Renal Failure

Gail l Lupica PhD, RN, CNE Nurs 211

The renal system works together with the bodys urinary system to collect the bodys waste products and expel them as urine. One kidney is located on each side of the abdomen, near the lower back. The kidneys filter about 45 gallons of fluid each day. The functional unit of the kidney is the nephron. Each kidney contains about 1 million nephrons.

Functions of the Renal System

Maintenance of fluid balance:

The kidneys maintain the fluid balance in the body by regulating the amount and makeup of fluid inside and outside (mainly) the cells.

The kidneys are continuously exchanging water, (plus sodium, potassium, chloride, and other ions across their cell membranes.)
Two hormones play a key role in the kidneys ability to maintain fluid balance in the body

Functions of the Renal System

1. ADH: controls the collecting tubules permeability to water according to the osmoreceptors ability to sense high concentration of solute in the plasma. (In other words when the plasma is concentrated, ADH is secreted to hold on to more water. When the plasma is dilute, ADH is not secreted so the permeability to water changes in the collecting tubules, and water is released.) 2. Aldosterone: regulates water reabsorption in the distal tubules by increasing sodium reabsorption and therefore water reabsorption when released from the adrenal cortex. (It is released as the final response in the renin angiotensin aldosterone system.) The presence of Aldosterone also helps increase the excretion of potassium.

Functions of the Renal System> Failure

When the kidneys fail:

Patients retain fluid and you see: Peripheral edema Pulmonary edema Decreased urine output Hypertension

Functions of the Renal System

The regulation of acid-base balance:
The kidneys regulate acid base balance by: Excreting just enough hydrogen ions to keep the ph of the blood in the normal range. Manufacturing bicarbonate (a base) as needed to maintain ph between 7.35-7.45.

Functions of the Renal System> Failure

When the kidneys fail:

Metabolic acidosis results. Patients may develop Kussmaul respirations.whats that?

Functions of the Renal System

The secretion of erythropoietin: The kidneys secrete erythropoietin when the oxygen supply in the tissue blood drops. This hormone prompts the bone marrow to produce more RBCs.

Functions of the Renal System> Failure

When the kidneys fail:

The patient becomes anemic.

(Remember also they are anemic due to the increased destruction of RBCs & PLTS by the uremic toxins, and even due to their bleeding tendency secondary to their low PLTS.)

Functions of the Renal System

Maintenance of electrolyte balance:
The kidneys function to regulate electrolyte concentrations. When the kidneys fail, electrolyte levels are not maintained: K+, Na, Phosphate, Ca+

Functions of the Renal System> Failure

Potassium:

Hypokalemia may occur

with vomiting or excessive diarrhea in early renal failure when uremic toxins begin to circulate. in the diuretic phase of acute renal failure as the kidney is unable to conserve water and electrolytes. . ARRYTHMIAS, NAUSEA, and LETHARGY occur. Hyperkalemia occurs with.. decreased renal excretion of potassium both in the oliguric phase of acute renal failure and in end stage renal disease. Hyperkalemia could lead to life threatening ARRYTHMIAS!!

Functions of the Renal System> Failure

Sodium:
Hyponatremia also occurs in the diuretic phase of acute renal failure when the kidneys cannot conserve sodium or water. MUSCLE WEAKNESS, CONFUSION, and ABDOMINAL CRAMPING occur.

Hypernatremia occurs with decreased renal excretion of sodium. This will occur in the end stages of renal disease and the person will be on a sodiumrestricted diet. DRY MUCOUS MEMBRANES, and OLIGURIA occurs.

Functions of the Renal System> Failure

Calcium: Hypocalcemia occurs for two reasons:
1. A hyperphosphatemia occurs because of a decreased excretion of phosphate.
There is an inverse relationship between phosphate and Calcium, so a hypocalcemia occurs. ( These electrolytes are regulated by the parathyroid gland, so when the phosphate level rises out of control due to the kidneys inability to excrete it, the parathyroid hormone (from the gland) is over secreted and starts to get Calcium from the bones, due to a depletion in the serum) OSTEOPOROSIS, OSTEODYSTROPHY (bone disease), AND TETANY occurs.

Functions of the Renal System> Failure

Hypocalcemia
2.

The kidneys normally secrete an active form of vitamin D (2-3 DPG), which help the intestines absorb calcium. When theres decreased absorption, theres hypocalcemia.

You tube . com

chvostek's sign and trousseau's sign

Functions of the Renal System

Maintenance of blood pressure:
The kidneys help regulate blood pressure by producing and secreting the enzyme renin in response to an actual or perceived decline in extra cellular fluid volume. (Angiotensinogen) turns Renin into angiotensin I which is converted into angiotensin II (by an enzyme), the most potent vasoconstrictor in the body. Angiotensin II raises arterial blood pressure by

RENIN 1. Increasing peripheral vasoconstriction 2. Stimulating Aldosterone secretion Aldosterone promotes the reabsorption of sodium and water to correct the fluid deficit and/or inadequate blood flow (renal ischemia)

Functions of the Renal System> Failure

When the kidneys fail:

Patients are often HYPERTENSIVE.

