Renal Failure

Wendy DeMartino, MD
PGY-2

Objectives
Anatomy
Function
Acute Renal Failure (ARF)
Causes
Symptoms
Management
Chronic Renal Failure (CRF)
Causes
Symptoms
Dialysis
Anatomy
2 Kidneys
2 Ureters
Bladder
Urethra





Kidney Function
Detoxify blood
Increase calcium absorption
calcitriol
Stimulate RBC production
erythropoietin
Regulate blood pressure and
electrolyte balance
renin


Classifications
Acute versus chronic
Pre-renal, renal, post-renal
Anuric, oliguric, polyuric
Acute Versus Chronic
Acute
sudden onset
rapid reduction in urine output
Usually reversible
Tubular cell death and regeneration
Chronic
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 =
vomiting, diarrhea, poor fluid intake, fever, use of
diuretics, and heart failure
cardiac failure, liver dysfunction, or septic shock
Intrinsic
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