ACUTE AND CHRONIC

RENAL FAILURE
Chindy Siffri P. Situmorang

Anatomy

2 Kidneys
2 Ureters
Bladder
Urethra

What do
the kidneys do??

Kidney Function
Detoxify blood
Increase calcium absorption
calcitriol

Stimulate RBC production

erythropoietin

Regulate blood pressure and

electrolyte balance
renin

Acute Renal Failure

is rapid loss of renal function due to
damage to the kidney.
In ARF, the kidney cant maintain
fluid and electrolyte balance or filter
metabolic waste products.

Pathopysiology
Although the exact pathogenesis of ARF adn
oliguria is not always known, many times there is
a spesific underlying problem.
This is true of the following conditions that reduce
blood flow to the kidney and impair kidney
function : hypovolemia, hypotension, reduce
cardiac output, heart failure, blood tumor, and
kidney stone. If these condition are treated and
corrected before the kidneys are permanently
damaged, the increased BUN, and cretainine
levels, oliguria and other signs may be reserved.

3 Categories of ARF :
Prerenal Failure : 55%
Occurs as a result impaired blood flow that leads to
hypoperfusion of the kidney and a decrease in the GFR.
( OLIGURIA )
Volume depletion resulting from :
a. Hemorrhage
b. Renal losses ( diuretic, osmotic
diuresis )
c. GI losses ( vomitting, diarrhea )
Impaired Cardiac efficiency resulting from :
a. Myocardial infarction
b. Heart failure
c. Dsyrhytmias

 Intrarenal Failure 40%

are the result of actual parenchymal damage to the glomeruli or
kidney tubules.

Prolonged renal ischemia resulting from :

a. Pigment nepropathy ( associated with
the break-down of blodd cells
containing pigment that in
turn occlude kidney stuctures )
b. Myoglobinuria ( trauma, crush injuries )
c. Hemoglobinuria ( hemolytic anemia )
Infectious processes such as :
a. Acute pyelonephritis
b. Acute glomerulonephritis

 Postrena Failure 5-15%

Urinary tract obstruction :
a. Calculi ( stones )
b. Tumors
c. Blood clots
d. Strictures

Clinical Stages :
Initiation period: initial insult and oliguria
Oliguric period (urine volume less than
400 mL/d): uremic symptoms first
appear and hyperkalemia may develop
Diuresis period: gradual increase in urine
output signaling beginning of glomerular
filtration's recovery. Laboratory values
stabilize and start to decrease.
Recovery period: improving renal
function (may take 3 to 12 months)

Clinical Manifestation
Nutritionalmetabolic pattern
a. Nausea
b. Weight loss
c. Increased saliva
or
dry mouth
d. Odd taste in
mouth

Elimination pattern
a. Decreased or
absent
urination
b. Change in urine
the
color and smell
c. Abdominal
cramps

Clinical Manifestation
Activity exercise pattern
a. Difficulty of breathing
at a rest and during
exercise.
b. Muscle cramps
Cognitive perceptual
pattern
a. Period of dizziness
b. Memory loss
c. Confusion

Medical Management
Maintain of fluid balance is based on daily body weight,
serial measurements of central venous pressure, serum
and urine concentration, fluid losses, blood pressure,
and the clinical status of the patient.
Hemodialysis ( a process that circulates the patients
blood through a dialyzer to remove waste products and
excess fluid )
Peritonea dialysis ( a produce that uses the patients
peritoneal membrane, as the semipermeable membrane
to exchange fluid and solutes )
CRRTs ( method used the replace normal kidney function
by circulating the patients blood through a hemofilter )

Pharmacologic Therapy
Hyperkalemia is the most life-treathening of
the fluid and electrolyte changes that occur in
patients with renal disturbances.
The elevated potassium levels may be reduced
by administering cation-exchange resins orally
or by retention enema
Kayexalate works by exchanging sodium ions
for potassium ions in the intestinal tract.
Sorbitol may be administered in commbination
with Kayexalate to induce diarrhea

 If te patient is hemodynamically
unstable ( low blood pressure,
change in mental status,
dyshythmias) IV dextros 50%, insulin,
and calcium replacement may be
administered to shift potassium back
into the cells.

