Care Of Patient With Renal Failure

Objectives
y y y y y y

Define acute & chronic renal failures. Identify causes of ARF & CRF. List the signs and symptoms. Describe the management & care. List the complications. Discuss relevant patient / family education.

Acute & Chronic

y Alternative
y Alternative names y Kidney failure -

names y Renal failure acute; Kidney failure; Kidney failure - acute; Renal failure; Arf

chronic; Renal failure - chronic; Chronic renal insufficiency; CRF; Chronic kidney failure

Definition
yDefinition yAcute renal failure is y Definition . y Chronic renal failure is

sudden loss of the ability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes. ("Acute" means sudden, "renal" refers to the kidneys.)

a gradual and progressive loss of the ability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes.

White Nail Syndrome (CRF)

Causes ( ARF )

y Decreased blood flow y Severe acute nephritic syndrome y Acute tubular necrosis (ATN) y Direct injury to the kidney y Myoglobinuria (myoglobin in the

urine)
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Causes ( ARF )

y Urinary tract obstruction y Infections such as acute

pyelonephritis or septicemia y Disorders of the blood y Autoimmune disorders

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Causes (ARF)

y Over-exposure to metals, solvents,

radiographic contrast materials, certain antibiotics, and other medications or substances y In young children, hemolytic uremic syndrome
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Causes (CRF)
y Decreased blood flow is one cause

of kidney damage y Acute tubular necrosis y Direct injury to the kidney y Disorders of the blood

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Causes (CRF)
y Infections y Urinary tract obstruction y Tumors y Kidney stones

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Symptoms (ARF)
y Decreased urine output y Decreased urine volume (oliguria) y No urine output (anuria) y Urination, excessive at night (can occur

in some types of renal failure)

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Symptoms (ARF)
y Generalized swelling, fluid retention y Decrease in sensation, especially

the hands or feet y Slow, sluggish, movements

y Ankle, feet, and leg swelling

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Symptoms (ARF)
y Seizures y Hand tremor y Nausea, vomiting y May persist for days y Morning sickness y Vomiting blood

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Symptoms (ARF)
y Prolonged bleeding, bruising easily y Stools, bloody y Nosebleed y Growth, slow (child 0-5 years)

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Symptoms (ARF)
y Changes in mental status or mood y Agitation y Drowsiness, lethargy y Delirium or confusion y Coma y Fluctuating mood y Difficulty paying attention (attention deficit) y Hallucinations

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Symptoms (ARF)
y Flank pain y Fatigue y Ear noise/buzzing y Breath odor y Breast development in males y Blood pressure, high

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Symptoms (CRF)
Initial symptoms may include the following: y Unintentional weight loss y Nausea, vomiting y General ill feeling y Fatigue y Headache

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Symptoms (CRF)
y Frequent hiccups y Generalized itching (pruritus)

Later symptoms may include the following: y Increased or decreased urine output

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Symptoms (CRF)
y Need to urinate at night y Easy bruising or bleeding; y May have blood in the vomit or in stools y Decreased alertness y Drowsiness, somnolence, lethargy y Confusion, delirium y Coma

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Symptoms (CRF)
y Muscle twitching or cramps y Seizures y Uremic frost -- deposits of white

crystals in and on the skin y Decreased sensation in the hands, feet, or other areas

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Symptoms (CRF)
Additional symptoms that may be associated with this disease: y Excessive nighttime urination y Excessive thirst

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Symptoms (CRF)
y Abnormally dark or light skin y Paleness y Nail abnormalities y Breath odor y High blood pressure y Loss of appetite y Agitation

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Signs (ARF)
Lab values may change suddenly (within a few days to 2 weeks): y Urinalysis may be abnormal. y Serum creatinine may increase by 2 mg/dl or more over a 2-week period. y Creatinine clearance may be decreased.

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Signs (ARF)
y BUN may increase suddenly. y Serum potassium levels may be

increased. y Arterial blood gas and blood chemistries may show metabolic acidosis.

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Signs (ARF)
y Kidney or abdominal ultrasound is

usually the best test, but abdominal xray, abdominal CT scan or abdominal MRI may also reveal the cause of acute renal failure. Kidney size is usually normal or slightly large.

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Signs (ARF)
y Chemical tests of blood and urine

may also help to distinguish the causes. A clean catch urine specimen will indicate if the cause is infection within the urinary tract.

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Signs (ARF)
y Renal angiography (renal

arteriography) may be used to diagnose causes within the blood vessels of the kidney.

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Signs (CRF)
y Blood pressure may be high, with

mild to severe hypertension. A neurologic examination may show polyneuropathy. Abnormal heart or lung sounds may be heard with a stethoscope.

