ACUTE RENAL FAILURE

Renal failure or kidney failure (formerly called renal insufficiency) describes a medical condition in which the kidneys fail to adequately filter toxins and waste products from the blood. The two forms are acute (acute kidney injury) and chronic (chronic kidney disease); a number of other diseases or health problems may cause either form of renal failure to occur. Renal failure is described as a decrease in the glomerular filtration rate. Biochemically, renal failure is typically detected by an elevated serum creatinine level. Problems frequently encountered in kidney malfunction include abnormal fluid levels in the body, deranged acid levels, abnormal levels of potassium, calcium, phosphate, and (in the longer term) anemia as well as delayed healing in broken bones. Depending on the cause, hematuria (blood loss in the urine) and proteinuria (protein loss in the urine) may occur. Long-term kidney problems have significant repercussions on other diseases, such as cardiovascular disease.

CAUSES
Acute kidney failure usually occurs when the blood supply to the kidneys is suddenly interrupted or when the kidneys become overloaded with toxins. Causes of acute failure include accidents, injuries, or complications from surgeries in which the kidneys are deprived of normal blood flow for extended periods of time. Heart-bypass surgery is an example of one such procedure. Drug overdoses, accidental or from chemical overloads of drugs such as antibiotics or chemotherapeutics, may also cause the onset of acute kidney failure. Unlike in chronic kidney disease, however, the kidneys can often recover from acute failure, allowing the patient to resume a normal life. People suffering from acute failure require supportive treatment until their kidneys recover function, and they often remain at increased risk of developing future kidney failure. Among the accidental causes of renal failure is there also the crush syndrome, when large amounts of toxins are suddenly released in the blood circulation after a long compressed limbis suddenly relieved from the pressure obstructing the blood flow through its tissues, causing ischemia. The resulting overload can lead to the clogging and the destruction of the kidneys. It is a reperfusion injury that appears after the release of the crushing pressure. The mechanism is believed to be the release into the bloodstream of muscle breakdown products notably myoglobin, potassium and phosphorus that are the products of rhabdomyolysis (the breakdown of skeletal muscle damaged by ischemic conditions). The specific action on thekidneys is not fully understood, but may be due in part to nephrotoxic metabolites of myoglobin.

CLASSIFICATION
Renal failure can be divided into two categories: acute kidney injury or chronic kidney disease. The type of renal failure is determined by the trend in the serum creatinine. Other factors which may help differentiate acute kidney injury from chronic kidney disease include anemia and the kidney size on ultrasound. Chronic kidney disease generally leads to anemia and small kidney size. Acute kidney injury Acute kidney injury (AKI), previously called acute renal failure (ARF), is a rapidly progressive loss of renal function, generally characterized by oliguria (decreased urine production, quantified as less than 400 mL per day in adults, less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants); and fluid and electrolyte imbalance. AKI can result from a variety of causes, generally classified as prerenal, intrinsic, and postrenal. An underlying cause must be identified and treated to arrest the progress, and dialysis may be necessary to bridge the time gap required for treating these fundamental causes. Chronic kidney disease Chronic kidney disease (CKD) can develop slowly and, initially, show few symptoms. CKD can be the long term consequence of irreversible acute disease or part of a disease progression. Acute-on-chronic renal failure Acute kidney injuries can be present on top of chronic kidney disease, a condition called acute-on-chronic renal failure (AoCRF). The acute part of AoCRF may be reversible, and the goal of treatment, as with AKI, is to return the

patient to baseline renal function, typically measured by serum creatinine. Like AKI, AoCRF can be difficult to distinguish from chronic kidney disease if the patient has not been monitored by a physician and no baseline (i.e., past) blood work is available for comparison.

PREVENTION
Since AKF can be caused by many things, prevention is difficult. Medications that may impair kidney function should be given cautiously. Patients with preexisting kidney conditions who are hospitalized for other illnesses or injuries should be carefully monitored for kidney failure complications. Treatments and procedures that may put them at risk for kidney failure (like diagnostic tests requiring radiocontrast agents or dyes) should be used with extreme caution.

