CHRONIC RENAL

FAILURE (CRF)
BY: NATALIE WANG
INSTRUCTOR: HIAM ABULABAN
 1. EPIDEMIOLOGY
2. ACUTE KIDNEY INJURY VS CHRONIC RENAL FAILURE
• CAUSES, PATHOPHYSIOLOGY, SIGNS &
SYMPTOMS, DIAGNOSTICS
3. STAGES OF CHRONIC RENAL FAILURE
4. COMPLICATIONS: MIND MAP & NURSING CARE
5. FLUID & ELECTROLYTE ISSUES & WHY THEY OCCUR
AGENDA & 6. MEDICAL INTERVENTIONS & TREATMENT GOALS

LEARNING 7. PERITONEAL DIALYSIS & HEMODIALYSIS

OUTCOMES
 STATS

• 1 IN 10 CANADIANS HAVE KIDNEY DISEASE

• INDIGENOUS PEOPLES IN CANADA HAVE A HIGHER PREVALENCE OF CHRONIC RENAL FAILURE
THAN OTHER POPULATIONS AT 25.5%
• ON AVERAGE, KIDNEY PATIENTS WAIT 4 YEARS OR MORE FOR A DECEASED-DONOR KIDNEY
TRANSPLANT
• 14% OF THE 24,114 PEOPLE ON DIALYSIS ARE ON THE WAITING LIST FOR A TRANSPLANT

(The Kidney Foundation of Canada, 2016)

 WHAT IS IT?
ACUTE KIDNEY INJURY (AKI) CHRONIC RENAL FAILURE
• ABRUPT & USUALLY REVERSIBLE DECREASE IN • PRESENCE OF KIDNEY DAMAGE OR SUBTLE
KIDNEY FUNCTION FOR LESS THAN 3 DECREASED KIDNEY FUNCTION FOR 3 OR
MONTHS (USUALLY WITHIN 48HRS) MORE MONTHS, REGARDLESS OF CAUSE
• RISE IN SERUM CREATININE • IRREVERSIBLE DAMAGE TO KIDNEYS
CONCENTRATION OR DECLINE IN URINE
OUTPUT DEVELOPING WITHIN HOURS TO
DAYS

(Levery & Coresh, 2019)

 CAUSES
ACUTE KIDNEY INJURY CHRONIC KIDNEY FAILURE
EVENTS LEADING TO KIDNEY INJURY LONG-TERM DISEASE: MOST COMMON
• PRE-RENAL CAUSES
• HYPERTENSION
• INTRA-RENAL
• POST-RENAL • DIABETES
OTHER CAUSES:
• INFECTIONS, AUTOIMMUNE DISORDERS,
CANCER, SUPPLEMENTS/ MEDICATIONS,
GENETICS

(Okusa & Rosner, 2017), (Osmosis, 2019)

 DIAGNOSTICS
ACUTE KIDNEY INJURY CHRONIC RENAL FAILURE

• INCREASE IN SERUM CREATININE • GFR < 90ML/MIN/1.73M2 FOR LONGER

(NORMAL: 40-95MMOL/L) THAN 3 MONTHS
AND/OR
AND/OR
• DECREASE IN URINE OUTPUT • PRESENCE OF KIDNEY DAMAGE FOR
LONGER THAN 3 MONTHS
WHICH OF THE FOLLOWING CLIENTS IS AT GREATEST
RISK FOR DEVELOPING AN ACUTE KIDNEY INJURY?
A. A DIALYSIS CLIENT WHO GETS INFLUENZA
B. A TEENAGER WHO HAS AN APPENDECTOMY
C. A PREGNANT WOMEN WHO HAS A FRACTURED FEMUR
D. A CLIENT WITH DIABETES WHO IS GOING FOR A HEART CATHETERIZATION

