Renal Failure

NUR 3218
 Renal Failure

• Partial or complete impairment of kidney

function

• Inability to excrete waste products

• Types
– Acute renal failure

– Chronic renal failure

 Notes
• Kidney disease has been on the rise & ESRD has
more than doubled in the past decade
• Due to diabetes, HBP & glomerulonephritis
• Acute – usually sudden onset, can affect many body
systems – can be reversible with aggressive care
– Loss of about 50% of function
• Chronic – slower onset, affects all body systems –
irreversible
– Loss of about 90-95% of nephron function
• Renal insufficiency – loss of about 25% function
 Acute Renal Failure
• Rapid loss of kidney function
– ↑ BUN & serum creatinine
– Oliguria
• Types of ARF
– Prerenal
• Hypovolemia, ↓ CO, vascular failure
– Intrarenal (Intrinsic)
• ATN (acute tubular necrosis), kidney tissue
damage, nephrotoxins
– Postrenal
• Obstructed urine flow
 Notes
• Leads to accumulation of waste products in the body
• Occurs due to compromised blood flow (shock), toxins, tubular
ischemia, infections & obstructions
• Prerenal – from decreased blood flow or ischemia in the nephrons –
conditions that cause decreased CO
– Prolonged prerenal (hypoperfusion) can cause further progression of RF
– Shock (septic, anaphalactic, cardiogenic), decreased CO,HF, Pulm emb,
cardiac tamponade
• Intrarenal - actual tissue damage from inflammatory or immunologic
processes OR from prolonged hypoperfusion causes impaired renal
function
– ATN, Acute glomerulonephritis, nephrotoxins (NSAID’s, antibiotics),
vasculitis, hepatorenal syndrome
• Postrenal – obstruction of urine flow b/t kidney & urethra
– Urethral or bladder cancer, urethral stricture, cervical cancer, Prostate
enlargement
 Acute Tubular Necrosis

• Intrarenal condition caused by

ischemia, nephrotoxins, or pigments.
• ATN (exception of causes from
pigments) results in 90% intrarenal
ARF
• Potentially reversible
 Acute Renal Failure
• Prerenal & Postrenal can resolve
quickly with treatment of the underlying
cause
• Intrarenal (ATN) takes longer to resolve
due to potential tissue damage
• If don’t recover from ARF, can develop
CRF
• Clinical course follows 4 phases
 Notes
• PREVENTION IS THE KEY!

• Often seen in ICUs.

• ATNs continue to have 50% mortality rate.

 Clinical Phases
• Initiating Phase
– Onset, Initial insult to kidney to symptoms
• Oliguric (< 400 ml/day)
– Most common manifestation of ARF
– Metabolic acidosis, mental changes
– Fluid overload, sodium depletion, potassium
build-up, low calcium, high phosphate
– BUN and creatinine elevations
– Variable length
 Notes
• See TABLE 47-2 in text and specific descriptions of
manifestations on pages 1200-1201
• Initiating Phase (Onset) – gradual accumulation of
nitrogenous wastes, with elevation of serum Ct & BUN
– Can last hours or days
• Oliguric – decreased GFR, sudden decrease in the UO
100-400/24 hrs which does not respond to diuretics or
fluid challenge
– Occurs 1-7 days after causative event; depends on cause
– Last about 8-15 days
• Longer the duration, the less chance of recovery
– May be drowsy, disoriented or comatose
 Clinical Phases
• Diuretic
– Kidneys begin to excrete urine, but can’t concentrate
– Occurs 2-6 weeks after initial injury
– May last 1-3 weeks
• Recovery
– GFR ↑, BUN & Ct decrease
– Outcome based upon overall health, severity of ARF
& any complications
– Can take up to 12 months
– Vulnerable to insult during this time
 Notes
• Diuretic – gradual increase in GFR, indicates recovery of
damaged nephrons
– UO increases, can be 3-5 L/day of dilute urine
• Can see hypotension from fluid loss & tachycardia
– LOC - will begin to improve
• Recovery – return to normal level of function or can develop
CRF if not full recovery
– - uremia may still be severe.