DIAGNOSTIC PROCEDURE
Measurement for CKD Stages of kidney failure Chronic kidney failure is measured in five stages, which are calculated using a patient s GFR, or glomerular filtration rate. Stage 1 CKD is mildly diminished renal function, with few overt symptoms. Stages 2 and 3 need increasing levels of supportive care from their medical providers to slow and treat their renal dysfunction. Patients in stages 4 and 5 usually require preparation of the patient towards active treatment in order to survive.Stage 5 CKD is considered a severe illness and requires some form of renal replacement therapy (dialysis) or kidney transplant whenever feasible. Glomerular filtration rate A normal GFR varies according to many factors, including sex, age, body size and ethnicity. Renal professionals consider the glomerular filtration rate (GFR) to be the best overall index of kidney function.The National Kidney Foundation offers an easy to use on-line GFR calculator for anyone who is interested in knowing their glomerular filtration rate. (A serumcreatinine level, a simple blood test, is needed to use the calculator).

SYMPTOMS
Symptoms can vary from person to person. Someone in early stage kidney disease may not feel sick or notice symptoms as they occur. When kidneys fail to filter properly, waste accumulates in the blood and the body, a condition called azotemia. Very low levels of azotaemia may produce few, if any, symptoms. If the disease progresses, symptoms become noticeable (if the failure is of sufficient degree to cause symptoms). Renal failure accompanied by noticeable symptoms is termed uraemia. Symptoms of kidney failure include:

High levels of urea in the blood, which can result in: Vomiting and/or diarrhea, which may lead to dehydration Nausea Weight loss Nocturnal urination More frequent urination, or in greater amounts than usual, with pale urine Less frequent urination, or in smaller amounts than usual, with dark coloured urine Blood in the urine Pressure, or difficulty urinating Unusual amounts of urination, usually in large quantities A build up of phosphates in the blood that diseased kidneys cannot filter out may cause: Itching Bone damage Nonunion in broken bones Muscle cramps (caused by low levels of calcium which can cause hypocalcaemia)  A build up of potassium in the blood that diseased kidneys cannot filter out (called hyperkalemia) may cause: Abnormal heart rhythms

Muscle paralysis Failure of kidneys to remove excess fluid may cause: Swelling of the legs, ankles, feet, face and/or hands Shortness of breath due to extra fluid on the lungs (may also be caused by anemia)  Polycystic kidney disease, which causes large, fluid-filled cysts on the kidneys and sometimes the liver, can cause: Pain in the back or side Healthy kidneys produce the hormone erythropoietin which stimulates the bone marrow to make oxygencarrying red blood cells. As the kidneys fail, they produce less erythropoietin, resulting in decreased production of red blood cells to replace the natural breakdown of old red blood cells. As a result, the blood carries less hemoglobin, a condition known as anemia. This can result in: Feeling tired and/or weak Memory problems Difficulty concentrating Dizziness Low blood pressure Proteins are usually too big to pass through the kidneys, but they can pass through when the glomeruli are damaged. This does not cause symptoms until extensive kidney damage has occurred, after which symptoms include: Foamy or bubbly urine Swelling in the hands, feet, abdomen, or face Other symptoms include: Appetite loss, a bad taste in the mouth Difficulty sleeping Darkening of the skin Excess protein in the blood

NURSING MANAGEMENT
To the nursing intervention, the nurses should be have good knowledge to decide which phase of his/her patient related to the acute renal failure. Base on that information, bellow are some nursing intervention they can do to the patient with acute renal failure : * Oliguric-anuric phase ; In this phase, the client's urine output falls bellow 400 ml/day. With resultant electrolyte imbalance, metabolic acidosis, and retention of nitrogenouse wastes from non functioning nephrons. This pahse may last up to 14 days. The Nurses should be follow these steps : 1. Maintain the client on complete bed rest, organize care to provide long rest periods. Activity increase the rate of metabolism, which increase production of nitrogenouse waste product. 2. Implement intervention to prevent infection and the complications of immobility. Because She/He is on bed rest, the client becomes susceptible to the hazards of immobility. Infection is a serious risk and the leading cause of death in client with acute renal failure. 3. Observe the client for metabolic acidosis to identify complication of renal failure.Observe the fluid and electrolyte balance hourly. 4. Insert an indwelling urinary catheter and measure output and specific gravity hourly. These action allow the nurse to monitor the kidneys, which have the major role in regulating fluid and electolyte balance. High potassium levels can occur. 5. Provide only enough fluid intake to replace urine output to avoid an edema caused by excessive fluid intake. 6. Monitor the client's diet to provide high carbohydrates, adequate fats, and low protein. If client receives high calories from fat and carbohydrate metabolism, the body doesn't break down protein for energy. Protein is thus available for growth and repair. 7. Reduce the client's potassium intake to help prevent elevated potassium levels. Protein catabolism causes potassium release from cells into the serum. 8. Observe for the arrhytmias and cardiac arrest to identify complications of high serum potassium. 9. Provide frequent oral hygiene to avoid tissue irritation and sometime ulcer formation caused by urea and other acid waste products excreted through the skin and mucous membranes. 10. Provide the client with hard candy and chewing gum to stimulate saliva flow and decrease thirst.

