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C E 2.

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Kidneys, dont
If toxic wastes build up too fast, Im liable to shut down!

Unfortunately, acute renal failure is on the rise, attributed to our aging population, more people living longer with comorbidities, and an increasing use of nephrotoxic drugs. Diagnosing it early, while its still reversible, is key. Find out what your role is in preventing permanent damage to the kidneys.
KATHRYN WARD, APRN,BC, CDE, MSN Outcomes Manager Suburban Hospital Bethesda, Md.
The author has disclosed that she has no signicant relationships with or nancial interest in any commercial companies that pertain to this educational activity.

AS YOU KNOW, the rising population of older adults in this country is contributing to a greater prevalence of certain health problems, such as diabetes, hypertension, some cancers, and cardiac disease. Theres another one you may not have considered: acute renal failure (ARF). Of course, age isnt the only factor: More people today are surviving longer with chronic illnesses, like congestive heart failure, human immunodeciency virus infection, and other autoimmune diseases. These comorbidities can tax the kidneys and trigger ARF. Plus were using more and more nephrotoxic drugs, such as various aminoglycosides, nonsteroidal anti-inammatory drugs (NSAIDs), and radiocontrast agents, that put the kidneys at risk (see Kidneys beware!). How prevalent is ARF? Between 5% and 7% of all hospitalized patients have it, with the percentage rising to around 20%
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in the critically ill. And these numbers are on the rise. Dened as a sudden loss of kidney function, ARF is characterized by a rapid accumulation of toxic waste products, such as urea and creatinine, in the blood. The sudden burden on the kidneys causes 50% or more of their nephrons to lose function so quickly that the body cant compensate. The nephrons may eventually recover, if the cause of ARF is corrected. But if the damage is permanent, ARF becomes chronic renal failure. The most common sign of ARF is oliguria, a decrease in urine output (less than 400 ml in 24 hours). This volume is insufcient to excrete waste products. Some patients experience nonoliguric renal failure, in which the kidneys cant lter out the waste products in the urine, but theyre still able to make urine. The waste products build up in the blood. Unfortunately, we havent found an effective pharmacologic therapy to prevent or treat ARF. So we generally fall back on

fail me now!
Portrait of a nephron
Glomerulus Bowmans capsule Renal tubule

Artery

Vein

Collecting tubule

Loop of Henle

Urine

March/April 2005 Nursing made Incredibly Easy! 19

supportive care, with renal replacement therapy the primary treatment option (see The ins and outs of renal replacement therapy). In fact, almost 30% of all the patients who experience ARF need renal replacement therapy. Despite improvements in this type of therapy, the mortality rate for ARF remains high, anywhere from 20% to 70%. Typically, overwhelming infection or cardiopulmonary problems are the causes of death. Because of this, prevention and early detection are vital. You play a pivotal role in assessing your patients and identifying changes associated with ARF. In this article, Ill show you what steps to take to prevent acute kidney failure in patients at risk and how to assess it early, while its still reversible.

in your body, and every minute, they receive about a quarter of the cardiac output. On average, the kidneys lter about 50 gallons (more than 189 liters) of uid every day. The kidneys also excrete wastes, concentrate urine, conserve electrolytes, and regulate blood pressure. And they produce other substances that are important to the function of other organs.

Kidney function
The powerhouse of the kidney is the nephron. Each kidney contains about 1 million nephrons. A nephron is composed of a glomerulus and a tubule. The glomerulus is a network of capillaries that receives blood from the renal artery. Bowmans capsule, a thin-walled, spherical structure, surrounds the glomerulus and then narrows, becoming the tubules. Substances are exchanged through the walls of the tubules. The function of the nephron is to produce urine using three processes: glomerular ltration, tubular reabsorption, and tubular secretion. Besides excreting the waste products of cellular metabolism, these processes maintain uid volume, electrolyte concentration, and the pH of body uids within a narrow margin. The rate at which the kidneys lter blood through the glomerulus is called the glomerular ltration rate (GFR). The GFR affects the amount of urine produced. Normally, the GFR is 120 to 125 ml/min. If the kidneys are damaged, the GFR drops. Because the kidneys are no longer ltering wastes from the blood, the blood urea nitrogen (BUN) and creatinine levels rise.

