GAGAL GINJAL/RENAL FAILURE

Acute Kidney Injury & Chronic Kidney

Diseases
Umar Zein

Medical Faculty
Islamic University of Sumatera Utara

BOWMANS
CAPSULE:
A spherical capsule
around glomerulus
(blood vessels).

PROXIMAL
CONVOLUTED
TUBULE:
About 75% of
sodium is removed
from fluid here (by
active transport,
chlorine follows
passively.)

LOOP OF HENLE:
The counter current
exchanger:
DESCENDING LOOP
OF HENLE:
Permeable to water and
other solutes.

LOOP OF HENLE:
The counter current
exchanger:
ASCENDING LOOP
OF HENLE:
Chlorine ions--active
transport out. Sodium
follows. Water does
NOT.

LOOP OF HENLE:
The counter current
exchanger sets up a
gradient of more salt
toward turn in loop, less
near convoluted tubules.

DISTAL
CONVOLUTED
TUBULE:
NaCl, Potassium,
ammonia, carbonate
removed here.

COLLECTING
TUBULE:
Passes parallel to Loop
of Henle, THROUGH
PROGRESSIVELY
MORE
CONCENTRATED
INTERSTITIAL
SPACE.

14

Assessment of Renal Function

Glomerular Filtration Rate (GFR) = the volume of fluid

filtered from the plasma per unit of time.
Gives a rough measure of the number of functioning
nephrons
Normal GFR:
Men: 130 mL/min./1.73m2
Women: 120 mL/min./1.73m2
Cannot be measured directly, so we use creatinine and
creatinine clearance to estimate.

Assessment of Renal Function (cont.)

Creatinine

A naturally occurring amino acid, predominately found in skeletal

muscle
Freely filtered in the glomerulus, excreted by the kidney and readily
measured in the plasma
As plasma creatinine increases, the GFR exponentially decreases.
Limitations to estimate GFR:
Patients with decrease in muscle mass, liver disease,
malnutrition, advanced age, may have low/normal creatinine
despite underlying kidney disease
15-20% of creatinine in the bloodstream is not filtered in
glomerulus, but secreted by renal tubules (giving overestimation
of GFR)
Medications may artificially elevate creatinine: Nephrotoxic

Assessment of Renal Function (cont.)

Creatinine Clearance ; Best way to estimate GFR

GFR = (creatinine clearance) x (body surface area in m 2/1.73)

Ways to measure:
24-hour urine creatinine:
Creatinine clearance = (Ucr x Uvol)/ plasma Cr

Cockcroft-Gault Equation:

(140 - age) x lean body weight [kg]

CrCl (mL/min) = x
Cr [mg/dL] x 72
0.85

if female

Acute Kidney Injury/Acute Renal

Failure

Sudden interruption of kidney function resulting from

obstruction, reduced circulation, or disease of the renal
tissue
Results in retention of toxins, fluids, and end products
of metabolism
Usually reversible with medical treatment
May progress to end stage renal disease, uremic
syndrome, and death without treatment

Persons at Risks

Major surgery
Major trauma
Receiving nephrotoxic medications
Elderly

Background

The incidence of AKI is estimated at 1% of patients that present

to the hospital and 7-50% of patients in the ICU.
Part of the initial history should be determining every patients
baseline Cr.
May present as Uremia (malaise, anorexia, nausea, vomiting),
but is usually asymptomatic.
Acute Kidney Injury Network (AKIN) Criteria

Stage

Cr Criteria

UOP Criteria

Crby 1.5-2x baseline or Crby

0.3 mg/dl

< 0.5 ml/kg/hr for 6hr

Crby 2-3x

< 0.5 ml/kg/hr for 12hr

Crby more than 3x or

if baseline >4mg/dl

Crby 0.5 < 0.3 ml/kg/hr for 24hr

Or anuria for 12h

Causes

Prerenal
Hypovolemia, shock, blood loss, embolism, pooling of fluid
d/t ascites or burns, cardiovascular disorders, sepsis
Intrarenal
Nephrotoxic agents, infections, ischemia and blockages,
polycystic kidney disease
Postrenal
Stones, blood clots, BPH, urethral edema from invasive
procedures

