Acute Renal Failure. general guidelinespptx

acute renal failure

1. Acute Renal Failure E kholowa

2. scenario Tuhin 7 yrs old male child, is admitted with a complaint of oliguria for 2 days associated with respiratory distress for same duration. He had history of bee sting all over body surfaces 7 days ago when he was returning home from school. He was afebrile , with a puffy face, he is restless , mildly pale , dyspenic , and has pedal edema. On palpation, Abdomen was soft, distended, non-tender, no organomegaly , ascites present evidenced by shifting dullness.   Investigation carried out include creatinine : 8 mg/dl Blood urea: 400 mg/dl Urine WBC – 4-6/ HPF, RBC – Nil Protein – (++).

3. Definition Sudden potentially reversible loss of kidney function leading to acute disturbance of fluid , electrolyte and acid base balance and creatinine retention Rapid deterioration of renal function resulting in retention of nitrogenous wastes and inability of kidney to regulate fluid and electrolyte homeostasis Failure occurs within hours or days

4. Causes Conditions that reduce renal blood flow e,g . Hypotension, cardiac failure hypovolemia reduced cardiac output obstruction of kidneys or lower urinary tract Obstruction of renal arteries and veins

5. The course of Renal Failure Pre-renal failure – renal failure occurs due to impaired blood flow to kidneys Kidneys retain their normal structure Shock causes inadequate blood supply to vital organs including kidneys leading to reduced glomerular filtration rate and oliguria Kidney damage can be reversed if the underlying problem is corrected

6. Intrinsic renal failure Kidney failure occurs due to pathology within the kidneys such as nephrotic syndrome or glomerulonephritis hemolytic uremic syndrome ( kidneys damaged as a result of toxins released by E Coli that originates from contaminated beef and attaches to glomerulus causing damage to the glomerulus and resulting kidney failure ) is the commonest cause for all age groups

7. Post renal failure Renal failure occurs due to conditions causing obstruction to urine outflow Examples include posterior urethral valves and neurogenic bladder, ureterovesico reflux These conditions impair the flow of urine and urine starts to flow back causing pressure to rise in the renal tubules more than pressure in the glomerulus thus affecting glomerular filtration rate

8. Diagnosis 1. Kidney failure anticipated if there are predisposing factors to the condition 2. Clinical manifestations - Oliguria (urine <0.5ml/kg/hour) or anuria ; or non oliguric ( >400mls per day) Oedema , nausea, vomiting, hypertension , confusion or seizures 3. Blood chemistry- increasing BUN, and creatinine ; abnormal electrolytes and pH; 4. Ultra sound of kidneys to detect obstruction 5. Renal biopsy if indicated

9. basic principles of management Treatment of life-threatening complications Maintenance of fluid and electrolyte balance Nutritional support. Specific management of underlying disorder

10. Medical management   Hyperkalemia : Calcium gluconate 0.5-1 ml/kg over 5 to 10 minute Salbutamol nebulization Glucose 0.5-1 gm/kg with 0.1-0.2 unit/kg insulin Sodium bicarbonate 1-2 ml/kg

11. Medical management Fluid overload : fluid restriction Oxygen Dopamine (5-10) mcg /kg /min infusion Frusemide (2-4)mg /kg Hypertension Nitroprusside 1-8 mcg/kg/min Frusemide 2-4 mg/kg Nifedipine 0.3-0.5 mg/kg Acidosis Sodium bicarbonate Anemia Pack red cell 3-5 ml/kg

12. Nursing Management Kidney failure is a life threatening condition Mother child interaction Parents and the child should be allowed to verbalise their feelings Discuss issues with honesty and accuracy Encourage parental involvement to an extent that they are comfortable with

13. Pain and comfort Assess pain and determine severity Manage according to severity Panadol or brufen if mild to moderate pain Morphine for severe pain ( refer to the WHO analgesic ladder)

14. Fluids and hydration Physical management of kidney failure aims at treating underlying cause, balancing fluids and electrolytes, controlling acidosis There may be fluid underload or overload thus fluids may need to be replaced or removed Intake and output monitoring and recording very important Document daily weight at least twice

15. Fluid replacement should be colloid, crystalloid or blood ( will depend on cause of failure) If fluid retention, restriction of fluids and sodium necessary Diuretics such as mannitol and furosemide prescribed and administered Dopamine

16. Electrolyte balance High levels of sodium cause fluid retention and oedema And therefore should be restricted Increased potassium is also dangerous and disturbs conduction of the heart causing irregular heart beat

17. Treatment for hyperkalemia Restriction of potassium intake Administration of potassium binding agents Diuretic therapy to increase urine output Administration of glucose and insulin to cause potassium to move into cells Renal replacement therapy may be indicated: Peritoneal dialysis Intermittent hemodialysis Continuous haemofiltration - Choice depends on age , clinical condition, and local experience

18. Acidosis Promotes movement of potassium from intracellular fluid to extracellular compartments and thus promotes hyperkalemia Affects cerebral function Neurological observations are important if there is evidence of confusion or mental impairment Treated with sodium bicarbonate