ANSWER: D) A CLIENT WITH DIABETES WHO IS GOING FOR A HEART CATHETERIZATION

(Medical Assistant Practice Exam, 2016)
 STAGES OF CRF

Stagea 1 2 3a 3b 4 5
Qualitative Kidney damage Kidney damage Moderate Moderate Severe ↓ GFR End-Stage
Description & normal GFR & mild ↓ GFR ↓ GFR ↓ GFR Renal Disease
(ESRD)
GFR > 90* 60-90* 45-59 30-44 15-29 < 15
(mL/min/1.73m2)
Signs & Asymptomatic Possible HTN Azotemia, Azotemia, Edema, Uremia, heart
Symptoms anemia, HTN, anemia, HTN, metabolic failure
associated with polyuria or polyuria or acidosis,
staging oliguria oliguria hypocalcemia,
hyperkalemia
(McFarlane, Cherney, Gilbert, & Senior, 2018)
 HELEN HAMES: STAGING OF CRF

• DEVELOPED CRF 3 YEARS AGO FOLLOWING MI

• LABWORK:

Urea Creatinine Albumin eGFR

Day 1 ↑ 8.6 ↑ 186 ↓ 29 ↓ 63
Day 2 ↑ 10.8 ↑ 212 N/A ↓ 61

WHAT STAGE OF CRF IS HELEN HAMES?

ANSWER: STAGE 2
 PATHOPHYSIOLOGY: AKI

Leads to elevation in serum

Abrupt & usually reversible blood urea nitrogen (BUN),
decline in glomerular creatinine, & other
filtration rate (GFR) metabolic waste products
normally excreted by the
kidney
 SOME SIGNS & SYMPTOMS OF AKI

Oliguria or Hematuria Nausea & Peripheral Fatigue & Decreased Seizures

anuria vomiting edema weakness LOC and/or
change in
mental
status
PATHOPHYSIOLOGY: HYPERTENSION & CRF

(Osmosis, 2019)
PATHOPHYSIOLOGY: DIABETES & CRF

(Osmosis, 2019)
 Hypertension & Fluid overload
Hypernatremia & Hyperkalemia
Polyuria, oliguria, & Anuria
COMPLICATIONS
OF CRF Anemia
Hyperphosphatemia & Hypocalcemia
Metabolic acidosis
Azotemia & Uremia
(Beatty, 2018)
 Nutrition & Diet changes

Lifestyle changes

MEDICAL
Kidney Transplantation
INTERVENTIONS

Dialysis

Conservative care

(The Kidney Foundation of Canada, 2019)

 Fluids

Sodium

NUTRITION Protein
& DIET
CHANGES Phosphorous

Potassium

Starfruit: contains neurotoxin caramboxin, a CNS inhibitor

(BC Provincial Renal Agency, 2012), (Oliveria & Aguiar, 2015)

 WHAT 2 THINGS COULD LEAD TO HYPERKALEMIA IN
HELEN HAMES?
1. ENALAPRIL 5MG PO ONCE DAILY
• ACE-INHIBITORS INCREASE RISK OF HYPERKALEMIA ESPECIALLY IF TAKING POTASSIUM
SUPPLEMENTS OR FOOD HIGH IN POTASSIUM
2. HUSBAND GIVES HER A BANANA OR ORANGE JUICE EVERY MORNING BECAUSE “HER
POTASSIUM CAN GO DOWN LOW DUE TO THE WATER PILLS”
BC DIET
GUIDELINES
HEALTHLINK BC - EARLY CRF BC RENAL AGENCY -
DIET GUIDELINES HEMODIALYSIS DIET
GUIDELINES
 HOW DOES DIALYSIS WORK?

OSMOSIS & DIFFUSION

• OSMOSIS: REMOVAL OF FLUID FROM BLOOD BY ALLOWING IT TO PASS THROUGH A SEMI-
PERMEABLE MEMBRANE TO AN AREA OF HIGH CONCENTRATION (DIALYSATE SOLUTION)
• DIFFUSION: PASSAGE OF PARTICLES (ELECTROLYTES, UREA, & CREATININE) FROM AN AREA OF
HIGH CONCENTRATION TO AN AREA OF LOWER CONCENTRATION

(Medical Assistant Practice Exam, 2016)