In review Kidneys beware!


The following drugs and other substances have a potential for nephrotoxicity: Antibiotics acyclovir (Zovirax) aminoglycosides (various) amphotericin B (Amphocin, Fungizone) pentamidine (Pentam 300) tetracycline Chemotherapies and immunosuppressants cisplatin (Platinol) cyclosporine (Sandimmune) methotrexate (Trexall) mitomycin (Mutamycin) Heavy metals arsenic bismuth lead mercury Miscellaneous illicit drugs (cocaine, Ecstasy) aspirin NSAIDs COX-2 inhibitors radiocontrast agents venom

The kidneys, two small, bean-shaped organs, are located on either side of the spinal column below the rib cage. An adult kidney weighs a quarter of a pound (0.11 mg)the weight of a stick of butter. Each organ is about 4 inches long by 212 inches wide (about 10 cm x 6.5 cm). You may not realize it, but your kidneys are working hard around the clock. Although small in size, theyre mighty in function and remarkably efcient. At any given time, theyre ltering half of the blood

When things go wrong


Every minute of every hour, your kidneys are working without you being aware of itor even needing to do anything to participate in the process. When a serious illness or a surgical complication suddenly occurs, the kidneys can stop working without warning. Normal blood ow is es-

20 Nursing made Incredibly Easy! March/April 2005

Looks like my MI patients heart isnt the only organ at risk!

sential to keeping the kidneys functioning smoothly. So any blood loss that compromises the kidneys blood supply can damage them and affect their function, as can a steep drop in the blood pressure or signicant dehydration. Take a look at the list of causes of ARF in Whats behind ARF? Looks familiar, doesnt it? These conditions are seen in hospitals and other health care facilities on a daily basis. When assessing any patient, then, keep in mind that the potential for ARF is always there. Never underestimate the possibility of it occurring. The key point to remember is that regard-

less of the cause, ARF can do permanent damage. So quickly reaching a diagnosis and establishing an effective management plan should be the overriding concerns of the health care team. Lets look at the three types of ARF and what triggers them.

System failure
Acute renal failure is classied according to the area of the renal system thats affected. Prerenal ARF is caused by decreased blood ow to the kidneys. This type of renal failure accounts for 55% to 60% of all cases of ARF. The most common causes of prerenal ARF are severe blood loss and low blood pressure due to major abdominal or cardiac surgery, sepsis, trauma, and dehydration. Use of NSAIDs and cyclooxygenase-2 (COX-2) inhibitors can also cause prerenal ARF. These drugs impair renal autoregulatory responses by blocking the production of prostaglandin, which is necessary to maintain renal perfusion. Angiotensin-converting enzyme inhibitors (ACE-Is) are used to preserve and maintain renal function in patients with diabetes, hypertension, and heart failure. But if the patient is already in ARF, these drugs can worsen the situation (see An ACE in the hole). Intrarenal ARF, also called intrinsic ARF, is caused by direct damage to both kidneys; it accounts for 35% to 40% of all cases of ARF. Nearly 90% of cases of intrarenal ARF are caused by ischemia (reduced blood ow) or toxins, both of which can lead to acute tubular necrosis, a condition in which the tubules are destroyed. Acute tubular necrosis is frequently a hospital-acquired problem, resulting from surgery, sepsis, or use of contrast dye or some antibiotics. Other causes include interruption of blood ow in the renal artery or renal vein and amyloidosis, an abnormal depositing of protein in kidney tissues.
March/April 2005 Nursing made Incredibly Easy! 21

Whats behind ARF?


