acute and chronic renal failure

acute and chronic renal failure

1. ACUTE RENAL FAILURE
&
CHRONIC RENAL FAILURE
SURENDRA SHARMA
Assist. Professor
Amity College of Nursing
Amity university, Gurgoan

2. ACUTE RENAL FAILURE
&
CHRONIC RENAL FAILURE

3. Definition
Acuterenalfailureisaseveredeteriorationofrenal
function,manifestedassuddenreductionofurine
excoriation(lessthan1ml/kg/hr.)
Etiology
Thecausesofacuterenalfailurecanbedividedinto
threegroups,prerenal,intrarenalandpostrenal
causes.

5. Prerenal
decreased renal perfusion
80% of cases
Renal
intrinsic renal disease
10% of cases
Postrenal
obstruction
10%
Acute Renal Failure

6. Prerenalcauses
Thesesconditionsarerelatedtotheproblemoccur
inbloodsupplytothekidneyeitherduetosystemic
hypovolemiaorduetorenalhypoperfusion.The
importantcausesarehypovolemiaduetodiarrheal
dehydration,shock,burns,diabeticacidosis,trauma
hemorrhage,etcandCCF.

7. Intrarenalcauses
Thesesinternsisrenal;conditionsarerelatedto
problemswithinthekidneysandtheirfunctions,
causingreductionofGFR,renalischemiaand
tubulardamage.
Theimportantcausesare:-
1.Glomerulonephritis.
2.Hemolyticuremicsyndrome(HUS).
3.Renalveinthrombosis.
4.Acutetubularnecrosis,(duetofluidloss,
hemorrhage,shock).
5.Sepsis.

8. Postrenalcauses
Theseconditionsarerelatedtotheproblemsofthe
upperorlowerurinarysystemcausingobstructions
ofurineflowduetoobstructiveuropathies.The
causesincluderenalcalculus,PUV,bladder-neck
obstructioncongenitallesionorpuscollectionin
urinarytractorfollowingdrugtherapy
(sulfonamide).

9. PhasesofARF
FourphasesofARFareidentifiedinchildren
dependinguponthecourseofillness.
Initiatingphase
Thisphaselastsfromhourstodayswithfeatures
ofrenalfunctionimpairment.

10. Oliguricphase
Thisphaseslastsfrom5to15daysbutcanbe
prolongedforweeks.Itisshorterininfantsand
children(3-5days)andlongerinolderchildren
(10-14days).Morethan3weeksdurationofoligouric
phaseindicatesirreversiblerenaldamage.Itdepends
uponseverityanddurationofinitialstagecausing
acuteVaso-spasticnephropathy.

11. Diureticphase
Thisphaselastsforfewdaysandhighlyvariable
withmildtosevereclinicalfeatures.
Recoveryphases
Thisphasemarksthefinalresumptionofnormal
urineosmolarity,constituentsandbiochemical
alterationintheblood.

12. PATHOPHYSIOLOGY
Reduction of glomerular filtration rate and renal blood flow
due to renal vasoconstriction
Sodium and fluid retention which leads to edema.
Hypertension may develop due to rennin angiotension mechanism
Arteriolar constriction
Acute renal failure
Increased circulatory overload and sodium retention.

13. Clinicalmanifestation
SevereOliguriaoranuria.
Nausea,vomiting
Lethargy
Dehydration
Acidoticbreathing
Alterationoflevelconsciousness
Irregularitiesincardiacrateandrhythm
Edema

14. DIAGNOSTIC EVALUATION
Bloodexamination
Showsraisedserumcreatininelevel
Completebloodcount
Bloodurea
Electrolysis
pH,bi-Carbonate

15. Urineexamination
proteinuria,
haematuria
presenceofcasts
Ultrasonographyhelpstodetectthestructural
abnormalities,calculi,etc.,
Radio-nucleotidestudiescanbedonetoevaluate
GFRandrenalbloodflowdistribution

16. Management
Correctionofdehydration
Treatmentofshockandhyperkalemia
Fluidandelectrolytebalancetobemaintained
promptly.
Dietshouldbeplanedwithlowsodium,low
potassium,lowphosphateandmoderateprotein
(0.6to1gm/kg).
Therecommendedcalorierequirementis50to
60cal/kg.
Liberalamountofcarbohydratesandfatscanbe
givenalongwithvitaminandmineralsupplementation.

