Kidney Failure

Introduction
The kidneys are bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. The kidneys are sophisticated reprocessing machines. Every day, a person's kidneys process about 200 quarts of blood to sift out about 2 quarts of waste products and extra water. The wastes and extra water become urine, which flows to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination. The actual removal of wastes occurs in tiny units inside the kidneys called nephrons. Each kidney has about a million nephrons. In the nephron, a glomerulus-which is a tiny blood vessel, or capillary-intertwines with a tiny urine-collecting tube called a tubule. The glomerulus acts as a filtering unit, or sieve, and keeps normal proteins and cells in the bloodstream, allowing extra fluid and wastes to pass through. A complicated chemical exchange takes place, as waste materials and water leave the blood and enter the urinary system.

In addition to removing wastes, the kidneys release three important hormones:

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Erythropoietin, or EPO, which stimulates the bone marrow to make red blood cells Renin, which regulates blood pressure Calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for normal chemical balance in the body

Why do kidneys fail? Most kidney diseases attack the nephrons, causing them to lose their filtering capacity. Damage to the nephrons can happen quickly, often as the result of injury or poisoning. But most kidney diseases destroy the nephrons slowly and silently. Only after years or even decades will the damage become apparent. Most kidney diseases attack both kidneys simultaneously

Acute Renal Failure

-is defined as an abrupt or rapid decline in renal filtration function. This condition is usually marked by a rise in serum creatinine concentration or by azotemia (a rise in blood urea nitrogen [BUN] concentration) -symptoms appear abruptly and is highly reversible

Causes of acute renal failure

It is caused by failure of the kidneys to perform their normal functions due to: y Prerenal - is the most common type of acute renal failure (60%-70% of all cases). The kidneys do not receive enough blood to filter due to: >Dehydration: - From vomiting, diarrhea, water pills, or blood loss >Disruption of blood flow to the kidneys

Postrenal - Problems referred to as obstructive renal failure, since it is often caused by something blocking elimination of urine produced by the kidneys. Its causes are: >Kidney stone: usually only on one side >Cancer of the urinary tract organs or structures near the urinary tract that may obstruct the outflow of urine >Bladder stone >Enlarged prostate (the most common cause in men) >Blood clot

Renal - Problems with the kidney itself that prevent proper filtration of blood or production of urine Most common cause is Glomerulonephritis: The glomeruli, the initial filtration system in the kidney, can be damaged by a variety of diseases, including infections. The resulting inflammation impairs kidney function.

Pathophysiology

Signs and Symptoms of ARF

y y y y y y y y y y Decreased urine production Body swelling Problems concentrating Confusion Fatigue Lethargy Nausea, vomiting Diarrhea Abdominal pain Metallic taste in the mouth

he Four Phases of Acute Renal Failure

Onset Phase this period represents the time from the onset of injury through the cell death period. This phase can last from hours to days and is characterized by:
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Renal flow at 25% of normal Oxygenation to the tissue at 25% of normal Urine output at 30 ml (or less) per hour Urine sodium excretion greater than 40 mEq/L.

Oliguric/Anuric Phase this phase usually lasts between 8-14 days and is characterized by further damage to the renal tubular wall and membranes. Other characteristics in the oliguric-anuric phase include:
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Great reduction in the glomerular filtration rate (GFR) Increased BUN/Creatinine Electrolyte abnormalities (hyperkalemia, hyperphosphatemia and hypocalcemia) Metabolic acidosis

Diuretic Phase this phase occurs when the source of obstruction has been removed but the residual scarring and edema of the renal tubules remains. This phase usually lasts and additional 7-14 days and is characterized by:
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Increase in glomerular filtration rate (GFR) Urine output as high as 2-4 L/day Urine that flows through renal tubules Renal cells that cannot concentrate urine

Increased GFR in this phase contributes to the passive loss of electrolytes which requires the administration of IV crystalloids to maintain hydration.

Recovery Period Phase The recovery phase can last from several months to over a year. During this phase, edema decreases, the renal tubules begin to function adequately and fluid and electrolyte balance are restored.

Diagnostic Exams for ARF

Laboratory Tests
Lab Test Urine Specific Gravity BUN/Creatinine ratio Urine Osmolality Urine Sodium Urine Sediment (urinalysis) Fractional excretion of sodium percent (FENa) Prerenal Value Greater than 1.020 Greater than 20:1 Greater than 500 mOsm/kg 10 mEq/L or less Hyaline casts Less than 1% Intrarenal Value 1.010 to 1.020 10-20:1 300-500 mOsm/kg 20 mEq/L or more Granular casts Greater than 1%

Creatinine Clearance Test this is believed to be the most accurate test to determine glomerular filtration rates. This test requires urine collection for a 24 hour period with normal clearance levels being 95 ml/min to 125 ml/min. Levels less than 50 ml/min are consistent with intrarenal disease. Prerenal disease levels vary depending on how long low renal flow has existed, with postrenal failure levels usually falling within normal limits. Ultrasound renal ultrasound can be effective in determining existing renal failure and/or obstruction of the urinary collecting system. Renal Biopsy renal biopsy can be effective in diagnosing intrarenal failure, but should only be done if the result will alter the treatment plan. Doppler Studies doppler scans can be effective in determining the presence and nature of renal blood flow.

