Renal FailureRenal Failure

Sanjay Kumar KulchaniaSanjay Kumar Kulchania (LECTURER)(LECTURER)

GURU NANAK COLLEGE OF GURU NANAK COLLEGE OF NURSING, DHAHAN KALERANNURSING, DHAHAN KALERAN

ObjectivesObjectivesAnatomyAnatomyFunctionFunctionAcute Renal Failure (ARF)Acute Renal Failure (ARF)– CausesCauses– SymptomsSymptoms– ManagementManagement

Chronic Renal Failure (CRF)Chronic Renal Failure (CRF)– CausesCauses– SymptomsSymptoms

DialysisDialysis

AnatomyAnatomy2 Kidneys2 Kidneys

2 Ureters2 Ureters

BladderBladder

UrethraUrethra

Kidney FunctionKidney FunctionDetoxify bloodDetoxify bloodIncrease calcium absorptionIncrease calcium absorption– calcitriolcalcitriol

Stimulate RBC productionStimulate RBC production– erythropoietinerythropoietin

Regulate blood pressure and Regulate blood pressure and electrolyte balance electrolyte balance – reninrenin

ClassificationsClassifications

Acute versus chronicAcute versus chronic

Pre-renal, renal, post-renalPre-renal, renal, post-renal

Anuric, oliguric, polyuricAnuric, oliguric, polyuric

Acute Versus ChronicAcute Versus ChronicAcute Acute – sudden onsetsudden onset– rapid reduction in urine outputrapid reduction in urine output– Usually reversibleUsually reversible– Tubular cell death and regenerationTubular cell death and regeneration

Chronic Chronic – ProgressiveProgressive– Not reversibleNot reversible– Nephron lossNephron loss

75% of function can be lost before its 75% of function can be lost before its noticeablenoticeable

Acute Renal FailureAcute Renal Failure

Pre-renal = 55%Pre-renal = 55%

Renal parenchymal (intrinsic)= 40%Renal parenchymal (intrinsic)= 40%

Post-renal = 5-15%Post-renal = 5-15%

Causes of ARFCauses of ARF

Pre-renal =Pre-renal =– vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and

heart failure heart failure – cardiac failure, liver dysfunction, or septic shock cardiac failure, liver dysfunction, or septic shock

Intrinsic Intrinsic – Interstitial nephritis, acute glomerulonephritis, tubular necrosis, Interstitial nephritis, acute glomerulonephritis, tubular necrosis,

ischemia, toxinsischemia, toxins

Post-renal =Post-renal =– prostatic hypertrophy, cancer of the prostate or cervix, or prostatic hypertrophy, cancer of the prostate or cervix, or

retroperitoneal disorders retroperitoneal disorders – neurogenic bladder neurogenic bladder – bilateral renal calculi, papillary necrosis, coagulated blood, bilateral renal calculi, papillary necrosis, coagulated blood,

bladder carcinoma, and fungus bladder carcinoma, and fungus

Symptoms of ARFSymptoms of ARFDecrease urine output (70%)Decrease urine output (70%)Edema, esp. lower extremityEdema, esp. lower extremityMental changesMental changesHeart failureHeart failureNausea, vomitingNausea, vomitingPruritusPruritusAnemiaAnemiaTachypenicTachypenicCool, pale, moist skinCool, pale, moist skin

Diagnosis of Renal FailureDiagnosis of Renal Failure

Acute Renal Failure Acute Renal Failure ManagementManagement

Make/think about the diagnosisMake/think about the diagnosisTreat life threatening conditionsTreat life threatening conditionsIdentify the cause if possibleIdentify the cause if possible– HypovolemiaHypovolemia– Toxic agents (drugs, myoglobin)Toxic agents (drugs, myoglobin)– ObstructionObstruction

Treat reversible elementsTreat reversible elements– HydrateHydrate– Remove drugRemove drug– Relieve obstructionRelieve obstruction

ARF: Life Threatening ARF: Life Threatening ConditionsConditions

HyperkalemiaHyperkalemia

Volume overloadVolume overload

Vascular accessVascular access

Hyperkalemia SymptomsHyperkalemia SymptomsWeaknessWeakness

LethargyLethargy

Muscle crampsMuscle cramps

ParesthesiasParesthesias

Hypoactive DTRsHypoactive DTRs

DysrhythmiasDysrhythmias

Hyperkalemia & EKGHyperkalemia & EKGK > 5.5 -6K > 5.5 -6

Tall, peaked T’sTall, peaked T’s

Wide QRSWide QRS

Prolong PRProlong PR

Diminished PDiminished P

Prolonged QTProlonged QT

QRS-T merge – sine QRS-T merge – sine wavewave

Hyperkalemia TreatmentHyperkalemia Treatment

Calcium gluconate (carbonate)Calcium gluconate (carbonate)