 HEMODIALYSIS (HD)
• EXCHANGES OCCUR OUTSIDE THE BODY
• ACCESS SITES:
• INTRAJUGULAR (IJ)
• PERMACATH
• ARTERIOVENOUS (AV) GRAFT OR
ARTERIOVENOUS (AV) FISTULA
• TYPES OF HD:
• IN-CENTER HD
• HOME HD
• DAILY HOME HD
• NOCTURNAL HOME HD
• CONTINUOUS HD (ICU ONLY)
https://www.youtube.com/watch?v=IQKQ4eoKfTg
 PERITONEAL DIALYSIS (PD)
• EXCHANGES TAKE PLACE WITHIN BODY
• ACCESS SITE:
• ABDOMEN (USUALLY CLOSE TO
UMBILICUS) WITH CATHETER TIP IN
https://www.sciencephoto.com/media/494318/view/peritoneal-dialysis-site-on-abdomen
PERITONEUM
• TYPES OF PD:
• CONTINUOUS AMBULATORY
PERITONEAL DIALYSIS (CAPD)
• AUTOMATED PERITONEAL DIALYSIS
(APD)

https://www.flickr.com/photos/the_taif_healthy_city_programme/883980217
 HEMODIALYSIS: NURSING CARE
PRE:
1. WHY DO WE HOLD (CERTAIN) MEDICATIONS BEFORE BEGINNING HD?
2. WHAT MEDICATIONS WOULD WE HOLD?
INTRA:
1. WHAT MEDICATIONS/ TREATMENTS ARE YOU LIKELY TO GIVE DURING HD? WHY?
POST:
1. WHAT WOULD YOU GIVE YOUR PATIENT AFTER THEY FINISH HD?

(EASY NURSING, 2017)

 HEMODIALYSIS DISEQUILIBRIUM SYNDROME
• REDUCED BUN INDUCED BY UREA REMOVAL IN DIALYZER
• LOWER PLASMA OSMOLALITY CREATING AN OSMOTIC GRADIENT THAT PROMOTES WATER
MOVEMENT INTO CELLS
• IN THE BRAIN, THIS FLUID SHIFT PRODUCES CEREBRAL EDEMA

RISK FACTORS:
• 1ST DIALYSIS TREATMENT, MARKEDLY HIGH BUN, SEVERE METABOLIC ACIDOSIS, GERIATRIC OR
PEDIATRIC PATIENTS, PRE-EXISTING NEUROLOGIC DISEASE
(Mailloux, 2018)
 YOUR CLIENT RETURNS TO THE UNIT FOLLOWING
HEMODIALYSIS. ON ASSESSMENT, YOU NOTICE YOUR
CLIENT’S TEMPERATURE IS 37.9ºC. WHICH OF THE
FOLLOWING IS THE MOST APPROPRIATE NURSING
ACTION?
A. ENCOURAGE FLUIDS
B. NOTIFY THE PHYSICIAN
C. ASSESS THE DIALYSIS ACCESS SITE FOR SIGNS OF INFECTION
D. CONTINUE TO MONITOR VITAL SIGNS

ANSWER: D) CONTINUE TO MONITOR VITAL SIGNS

(Medical Assistant Practice Exam, 2016)
 THE NURSE IS PERFORMING AN ASSESSMENT ON A CLIENT
WHO HAS JUST RETURNED FROM HEMODIALYSIS. THE
CLIENT IS COMPLAINING OF HEADACHE, NAUSEA, & IS
EXTREMELY RESTLESS. WHICH OF THE FOLLOWING IS THE
MOST APPROPRIATE NURSING ACTION?
A. NOTIFY THE PHYSICIAN
B. MONITOR THE CLIENT
C. ELEVATE THE HEAD OF THE BED
D. GIVE THE CLIENT AN ANTI-EMETIC FOR THE NAUSEA