Management of ARF
1. Treat hyperkalemia
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Sodium bicarbonate Glucose Insulin Calcium chloride Sodium Polysterene Sulfonate (Kayexalate): For the exchange of Sodium and Potassium in the gastrointestinal tract.

2. Treat hyperphosphatemia: Aluminum hydroxide (Amphojel) 3. Diuretics: Furosemide, Mannitol 4. Dopamine 5. ACE inhibitor: Captopril 6. Diet: Decreased Protein, increased Calcium 7. Fluids 8. Dialysis -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. 9. 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. -uses when patients are too weak to withstand the rapid filtration rates of hemodialysis 10. Peritoneal Dialysis -is often the best treatment option for infants and children. -may be used if the patient in AKF is stable and not in immediate crisis. -a catheter is surgically implanted into the peritoneum and dialysate is infused. During the treatment, the waste products from the bloodstream enter the peritoneum and binds with the dialysate. The dialysate after some period of time is drained and is replaced with a clean dialysate.

Nursing Care for ARF

1. Excess Fluid Volume Nursing Care Management: y y y y 2. Weight, hourly check the urine output BUN, creatinine Restrict fluids and sodium Offer hard candies and ice chips Imbalanced Nutrition: Less Than Body Requirements Nursing Care Management: y y y Frequent small feedings Ask the family members to join the patient in eating Provide a high caloric or carbohydrate diet

Chronic Renal Failure

-Chronic kidney disease occurs when one suffers from gradual and usually permanent loss of kidney function over time. -With loss of kidney function, there is an accumulation of water, waste and toxic substances in the body that are normally excreted by the kidney.

Stages of Chronic Kidney Disease

Stage 1 2 3 4 5 Description Slight kidney damage with normal or increased filtration Mild decrease in kidney function Moderate decrease in kidney function Severe decrease in kidney function Kidney failure GFR* mL/min/1.73m2 More than 90 60-89 30-59 15-29 Less than 15 (or dialysis)

*GFR is glomerular filtration rate, a measure of the kidney's function.

Causes of CRD
y Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the leading cause of kidney disease in the United States. High blood pressure Glomerulonephritis is the inflammation and damage of the filtration system of the kidneys, which can cause kidney failure Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease wherein both kidneys have multiple cysts. Use of analgesics regularly over long durations of time can cause analgesic nephropathy Atherosclerosis) leading to the kidneys causes a condition called ischemic nephropathy,

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Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings), or cancers may also cause kidney disease.

Signs and Symptoms

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Lethargy Weakness shortness of breath generalized swelling may occur

Metabolic acidosis

Inability to excrete potassium and rising potassium levels in the serum (hyperkalemia) is associated fatal heart rhythm disturbances (arrhythmias) including ventricular tachycardia and ventricular fibrillation Uremia Pericarditis Hypocalcemia

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Laboratory Studies
y y Elevated serum urea and creatinine Hyperkalemia, low serum bicarbonate, hypocalcemia, hyperphosphatemia, hyponatremia Normochromic normocytic anemia Twenty-four hour urine collection for total protein

Imaging Studies
y y y y y y Plain abdominal x-ray Intravenous pyelogram Renal ultrasound Renal radionuclide scan CT scan MRI

Treatment Regimen
There is no cure for chronic kidney disease. The four goals of therapy are to: y y y y Slow the progression of disease Treat underlying causes and contributing factors Treat complications of disease Replace lost kidney function

Strategies for slowing progression and treating conditions underlying chronic kidney disease include the following:
y y y Control of blood glucose Control of high blood pressure Diet

Patient Education Regarding Diet Modification

y Protein restriction: Decreasing protein intake may slow the progression of chronic kidney disease. Salt restriction: Limit to 4-6 grams a day to avoid fluid retention and help control high blood pressure Fluid intake: Excessive water intake does not help prevent kidney disease. Potassium restriction: This is necessary in advanced kidney disease because the kidneys are unable to remove potassium Phosphorus restriction: Decreasing phosphorus intake is recommended to protect bones.

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Surgical Treatment for CRF

y y y Kidney Transplant Hemodialysis Peritoneal Dialysis

Nursing Supportive Management

1. Proper assessment for risk factors that might cause a rapid decline 2. Encourage self-management such a blood pressure monitoring and glucose monitoring 3. Administer prescribe medications ( ion exchange resin, alkalizing agents, antibiotics, erythropoietin, folic acid supplements) 4. Maintain strict fluid control 5. Encourage intake of high biologic value protein (eggs, dairy products and meats) 6. Encourage adequate rest