RENAL FAILURE

Renal failure or kidney failure (formerly called renal insufficiency) Describes a medical condition in which the kidneys fail to adequately filter toxins and waste products from the blood. Systemic disease

2 FORMS OF RENAL FAILURE A. ACUTE RENAL FAILURE Rapid decline (days to weeks) in the kidneys ability to filter metabolic waste products from the blood reversible B. CHRONIC RENAL FAILURE Slowly progressive decline (months to years) in the kidneys ability to filter metabolic waste from the blood irreversible

1.STAGES
Stage 1. Reduced renal reserve Description Nephron Function 40% to 75% loss

The patient usually does not have symptoms because the remaining nephrons are able o carry out the normal functions of the kidney. 2. Renal insufficiency At this point serum creatinine & blood urea nitrogen rise, the kidney losses its ability to concentrate urine & anemia develops. The patient may report polyuria & oliguria. 3. End stage renal The final stage of chronic renal failure occurs disease when there is less than 10% nephron function remaining. All of the normal regulatory, excretory & hormonal functions of the kidney are severely impaired. Elevated creatinine, BUN, & electrolytes imbalance. Once the patient reaches this point, dialysis is indicated. *GFR is glomerular filtration rate, a measure of the kidney's function

75% to 90% loss

Less than 10% remaining

2. CLASSIFICATION
Stage Description Other terms used GRF (ml/min/1.73 m2) Greater than 90 60-89 30-59

2 3

Kidney damage with normal glomerular filtration rate(GRF) Kidney damage with mild decrease in GFR Moderate decrease in GFR Severe decrease in GFR

At risk

Chronic renal insufficiency(CRI) CRI, Chronic renal failure (CRF) CRF

15-29

Kidney failure

End-stage renal disease (ESRD)

Less than 15

3.RISK FACTORS
family history of heritable renal disease, HPN, DM, autoimmune disease older age alcohol drinking, smoking obesity diet race: African- American past episode of acute renal failure current evidence of kidney damage even with normal or increased GFR

4.CLINICAL MANIFESTATIONS
BODY FLUIDS

-Fixed specific gravity; polyuria and nocturia -Metabolic acidosis -Hyperkalemia -Salt wasting or Sodium retention -Hyperphostanemia -Hypercalcemia and increased levels of Parathyroid hormone HEMATOLOGIC

-Anemia -Bleeding tendencies CARDIOVASCULAR

-Hypertension -Edema -Congestive Heart failure; Pulmonary Edema -Uremic Pericarditis GASTROINTESTINAL

-Anorexia, Nausea, Vomiting -Gastrointestinal bleeding NEUROLOGIC

-Headache

-Signs of uremic encephalopathy, lethargy; decreased alertness, loss of recent memory, delirium, coma, seizures, muscle twitching, OSTEODYSTROPHY

-Muscle weakness -Bone pain and tenderness SKIN

-Pale, Shallow complexion -Pruritus -Uremic frost and odor of urine on skin and breath GENITOURINARY

-Impotence and loss of libido -Amenorrhea and loss of libido

5.MOST COMMON CAUSES

Diabetes Mellitus and High Blood Pressure

Other causes: -Urinary Tract Obstruction -Kidney abnormalities (Polycystic Kidney Disease and Glumerulonephritis) -Autoimmune Disorders (Systemic Lupus Erythematosus)

6. DIAGNOSTIC TESTS
1. Urinalysis: This test evaluates physical characteristics of urine; determine specific gravity & Ph; detects & measures protein, glucose & ketone bodies & examines sediments for blood cells, casts & crystals. The presence of protein in the urine indicates kidney damage. The amount of creatinine and urea excreted in the urine can be used to calculate the level of kidney function and the glomerular filtration rate (GFR). Patient preparation: Explain to the patient that the urinalysis aids in the diagnosis of renal or urinary tract disease and helps evaluate overall body function Inform the patient that she need not restrict food and fluids Procedure & posttest care: Collect a urine specimen of at least 15 ml Obtain a first voided urine specimen if possible Inform the patient that she may resume his usual diet & medications as ordered

2. Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function. As kidney disease progresses, GFR falls. The normal GFR is about 100-140 mL/min in men and 85-115 mL/min in women. It decreases in most people with age. The GFR may be calculated from the amount of waste products in the 24-hour urine or by using special markers administered intravenously. An estimation of the GFR (eGFR) can be calculated from the patient's routine blood tests. 3. Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum creatinine are the most commonly used blood tests to screen for, and monitor renal disease. Creatinine is a product of normal muscle breakdown. BUN test is used to measure the nitrogen fraction of urea, the chief end product of protein metabolism. Formed in the liver from ammonia & excreted by the kidneys. BUN level reflects protein intake but less reliable indicator of uremia than serum creatinine level. The level of these substances rises in the blood as kidney function worsens. Patient preparation for serum creatinine & BUN test: Explain to the patient that the serum creatinine test is used to evaluate kidney function. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture & when. Explain to the patient that he may experienced slight discomfort from the tourniquet & needle puncture Instruct the patient that she need not restrict food & fluids(in BUN test avoid diet high In meat) Notify the laboratory & physician of medications the patient is taking that may affect lab results; they may need to be restricted Procedure & posttest care: Perform a venipuncture & collect the sample in a 3 OR 4 clot-activator tube Apply direct pressure to the venipuncture site until bleeding stops If a hematoma develops at the venipuncture site apply pressure Inform the patient that he may resume her usual medications discontinued before the test, as ordered. 4. Electrolyte levels and acid-base balance: Kidney dysfunction causes imbalances in electrolytes, especially potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a particular concern. The acid-base balance of the blood is usually disrupted as well. Decreased production of the active form of vitamin D can cause low levels of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes its levels in the blood to rise. Testicular or ovarian hormone levels may also be abnormal. 5. Blood cell counts: Because kidney disease disrupts blood cell production and shortens the survival of red cells, the red blood cell count and hemoglobin may be low (anemia). Some patients may also have iron deficiency due to blood loss in their gastrointestinal system. Other nutritional deficiencies may also impair the production of red cells. Patient preparation: Explain to the patient that the RBC count is used to evaluate the # of RBCs & to detect possible blood disorders.