17. Useofdiureticslikemannitolandfrusemideis
recommendedbysameauthority.
Steroidcanalsobeused
Dialysis(peritonealorhemodialysisisindicatedin
lifethreateningcomplications
a)Persistenthyperkalemia,serumpotassium
morethansevenml/eq/lt.
b)CCF
c)Pulmonaryedema
d)Neurologicalproblem
e)Hyperphosapatemia

18. Complication
Fluidelectrolyteimbalance
Hyperkalemia
Metabolicacidosis
Convulsion
Hyponatremia

19. CHRONIC RENAL FAILURE (CRF)
Definition
Chronicrenalfailureisapermanentirreversible
destructionofnephronleadingtosevere
deteriorationofrenalfunction,finallyresultingto
endstagerenaldisease(ESRD)

20. ETIOLOGY
Glomerulardiseases-glomerulonephritis,SLE,
HUS,familialnephropathy,Henoch-Schonlein
purpura,amyloidosis.
Congenitalanomalies-Bilateralrenalhypoplasia
ordysplasia,polycystickidney.
Obstructiveuropathy-PUJ,renalstones,PUV.
Miscellaneous- BilateralWilm’stumor,
renalveinthrombosis,renalcorticalnecrosis,renal
tuberculosis,refluxnephropathy.

21. Reduction in the renal functions.
Metabolic, endocrinal and hematological disturbances.
Damage of nephron results in hypertrophy and hyper
phosphatemia of remaining nephron.
Reduced functions of nephrons to excrete effectively
thus resulting azotemia and clinical uremia.
Impaired renal function.
Fluid overload leads to edema and hypertension.
Chronic renal failure
PATHOPHYSIOLOGY

22. Clinicalmanifestations
Initialpolyuriaorfrequentpassageofurine
Oliguriaoranuria
Increasedthirst
Decreasedappetite,weakness
Lowenergylevel
Bonepainorjointpain
Drynessanditchingofskin
Hypertensionandgrowthretardation

23. Inlatestage
Acidoticbreathing
Nausea/vomiting
Diarrhea
Peripheral;neuropathy
Convulsions

24. DIAGNOSTIC EVALUATION
Bloodexamination
Decreasedlevelofhematocrit,Hb%,Na+,Ca++,HCO-,
IncreasedlevelofK+andphosphorus.
RenalfunctiontestshowsgradualincreaseofBUN,uric
acidandcreatininevalues.
Urinalysis
Variationinspecificgravityincreasedcreatininelevel
inurineandchangeintotalamountofurineoutput.
ChestX-raytodetectbonyinvolvement.
ECG,IVP,MCU,Radionuclideimaginghelpstodetect
theextentofcomplications.

25. Management
Attheinitialstage,themanagementofCRFisplaned
toretardtheprogressionofthediseasesbyrest,
diet,supportivecareandsymptomaticrelief.
Later,thetreatmentofcomplication,dialysisand
renaltransplantationtobeprovidedasperneed.
Dietshouldbeplanedwithspecialattentionon
maintenanceofcalorieaspernormalrequirements.
Dietshouldcontainhighpolyunsaturatedfatand
complexcarbohydrates.

26. Protein intake should be adequate
(0.8-1gm/kg/day)withfooditemshighbiologicvalue
(egg,milk,meat,fish).
Sodiumintakeneedstobealloweddependingupon
thelevelofimpairmentofsodiumreabsorption,
presenceofedema,hypertensionandazotemia.
Potassiumbalancetobemaintainbyavoiding
potassiumcontainfood.
Dairymilkcontaininghighphosphateneedtobe
avoided.Butcalciumsupplementationisrequired.