Some of the diseases and conditions that can lead to kidney failure include: acute glomerulonephritis anaphylaxis autoimmune disorders burns cardiogenic shock chemical exposure (lead, arsenic, carbon tetrachloride, ethylene glycol) congestive heart failure dehydration drugs (gentamicin, amphotericin, NSAIDs, ACE inhibitors, rifampin, aminoglycosides) excessive diuresis Hantavirus infection hemolytic blood transfusion reaction HIV infection hypovolemia lithotripsy medication allergies myocardial infarction renal artery thrombosis rhabdomyolysis septic shock severe crush injury trauma, especially to the back, pelvis, and perineum urinary tract obstructions (stricture, tumors, stones, enlarged prostate) vascular surgery

Levels of renal dysfunction


Description Normal function Mild renal failure Moderate renal failure Severe renal failure End-stage renal disease Approximate creatinine clearance (ml/min) >80 >50 to 80 30 to 50 <30 Requires dialysis

Postrenal ARF is caused by a blockage that affects the outow of urine from both kidneys. Only about 5% of cases of ARF are classied as postrenal ARF. This condition is most commonly seen in older men with an enlarged prostate that interferes with urine ow. When urine ow is obstructed, the urine backs up into the kidneys. As the pressure builds, the nephrons eventually shut down. Bladder or kidney stones in both ureters, a neurogenic bladder, and traumatic injury to the kidneys are other potential causes.

cording to the degree of renal dysfunction (see Levels of renal dysfunction) and the etiology of the condition. Patients with mild, early-stage ARF may not have symptoms. The classic sign of ARF is oliguria (reduced urine output relative to uid intake), quantied at <400 ml/day. You should also suspect renal failure when a patient presents with unexplained weight gain or edema. These are red ags that the bodys not excreting uid efciently. Also nd out if the patient has a history of renal calculi or urinary outlet problems or if he has a family history of renal disease. Remember that the effects of ARF arent conned to the renal system. See The farreaching effects of ARF for more information.

How diagnostics help


Lab tests and a thorough history and physical exam provide important information that can point to a diagnosis of kidney failure. The quicker a diagnosis is made, the sooner appropriate intervention can begin. Always keep in mind that ARF is most reversible in its earliest stages. Left untreated, the potential for permanent damage to renal system function increases.

Recognizing renal failure


Earlier, I said that quick identication of ARF is important to reversing it. So what are the clues to ARF? Symptoms vary ac-

An ACE in the hole


Angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) are renal protective, making them good choices for complex patients at risk for kidney disease, such as those with hypertension, heart failure, or diabetes. These drugs prevent endothelial dysfunction and maintain renal function. However, when used in a patient with renal failure, ACE-Is can exacerbate renal problems. ACE-Is are appropriate treatment for any patient with hypertension, but theyre especially helpful when a hypertensive patient has diabetes or a comorbidity caused by endothelial dysfunction, such as heart failure, myocardial infarction, left ventricular hypertrophy, and renal insufciency with a creatinine level <3 mg/dl. ARBs are used to treat hypertension and heart failure and maintain renal function in patients with diabetes. Often, these two classes of drugs are combined to treat patients with heart failure. Because they affect the renin-angiotensin-aldosterone system at different places, heart function improves and symptoms lessen. Be aware that pregnant women and women who are likely to become pregnant shouldnt take ACE-Is or ARBs because of the potential for fetal injury or death.

22 Nursing made Incredibly Easy! March/April 2005

A diagnosis of ARF is made based on increasing levels of creatinine. Because other processes, such as internal bleeding, infection, and protein metabolism, can increase the BUN level, BUN is less accurate than creatinine as an indicator of renal function. The most widely accepted indicators include a decline in renal function occurring over hours to days and involving an increase in serum creatinine by more than 0.5 mg/dl, an increase of 50% or more in serum creatinine over baseline levels, and a decline in creatinine clearance of more than 25%. Serum electrolytes may offer additional information about volume status and should be included in the lab workup. Electrolyte balance is vital to your patients well-being. Hyperkalemia, which can arise from kidney failure, typically affects cardiac function. Dont underestimate the importance of urinalysis in helping to determine the cause of ARF. For example, red cells and casts may indicate glomerular disease. Further analysis may indicate if casts are glomerular, tubulointerstitial, or vascular. A renal biopsy may be needed if theres no apparent cause of ARF or if glomerulonephritis is suspected. Renal ultrasound can measure kidney size, detect tumors and blockages, and reveal cystic disease. It can also identify hydronephrosis, which refers to a kidney with a dilated pelvis and collecting system caused by obstruction of the ureters or bladder outlet. This can result from reux, retrograde leakage of urine from the bladder up the ureters to the renal pelvis.

