchemotherapy

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&re#ent and treat shock promptly

(blood and fluid replacements)

* onitor central #enous and arterial

pressures and hourly urine output ofcritically ill patients

(to detect A'A&)

+ 5reat hypotension promptly

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Continually assess renal function

(urine output, laboratory #alues)

1 @nsure proper blood transfusion

2 &re#ent and treat infections promptly(Infections can produce progressi#e renal

damage)

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&ay special attention to wounds, burns, and

other precursors of sepsis%infection

G 5o pre#ent infections from ascending in the

urinary tract

gi#e meticulous catheter careRemo#e catheters as soon as possible

$! &re#ent to

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A#oid prolonged use of /'AI9Es

may cause interstitial nephritis

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Radiocontrast?induced nephropathy (CI/) is a

ma=or cause of hospital?ac>uired ARF:

Limit e0posure

4i#ing !1acetylcysteine 2%luimucil3 andsodium bicarbonate 2!a)$O43 before and

during procedures reduces ris5

but prehydration with saline (/'') is

considered the most effecti6e method to

pre6ent $!

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4erontologic care

0lder people are more #ulnerable to to

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edical anagement

5reat underlying cause

anage symptoms

&re#ent complications

aintain fluid balance

&rerenal a7otemia: increase perfusion

Intrarenal a7otemia: supporti#e therapy

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edical anagement

9iureticsannitol (0smitrol)Furosemide (asi

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edical anagement

&eritoneal 9ialysis &9

emodialysis 9

Continuous Renal Replacement 5herapy

CRR5

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For e

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/ursing Careonitor o#erall status

onitor electrolytes

Reduca metabolic rate-ed rest

5reat fe#er and infection

&ulmonary function

&re#ent infection

&ro#iding skin care

&sychosocial support