Sodium BicarbonateSodium Bicarbonate

Insulin/glucoseInsulin/glucose

KayexalateKayexalate

Lasix Lasix

AlbuterolAlbuterol

HemodialysisHemodialysis

Chronic Renal FailureChronic Renal Failure

150–200 cases per million people = 150–200 cases per million people = new cases each yearnew cases each year

Chronic renal failure and ESRD affect Chronic renal failure and ESRD affect more than 2 out of 1,000 people in more than 2 out of 1,000 people in the U.Sthe U.S

Mortality = 20%Mortality = 20%

Chronic Renal Failure CausesChronic Renal Failure Causes

Diabetic NephropathyDiabetic Nephropathy

HypertensionHypertension

GlomerulonephritisGlomerulonephritis

HIV nephropathyHIV nephropathy

Reflux nephropathy in childrenReflux nephropathy in children

Polycystic kidney diseasePolycystic kidney disease

Kidney infections & obstructionsKidney infections & obstructions

CRF SymptomsCRF SymptomsMalaiseMalaise

WeaknessWeakness

FatigueFatigue

NeuropathyNeuropathy

CHFCHF

AnorexiaAnorexia

NauseaNausea

VomitingVomiting

SeizureSeizureConstipationConstipationPeptic ulcerationPeptic ulcerationDiverticulosisDiverticulosisAnemiaAnemiaPruritusPruritusJaundiceJaundiceAbnormal Abnormal hemostasishemostasis

Acute Problems in CRFAcute Problems in CRF

Relating to underlying diseaseRelating to underlying disease

Relating to ESRDRelating to ESRD

Dialysis related problemsDialysis related problems

Problems Related to ESRDProblems Related to ESRD

Metabolic – K/CaMetabolic – K/Ca

Volume overloadVolume overload

Anemia, platelet disorder, GI bleedAnemia, platelet disorder, GI bleed

HTN, pericarditisHTN, pericarditis

Peripheral neuropathy, dialysis Peripheral neuropathy, dialysis dementiadementia

Abnormal immune functionAbnormal immune function

DialysisDialysis½ of patients with CRF eventually ½ of patients with CRF eventually require dialysisrequire dialysisDiffuse harmful waste out of bodyDiffuse harmful waste out of bodyControl BPControl BPKeep safe level of chemicals in bodyKeep safe level of chemicals in body2 types 2 types – HemodialysisHemodialysis– Peritoneal dialysis Peritoneal dialysis

HemodialysisHemodialysis

3-4 times a week3-4 times a week

Takes 2-4 hours Takes 2-4 hours

Machine filters Machine filters

blood andblood and

returns it toreturns it to

bodybody

Types of AccessTypes of AccessTemporary siteTemporary site

AV fistulaAV fistula– Surgeon constructs by combining an artery and Surgeon constructs by combining an artery and

a veina vein– 3 to 6 months to mature3 to 6 months to mature

AV graftAV graft– Man-made tube inserted by a surgeon to Man-made tube inserted by a surgeon to

connect artery and veinconnect artery and vein– 2 to 6 weeks to mature2 to 6 weeks to mature

Temporary CatheterTemporary Catheter

AV Fistula & GraftAV Fistula & Graft

What This Means For YouWhat This Means For You

No BP on same arm as fistulaNo BP on same arm as fistula

Protect arm from injuryProtect arm from injury

Control obvious hemorrhageControl obvious hemorrhage– Bleeding will be arterialBleeding will be arterial– Maintain direct pressureMaintain direct pressure

No IV on same arm as fistulaNo IV on same arm as fistula

A thrill will be felt – this is normalA thrill will be felt – this is normal

Access ProblemsAccess ProblemsAV graft thrombosis AV graft thrombosis AV fistula or graft bleedingAV fistula or graft bleedingAV graft infectionAV graft infectionSteal PhenomenonSteal Phenomenon– Early post-opEarly post-op– Ischemic distallyIschemic distally– Apply small amount of pressure to Apply small amount of pressure to

reverse symptomsreverse symptoms

Peritoneal DialysisPeritoneal Dialysis

Abdominal lining filters bloodAbdominal lining filters blood

3 types3 types– Continuous ambulatoryContinuous ambulatory– Continuous cyclicalContinuous cyclical– Intermittent Intermittent

EMS ConsiderationsEMS ConsiderationsMake sure the dressing remains Make sure the dressing remains intactintactDo not push or pull on the catheterDo not push or pull on the catheterDo not disconnect any of the Do not disconnect any of the catheterscathetersAlways transport the patient and Always transport the patient and bags/catheters as one piecebags/catheters as one pieceNever inject anything into catheterNever inject anything into catheter

Dialysis Related ProblemsDialysis Related ProblemsLightheaded –give fluidsLightheaded –give fluidsHypotensionHypotensionDysrhythmiasDysrhythmiasDisequilibration SyndromeDisequilibration Syndrome– At end of early sessionsAt end of early sessions– Confusion, tremor, seizureConfusion, tremor, seizure– Due to decrease concentration of blood Due to decrease concentration of blood

versus brain leading to cerebral edemaversus brain leading to cerebral edema