Renal Failure

Wendy DeMartino, MD
PGY-2

Objectives

Anatomy
Function
Acute Renal Failure (ARF)

Chronic Renal Failure (CRF)

Causes
Symptoms
Management
Causes
Symptoms

Dialysis

Anatomy

2 Kidneys
2 Ureters
Bladder
Urethra

Kidney Function
Detoxify blood
Increase calcium absorption

Stimulate RBC production

calcitriol
erythropoietin

Regulate blood pressure and

electrolyte balance

renin

Classifications
Acute versus chronic
Pre-renal, renal, post-renal
Anuric, oliguric, polyuric

Acute Versus Chronic

Acute

Chronic

sudden onset
rapid reduction in urine output
Usually reversible
Tubular cell death and regeneration
Progressive
Not reversible
Nephron loss

75% of function can be lost before its

noticeable

Acute Renal Failure

Pre-renal = 55%

Renal parenchymal (intrinsic)= 40%

Post-renal = 5-15%

Causes of ARF

Pre-renal =

Intrinsic

vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart
failure
cardiac failure, liver dysfunction, or septic shock
Interstitial nephritis, acute glomerulonephritis, tubular necrosis,
ischemia, toxins

Post-renal =

prostatic hypertrophy, cancer of the prostate or cervix, or

retroperitoneal disorders
neurogenic bladder
bilateral renal calculi, papillary necrosis, coagulated blood, bladder
carcinoma, and fungus

Symptoms of ARF

Decrease urine output (70%)

Edema, esp. lower extremity
Mental changes
Heart failure
Nausea, vomiting
Pruritus
Anemia
Tachypenic
Cool, pale, moist skin

Diagnosis of Renal Failure

Acute Renal Failure

Management

Make/think about the diagnosis

Treat life threatening conditions
Identify the cause if possible

Hypovolemia
Toxic agents (drugs, myoglobin)
Obstruction

Treat reversible elements

Hydrate
Remove drug
Relieve obstruction

ARF: Life Threatening

Conditions
Hyperkalemia
Volume overload
Vascular access

Hyperkalemia Symptoms

Weakness
Lethargy
Muscle cramps
Paresthesias
Hypoactive DTRs
Dysrhythmias

Hyperkalemia & EKG

K > 5.5 -6
Tall, peaked Ts
Wide QRS
Prolong PR
Diminished P
Prolonged QT
QRS-T merge
sine wave

Hyperkalemia Treatment
Calcium gluconate (carbonate)
Sodium Bicarbonate
Insulin/glucose
Kayexalate
Lasix
Albuterol
Hemodialysis

Chronic Renal Failure

150200 cases per million people =
new cases each year
Chronic renal failure and ESRD
affect more than 2 out of 1,000
people in the U.S
Mortality = 20%

Chronic Renal Failure

Causes
Diabetic Nephropathy
Hypertension
Glomerulonephritis
HIV nephropathy
Reflux nephropathy in children
Polycystic kidney disease
Kidney infections & obstructions

CRF Symptoms

Malaise
Weakness
Fatigue
Neuropathy
CHF
Anorexia
Nausea
Vomiting

Seizure
Constipation
Peptic ulceration
Diverticulosis
Anemia
Pruritus
Jaundice
Abnormal
hemostasis

Acute Problems in CRF

Relating to underlying disease
Relating to ESRD
Dialysis related problems

Problems Related to ESRD

Metabolic K/Ca
Volume overload
Anemia, platelet disorder, GI bleed
HTN, pericarditis
Peripheral neuropathy, dialysis
dementia
Abnormal immune function

Dialysis
of patients with CRF eventually
require dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types

Hemodialysis
Peritoneal dialysis

Hemodialysis
3-4 times a week
Takes 2-4 hours
Machine filters
blood and
returns it to
body

Types of Access

Temporary site
AV fistula

Surgeon constructs by combining an artery

and a vein
3 to 6 months to mature

AV graft

Man-made tube inserted by a surgeon to

connect artery and vein
2 to 6 weeks to mature

Temporary Catheter

AV Fistula & Graft

What This Means For You

No BP on same arm as fistula
Protect arm from injury
Control obvious hemorrhage

Bleeding will be arterial

Maintain direct pressure

No IV on same arm as fistula

A thrill will be felt this is normal

Access Problems
AV graft thrombosis
AV fistula or graft bleeding
AV graft infection
Steal Phenomenon

Early post-op
Ischemic distally
Apply small amount of pressure to
reverse symptoms

Peritoneal Dialysis
Abdominal lining filters blood
3 types

Continuous ambulatory
Continuous cyclical
Intermittent

EMS Considerations
Make sure the dressing remains
intact
Do not push or pull on the catheter
Do not disconnect any of the
catheters
Always transport the patient and
bags/catheters as one piece
Never inject anything into catheter

Dialysis Related Problems

Lightheaded give fluids
Hypotension
Dysrhythmias
Disequilibration Syndrome

At end of early sessions

Confusion, tremor, seizure
Due to decrease concentration of blood
versus brain leading to cerebral edema