Functions of the Renal System

The collection and elimination of metabolic waste such as urea and creatinine:
The kidneys job is to excrete the waste products of metabolism. Urea is a byproduct of protein metabolism. It is not as adequate an indicator of renal disease as elevated creatinine levels are because urea (BUN) levels elevate with an increased protein intake, trauma, dehydration etc.. Serum creatinine levels are an accurate indicator of renal function/dysfunction. The urinary excretion should equal the amount produced by the body (by skeletal muscle catabolism).

Functions of the Renal System> Failure

When the kidneys fail: The patient suffers from an overload of these circulating uremic toxins. All body systems may be affected.

the CNS is affected by the uremic toxins. Drowsiness, poor memory, inability to concentrate, seizures, and even come may result. GI distress may result such as nausea, vomiting, abdominal distension, diarrhea, and constipation.

Functions of the Renal System> Failure

Pericarditis may result as pericardium is inflamed due to the buildup of these uremic wastes. A pericardial friction rub and pain may result. Pruritis may result as the excretory function of the skin attempts to excrete the waste products. A uremic frost may be notable on skin and collect on eyebrows. Skin may become a pale yellowish color, as urochrome pigments are present. Anemia and thrombocytopenia occur because the uremic toxins destroy RBCs and

Acute Renal Failure:

Etiology: Acute renal failure is defined as loss of functional ability of the kidney. It has a sudden onset and is reversible. It may be classified as:
1. 2. 3. Prerenal Renal (intrarenal) Causes Postrenal

Classifications of ARF

Prerenal failure results from conditions that diminish blood flow to the kidneys. (hypovolemia, hypotension, poor cardiac output states) Renal (intrarenal) failure results from damage to the filtering structures of the kidneys. (trauma, disease, antibiotics, pesticides) Postrenal failure results from bilateral obstruction of urine outflow. (ureteral obstruction, bladder obstruction, urethral obstruction)

Pre-renal- renal artery not getting the job done

Diseases affect basement membrane which leads to nephrotic syndrome= proteinuria

Pyelonenritis

Intra-renal fx

Bladder/uretal stones- post renal fx.

Acute Renal Failure- Phases

Phases: The course of acute renal failure is characterized by three phases.

The oliguric phase occurs at the onset of symptoms and could last as long as eight weeks. It is characterized by a decreased urine output (less than 400ml in 24 hours). The kidney is trying to conserve sodium and water, and therefore hypervolemia, edema, weight gain, pulmonary edema, and elevated blood pressure occur. The BUN and creatinine rise thereby causing uremic signs and symptoms. (nausea, changes in mental acuity, fatigue, pericarditis)

Acute Renal Failure- Phases

The diuretic phase is marked by urine output that can range from 1-5 L/day. The kidney has lost its ability to conserve water. Hypovolemia, (fluid) weight loss, hypokalemia, hyponatremia all can result. The BUN and creatinine begin to level out. May last 7-14 days.

Acute Renal Failure- Phases

The recovery phase is reached when the BUN and creatinine have returned to normal. This phase can last from 3-12 months.

Acute Renal Failure- Diagnostic Findings:

Laboratory data and other assessments reveal the following:
.....(In the oliguric phase)
1.

2.
3.

4.

Decreased or absent urinary output Increased BUN, creatinine, sodium, potassium, chloride Decreased calcium (high phos), bicarbonate (acidosis), H/H (anemic) Metabolic acidosis

Acute Renal Failure Management

What do you think is done to manage fluid overload? What do you think is used to manage the hypertension? What do you think is used to manage the anemia?
Fluid restriction may be based on the previous days output plus 400-500ml for insensible losses.)
(

Chronic Renal Failure-irreversible

Chronic renal failure is a progressive and irreversible deterioration of kidney function. Eventually, in end stage renal disease there is less than 20% of nephron function left.
Any diseases involving the kidney could progress to chronic renal failure. (Acute renal failure could terminate in chronic renal failure if left untreated. )
Examples of causes .include renal calculi, polycystic kidney disease, and Diabetes Mellitus.

Chronic Renal Failure- Clinical Manifestations:

Uremic

Signs and Symptoms Electrolyte Disturbances, acid base imbalances, and anemias Fluid Volume Excess:

Chronic Renal FailureManagement

Diet Protein? Sodium? Potassium? Fluid?

Chronic Renal FailureManagement

Drug therapy Which drugs are used to treat the patient in ESRD in the following areas? Please provide specific examples.

Fluid overload & edema? Blood pressure? Nausea and vomiting? Gastric acid secretions? Constipation? Anemia? Itching /Pruritis? Hyperphosphatemia?

Chronic Renal Failure- Emergency Management of Hyperkalemia

Emergency measures:

Hyperkalemia 1. 2. 3. 4. Any more??????

Chronic Renal Failure- Emergency Management

Cardiac tamponade Pleural effusions Pulmonary edema

Chronic Renal Failure Management: Dialysis

Dialysis is a treatment used to:

Restore fluid and electrolyte balance Correct Acid-base im balance Remove wastes like BUN & creatinine Remove toxic materials from the body.