The far-reaching effects of ARF


Acute renal failure (ARF) affects more than the renal system, causing the following problems throughout the body.

Cardiovascular and pulmonary


Fluid overload results in hypertension and peripheral and pulmonary edema. Hyperkalemia causes arrhythmias; look for tall, tented T waves on the electrocardiogram. Bradycardia, heart block, and asystole could develop if the serum potassium level rises above 6 mEq/L.

Fluids and electrolytes


Alterations in the uid and electrolyte balance can lead to hyponatremia, hyperkalemia, hyperphosphatemia, and uid overload.

Neurologic
A build-up of metabolic wastes in the blood can cause sensory changes, decreased mentation, confusion, and coma.

Hematologic
Anemia occurs as a result of decreased erythropoietin production by the kidneys and the red blood cells (RBCs) shortened lifespan. Erythropoietin is needed to stimulate RBC production. In patients with ARF, the RBC lifespan, which is usually 120 days, is only 60 days. Because theres less erythropoietin in the bone marrow, the body cant replace the lost RBCs.

Gastrointestinal
The build-up of wastes in the blood (uremia) causes loss of appetite, nausea, vomiting, and, eventually, a decrease in body mass and muscle. The build-up of urea can cause a metallic taste in the mouth or a foul urine odor to the breath.

Interventions and outcomes


The goals of managing ARF are to eliminate the cause, manage the signs and symptoms, provide supportive care, and prevent permanent kidney damage. Several treatment modalities are available, with the treatment selected according to the cause of ARF. Steps in managing ARF may include: replacing uids to restore uid and

electrolyte balance discontinuing medications that may be the cause of the problem instituting short-term renal replacement therapy to lter the blood and restore potassium and other electrolyte levels to normal eliminating or bypassing urinary tract obstruction, such as removing stones or catheterizing the bladder offering nutritional support that provides adequate calories without increasing the protein or sodium load to combat malnutrition and uid and electrolyte imbalances. Prerenal and postrenal ARF can resolve fairly quickly if the cause is known and acted on without delay. Recovery time may be proMarch/April 2005 Nursing made Incredibly Easy! 23

Im down but not outalthough recovery could take up to a year.


longed in intrarenal ARF because the functional units of the kidneys may be damaged. Recovery from ARF depends in part on whether the patient has an underlying illness. His general health, the length of the oliguric phase, and the degree of nephron damage are important factors in the patients recovery. A return to health may take weeks to a year. Older patients are at higher risk for ARF related to comorbidities, and they may also need a longer recovery time. For optimal recovery, the patient must regain and maintain a normal uid and electrolyte balance and must be free of infections or complications. Despite the best care, some patients may not respond well and the disease may progress to chronic renal failure, which requires long-term renal replacement therapy. early detection of ARF. Youre on the front line of patient care, making it essential for you to recognize and report abnormal assessments, maintain correct uid balance, prevent infection, monitor and interpret lab results, and identify patients at greatest risk for developing ARF. Acute renal failure, by denition, is sudden, and it may have a traumatic impact on the patient and his family. Provide emotional support, keeping in mind the nancial and psychological hardships that may occur as a result of a lengthy recovery. A referral to case management, social services, or other ancillary service can be of great help to the patient and his family. Once your patients ready for discharge, emphasize prevention. Teach him about the potential signs and symptoms of ARF, such as edema and weight gain; the medications hell be taking after discharge; his nutritional needs; any uid restriction; and the role of renal replacement therapy (if applicable). Also stress the need for regular medical checkups. Highlight the risks from chronic use of NSAIDs and COX-2 inhibitors, such as adverse cardiac and

What you can do


An accurate record of intake and output, daily weights, and frequent blood pressure measurements are essential when a patients been diagnosed with ARF. So is closely monitoring serum creatinine, BUN, potassium, and other electrolyte levels so you can watch for (and report) any deviation. You play a key role in prevention and