• ALSO, non-oliguric form of ARF.

– No major decrease in urine output so less complicated
– Still need to observe blood and urine components for waste product
accumulation and changes in electrolyte, acid-base, and fluid
balances.
 Nursing and Collaborative
Management
• PREVENTION IS KEY!!
– Health promotion
– Avoid dehydration
– Avoid conditions that cause ARF
• History
– Early recognition of renal problems
• Autoimmune conditions
• Infections
– Monitor lab values
– Awareness of nephrotoxic substances
• Drug history
 Notes
• TEXT gives long list of causes of ARF
• Are numerous clinical conditions that can lead to ARF
• Avoid dehydration – esp in FL & in the summer for children and
older adults
• Infections – streptococcal especially
• Nephrotoxic – NSAID’s, tylenol, antibiotics like amphoteracin B,
vancomycin, tetracycline – aminiglycosides like gentamicin –
antineoplastics like cisplatin & methotrexate – Other things like
pesticides & fungicides & heavy metals & X-ray dyes (especially
in older adults)

• Careful matching of blood products

Clinical Manifestations of ARF

• Azotemia - accumulation of nitrogenous

waste products in the blood

• Uremia - syndrome of renal failure as it

affects other body systems
 Notes
• AZOTEMIA – accumulation of nitrogenous
waste in the blood – measured by BUN & Ct

• Uremia - urinary, cardiovascular, respiratory,

GI, Hematologic, neurologic, and metabolic
changes (See Table 47-3) in text
 Diagnostic Tests

• Serum BUN & creatinine, electrolytes,

anemia

• Metabolic acidosis

• Creatinine clearance

• Urinalysis

• Renal ultrasound, CT scan, IVP

 Notes
• Acute & Chronic lab values are very similar
• CT & BUN will gradually increase – see metabolic acidosis
– Remember Ct is better indicator of renal function b/c not affected by
hydration or catabolism
• Serum potassium – will increase as renal fx declines
• Serum phosphorus – will be increased
• Serum calcium decreased
• Can also see anemia if decreased erythropoietin
• Creatinine clearance – decreased b/c GFR is decreased
• Urine – will have RBC’s casts, myoglobin
• KUB – an enlarged kidney may indicate obstruction

• IVP – especially dangerous with decreased renal function because

of dye
 Nursing Diagnosis
• Excess fluid volume r/t compromised
regulatory mechanisms
• Imbalanced nutrition: Less than body
requirements r/t dietary restrictions
• Ineffective protection r/t abnormal
blood profiles
 Nursing & Collaborative Care
• Ensure adequate intravascular volume &
adequate cardiac output
• Pharmacology
– Volume replacement
– Loop diuretics
– Low-dose dopamine
– Kayexalate (if hyperkalemia)
– Sodium bicarbonate (if metabolic acidosis)
– Avoid NSAID’s & ace inhibitors
– Use nephrotoxic drugs sparingly
 Notes
• Maintain renal perfusion!!!

• Goals aimed at treating the underlying cause & preserving

as much kidney fx as possible
• Treatment varies some based on the clinical phase in
• Volume – fluid challenges to increase renal blood flow
• May or may not be prescribed with diuretics
• Low dose dopamine to increase blood flow to the kidney -
& increases BP
• Some type of invasive monitoring to know fluid & pressure
status
• Ace inhibitors – used to help ARF from nephrotoxic ATN
Nursing & Collaborative Care

• Fluid Balance
– Assess edema, CHF, & pulmonary
edema
– Accurate I & O, daily weights
– Restrict fluid if hyponatremic
– Problems that occur
• Hyperkalemia
• Hyponatremia
• Metabolic acidosis
 Notes
• Careful monitoring of labs and working with dietician

• Assess edema, CHF, & pulmonary edema

• Provide adequate nutrition w/o placing a stress on the kidney
• Accurate I & O, daily weights (1 kg = 1000 ml fluid)
• If fluid is restricted, it can be calculated as the UO + 600 ml.
• Restrict fluid if hyponatremic
– Problems that occur
• Hyperkalemia
• Hyponatremia – may be dilutional with actual high levels of sodium
• Metabolic acidosis

