ACUTE RENAL FAILURE

&
CHRONIC RENAL FAILURE

SURENDRA SHARMA
Assist. Professor
Amity College of Nursing
Amity university, Gurgoan
 ACUTE RENAL FAILURE

&
CHRONIC RENAL FAILURE
Definition

Acute renal failure is a severe deterioration of renal

function, manifested as sudden reduction of urine
excoriation (less than 1ml/kg/hr.)

Etiology

The causes of acute renal failure can be divided into

three groups, prerenal, intrarenal and postrenal
causes.
 A c u te R e n a l F a ilu re

P re re n a l R enal P o s tre n a l
d e c r e a s e d r e n a l p e rfu s io n in tr in s ic re n a l d is e a s e o b s tru c tio n
8 0 % o f ca ses 1 0 % o f ca ses 10%
Prerenal causes

These s conditions are related to the problem occur

in blood supply to the kidney either due to systemic
hypovolemia or due to renal hypoperfusion. The
important causes are hypovolemia due to diarrheal
dehydration, shock, burns, diabetic acidosis, trauma
hemorrhage, etc and CCF.
Intrarenal causes

Theses internsis renal; conditions are related to

problems within the kidneys and their functions,
causing reduction of GFR, renal ischemia and
tubular damage.

The important causes are:-

1. Glomerulonephritis.
2. Hemolytic uremic syndrome (HUS).
3. Renal vein thrombosis.
4. Acute tubular necrosis, (due to fluid loss,
hemorrhage, shock).
5. Sepsis.
Postrenal causes

These conditions are related to the problems of the

upper or lower urinary system causing obstructions
of urine flow due to obstructive uropathies. The
causes include renal calculus, PUV, bladder-neck
obstruction congenital lesion or pus collection in
urinary tract or following drug therapy
( sulfonamide).
Phases of ARF

Four phases of ARF are identified in children

depending upon the course of illness.

Initiating phase

This phase lasts from hours to days with features

of renal function impairment.
Oliguric phase

This phases lasts from 5 to 15 days but can be

prolonged for weeks. It is shorter in infants and
children (3-5 days) and longer in older children
(10-14 days). More than 3 weeks duration of
oligouric phase indicates irreversible renal damage. It
depends upon severity and duration of initial stage
causing acute Vaso -spastic nephropathy.
Diuretic phase

This phase lasts for few days and highly variable

with mild to severe clinical features.

Recovery phases

This phase marks the final resumption of normal

urine osmolarity, constituents and biochemical
alteration in the blood.
 PATHOPHYSIOLOGY

Reduction of glomerular filtration rate and renal blood flow

due to renal vasoconstriction

Sodium and fluid retention which leads to edema.

Hypertension may develop due to rennin angiotension mechanism

Arteriolar constriction

Increased circulatory overload and sodium retention.

Acute renal failure

Clinical manifestation

Severe Oliguria or anuria.

Nausea, vomiting
Lethargy
Dehydration
Acidotic breathing
Alteration of level consciousness
Irregularities in cardiac rate and rhythm
Edema
DIAGNOSTIC EVALUATION

Blood examination

Shows raised serum creatinine level

Complete blood count
Blood urea
Electrolysis
pH , bi - Carbonate
Urine examination

proteinuria,
haematuria
presence of casts

Ultrasonography helps to detect the structural

abnormalities, calculi, etc.,

Radio-nucleotide studies can be done to evaluate

GFR and renal blood flow distribution
Management

Correction of dehydration
Treatment of shock and hyper kalemia
Fluid and electrolyte balance to be maintained
promptly.
Diet should be planed with low sodium, low
potassium, low phosphate and moderate protein
(0.6 to 1gm/kg).
The recommended calorie requirement is 50 to
60 cal/kg.
Liberal amount of carbohydrates and fats can be
given along with vitamin and mineral supplementation.
 Use of diuretics like mannitol and frusemide is
recommended by same authority.
 Steroid can also be used
 Dialysis ( peritoneal or hemodialysis is indicated in
life threatening complications
a) Persistent hyper kalemia, serum potassium
more than seven ml/eq/ lt.
b) CCF
c) Pulmonary edema
d) Neurological problem
e) Hyper phosapatemia
Complication

Fluid electrolyte imbalance

Hyper kalemia
Metabolic acidosis
Convulsion
Hyponatremia
 CHRONIC RENAL FAILURE (CRF)

Definition

Chronic renal failure is a permanent irreversible

destruction of nephron leading to severe
deterioration of renal function , finally resulting to
end stage renal disease (ESRD)
ETIOLOGY

Glomerular diseases- glomerulonephritis, SLE,

HUS, familial nephropathy, Henoch-Schonlein
purpura, amyloidosis.

Congenital anomalies- Bilateral renal hypoplasia

or dysplasia, polycystic kidney.

Obstructive uropathy- PUJ, renal stones, PUV.

Miscellaneous- Bilateral Wilm’s tumor,

renal vein thrombosis, renal cortical necrosis, renal
tuberculosis, reflux nephropathy.
 PATHOPHYSIOLOGY

Reduction in the renal functions.