11. Maintain skin care with cool water to relive pruritus and remove uremic frost (white crystal formed on skin from excretion of urea). 12. Administer stool softeners to prevent colon irritation from high levels urea and organic acids. 13. Provide emotional reassurance to the client and family members to help decrease anxiety levels caused by the fact that the client has an acute illness with unknown prognosis. 14. Explain treatments and progress to the client to help reduce anxiety. 15. Provide hemodialysis or peritoneal dialysis as ordered.

MEDICAL MANAGEMENT
y y y y y y y y y
Alkalinizing agent ; sodium bicarbonate Antacid ; aluminum hydroxide (AlternaGEL) Antibiotic ; cefazolin (Ancef) Anticonvulsant ; phenytoin (Dilantin) Antiemetic ; prochlorperazine (Compazine) Antipyretic ; acetaminophen (Tylenol) Beta-adrenergic blocker ; dopamine (Intropin) initially to improve renal perfusion Cation exchange resin ; sodium polystyrene sulfonate (Kayexalate) Diuretic ; furosemide (Lasix) , metolazone (Zaroxolyn)

TREATMENT
Treatment for AKF varies, since it is directed to the underlying, primary medical condition that triggered thekidney failure. Prerenal conditions may be treated with replacement fluids given through a vein, diuretics, blood transfusion, restricted salt intake, or medications. Postrenal conditions and intrarenal conditions may require surgery and/or medication. Frequently, patients in AKF require hemodialysis, hemofiltration, or peritoneal dialysis to filter fluids and wastes from the bloodstream until the primary medical condition can be controlled. Hemodialysis Hemodialysis involves circulating the patient's blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. The ECC is made up of plastic blood tubing, a filter known as a dialyzer (or artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a sterile chemical solution that is used to draw waste products out of the blood. The patient's blood leaves the body through the vein and travels through the ECC and the dialyzer, where fluid removal takes place. During dialysis, waste products in the bloodstream are carried out of the body. At the same time, electrolytes and other chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the body. A dialysis "run" typically lasts three to four hours, depending on the type of dialyzer used and the physical condition of the patient. Dialysis is used several times a week until AKF has resolved. Blood pressure changes associated with hemodialysis may pose a risk for patients with heart problems. Peritoneal dialysis may be the preferred treatment option in these cases. Hemofiltration Hemofiltration, also called continuous renal replacement therapy (CRRT), is a slow, continuous blood filtration therapy used to control acute kidney failure in critically ill patients. These patients are typically very sick and may have heart problems or circulatory problems. They cannot endure the rapid filtration rates of hemodialysis. They also frequently need antibiotics, nutrition, vasopressors, and other fluids given through a vein to treat their primary condition. Because hemofiltration is continuous, prescription fluids can be given to patients in kidney failure without the risk of fluid overload. Like hemodialysis, hemofiltration uses an ECC. A hollow fiber hemofilter is used instead of a dialyzer to remove fluids and toxins. Instead of a dialysis machine, a blood pump makes the blood flow through the ECC. The volume of blood circulating through the ECC in hemofiltration is less than that in hemodialysis. Filtration rates are slower and gentler on the circulatory system. Hemofiltration treatment will generally be used until kidney failure is reversed.

Peritoneal dialysis Peritoneal dialysis may be used if the patient in AKF is stable and not in immediate crisis. In peritoneal dialysis (PD), the lining of the patient's abdomen, the peritoneum, acts as a blood filter. A flexible tube-like instrument (catheter) is surgically inserted into the patient's abdomen. During treatment, the catheter is used to fill the abdominal cavity with dialysate. Waste products and excess fluids move from the patient's bloodstream into the dialysate solution. After a certain time period, the waste-filled dialysate is drained from the abdomen, and replaced with clean dialysate. There are three types of peritoneal dialysis, which vary according to treatment time and administration method. Peritoneal dialysis is often the best treatment option for infants and children. Their small size can make vein access difficult to maintain. It is not recommended for patients with abdominal adhesions or other abdominal defects (like a hernia) that might reduce the efficiency of the treatment. It is also not recommended for patients who suffer frequent bouts of an inflammation of the small pouches in the intestinal tract (diverticulitis).