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Signs (CRF)
y A urinalysis may show protein or

other abnormalities. An abnormal urinalysis may occur 6 months to 10 or more years before symptoms appear. y Creatinine levels progressively increase.

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Signs (CRF)
y BUN is progressively increased. y Creatinine clearance progressively

decreases. y Potassium test may show elevated levels. y Arterial blood gas and blood chemistry analysis may show metabolic acidosis.

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Signs (CRF)
y Changes that indicate chronic renal

failure, including both kidneys being smaller than normal, may be seen on: y Renal or abdominal x-ray. y Abdominal CT scan. y Abdominal MRI. y Abdominal ultrasound.

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Signs (CRF)
y This disease may also alter the results

of the following tests: y Urinary casts y Renal scan y Pth y Serum magnesium - test y Erythropoietin

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Care & Management (ARF)

The goal of treatment is to identify and treat any reversible causes of the kidney failure (e.G., Use of kidney-toxic medications, obstructive uropathy, volume depletion).

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Care & Management (ARF)

y Treatment also focuses on

preventing excess accumulation of fluids and wastes, while allowing the kidneys to heal and gradually resume their normal function. Hospitalization is required for treatment and monitoring.

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Care & Management (ARF)

Your fluid intake may be severely restricted to an amount equal to the volume of urine you produce. You may be given specific dietary modifications to reduce build-up of toxins normally handled by the kidneys, including a diet plan high in carbohydrates and low in protein, salt, and potassium.

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Care & Management (ARF)

Antibiotics may be used to treat or prevent infection. Diuretics may be used to remove fluid from the kidney.

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Care & Management (ARF)

y A major priority in treatment is to control

dangerous hyperkalemia (increased blood potassium levels). A variety of different medications may be used, including IV (intravenous) calcium, glucose/insulin, and oral or rectal administration of potassium exchange resin (kayexalate).

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Care & Management (ARF)

y Dialysis may be used to remove excess

waste and fluids. This often makes the person feel better and may make the kidney failure easier to control. Dialysis may not be necessary for all people, but is frequently lifesaving, particularly if serum potassium is dangerously high.

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Care & Management (ARF)

y Common symptoms that require the use

of dialysis include decreased mental status, pericarditis, increased potassium levels, total lack of urine production, fluid overload, and uncontrolled accumulation of nitrogen waste products (serum creatinine > 10 mg/dl and BUN > 120 mg/dl).

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Care & Management (CRF)

y Treatment focuses on controlling

the symptoms, minimizing complications, and slowing the progression of the disease.

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Care & Management (CRF)

y Associated diseases that cause or result

from chronic renal failure must be controlled. Hypertension, congestive heart failure, urinary tract infections, kidney stones, obstructions of the urinary tract, glomerulonephritis, and other disorders should be treated as appropriate.

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Care & Management (CRF)

y Blood transfusions or medications such as iron

and erythropoietin supplements may be needed to control anemia. Fluid intake may be restricted, often to an amount equal to the volume of urine produced. Dialysis or kidney transplant may be required eventually.

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Care & Management (CRF)

y Dietary protein restriction may slow

the build-up of wastes in the bloodstream and control associated symptoms such as nausea and vomiting. Salt, potassium, phosphorus, and other electrolytes may be restricted.

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Complications (ARF)
increased risk of infections y gastrointestinal loss of blood y chronic renal failure y End-stage renal disease y Damage to the heart or nervous system y Hypertension
y

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Complications (CRF)
y End-stage renal disease y Pericarditis y Cardiac tamponade y Congestive heart failure

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Complications (CRF)
y Hypertension y Platelet dysfunction y Decreased immune response

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Complications (CRF)
y Loss of blood from the gastrointestinal tract y Ulcers y Hemorrhage y Anemia y Hepatitis B, hepatitis C, liver failure y Decreased functioning of white blood cells

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Complications (CRF)
y Increased incidence of infection y Peripheral neuropathy y Seizures y Encephalopathy, nerve damage,

dementia y Weakening of the bones y Fractures

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Complications (CRF)
y Joint disorders y Changes in glucose metabolism y Electrolyte abnormalities including hyperkalemia y Decreased libido, impotence y Miscarriage, menstrual irregularities, infertility y Skin dryness, itching/scratching with resultant

skin infection

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Patient / Family Education

y Call your health care provider if decreased urine

output or other symptoms indicate the possibility of acute renal failure. y Call your health care provider if nausea or vomiting persists for more than 2 weeks. y Call your health care provider if decreased urine output or other symptoms of chronic renal failure occur.
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Any Question ?

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