Dialysis three principles

It is based on three principles:

1. Diffusion: which is the movement of particles across a semipermeable membrane from areas of higher concentration to lower concentration. This clears solutes from the body. 2. Osmosis: which is the movement of fluid across a semipermeable membrane from an area of lesser solute concentration to an area of greater solute concentration. 3. Ultrafiltration: which is the movement of fluid across a semipermeable membrane as a result of an artificially created pressure gradient.

Dialysis
Goals of Dialysis: To remove metabolic waste products Like what? To maintain safe concentrations of electrolytes (Especially potassium!!) Why? To correct acid-base imbalances Which one? To remove excess fluids

There are two types of dialysis available

1. Peritoneal

Dialysis 2. Hemodialysis

Peritoneal Dialysis
This method involves the instillation of a hypertonic solution into the peritoneal cavity where it remains for a prescribed period of time, until it is drained. The amount of time the Dialysate remains in the peritoneal cavity depends upon the type of peritoneal dialysis used. Fluids and solutes are transferred from the bloodstream into the peritoneum when dialysate solution is instilled into the peritoneal cavity. The principles of osmosis and diffusion are carried out.

Peritoneal Dialysis
In intermittent peritoneal dialysis: 2 liters of dialysate is instilled into the peritoneal cavity every night at bedtime. It is allowed to drain after 5-7 hours. During the day the abdomen remains empty.

Peritoneal Dialysis

Other methods leave the dialysate in the peritoneal cavity (dwell time) for as little as 30 minutes.
Sometimes an automatic cycler is used and other times the dialysate is timed manually.

Smaller amounts than 2 liters of dialysate may be used at first until the client adjusts.)

Dialysate concentrations can be 1.5% or 4.25%

Peritoneal Dialysis

A thick catheter is used to gain access to the peritoneal cavity. The catheter can be used for long term or temporary use.
Tenckhoff Gore-Tex Column-disc

Peritoneal Dialysis
Peritonitis: Meticulous aseptic technique must be maintained during handling of the catheter, tubing, and dialysate solution. What do you think the clinical evidence of peritonitis would be?

Peritoneal Dialysis
Catheter related complications: Displacement or obstruction may occur. Obstruction may be due to the adherence of the catheter tip to the omentum, or to exudates present due to infection, or to malposition of the catheter. Peristalsis facilitates outflow, so constipation can reduce catheter flow.

Peritoneal Dialysis

Fibrin clot formation may be a problem inside the catheter so heparin is often added to the dialysate. Bowel perforation may occur especially in those who are malnourished. What do you think your first clue would to tell if this complication has occurred?

Peritoneal Dialysis
Dialysis related complications: Pain: This may be due to rapid instillation of dialysate, incorrect dialysate temp or ph, dialysate accumulation under the diaphragm, or excessive suction during outflow. Fluid and electrolyte imbalance may occur. Hyperglycemia Why do you think this could occur?

You tube

peritoneal dialysis in renal failure #8 Sam Scarce

Hemodialysis
In hemodialysis toxin-filled blood is removed from the patient via some type of vascular access site, pumped through a dialyzer, and then returned to the client. The dialyzer has a blood compartment and a dialysate compartment. The two compartments are separated by a semipermeable membrane. Toxins and wastes diffuse across the membrane from the blood to the dialysate.

Hemodialysis -Vascular access Sites

Various vascular access sites may be used: Internal Arteriovenous Fistulas: This involves a surgical creation of an arteriovenous anastomosis to provide easy access to blood. This is used for clients requiring chronic dialysis. An artery is anastomosed to a vein so that there is an opening (fistula) between the artery and vein. The flow of arterial blood causes the vein to become engorged, and therefore usable in the dialysis procedure. These fistulas require 6 weeks to be mature enough for use. Other dialysis approaches are used until then.

Hemodialysis -Vascular access Sites

Internal Arteriovenous Grafts:

An artificial graft is made to create an artificial vein for blood flow. One end of the graft if anastomosed to an artery, tunneled under the skin and then anastomosed to a vein. It can be used two weeks after insertion.

Hemodialysis -Vascular access Sites

External Arteriovenous Shunts:

An external arterial cannula is connected to the dialyzer. Blood returns through the venous cannula. When not connected to the hemodialyzer, the cannulas are connected to each other.

Hemodialysis-Vascular access Sites

Femoral or Subclavian Vein:

These catheters are temporary sources of vascular access, and must be replaced frequently.

Hemodialysis
Schedule:

Hemodialysis must be continued intermittently for a clients lifetime if they have ESRD. A typical treatment is 3-4 hours of treatment, 3-4 days a week.

Hemodialysis
Complications of Hemodialysis:

Hypovolemic shock Blood loss Electrolyte imbalance Air embolus

Hemodialysis on you tube

hemodialysis procedure video
Hemo Dialysis (Labs, H/H, Cautions) Nursing Students