– Adequate calories, high carb, low Na, low K, low phosphorus, low protein
• Know foods that should be avoided
– High K – apricots, artichokes, bananas, etc
– High Na - bouillon, canned soups, preserved meats, cheeses, olives, pickles, etc
– High phos – dried beans & peas, eggs, fish, organ meats, nuts & seeds
• TPN/enteral feedings if unable to tolerate oral
Nursing & Collaborative Care
• Nutrition
– Adequate calories to prevent catabolism
– Monitor protein intake
– Restrict potassium, phosphate, & sodium
– Give calcium supplements/phosphate
binding agents
 Notes
• Adequate calories from carbs and fats
• - calories average 30 – 35 kcal/kg of body weight
• - 30-40% total calories from fat

• Protein intake depends upon degree of catabolism

• - control nitrogenous waste production
• - limit starvation ketosis
• - about 0.6 – 2 grams/kg/day
• - can add essential Amino Acid supplements

• Restrict potassium, phosphate, and sodium

• - potassium and sodium depends on plasma levels and symptoms of
edma, hypertension, and CHF
• - limit phoshates and give calcium supplements and/or phosphate-
binding agents
Nursing & Collaborative Care
– Treat elevated potassium levels
• Regular insulin IV
• Sodium bicarbonate
• Calcium gluconate IV
• Dialysis
• Kayexalate (sodium polystyrene
sulfonate)
• Dietary restriction of potassium
 Notes
• See Table 47-5
Nursing & Collaborative Care
• Promote Rest
– Anemia contributes to fatigue
– Increase activity/ambulation as condition
improves
• Prevent Injury & Infection
– Electrolyte imbalance & uremia may contribute
to mental confusion
– Good skin care, measures to relieve pruritus
– Aseptic technique for all invasive lines
• Assist with Patient & Family Coping
– Mental changes
– ARF explanations
– Medications, diet, infections, follow-up care
 Notes
• Pruritis occurs because of uremic deposits
in the skin
 Gerontologic Considerations

• Older adult more susceptible to ARF

• Consider differences in treatment, e.g.

diuretics
• Higher mortality rate due to infection, GI
hemorrhage, or MI
 Collaborative Care
• Temporary dialysis therapies
– Hemodialysis
• Special vascular access, Vas-Cath
– Peritoneal dialysis
• Tenkoff catheter
– Hemofiltration - CRRT
 Notes
• Vascular access – preferred site is subclavian vein or jugular over
the femoral
– b/c infection, mobility & visualization
– Can be used immediately
– Special catheter with 2 lumens – outflow & inflow
• PD – abd catheter has to be placed – uses the peritoneum as the
dialysis membrane
– Slower process, some pts may not tolerate the large amount of fluid
introduced into the abdomen
• Hemofiltration – CRRT – Continuous renal replacement therapy -
procedures that are better tolerated by critically ill pts for removing
waste products, uses a dialysate solution, but is better tolerated,
need to be hospitalized & require intensive are nursing
– – double lumen dialysis catheter inserted in the subclavian or jugular
 Chronic Renal Failure

Presence of kidney damage or glomerular

filtration rate (GFR) less than 60 ml/min for 3
months or longer
 Notes
• Normal GFR is 125 ml/min
• Measured by Urine Creatinine Clearance
 Chronic Renal Failure
• Progressive, irreversible destruction of the
nephrons of both kidneys
• Occurs over months to years, determined by
severity of symptoms & preservation of
function
• Deteriorates to End Stage Renal Disease
(ESRD) & will need dialysis or transplant
• Uremic syndrome- systemic & lab
manifestations of ESRD
 Notes
• Disease is usually a slow process occurring over years of
damage
– *Diabetes – see most in obesity, sedentary, family history, Native
Americans
– *Hypertension – African Americans likely to have HTN
– *Glomerulonephritis
– Systemic Diseases
• Sickle cell
• Scleroderma
• SLE
– Polycystic disease