The ins and outs of renal replacement therapy


A patient with acute renal failure may rely on one of the following options until normal kidney function returns: Hemodialysis uses a machine and an articial kidney to remove excess uid and waste products from the blood, but it doesnt regulate blood pressure or other renal functions linked to hormonal control. Its the preferred method when quick removal of water or toxins is indicated and the patient can tolerate the procedure. Because hemodialysis requires removing a substantial amount of uid from the patients intravascular system, he could develop hypotension from hypovolemia. Continuous arteriovenous hemoltration is based on a simpler concept. Driven by the patients own blood pressure, it rarely causes hypotension. As the patients blood is removed, an anticoagulant is added. The blood passes through a porous lter where uid or solutes are removed, and then the blood is returned to the patient. Easier on the body and slower than hemodialysis, the process allows time for uids to move into the vasculature from the tissues, but dramatic results take longer. Either of these options requires vascular access via a temporary catheter inserted into a large blood vessel.

March/April 2005 Nursing made Incredibly Easy! 25

Stages of kidney disease


Stage 1 2 3 4 5 Glomerular ltration rate (GFR) (ml/min/1.73 m2) 90 60 to 89 30 to 59 15 to 29 15

diabetes and chronic renal insufciency, and those with low muscle mass, many instances of ARF can be avoided. Minimizing factors that can predispose them to renal failure is essential. If the disease isnt preventable, the primary goals are to quickly restore renal perfusion and manage the underlying pathology.

gastrointestinal effects, worsening hypertension, and interference with the effectiveness of ACE-Is.

Learn more about it


Albright RC. Acute renal failure: A practical update. Mayo Clinic Proceedings. 76:67-74, January 2001. Campbell D. How acute renal failure puts the brakes on kidney function. Nursing2003. 33(1):59-63, January 2003. Holechek MJ. Nursing management of acute renal failure and chronic kidney disease. Medical Surgical Nursing: Assessment and Management of Clinical Problems, 6th edition, Lewis S, et al (ed.). St. Louis, Mo., Mosby, Inc., 2003. Mahendra A, et al. Acute renal failure. http://www. emedicine.com/med/topic1595.htm. Accessed December 27, 2004. Schrier RW, et al. Acute renal failure: Denitions, diagnosis, pathogenesis, and therapy. The Journal of Clinical Investigation. 114(1):5-14, July 2004. Singri N, et al. Acute renal failure. JAMA. 289(6):747-751, February 2003.

Minimizing the risk


Acute renal failure is a signicant problem. Its showing up in hospitalized patients more often because of an older patient population and an increased survival rate of sicker patients. By recognizing patients who are at increased risk, such as older individuals with multiple comorbidities, patients with chronic illnesses such as

CE Test

Kidneys, dont fail me now!


Instructions Read the article beginning on page 18. Take the test, recording your answers in the test answers section (Section B) of the CE enrollment form on page 42. Each question has only one correct answer. Complete registration information (Section A) and course evaluation (Section C). Mail completed test with registration fee to: Lippincott Williams & Wilkins, CE Group, 333 7th Ave., 19th Floor, New York, N.Y. 10001. Within 3 to 4 weeks after your CE enrollment form is received, you will be notied of your test results. If you pass, you will receive a certicate of earned contact hours and an answer key. If you fail, you have the option of taking the test again at no additional cost. A passing score for this test is 11 correct answers. Need CE STAT? Visit http://www.nursingcenter.com for immediate results, other CE activities, and your personalized CE planner tool. No Internet access? Call 1-800-933-6525, ext. 6617 or ext. 6621, for other rush service options. Questions? Contact Lippincott Williams & Wilkins: 646-6746617 or 646-674-6621. Registration Deadline: April 30, 2007 Provider Accreditation This Continuing Nursing Education (CNE) activity for 2.5 contact hours is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Centers Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 00012278, CERP Category A). This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.5 contact hours. LWW is also an approved provider of CNE in Alabama, Florida, and Iowa and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classied for Texas nursing continuing education requirements as Type I. Your certicate is valid in all states. This means that your certicate of earned contact hours is valid no matter where you live. Payment and Discounts The registration fee for this test is $17.95. If you take two or more tests in any nursing journal published by LWW and send in your CE enrollment forms together, you may deduct $0.75 from the price of each test. We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. Call 1-800-933-6525, ext. 6617 or ext. 6621, for more information.

