RENAL FAILURE
CENTRAL OBJECTIVE
On completion of the class, the client and his family will be able to explain about renal failure
SPECIFIC OBJECTIVES
Define renal failure
Enlist the classification of renal failure
Define acute reneal failure
Enlist the causes of acute renal failure
Describe the pathophysiology of acute renal failure
Explain the clinical manifestation of acute renal failure
Enlist the diagnostic evaluation of the acute renal failure
Explain the management of the acute renal failure
INTRODUCTION
Renal failure is severe impairment or total lack of kidney function. Renal failures results when the kidney cannot remove the bodies metabolic waste or perform their regulatory function.
Definition
Renal failure is a systemic disease in which the kidney cannot excrete metabolic waste, electrolytes, and fluid from the body leading to acid base imbalance.
The renal failure is classified into two type
Acute Renal Failure
Definition
Acute Renal Failure is a clinical syndrome characterized by rapid decline in renal function with progressive azotemia. Acute Renal Failure is usually associated with decreased urine output less than 400ml per day (oliguria ).
Etiology
There are three major categories of condition causes Acute Renal Failure
Prerenal
Volume depletion
Impaired cardiac efficiency
Vasodilatation
Intra renal Failure
Prolonged renal ischemia resulting from
Nephrotoxic agents
Infectious process
Post renal failure
Urinary tract obstruction
PATHOPHYSIOLOGY
The possible pathologic process involves in acute renal failure are following
Renal vasoconstriction : Hypovolemia and decreased renal blood flow stimulate rennin release , which activates the angiotensin –aldesterone system and resulting into the constriction of the peripheral arteries and renal afferent arterioles. Due to the decreased blood flow and decreased pressure glomerular filtration rate is reduced
Cellular edema : Ischemia causes anoxia, which leads to endothelial edema . cellular edam rises tissue pressure above capillary flow pressure. These inadequate renal blood flow further depress the GFR.
Decreased Glomerular Capillary Permeability: Ischemia alters glomerular epithelial cells and thus decreases glomerular capillary permeability.
Intratubular obstruction : when tubules are damaged interstitial edema occurs, and necrotic epithelial cell accumulate in the tubules. This accumulated debris also lowers the GFR by obstructing the tubules and increasing intratubular pressure
Leakage of glomerular filtrate : Glomerular filtrate leaks back into plasma through holes in the damaged tubular membrane, which decrease intra tubular fluid flow
CLINICAL PHASES OF ACUTE RENAL FAILURE
There are four clinical phases of ARF
Initiation phase : This phase is begins with initial insult and ends when oliguria develops.
The manifestation of oliguric phases are
Diuretic phase : The diuretic phase begins with a gradual increase in daily urine output of 1 to 3 L per day. In this phase kidneys have3 recovered their ability to excrete wastes but not to concentrate the urine.
The manifestation of this phase are
Recovery phase : The recovery phase begins when the GFR increases so that BUN and serum creatinine levels start to stabilize and then decrease. It may take 3 to 12 months
CLINICAL MANIFESTATION
DIAGNOSTIC EVALUATION
MANAGEMENT
Therapeutic management
Acute Renal failure is potentially reversible. The primary goal of the treatment is to maintain the patient in as a normal state as possible while the kidneys are repairing themselves
To management is focused on controlling the patient symptoms and preventing complications.
Pharmacological management
Insulin administration IV : Pottasium moves into cells when insulin is given concurrently to prevent hypoglycemia.
Sodium Bicarbonate : Therapy can correct acidosis and causes shift to potassium into cells
Calcium Gluconate : Therapy is given IV and is gernallry used in advanced cardiac toxicity. Calcium raises the threshold for dysrhymias.
Sodium Poly styrene sulfonate ( kayexalate) : therapy is removes 1mEq of potassium sorbitol to produce osmotic diarrhea .
PREVENTION OF ARF
To prevent toxic drug effects, closely monitor dosage , duration of use , and blood level of all medication metabolised or extracted by the kidney
NUTRITIONAL THERAPY
Dietary intervention is necessary with deterioration of renal function and include careful regulation or protein intake, fluid intake to balance fluid losses, sodium intake
to balance sodium losses and some restriction of potassium. At the same time adequate caloric intake and vitamin supplementation must be ensured
Protein restriction : the recommended protein intake is 1.2 to 2 g/kg of IBM, depending on the individual needs of the patients
Water restriction: water intake depends on the daily urine output. The fluid allowance is 500 to 600 mL more than the previously day’s 24 hours urine output.