• *Most frequent causes

Etiology of Chronic Renal Failure

• Born with over 2 million nephrons, kidney

failure after 85%-90% lost
• African Americans with hypertension
• Native Americans with diabetes
• Incidence increasing
• Insurance companies & Medicare now pay
for ESRD treatment
 Notes
• Causes – are due to many different
diseases

• Incidence is on the rise

– Greater in persons over 65 & with a risk factor
Chronic Renal Failure - Terms
• Diminished Renal Reserve
– Renal function declines
– Creatinine clearance declines – Ct & BUN normal
– Nocturia & polyuria
• Renal Insufficiency
– GFR continues to decline
– Ct & BUN begin to elevate
– Medical management
• End-Stage Renal Disease
– Excessive waste build-up
 Notes
• CRF – Terms often heard– NOT Current Stage Guidelines – SEE
TABLE 47-6 for STAGES of Chronic Kidney Disease
– Diminished renal reserve, but not metabolic wastes in blood – a healthy
kidney is able to compensate
• See more nocturia & polyuria b/c the kidney is less able to concentrate urine
– Renal Insufficiency - kidney is now unable to compensate & see waste
accumulate & the kidney beginning to be unable to handle the body’s
needs
• Elevated uric acid, phosphorus
• Care is medical management here with medications, managing fluid, BP,
electrolytes, & diet
• Always progresses to stage III – just depends upon how fast the progression is
• May have this for years
– End – Stage Renal Disease - excessive build-up of waste products in the
blood & kidney can no handle
• More severe fluid & electrolyte imbalances
• Without treatment, is fatal
Clinical Effects of ESRD
 Notes
• Can develop slowly over months to years
• Urea is the end product of protein metabolism,
so BUN & Ct will elevate
• Kidney normally excretes K+, so if function
declines, then potassium will accumulate
• Bones will demineralize d/t high phos & low ca
– stimulates parathyroid hormone, which
releases Ca
 Clinical Effects of ESRD
• Regulatory Functions
– Waste product accumulation (BUN, Ct)
– Anemia because ↓ erythropoietin
– Metabolic acidosis
– Hyperkalemia
– Abnormal fluid & sodium balance (HBP)
– Hyperuricemia
– Hyperphosphatemia, hypocalcemia
– Glucose intolerance
• Cardiac System
– HBP  LV hypertrophy  CHF
– Cardiac arrhythmias
– Uremic pericarditis
 Notes
• Can develop slowly over months to years

• Urea is the end product of protein metabolism, so BUN & Creatinine

will elevate

• Kidney normally excretes potassium, so if function declines, then

potassium will accumlate

• Bones will demineralize due to high phosphorus and low calcium –

stimulates parathyroid hormone, which releases Ca

• Hyperlipidemia occurs causing cardiac problems – from impaired fat

metabolism – leads to increased triglycerides, increased cholesterol,
increased LDL
 Clinical Manifestations