Tell the patient that a blood sample will be taken Explain to the patient that he may experienced slight discomfort from the tourniquet & needle puncture 6. Ultrasound: (renal ultrasonography) Ultrasound is often used in the diagnosis of kidney disease. An ultrasound is a noninvasive type of imaging test. In general, kidneys are shrunken in size in chronic kidney disease, although they may be normal or even large in size in cases caused by adult polycystic kidney disease & diabetic nephropathy. Ultrasound may also be used to diagnose the presence of urinary obstruction, kidney stones and also to assess the blood flow into the kidneys.

Patient preparation: Explain to the patient that renal ultrasonography is used to detect kidney abnormalities Inform the patient that she need not restrict food & fluids Tell the patient who will perform the test, when & where it will take place & that its safe & painless. Procedure & posttest care: The patient is placed in prone position, the area to be scanned is exposed & conductive gel is applied During the test, the patient may be asked to breathe deeply to visualize upper portions of the kidney After the test, remove the conductive gel from the patients skin 7. Renal Biopsy: is performed if you have an unexplained drop in kidney function, persistent blood in the urine, or protein in the urine. The test is sometimes used to evaluate a transplanted kidney. Nursing responsibilities: instruct the client to avoid foods & fluids before the test. Inform the physician if the client has any drug allergies or bleeding problem. Tell your client the possible effects of the test like the amount of pain during & after the procedure depends on the patient. Because a local anesthetic is used, discomfort during the procedure is usually minimal. The anesthetic may burn when first injected. After the procedure, the area may feel tender or sore for a few days.

7.ASSESSMENT AND DIAGNOSTIC FINDINGS

GLOMERULAR FILTRATION RATE SODIUM AND WATER RETENTION ACIDOSIS ANEMIA CALCIUM AND PHOSPHORUS IMBALANCE

8.COMPLICATIONS
Hyperkalemia Pericarditis, Pericardial Effusion, and Pericardial Tamponade Hypertension Anemia

Bone disease and Metastatic Calcifications

9.MEDICAL MANAGEMENT
Reduce Blood Pressure Reduce serum lipids Control Blood Glucose Level Control Phosphorus Intake Complications- can be prevented or delayed by administering prescribed antihypertensive, erythropoietin, iron supplements, phosphate binding agents, and calcium supplements Antacids Antihypertensive and Cardiovascular Agents Antiseizure agent Erythropoietin Dialysis Diuretics DIALYSIS -Is the process of removing waste products and excess fluids from the body. FOR CHRONIC RENAL FAILURE: -It is recommended when tests indicate that the kidneys are not removing metabolic waste product adequately -May be used as long term therapy for chronic kidney failure or as an interim measure before kidney transplantation

2 TYPES OF DIALYSIS HEMODIALYSIS

-Blood is removed from the body and pumped by a machine outside the body into a dialyzer (artificial kidney) -The dialyzer filters metabolic waste product from the blood and then turns the purified blood to the person PERITONEAL DIALYSIS

-Involves repeated cycles of stilling dialysate into the peritoneal cavity, allowing time for substance exchange, and then removing the dialysate.

10.NURSING MANAGEMENT
Check blood pressure regularly Monitor urine studies as well as blood creatinine level, GFR, red blood cell count, levels of electrolytes, glucose, and lipids for changes suggesting increasing renal failure.

Physical assessment findings that suggest progressing renal may include fatigue, peripheral edema, shortness of breath, adventitious lung sounds, heart murmurs or gallops, bruising, memory loss, GI disturbances, impaired wound healing, and increased infections Fluid restriction Smoking cessation Reduce salt and alcohol intake Exercise programs

11.SURGICAL MANAGEMENT (KIDNEY TRANSPLANT)

INDICATIONS

-Renal Transplantation is the surgical implantation of a human kidney from compatible donor in a recipient -Performed as an intervention in stage 5 CKD Nursing Management

Pre operative: -Before kidney transplantation, assess the clients understanding of the procedure and follow-up regimen. -Assess the clients to cope with a complex medication regimen

Post operative: - Give particular attention to fluid balance, and carefully monitor intake and output (every 30 60 min) and weight daily e daily) -Auscultate the kidney regularly to check for bruits, which might indicate stenosis at the site of anastomosis -Monitoring of vital signs -Provide education and counselling to enhance changes in lifestyle that promote health seeking behaviours and compliance with transplant medications

12.PROGNOSIS
Despite the advent of dialysis, most people with advance kidney failure die within 5-10 years