Sodium potassium restriction : the amount of sodium and potassium restriction depends on the ability of the kidneys to excrete these electrolyte. Depending on the degree of edema and hypertension, the average daily intake of sodium is 3g to 7gm. The patient should avoid foods known to be high in sodium such as cured meats, pickled food, salad dressing.
Potassium restriction is range from 1500gm to 4000gm. The food with high potassium level that should be avoided are dried fruits, orange, bananas, deep green and deep yellow vegetables, beans and peas.
FOOD ALLOWED
Bread, salt, free butter, grape fruit juice, low protein puddins
FOOD AVOIDED
Protein concentrates, pulses, excess conception of milk, egg and meat
COMPLICATIONS
Complications and sequelae of Acute Renal Failure from the Diseases Database include:
CENTRAL OBJECTIVE
On completion of the class, the client and his family will be able to explain about renal failure
SPECIFIC OBJECTIVES
Define renal failure
Enlist the classification of renal failure
Define acute reneal failure
Enlist the causes of acute renal failure
Describe the pathophysiology of acute renal failure
Explain the clinical manifestation of acute renal failure
Enlist the diagnostic evaluation of the acute renal failure
Explain the management of the acute renal failure
INTRODUCTION
Renal failure is severe impairment or total lack of kidney function. Renal failures results when the kidney cannot remove the bodies metabolic waste or perform their regulatory function.
Definition
Renal failure is a systemic disease in which the kidney cannot excrete metabolic waste, electrolytes, and fluid from the body leading to acid base imbalance.
The renal failure is classified into two type
- Acute Renal Failure
- Chronic Renal Failure
Acute Renal Failure
Definition
Acute Renal Failure is a clinical syndrome characterized by rapid decline in renal function with progressive azotemia. Acute Renal Failure is usually associated with decreased urine output less than 400ml per day (oliguria ).
Etiology
There are three major categories of condition causes Acute Renal Failure
- Prerenal
- Intrarenal
- Postrenal
Prerenal
Volume depletion
Impaired cardiac efficiency
Vasodilatation
Intra renal Failure
Prolonged renal ischemia resulting from
Nephrotoxic agents
Infectious process
Post renal failure
Urinary tract obstruction
PATHOPHYSIOLOGY
The possible pathologic process involves in acute renal failure are following
Renal vasoconstriction : Hypovolemia and decreased renal blood flow stimulate rennin release , which activates the angiotensin –aldesterone system and resulting into the constriction of the peripheral arteries and renal afferent arterioles. Due to the decreased blood flow and decreased pressure glomerular filtration rate is reduced
Cellular edema : Ischemia causes anoxia, which leads to endothelial edema . cellular edam rises tissue pressure above capillary flow pressure. These inadequate renal blood flow further depress the GFR.
Decreased Glomerular Capillary Permeability: Ischemia alters glomerular epithelial cells and thus decreases glomerular capillary permeability.
Intratubular obstruction : when tubules are damaged interstitial edema occurs, and necrotic epithelial cell accumulate in the tubules. This accumulated debris also lowers the GFR by obstructing the tubules and increasing intratubular pressure
Leakage of glomerular filtrate : Glomerular filtrate leaks back into plasma through holes in the damaged tubular membrane, which decrease intra tubular fluid flow
CLINICAL PHASES OF ACUTE RENAL FAILURE
There are four clinical phases of ARF
- Initiation
- Oliguria
- Diuresis
- Recovery
Initiation phase : This phase is begins with initial insult and ends when oliguria develops.
The manifestation of oliguric phases are
- Urinary changes
- Fluid volume excess
- Metabolic acidosis
- Sodium imbalance
- Calcium deficit and potassium excess
- Nitrogenous product accumulation
Diuretic phase : The diuretic phase begins with a gradual increase in daily urine output of 1 to 3 L per day. In this phase kidneys have3 recovered their ability to excrete wastes but not to concentrate the urine.