• Respiratory System
– Dyspnea, tachypnea
– Kussmaul's respirations
– Uremic pleuritis/lung
• GI System
– Mucosal ulcerations
– Metallic taste in mouth
– N, V, D, C,
– Anorexia
– Weight loss, malnutrition
– GI bleeding
 Notes
• CRF causes changes to ALL body systems – primarily effects
of those things related to fluid volume, electrolyte, acid-base
& the build up of nitrogenous waste
• RESPIRATORY
– d/t metabolic acidosis
– Kussmaul's esp if severe metabolic acidosis
– Can develop “uremic lung” – type of pneumonia due to elevated uric
acid
• GI – excessive ammonia from uremia irritates the GI mucosa
& causes ulcerations
– Ulcerations can place the pt at risk for bleeding from them if they
become severe
– Constipation is due to the fluid limitations, activity limitations
 Clinical Manifestations
• Cardiovascular
– Hypertension, peripheral edema
– CHF
– Arrhythmias
– Cardiomyopathy
– Uremic pericarditis
• Hematology
– Anemia
 Notes
• CV – effects related to excess volume
– Arrhythmia – electrolyte imbalances
• HEME – anemia b/c of decreased EPO
production by the kidneys – also deficient
in iron
– Bleeding from the GI tract
 Clinical Manifestations
• Neurological System
– ↑ as CRF progresses
– CNS depression (lethargy, inability to concentrate, declining mental
ability, seizures)
– Peripheral neuropathy, paresthesias
– Cerebral swelling
• Integumentary System
– ↑ skin pigment
– Uremic frost
– Hair & nails dry & brittle
 Notes
• NEURO – develop a uremic encephalopathy b/c uremic toxins
damage the axons – also is from the build-up of waste products
– General CNS depression which will continue to progress if untreated
– Peripheral neuropathy – see changes in sensation, may complain of
“restless leg syndrome” or “feeling bugs crawling inside of legs”
– Muscle weaknesses, diminished DTR’s
– Asterixis can occur
• SKIN – increased pigment due to urochrome being deposited in the
skin, which has a yellowish-grey coloration
– Just darker in dark skinned clients
– The uremia causes prurutis
– May also see uremic frost – when urea crystallizes on the skin, see
most when the BUN is very high & pt has refused or dialysis has been
w/d
 Clinical Manifestations
• Urinary
– Decreased or absent urine output
– + for protein, heme & casts
• Musculoskeletal
– Muscle weakness, bone pain
– Renal osteodystrophy
– Uremic deposits in the eye
 Notes
• URINE – unless it is the early stages, their
may be high UO of dilute, unconcentrated
urine esp at night
• MS – renal osteodystrophy from the
abnormalities in calcium & phosphorus –
bones become thin & weak & can have
pathological fxs
– Eye – may burn & water from irritation
 Clinical Manifestations
• Reproductive System
– Infertility, ↓ libido
– ↓ hormone levels, amenorrhea
• Psychological Changes
– Personality & behavioral changes
– Body image alterations
– Anxiety, depression, & grief
 Geriatric Considerations of
Renal Failure
• GFR rate declines every 10 years after age 50
• Older adults are more likely to have other
chronic conditions that contribute to RF
• Have difficulty performing PD & have difficulty
getting to HD
appointments
• Often need community
resources for assistance
 Chronic Renal Failure
Diagnostic Tests
• Serum creatinine, BUN
• Urinalysis
• 24-hour urine
– Creatinine clearance (= GFR)
• KUB, ultrasound, CT
• Renal scan, angiogram
• Renal biopsy
• Serum electrolytes
 Notes
• See Textbook discussion
• Causes extreme changes in some blood values
• Can also calculate the GFR & CrCl
• Other studies would be included to monitor the
effects on the other body systems, there are
just the RF ones
• X-rays can be done – but of limited value
 Nursing Diagnosis for
Renal Failure
• Excess Fluid Volume r/t compromised regulatory
mechanism
• Activity Intolerance r/t weakness, metabolic
alterations
• Imbalanced Nutrition: Less than body
requirements r/t restricted diet, anorexia
• Impaired skin integrity r/t prurutis of uremia
• Ineffective Protection r/t hyperkalemia
• Risk for Infection r/t uremic toxins, chronic
disease
• Fatigue r/t anemia, disease state
 Notes
• Many ND could be included in the list –
these relate to the primary problems seen,
but their could be others depending upon
the health status of the individual pt
 Nursing & Collaborative Care
• Administer prescribed medications
– Antihypertensives
• ACE or ARB
• BB or Ca channel blockers
– Antidiabetic agents
– Electrolytes to correct imbalances,
kayexealate
– Phosphate binding agents
– Erythropoietin
– Caution with digixon preparations & other
drugs with kidney clearance
 Notes
• See Text, pp. 1209-1211

• Conservative measures are always tried first with dialysis being the
last resort
• Aimed at slowing the progression of the CRF & preventing
complications
– Especially those pts with DM & HBP