ANSWER: A) NOTIFY THE PHYSICIAN

(MEDICAL ASSISTANT PRACTICE EXAM, 2016)
REFERENCES CITED:
• BC PROVINCIAL RENAL AGENCY. (2012, DECEMBER). DIET FOR HEMODIALYSIS. RETRIEVED FROM BC RENAL AGENCY:
HTTP://WWW.BCRENALAGENCY.CA/RESOURCE-GALLERY/DOCUMENTS/DIETFORHEMODIALYSISFINALDEC2012.PDF
• BEATTY, C. (2018, APRIL 30). MODULE 5: RENAL AND URINARY PATHOPHYSIOLOGY. RETRIEVED FROM BCIT LEARNING HUB.
• EASY NURSING. (2017, JUNE 26). HEMODIALYSIS - NCLEX REVIEW. RETRIEVED FEBRUARY 27, 2019, FROM YOUTUBE:
HTTPS://WWW.YOUTUBE.COM/WATCH?V=3KMNLOWLUAQ
• FISCHER, K. (2007, APRIL). ESSENTIALS OF ANTICOAGULATION IN HEMODIALYSIS. HEMODIALYSIS INTERNATIONAL, 11(2), 178-189.
• HEALTHLINK BC. (2019). HEALTHY EATING GUIDELINES FOR PEOPLE WITH EARLY CHRONIC KIDNEY DISEASE (CD) STAGES 1 AND 2 . RETRIEVED
FROM HEALTHLINK BC: HTTPS://WWW.HEALTHLINKBC.CA/HEALTHY-EATING/EARLY-CHRONIC-KIDNEY-DISEASE
• LEVERY, A., & CORESH, J. (2019). DEFINITION AND CRITERIA FOR CHRONIC KIDNEY DISEASE. RETRIEVED FROM UPTODATE:
HTTPS://WWW.UPTODATE.COM/CONTENTS/IMAGE?IMAGEKEY=NEPH%2F80632&TOPICKEY=NEPH%2F16406&SEARCH=CHRONIC&SOURCE=S
EE_LINK
• MCFARLANE, P., CHERNEY, D., GILBERT, R. E., & SENIOR, P. (2018). CHRONIC KIDNEY DISEASE IN DIABETES . RETRIEVED FROM DIABETES CANADA:
HTTP://GUIDELINES.DIABETES.CA/CPG/CHAPTER29
• MEDICAL ASSISTANT PRACTICE EXAM. (2016, OCTOBER 13). NCLEX PRACTICE EXAM: RENAL FAILURE & DIALYSIS, PART 1. RETRIEVED FROM
YOUTUBE: HTTPS://WWW.YOUTUBE.COM/WATCH?V=XQQSO0-N5TA
REFERENCES CITED:
• OKUSA, M. D., & ROSNER, M. H. (2017, NOVEMBER 16). OVERVIEW OF THE MANAGEMENT OF ACUTE KIDNEY INJURY IN ADULTS. RETRIEVED
FEBRUARY 28, 2019, FROM UPTODATE: HTTPS://WWW.UPTODATE.COM/CONTENTS/OVERVIEW-OF-THE-MANAGEMENT-OF-ACUTE-KIDNEY-
INJURY-IN-
ADULTS?SEARCH=ACUTE%20KIDNEY%20INJURY%20PATHOPHYSIOLOGY&SECTIONRANK=1&USAGE_TYPE=DEFAULT&ANCHOR=H2271117744&
SOURCE=MACHINELEARNING&SELECTEDTITLE=2~150&DISPLAY_RANK=2#H2
• OLIVERIA, E. S., & AGUIAR, A. S. (2015, JUNE). WHY EATING STAR FRUIT IS PROHIBITED FOR PATIENTS WITH CHRONIC KIDNEY DISEASE? BRAZILIAN
JOURNAL OF NEPHROLOGY, 37(2).
• OSMOSIS. (2019). CHRONIC KIDNEY DISEASE. RETRIEVED MARCH 2, 2018, FROM OSMOSIS:
HTTPS://WWW.OSMOSIS.ORG/LEARN/CHRONIC_KIDNEY_DISEASE
• ROSENBERG, M. (2018, JUNE 29). OVERVIEW OF THE MANAGEMENT OF CHRONIC KIDNEY DISEASE IN ADULTS. RETRIEVED FEBRUARY 28, 2019,
FROM UPTODATE: HTTPS://WWW.UPTODATE.COM/CONTENTS/OVERVIEW-OF-THE-MANAGEMENT-OF-CHRONIC-KIDNEY-DISEASE-IN-
ADULTS?SEARCH=MANAGEMENT%20OF%20CHRONIC%20KIDNEY%20DISEASE&SOURCE=SEARCH_RESULT&SELECTEDTITLE=1~150&USAGE_TYPE
=DEFAULT&DISPLAY_RANK=1#H7
• THE KIDNEY FOUNDATION OF CANADA. (2019). CONSERVATIVE CARE. RETRIEVED FROM THE KIDNEY FOUNDATION OF CANADA:
HTTPS://WWW.KIDNEY.CA/CONSERVATIVE-CARE