Stages

Onset : 1-3 days with BUN and creatinine and possible

decreased UOP
Oliguric: UOP < 400/d, BUN, Crest, Phos, K, may last up
to 14 d
Diuretic : UOP to as much as 4000 mL/d but no waste
products, at end of this stage may begin to see
improvement
Recovery: things go back to normal or may remain
insufficient and become chronic

AKI can be Prerenal, Intrinsic or Postrenal

Acute Kideny Injury

Prerenal
Uosm > 5000 mosm/kg
Una < 20meq/L
FEna < 1%
Microscopy - bland

Ischemic / Toxic ATN

Uosm ~ 300 mosm/kg
Una > 40meq/L
FEna > 2%
Microscopy dark pigment cast

Intrinsic Renal Diseases

Acute Interstitial Nephritis

Uosm: variable, ~300 mosm.kg
Una > 40 meq/L
FEna > 2%
Microscopy leukocytes,
erythrocyts, leukocyte casts

Postrenal
Uosm: variable
Una: low early, high late
FEna: variable
Microscopy - bland

Acute Glomerulonephritis
Uosm: variable (>400 in early GN)
Una: variable (<20meq/l in early GN)
FEna: variable, <1% in early GN
Microscopy hematuria, proteinuria
Erythrocyte casts (dysmorphic)

Acute Renal Failure

Diagnostic Tools

Urinary sediment
Urinary indices

Urine volume
Urine electrolytes

Radiologic studies

Urinary Sediment (1)

Bland

Pre-renal azotaemia
Urinary outlet obstruction

Urinary Sediment (2)

RBC casts or dysmorphic RBCs

Acute glomerulonephritis
Small vessel vasculitis

Red Blood Cell Cast

Red Blood Cells

Monomorphic

Dysmorphic

Dysmorphic Red Blood Cells

Dysmorphic Red Blood Cells

Urinary Sediment (3)

WBC Cells and WBC Casts

Acute interstitial nephritis

Acute pyelonephritis

White Blood Cells

White Blood Cell Cast

Urinary Sediment (4)

Renal Tubular Epithelial (RTE) cells, RTE cell

casts, pigmented granular (muddy brown)
casts

Acute tubular necrosis

Renal Tubular Epithelial Cell Cast

Pigmented Granular Casts

Hydronephrosis

Normal Renal Ultrasound

Hydronephrosis

Hydronephrosis

Acute Renal Failure

Subjective symptoms

Nausea
Loss of appetite
Headache
Lethargy
Tingling in extremities

Objective symptoms

Oliguric phase

vomiting
disorientation,
edema,
^K+
decrease Na
^ BUN and creatinine
Acidosis
uremic breath

CHF and pulmonary edema

hypertension caused by
hypovolemia, anorexia
sudden drop in UOP
convulsions, coma
changes in bowels

Objective systoms

Diuretic phase
Increased UOP
Gradual decline in BUN and creatinine
Hypokalemia
Hyponaturmia
Tachycardia
Improved LOC

Diagnostic tests

H&P
BUN, creatinine, sodium, potassium. pH, bicarb. Hgb and Hct
Urine studies
US of kidneys
KUB
ABD and renal CT/MRI
Retrograde pyloegram

Medical treatment

Fluid and dietary restrictions

Maintain E-lytes
D/C or change cause
May need dialysis to jump start renal function
May need to stimulate production of urine with IV
fluids, Dopomine, diuretics, etc.