Metabolic, endocrinal and hematological disturbances.

Damage of nephron results in hypertrophy and hyper

phosphatemia of remaining nephron.

Reduced functions of nephrons to excrete effectively

thus resulting azotemia and clinical uremia.

Impaired renal function.

Fluid overload leads to edema and hypertension.

Chronic renal failure

Clinical manifestations

Initial polyuria or frequent passage of urine

Oliguria or anuria
Increased thirst
Decreased appetite, weakness
Low energy level
Bone pain or joint pain
Dryness and itching of skin
Hypertension and growth retardation
In late stage

Acidotic breathing
Nausea / vomiting
Diarrhea
Peripheral; neuropathy
Convulsions
DIAGNOSTIC EVALUATION

Blood examination
Decreased level of hematocrit, Hb%, Na+, Ca++, HCO-,
Increased level of K + and phosphorus.
Renal function test shows gradual increase of BUN, uric
acid and creatinine values.
Urinalysis
Variation in specific gravity increased creatinine level
in urine and change in total amount of urine output.
Chest X-ray to detect bony involvement.
ECG, IVP, MCU, Radionuclide imaging helps to detect
the extent of complications.
Management

At the initial stage, the management of CRF is

planed to retard the progression of the diseases by
rest, diet, supportive care and symptomatic relief.

Later, the treatment of complication, dialysis and

renal transplantation to be provided as per need.

Diet should be planed with special attention on

maintenance of calorie as per normal requirements.

Diet should contain high polyunsaturated fat and

complex carbohydrates.
Protein intake should be adequate
( 0.8 -1 gm/kg/day) with food items high
biologic value ( egg, milk, meat, fish) .

Sodium intake needs to be allowed depending upon

the level of impairment of sodium reabsorption,
presence of edema, hypertension and azotemia.

Potassium balance to be maintain by avoiding

potassium contain food.

Dairy milk containing high phosphate need to be

avoided. But calcium supplementation is required.
Vitamin B1, B2, folic acid, B6 and B12
supplementation to be given. Water restriction is
usually not essential except in ESRD and fluid
overload.

Correction of acidosis to be done with sodium-bi-

carbonate.

Hypertension to be managed with antihypertensive

drugs. Infection with least toxic antibiotics.

Antihistamines is given to relief from pruritus.

Correction of acidosis to be done with sodium –bi-
carbonate.

Hypertension to be managed with antihypertensive

drugs.

Infection should be managed with least toxic

antibiotics.

Antihistamines is given to relief from pruritus.

Correction of anemia can be done with iron-folic
acid supplementation. Blood transfusion can be done.

Correction of calcium and phosphorus imbalance is

essential.

Growth hormone may be needed to correct growth

retardation.

Dialysis (peritoneal or hemodialysis) and renal

transplantation are indicated in CRF.
Nursing management

Through assessment of all systems are essential to

detect the problems and planning of care.

Special care to provide in relation to renal

transplant, and dialysis. Routine care should emphasize
on maintenance of fluid - electrolyte balance, skin
integrity, nutritious diet, ensuring safety from
infections and injury, assisting to cope with long-term
illness and teaching for continuation of care.
Complication

Azotemia
Metabolic acidosis
Electrolyte imbalance
CCF
Hypertension
Growth retardation
Delayed or absent sexual maturation
Nursing diagnoses

Risk of fluid electrolyte imbalance relates to

impaired renal functions
Risk for infection related to alteration of host
defense
Actively intolerance related to acute illness
Altered thought process related to CNS problem
Altered nutrition less than body requirement
related to GI disturbance
Fear and anxiety related to life threatening illness
Knowledge defecated related to management of
ARF
 INTERVENTION

Risk of fluid electrolyte imbalance relates to

impaired renal functions

Intervention

Weigh the child daily and monitor urine output

every four hours.
Assess the child for edema measure abdominal
girth every eight hours.
Monitor and record the child’s fluid intake.
Assess the color consistency and specific
gravity of the child’s urine.
Risk for infection related to alteration of host
defense

Intervention

Keep the catheter drainage bag below the child’s

balder level, making sure the tubing is free from
kinks loops.
Use aseptic technique when emptying the catheter
bag.
Engorge the child to drink at least 60 ml fluid per
hour.
Administer antibiotics.
Actively intolerance related to acute illness

Intervention

Provide quit environment.

Provide proper nursing care.
Provide comfort slip.
Provide rest periods to follow each activity.
Altered nutrition less than body requirement
related to GI disturbance

Intervention

Assess the nutrition status of the child.

Provide high carbohydrate diet.
Small and frequent meals.
Restrict sodium and protein intake.
Fear and anxiety related to life threatening illness

Intervention

Listen to pares concerns.

Explain all procedure to the parents.
Discussion about Childs care.
Provide psychological support to the parents.
Knowledge defecated related to management of ARF

Intervention

Explain to the parents about the diseases.

Reassure the parents about long term effects.
Explain to the parents about sodium restricted diet.
Instruct the parents to limit the chills activity.