Nutritional Therapy
ARF can cause severe nutritional
imbalances ( because nausea and
vomiting contribute to inadequate
dietary intake ), impaired glucose use
and protein synthesis.
High protein and High calorie diet
for diuretic phase
Foods and fluids that restricted :
banana, citrus fruits and juices,
coffee

Nursing Diagnosis
Fluid volume excess related to decreased
urine output
Activity intolerance related to fatigue,
toxins, and fluid build up
Risk for impaired skin integrity related to
edema, toxins, or impaired tissue perfusion
Risk for infection related to intravenous lines
or catheters or uremic toxins
Deficient knowledge regarding condition and
its treatment

 Planning and Goals

Major goals include ideal fluid
balance, body weight, and electrolyte
levels, increased knowledge about
condition and treatment,
participation in activities as
tolerated, and absence of
complications.

 Monitoring Fluid and Electrolyte Levels

Screen parenteral fluids, all oral intake, and all medications for
hidden sources of potassium.
Pay careful attention to parenteral and oral intake, urine output,
gastric and stool output, wound drainage and perspiration,
changes in body weight, edema, distention of jugular veins,
changes in heart and breath sounds, and increasing difficulty
breathing.
Auscultate lungs for moist crackles.
Assess for generalized edema by examining presacral and
pretibial areas regularly.
Report indicators of deteriorating fluid and electrolyte status
immediately. Prepare for emergency treatment of hyperkalemia.
Prepare patient for dialysis as indicated to correct fluid and
electrolyte imbalances.

Reducing Metabolic Rate

Reduce exertion and metabolic rate during most acute stage with
bed rest.
Prevent or treat fever and infection promptly.

 Promoting Pulmonary Function

Assist patient to turn, cough, and take deep
breaths frequently. Encourage and assist patient
to move and turn.

Avoiding Infection
Practice asepsis when working with invasive lines
and catheters.
Avoid using an indwelling catheter if possible.

Providing Skin Care

Perform meticulous skin care.
Massage bony prominences, turn patient
frequently, encourage bathing with tepid water for
comfort, and prevent skin breakdown.

 Providing Support During Dialysis

Assist, explain, and support patient and family; do

not overlook psychological needs and concerns.
Explain rationale of treatment to patient and family.
Repeat explanations and clarify answers as needed.
Encourage family to touch and talk to patient
during dialysis.
Continually assess patient for complications (eg,
pericarditis, bone disease, anemia) and their
precipitating causes.

Diagnostic Test
24 hour urine output and serum creatinin
eand blood urea nitrogen (BUN) levels
monitor the kidneys ability to excrete fluid
and waste products.
Serum electrolyte panel monitors fluid,
electrolyte, acid-base status
Urinalysis monitors renal excretion and
concentration ability

Diagnostic Test
Creatinine clearance reflects
glomerular filtration rate ( GFR ) and is
accurate indication of renal function.
e.g : if value 50 to 84 ml/minute
indicates mild failure
if value 10 to 49 ml/minute indicates
moderate failure
if value less than 10ml/minute
indicates
severe failure

Chronic Renal Failure

Is progressive, irreversible decrease in
kidney function to the point where
homeostasis can no longer be maintained.
Usually slow and insidious
The final stages of CRF, when more than
90% of kidney function is permanently lost,
is called End Stages Renal Disease (ESRD)
The nephron was lost, cannot secretion,
excretion

Causes
It may be caused by diabetes, hypertension,
chronic glomerulonephritis, pyelonephritis,
hereditary lesions (eg, polycystic disease),
vascular disorders, obstruction of the urinary
tract, infections, or toxic agents.
Environmental and occupational agents that
have been implicated in chronic renal failure
include lead, cadmium, mercury, and
chromium. Dialysis or kidney transplantation
eventually becomes necessary for survival.