Medical treatment

Hemodialysis
Subclavian approach
Femoral approach

Peritoneal dialysis
Continous renal replacement therapy (CRRT)
Can be done continuously
Does not require dialysate

Nursing interventions

Monitor I/O, including all body

fluids
Monitor lab results
Watch hyperkalemia symptoms:
malaise, anorexia, parenthesia,
or muscle weakness, EKG
changes
watch for hyperglycemia or
hypoglycemia if receiving TPN
or insulin infusions

Maintain nutrition
Safety measures
Mouth care
Daily weights
Assess for signs of heart failure
GCS and Denny Brown
Skin integrity problems

Prerenal Azotemia

Prerenal azotemia is the most common cause of

acute kidney injury in the outpatient setting

Look for patients with decreased PO, diarrhea, vomiting,

tachycardia, orthostasis.
Order: UA, Uosm, Una, Ucr, BMP, Uurea (if on diuretics)

The kidney functions properly in patients with

prerenal azotemia.

True volume depletion can be treated with normal saline.

Decreased effective arterial blood volume can be
present in CHF, Cirrhosis or nephrotic syndrome.
Treatment should focus on the underlying disease.

Intrinsic Kidney Diseases

ATN - Acute Tubular Necrosis

AIN - Acute Interstitial Nephritis

Classic presentation is fever, rash, eosinophilia and Cr bump 7-10 days

after drug exposure.
Urine may show leukocytes, leukocyte casts and erythrocytes, cultures
will be negative.

CIN - Contrast Induced Nephropathy

Usually occurs after an ischemic event or exposure to nephrotoxic

agents.
Look for muddy brown casts and FeNa>2%

Increased Cr of 0.5mg/dl or 25% 48hrs after contrast administration.

Prevent with NS or isotonic fluid+sodium bicarb, hold NSAIDs, metformin
and diuretics (in patients without fluid overload).

Others Glomerular Disease, Pigmented Nephropathy,

Thrombotic Microangiopathy

Postrenal Disease

Obstruction anywhere in the urinary tract

Bladder outlet obstruction can be seen with bladder

scan and relieved with catheterization
Ureteral obstruction and hydronephrosis may be seen
on ultrasound and noncontrast CT
Order: UA, Uosm, Una, Ucr, BMP, Uurea (if on diuretics)

Patients often have a history of pelvic tumors,

irradiation, congential abnormalities, kidney stones,
genitourinary, procedures or surgeries, and
prostatic enlargement.

Indications for acute dialysis

AEIOU

Acidosis (metabolic)
Electrolytes (hyperkalemia)
Ingestion of drugs/Ischemia
Overload (fluid)
Uremia

Conclusion

Think about who might be vulnerable to acute

renal failure
Think twice before initiating therapy that may
cause ARF
Think about it as a diagnosis dont look/wont
find

Chronic Renal Failure

Results form gradual, progressive loss of renal function

Occasionally results from rapid progression of acute
renal failure
Symptoms occur when 75% of function is lost but
considered cohrnic if 90-95% loss of function
Dialysis is necessary D/T accumulation or uremic
toxins, which produce changes in major organs

Chronic Renal Failure

Subjective symptoms are relatively same as acute

Objective symptoms

Renal

Hyponaturmia
Dry mouth
Poor skin turgor
Confusion, salt overload, accumulation of K with muscle weakness
Fluid overload and metabolic acidosis
Proteinuria, glycosuria
Urine = RBCs, WBCs, and casts

Chronic Renal Failure

Objective symptoms

Cardiovascular

Hypertension
Arrythmias
Pericardial effusion
CHF
Peripheral edema

Neurological

Burning, pain, and itching,

parestnesia
Motor nerve dysfunction
Muscle cramping
Shortened memory span
Apathy
Drowsy, confused, seizures,
coma, EEG changes

Chronic Renal Failure

Objective symptoms

GI

Stomatitis
Ulcers
Pancreatitis
Uremic fetor
Vomiting
consitpation

Respiratory

^ chance of infection
Pulmonary edema
Pleural friction rub and
effusion
Dyspnea
Kussmauls respirations
from acidosis