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C E 2.5

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Kidneys, dont fail me now!


GENERAL PURPOSE: To identify the risk factors for and manifestations of acute renal failure (ARF), its current diagnostic measures and treatments, and specic nursing interventions to treat the disease and prevent its development. LEARNING OBJECTIVES: After reading the article and taking this test, youll be able to: 1. Accurately assess for risks and manifestations associated with ARF. 2. Describe recommended treatments for ARF. 3. Explain nursing interventions and patient teaching to manage and prevent ARF.

1. ARF occurs when a. theres a major build-up of RBCs. b. the glomerular ltration rate is between 120 ml/min and 125 ml/min. c. half of the nephrons lose their ability to function. 2. Prerenal failure is caused by a. renal calculi. b. decreased blood ow to the kidneys. c. acute tubular necrosis. 3. Patients with ARF develop a. electrolyte and acid-base abnormalities. b. excessive erythropoietin production. c. collapse of the immune system. 4. The classic sign of ARF is urine output of less than a. 400 ml/day. b. 600 ml/day. c. 800 ml/day. 5. Which of the following statements is true? a. ARF can always be cured with proper drug therapy. b. Administering aminoglycosides to at-risk patients can prevent ARF. c. The sooner ARF is recognized and treated the less likely that chronic renal failure will occur. 6. Which of the following statements is true? a. Renal calculi can cause prerenal failure. b. The serum blood urea nitrogen level is less accurate than the serum creatinine level as an indicator of renal function. c. Daily weights arent helpful in monitoring a patient with ARF. 7. Based on the serum creatinine level, which of the following patients is most likely to have ARF? a. Mrs. M., whose serum creatinine level was 1.4 mg/dl on Monday and 2.1 mg/dl on Tuesday b. Mr. N., whose serum creatinine level was 1.4 mg/dl on Monday and 1.5 mg/dl on Tuesday c. Mrs. O., whose serum creatinine level was 1.4 mg/dl on Monday and 1.3 mg/dl on Tuesday 8. Based on the creatinine clearance value, which of the following patients is most likely to have ARF? a. Mr. A., whose creatinine clearance level was 90 ml/min on Monday and 60 ml/min on Tuesday b. Mrs. C., whose creatinine clearance level was 90 ml/min on Monday and 85 ml/min on Tuesday c. Mrs. D., whose creatinine clearance level was 90 ml/min on Monday and 95 ml/min on Tuesday

9. Hydronephrosis is an example of a. prerenal ARF. b. intrinsic ARF. c. postrenal ARF. 10. Mrs. R. is recovering from ARF and is ready for discharge. During discharge teaching, you need to make sure she knows a. the importance of taking nonsteroidal antiinammatory drugs (NSAIDs) to decrease nephron inammation. b. the importance of increasing uid intake to at least 3 L/day. c. the signs and symptoms of renal failure. 11. Drugs with a renal protective effect include a. NSAIDs. b. aminoglycosides. c. angiotensin-converting enzyme inhibitors (ACE-Is). 12. All of the following patients are at high risk for ARF, except the a. patient with chronic angina whos taking a beta-blocker. b. trauma patient with severe blood loss. c. patient with renal calculi. 13. Acute tubular necrosis can be caused by a. decreased blood ow from shock. b. a contrast medium. c. renal calculi.

Ready? Just go with the ow!

14. Mrs. Rs creatinine clearance level is 72 ml/min. This lab value is consistent with a. mild renal failure. b. moderate renal failure. c. severe renal failure. 15. Mr. S. is in ARF with severe acid-base imbalance. His health care provider would appropriately prescribe a. an ACE-I. b. a potassium-sparing diuretic. c. hemodialysis.

Turn to page 42 for the CE Enrollment Form. March/April 2005 Nursing made Incredibly Easy! 27