27. VitaminB1,B2,folicacid,B6andB12
supplementationtobegiven.Waterrestrictionis
usuallynotessentialexceptinESRDandfluid
overload.
Correctionofacidosistobedonewithsodium-bi-
carbonate.
Hypertensiontobemanagedwithantihypertensive
drugs.Infectionwithleasttoxicantibiotics.
Antihistaminesisgiventorelieffrompruritus.

28. Correctionofacidosistobedonewithsodium–bi-
carbonate.
Hypertensiontobemanagedwithantihypertensive
drugs.
Infectionshouldbemanagedwithleasttoxic
antibiotics.
Antihistaminesisgiventorelieffrompruritus.

29. Correctionofanemiacanbedonewithiron-folic
acidsupplementation.Bloodtransfusioncanbedone.
Correctionofcalciumandphosphorusimbalanceis
essential.
Growthhormonemaybeneededtocorrectgrowth
retardation.
Dialysis(peritonealorhemodialysis)andrenal
transplantationareindicatedinCRF.

30. Nursingmanagement
Throughassessmentofallsystemsareessentialto
detecttheproblemsandplanningofcare.
Specialcaretoprovideinrelationtorenal
transplant,anddialysis.Routinecareshouldemphasize
onmaintenanceoffluid-electrolytebalance,skin
integrity,nutritiousdiet,ensuringsafetyfrom
infectionsandinjury,assistingtocopewithlong-term
illnessandteachingforcontinuationofcare.

31. Complication
Azotemia
Metabolicacidosis
Electrolyteimbalance
CCF
Hypertension
Growthretardation
Delayedorabsentsexualmaturation

32. Nursingdiagnoses
Riskoffluidelectrolyteimbalancerelatesto
impairedrenalfunctions
Riskforinfectionrelatedtoalterationofhost
defense
Activelyintolerancerelatedtoacuteillness
AlteredthoughtprocessrelatedtoCNSproblem
Alterednutritionlessthanbodyrequirement
relatedtoGIdisturbance
Fearandanxietyrelatedtolifethreateningillness
Knowledgedefecatedrelatedtomanagementof
ARF

33. INTERVENTION
Riskoffluidelectrolyteimbalancerelatesto
impairedrenalfunctions
Intervention
Weighthechilddailyandmonitorurineoutput
everyfourhours.
Assessthechildforedemameasureabdominal
girtheveryeighthours.
Monitorandrecordthechild’sfluidintake.
Assessthecolorconsistencyandspecific
gravityofthechild’surine.

34. Riskforinfectionrelatedtoalterationofhost
defense
Intervention
Keepthecatheterdrainagebagbelowthechild’s
balderlevel,makingsurethetubingisfreefrom
kinksloops.
Useaseptictechniquewhenemptyingthecatheter
bag.
Engorgethechildtodrinkatleast60mlfluidper
hour.
Administerantibiotics.

35. Activelyintolerancerelatedtoacuteillness
Intervention
Providequitenvironment.
Providepropernursingcare.
Providecomfortslip.
Providerestperiodstofolloweachactivity.

36. Alterednutritionlessthanbodyrequirement
relatedtoGIdisturbance
Intervention
Assessthenutritionstatusofthechild.
Providehighcarbohydratediet.
Smallandfrequentmeals.
Restrictsodiumandproteinintake.

37. Fearandanxietyrelatedtolifethreateningillness
Intervention
Listentoparesconcerns.
Explainallproceduretotheparents.
DiscussionaboutChildscare.
Providepsychologicalsupporttotheparents.

38. KnowledgedefecatedrelatedtomanagementofARF
Intervention
Explaintotheparentsaboutthediseases.
Reassuretheparentsaboutlongtermeffects.
Explaintotheparentsaboutsodiumrestricteddiet.
Instructtheparentstolimitthechillsactivity.