The manifestation of this phase are
- Uremia
- Hyponatremia
- Hypokalemia
- Dehydration
Recovery phase : The recovery phase begins when the GFR increases so that BUN and serum creatinine levels start to stabilize and then decrease. It may take 3 to 12 months
CLINICAL MANIFESTATION
- ↓ urinary output
- Proteinuria
- ↓Specific gravity
- ↓Osmolarity
- ↑Urinary sodium
- Dysarrythmia
- Pulmonary edema
- ↑BUN
- ↑Creatinine
- ↑Posttasium
- ↓pH
- ↓bicarbonate
- ↓calcium
DIAGNOSTIC EVALUATION
- History and physical examination
- Blood studies Serum creatinine and BUN level
- Serum electrolytes
- Urine analysis
- Renal scan
- Renal ultrasound
- CT / MRI scan
MANAGEMENT
Therapeutic management
Acute Renal failure is potentially reversible. The primary goal of the treatment is to maintain the patient in as a normal state as possible while the kidneys are repairing themselves
To management is focused on controlling the patient symptoms and preventing complications.
- Maintain fluid balance : Fluid balance is based on the body weight,serial measurement of central venous pressure and serum and urine concentration , fluid loss, blood pressure of the patient
- Avoid excessive fluid : It can be detected by clinical findings like dyspnea, tachycardia and distended neck vein . Mannitol , frusemide may be prescribed to initiate a diuresis and to prevent subsequent renal failure
- Performing dialysis : It is may be initiated to prevent serious complication of ARF such as• Metabolic acidosis
• Reduced level of consciousness
• Nausea and vomiting
• Diabetes insipidus, nephrogenic
• Pyruvic acid levels raised (blood)
• Urea levels raised (plasma or serum)
• Pericarditis
• Immune deficiency
• Hypermagnesaemia
• Bicarbonate levels low (plasma)
• Oedema
• Weight gain
• Creatinine levels raised (plasma or serum)
• Acute confusional state
• Pulmonary oedema
, severe metabolic acidosis, pulmonary oedema
Pharmacological management
Insulin administration IV : Pottasium moves into cells when insulin is given concurrently to prevent hypoglycemia.
Sodium Bicarbonate : Therapy can correct acidosis and causes shift to potassium into cells
Calcium Gluconate : Therapy is given IV and is gernallry used in advanced cardiac toxicity. Calcium raises the threshold for dysrhymias.
Sodium Poly styrene sulfonate ( kayexalate) : therapy is removes 1mEq of potassium sorbitol to produce osmotic diarrhea .
PREVENTION OF ARF
- Provide adequate hydration to patients at risk for dehydration
- Prevent and treat shock promptly with blood and fluid replacement
- Continuously assess renal functions when appropriate
- Prevent and treat infections promptly , infection can produce progressive renal damage
To prevent toxic drug effects, closely monitor dosage , duration of use , and blood level of all medication metabolised or extracted by the kidney
NUTRITIONAL THERAPY
Dietary intervention is necessary with deterioration of renal function and include careful regulation or protein intake, fluid intake to balance fluid losses, sodium intake
to balance sodium losses and some restriction of potassium. At the same time adequate caloric intake and vitamin supplementation must be ensured
Protein restriction : the recommended protein intake is 1.2 to 2 g/kg of IBM, depending on the individual needs of the patients
Water restriction: water intake depends on the daily urine output. The fluid allowance is 500 to 600 mL more than the previously day’s 24 hours urine output.
Sodium potassium restriction : the amount of sodium and potassium restriction depends on the ability of the kidneys to excrete these electrolyte. Depending on the degree of edema and hypertension, the average daily intake of sodium is 3g to 7gm. The patient should avoid foods known to be high in sodium such as cured meats, pickled food, salad dressing.
Potassium restriction is range from 1500gm to 4000gm. The food with high potassium level that should be avoided are dried fruits, orange, bananas, deep green and deep yellow vegetables, beans and peas.
FOOD ALLOWED
Bread, salt, free butter, grape fruit juice, low protein puddins
FOOD AVOIDED
Protein concentrates, pulses, excess conception of milk, egg and meat
COMPLICATIONS
Complications and sequelae of Acute Renal Failure from the Diseases Database include:
- Water overload
- Hyperphoshatemia
- Hyperkalaemia
- Hypocalaemia
- Metabolic acidosis
- Reduced level of conciousness
- Nausea and Vomiting
- Diabetes insipidus
- Increased urea level
- Pericarditis
- Immune deficiency
- Oedema
- Weight gain
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