RENAL FAILURE

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RENAL FAILURE
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TOPICS TO BE COVERED

• ? How the kidney works
• ? Acute Renal Failure
• ? Chronic Renal Failure

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The nephron
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Blood flow in and around the nephron
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Tubular Function

• Filtration
• Reabsorption
• Tubular Secretion

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Diagnostic Tests

• Urinalysis
• Creatinine Clearance
• Serum BUN
• Serum Creatinine
• BUN Ratio

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Acute Renal Failure
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Acute Renal Failure

• Rapid decline in renal function with an
  accumulation of BUN and Creatinine.
• Uremia
• There is no correlation between the volume of
  urine output and the severity of renal failure.
• 30-60 Mortality Rate

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Causes of Acute Renal Failure(See Table 44-1 in
text)

• Pre-renal Causes (70)
• Intra-renal Causes (25)
• Post-renal Causes (5)
• The two major causes of ARF is renal ischemia
  and nephrotoxic injury - these are often referred
  to as Acute Tubular Necrosis.

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Acute Tubular Necrosis

• Damage to the basement membrane of the tubule
  from ischemia
• Damage to the epithelium from nephrotoxic agents

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Clinical Course Oliguric Phase

• Decreased GFR causing oliguria or anuria
• fluid volume excess
• Metabolic acidosis
• Electrolyte Imbalances
• sodium balance
• potassium excess
• calcium deficit
• Elevated BUN and Creatinine

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Clinical Course Diuretic Phase

• Begins with gradual increase in OU may last 1-3
  weeks
• 1-3 liters/day--up to 3-5 L/day
• kidneys have recovered ability to excrete waste
  but not to concentrate urine
• uremia may still be severe
• monitor for hyponatremia, hypokalemia, dehydration

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Clinical Course Recovery Phase

• Begins when GFR increase so that BUN and
  Creatinine stabilize, then decrease
• renal function can improve over 12 months
• outcome of ARF is influenced by patients overall
  health
• mortality varies from 30-60 most common cause
  of death is infection
• some progress to CRF

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Diagnosis of ARF

• History is most important to determine prerenal,
  intrarenal or postrenal cause
• Urinalysis
• If unable to determine cause, then further
  testing may be done

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Nursing Collaborative Care

• PC Fluid Balance
• PC Electrolyte Imbalance
• potassium huge concern
• PC Metabolic Acidosis
• Risk for Infection
• Altered Nutrition
• Altered Thought Process
• Altered Skin Integrity

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PC Fluid Imbalance

• Oliguric phase
• diuretic therapy to prevent fluid overload
• intake must be monitored
• Dialysis may be necessary
• Diuretic Phase
• Need to maintain adequate fluids - prevent fluid
  volume deficit

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PC Hyperkalemia

• Insulin IV
• Calcium gluconate
• Dialysis
• Kayexalate
• Dietary restrictions
• ? ??? PC Arrythmias

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PC Metabolic Acidosis

• Sodium Bicarbonate
• Dialysis

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Risk for Infection

• Infection leading cause of death in acute renal
  failure
• Meticulous aseptic technique is critical!

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Altered Nutrition

• Main goal is to prevent catabolism
• Protein restriction
• potassium restriction
• sodium restriction
• increase fat intake

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Altered Thought Process

• Uremic toxins can affect central nervous system
• May also be at risk for injury

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Altered Skin Integrity

• Edema to the skin makes patient at risk for
  pressure ulcers
• Stomatitis may result from increased ammonia
  levels

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AUCTE RENAL FAILURE

• Outcome of ARF is influenced by
• patients overall health
• Renal function can improve over 12 months
• Mortality varies from 30-60 most common cause
  of death is infection
• Some ARF patients will progress to CRF, dialysis
  and/or transplantation