Pathopysiology
As renal function declines, the end products
of protein metabolism ( normally excreted
in urine ) accumulate in the blood.
Uremia develops and adversely affects every
system in the body.

Clinical manifestation
Itchy skin
Hypertension
Seizures

Clinical Manifestation

Diagnostic Test
Blood test - to find out if waste substances have been
filtered out
Urine test - to see if there is blood or protein in the urine.
Kidney scans such as MRI scan, CT scan or ultrasound - to
find if there are any unusual blockages in urine flow. When
kidney disease is advanced, the kidneys are shrunken, have
an uneven shape and are firm to touch.
Kidney biopsy - taking a small sample of tissue to test the
cells and look for damage
Calculating the glomerular filtration rate (GFR) - to check
how efficiently the kidneys are filtering waste, in particular
a substance called creatinine.

Pharmacologic Therapy
Calcium and Phosphorus Binders
For hyperphosphatemia and hypocalcemia

Antihypertensive and Cardiovascular Agents

For hypertensi
Dobutamin, digoxin, dialysis for heart failure and
pulmonary
edema

Antiseizures Agents
IV Diazepam and phenytoin administered control
seizures

Nutritional Therapy
Protein is restricted allowed protein high
biologic value ( e.g : dairy products, eggs,
meats) because of complete protein and
supply the essential amino acids necessary
for growth and cell repair.
Fluid allowance per day is 500ml to 600ml.
Calories are suplied by carbohydrates and
fat to prevent wasting.
Vitamin supplementation is necessary
because of protein restricted diet.

Complication
Hyperkalemia
Pericarditis retention of uremic
waste
products and
inadequate
dyalisis.
Hypertension due to sodium and
water
retention
Anemia -

Nursing Diagnoses
Excess fluid volume related to decreased
urine output, dietary excesses, and
retention of sodium and water
Imbalanced nutrition: Less than body
requirements related to anorexia, nausea
and vomiting, dietary restrictions, and
altered oral mucous membranes
Deficient knowledge regarding condition
and treatment regimen

 Planning and Goals

Goals for the patient are fluid

balance, optimal nutritional status,
and knowledge about the disease
and treatment regimen.

 Nursing Interventions

Managing Excess Fluid Volume

Assess fluid status and identify potential
sources of imbalance.
Monitor patient's progress and compliance with
treatment regimen.
Promoting Balanced Nutrition
Implement a dietary program to ensure proper
nutritional intake within the limits of the
treatment regimen.
Provide a referral for a nutritional consultation.

Renal Replacement
Therapies..
Dialysis
a. Hemodyalisis
b. CRRT
c. PD

HEMODYALISIS
Prevent death but doesnt cure renal disease and doesnt compensate for
the loss of endocrine activites of the kidney
3 times a week with the average treatment duration of 3-4 hours.

A dialyzer ( also reffered to as an artificial kidney ) serves as a

synthetic semipermeable mebrane, replacing the renal glomeruli and
tubules as the filter for the impaired kidneys.
Diffusion ( the toxins and waste in the blood are removed ), osmosis (
excess water is removed from the blood ), ultrafiltration ( water
moves under high pressure to an area of lower pressure ) ---hemodyalisis based

 Asses before insert the needle when

hemodyalisis
- patency of fistula
Advice one boil egg before
hemodyalisis.
Affect all system of the body,

Peritoneal Dyalisis
Are to removed toxic
substances and
metabolic waste and to
reestablish normal fluid
and electrolyte
balance.
Restrict for patient :
hypertension, heart
failure, pulmonary
edema, diabetes
The complication :
peritonitis

 Kidney Surgery
Kidney Transplantation
A. living donor
B. cadaveric donor

VIDEO

Summary
Acute

sudden onset
rapid reduction in urine output
Usually reversible
Tubular cell death and regeneration

Chronic
Progressive
Not reversible
Nephron loss