• Control BP – antihypertensive & diuretics

– Weight loss if obese
– Therapeutic lifestyle – exercise, smoking cessation, avoid alcohol
– Beta blockers decrease the incidence of cardiac mortality
– ACE – decrease proteinuria & delay progression of CRF, also ARB,
angio rec inh -
 Notes
• Control BS – monitor & keep bs under control
• Hyperkalemia – another problem of CRF – can give IV glucose & insulin
to move K out of the cell or can give Kayexelate – a cation exchange
resin – give PO or as a retention enema; dialysis
• Phosphate binding – tums or Remegel to bind with ph – want aluminum
free phosphate binder
• EPO – to get Hct between 30-35%, very effective in helping to improve
fatigue
• Drugs to avoid – drugs excreted by the kidney are always a concern - &
doses may have to be adjusted
– Includes primarily Dig, antibiotics, & pain meds
– Dig adjust dose down
– Aminoglycosides, penicillin &tetracycline – have to adjusted down
– NEVER give Demerol b/c liver changes then kidney has to excrete
– NEVER give NSAID’s b/c they cause renal vasoconstriction
– Avoid or only use in very small amounts as prescribed - Tylenol
 Nursing & Collaborative Care

• Nutrition & Fluid Balance

– Protein restriction
– Sodium restriction
– Protein restriction
– Avoid salt substitutes, foods high in
potassium
– Limit fluid intake
– Restrict phosphorus
– Comply with dietary restrictions
 Notes
• See Table 47-8 in text
• Protein metabolism is the primary cause of uremia, so
protein should be limited in CKD, 0.6 – 0.75 g/kg of ideal
body weight) (unless on dialysis) but not avoided when
creatinine clearance is 25 ml/min or less. or will develop
negative nitrogen balance & lose muscle & become
malnurished
– Chronic renal insufficiency – 0.6 – 0.8 g/kg of body weight/day
– Dialysis – 1.2 – 1.3 g/kg of ideal body weight/day
– 50% protein should be high biologic value containing all of the
essential amino acides
– Evaluated & calculated based upon individual needs & type of
dialysis being used
 Notes
• Sodium restriction – 2-4 g/day depending on
edema and HTN - esp when little or no urine
output as it will contribute to edema
– Also BP, weight. & if on dialysis is factored in
• Potassium restriction – 2-4 g (39 mg = 1 mEq)
• Fluid will also depend upon the UO & type of
dialysis
• Phosphorus – limited (1000 mg/day) but is
primarily in foods that are high in protein
– May need calcium supplements, foods with calcium
• Use calcium or aluminum based antacids
Nursing & Collaborative Care

• Prevent infection & injury

– Meticulous skin care
• Pruritis
– Avoid places/persons with infections
• Stool softeners
• Activities to lessen bleeding
• Monitor for confusion, falls
 Notes
• Skin – attention to any breaks in skin –
vascular access or PD catheter site
– Pruritis – d/t urate crystal excreted thru the
skin, sometimes uremic frost
• Avoid soaps, lotions that may be irritating
• May need antipuritics, such as Benadryl
• Monitor H & H, stools for occult blood,
avoid aspirin products
Collaborative Care & Nursing
Management of CRF
• Promote comfort, rest & sleep
– Tend to have a number of chronic complaints, not acute
pain
– Cool room temperature at night
– Rest periods as needed
– Fatigue – Epogen or Procrit
• Promote coping
– Noncompliance is an issue, also depression
– Social problems, relationships, vocation
– Adjustments to dialysis
– Implications for the future
 Collaborative Care & Nursing
Management of CRF
• Dialysis is initiated when GFR is less than 10-15
ml/min (severe kidney impairment)
• Movement of fluid & particles across a
semipermeable membrane
• Removes waste & toxic material
• Sustains body function for both acute & chronic
RF
• Can also be used to remove drugs & poisons
from the body, to correct serious metabolic
imbalances
 Notes
• Selection of dialysis is based upon a number of
factors, lab values + clinical manifestations
• Begins when conservative approaches no longer
work
• Type of dialysis is determined by the physician
based upon patient factors
– Adv & disadv to both

– Diet and fluid amounts more difficult before dialysis

initiated; hemodialysis more restrictive than peritoneal