Chronic Renal Failure

Objective symptoms

Endocrine

Stunted growth in children

Amenorrhea
Male impotence
^ aldosterone secretion
Impaired glucose levels R/T
impaired CHO metabolism
Thyroid and parathyroid
abnormalities

Hemopoietic

Anemia
Decrease in RBC survival time
Blood loss from dialysis and GI
bleed
Platelet deficits
Bleeding and clotting disorders
purpura and hemorrhage
from body orifices ,
ecchymoses

Chronic Renal Failure

Objective symptoms

Skeletal

Muscle and bone pain

Bone demineralization
Pathological fractures
Blood vessel calcifications
in myocardium, joints, eyes,
and brain

Skin

Yellow-bronze skin with

pallor
Puritus
Purpura
Uremic frost
Thin, brittle nails
Dry, brittle hair, and may
have color changes and
alopecia

Chronic Renal Failure

Lab findings

BUN indicator of glomerular filtration rate and is affected by

the breakdown of protein. Normal is 10-20mg/dL. When
reaches 70 = dialysis
Serum creatinine waste product of skeletal muscle
breakdown and is a better indicator of kidney function.
Normal is 0.5-1.5 mg/dL. When reaches 10 x normal, it is
time for dialysis
Creatinine clearance is best determent of kidney function.
Must be a 12-24 hour urine collection. Normal is > 100
ml/min

Chronic Renal Failure

K+

The kidneys are means which K+ is excreted. Normal is 3.55.0 ,mEq/L. maintains muscle contraction and is essential for
cardiac function.
Both elevated and decreased can cause problems with
cardiac rhythm
Hyperkalemia is treated with IV glucose and Na Bicarb which
pushes K+ back into the cell
Kayexalate is also used

Chronic Renal Failure

Ca

With disease in the kidney, the enzyme for utilization of Vit D

is absent
Ca absorption depends upon Vit D
Body moves Ca out of the bone to compensate and with that
Ca comes phosphate bound to it.
Normal Ca level is 4.5-5.5 mEq/L
Hypocalcemia = tetany

Treat with calcium with Vit D and phosphate

Avoid antacids with magnesium

Chronic Renal Failure

Other abnormal findings

Metabolic acidosis
Fluid imbalance
Insulin resistance
Anemia
Immunological problems

Chronic Renal Failure

Medical treatment
IV glucose and insulin
Na bicarb, Ca, Vit D, phosphate binders
Fluid restriction, diuretics
Iron supplements, blood, erythropoietin
High carbs, low protein
Dialysis - After all other methods have failed

Chronic Renal Failure

Hemodialysis

Vascular access
Temporary subclavian or femoral
Permanent shunt, in arm

Care post insertion

Can be done rapidly

Takes about 4 hours
Done 3 x a week

Chronic Kidney Diseases

Peritoneal dialysis

Semipermeable membrane
Catheter inserted through
abdominal wall into peritoneal
cavity
Cost less
Fewer restrictions
Can be done at home
Risk of peritonitis
3 phases inflow, dwell and
outflow

Automated peritoneal dialysis

Done at home at night

Maybe 6-7 times /week

CAPD

Continous ambulatory
peritoneal dialysis
Done as outpatient
Usually 4 X/d

Nursing care

Frequent monitoring
Hydration and output
Cardiovascular function
Respiratory status
E-lytes
Nutrition
Mental status
Emotional well being

Ensure proper medication

regimen
Skin care
Bleeding problems
Care of the shunt
Education to client and
family

Nursing diagnosis

Excess fluid volume

Imbalanced nutrition
Ineffective coping
Risk for infection
Risk for injury

Transplant

Must find donor

Waiting period long
Good survival rate 1 year 95-97%
Must take immunosuppressants for life
Rejection

Watch for fever, elevated B/P, and pain over site of new
kidney

CVVH, HVHF, CVVHD, CVVHDF

SLED

Hemodialysis

Hemofiltration