19. Nutrition Acute renal failure causes a lot of tissue breakdown Parenteral or Enteral feeding necessary to meet nutritional requirements High energy to prevent the body metabolising tissues to get energy ( if the body metabolises tissues for energy, potassium is released into the blood where there may already be hyperkalemia )

20. Infection prevention The child needs to be protected from infections because the immune system is compromised when homeostasis is disturbed Death may commonly occur due to infections Protect the child from nosocomial infections Hand washing Hygiene measures Observe for signs of infections and Antibiotic therapy given for any existing infections Measures that promote cross infection to be avoided

21. Use of medicines Great care should be taken when prescrobing medication The following are safe medicines Doxycycline Erythromycine Penicillin Phenytoin Rifampicin

22. Administer with care Amoxycillin Chloramphenicol Diazepam Digoxin Insulin Pethidine Phenobarb Propranolol ARVs

23. Avoid using t the following Aspirin Ibuprofen Indomethacin Ethambutol Gentamycin Nalidixic acid Nitrofurantoin Streptomycin

24. Peritoneal Dialysis A catheter inserted into the child’s abdomen Gravity is utilised to allow dialysate to flow into the abdominal cavity It lies on one side of the peritoneal membrane An exchange between the dialysate fluid and body fluid on the other side of the membrane takes place The process takes 2 hours and then the now mixed dialysate is removed by allowing it to drain into a bag attached to the catheter and placed below the abdomen Repeated several times a day may be done at home

25. Indications for peritoneal dialysis Acute and chronic renal failure where haemodialysis can’t be tolerated Severe blood clotting disorders Exhausted circulatory access sites Cardiovascular disease Inadequate veins in very young or old patients Atherosclerotic veins in diabetic patients Patients refusing to receive blood transfusions

26. Contraindications Severe acidosis Paralytic ileus with abdominal distension Diaphragmtic leaks Severe resp insufficiency Large abdominal wounds with drains Intraabdominal cancer Multiple abdominal adhesions Diffusely infected abdominal wall unless the patient is already on peritoneal dialysis programme

27. Advantages of peritoneal dialysis No circulatory access necessary Patient at less risk of immediate life threatening complications e.g. haemorrhage Treatment is less expensive than haemodialysis Gradual fluid and electrolyte level shifts Diabetic pts have less risk for retinopathy than those on haemodialysis Treatment more efficient than haemodialysis for removal of middle weight molecular substances

28. Disadvantages of peritoneal dialysis Acute or intermittent peritoneal dialysis treatment can take 10 to 48 hours May take more than 4 sessions per week . For continuous ambulatory peritoneal dialysis, treatment goes on for 24 hours per day Risk of peritonitis is high Pt must be given protein rich diet due to excessive protein loss

29. Complications of peritoneal dialysis Peritonitis Exit site infection Subcutaneous tunnel infection Bladder or bowel perforation Bleeding through catheter Dialysate leakage around catheter Kinking of catheter Low back pain abdominal or rectal pain Ileus Cramping Excessive fluid loss Fluid overload Hernia

30. haemodialysis Haemodialysis next best action Done 3 to 4 times a week In haemodialysis , an arteriovenous fistula or shunt is placed in a large vessel. Blood is taken out through the vessel to an external circuit and through filtration system to remove body wastes that can no longer be removed through the kidneys

31. Indications for haemodialysis Acute or chronic renal failure where peritoneal dialysis cant be used Severe Hyperkalemia Diaphragmatic leaks Severe resp insufficiency Large abdominal wounds with drains Intraabdominal cancer Multiple abdominal adhesions Diffusely infected abdominal wall Acidosis Congestive cardiac failure not controlled by fluid management Severe systemic hypertension Pulmonary oedema

32. Contraindications to haemodialysis Cardiovascular disease Severe blood clotting disorders Circulatory instability

33. Advantages of haemodialysis Requires up to three treatments per week Treatment periods is usually short Treatment if 3 to 6 times more efficient than peritoneal dialysis in removing low molecular weight substances

34. Disadvantages of haemodialysis Treatment requires Access to circulatory system Treatment is expensive because it necessitates special equipment and trained personnel During treatment, 350 to 600mls blood circulates outside the body so that blood volume is reduced and children and patient with circulatory impairment may not tolerate it Patient may require blood transfusions during or between dialysis sessions which must be done in hosp of OPD Rapid fluid and electrolyte level shifts may cause dialysis disequilibrium syndrome

35. Complications Internal haemorrhage External haemorrhage Aggravated anemia Hepatitis Dialysis disequilibrium syndrome ( headache , fatigue, muscle agitation, twitching, confusion, grandmal seizures) Hypotension Cardiac arrhythmia or angina Muscle cramps Air embolism Lower back pain Convulsions

36. Education Report any reduction in urine output Maintain a routine schedule for dialysis Maintain meticulous care of the of the catheter site to protect the child from infection The home should have a functional telephone and running water Electricity should not be interrupted if it can be avoided Family to have backup generator in case of electricity failure Assess for signs of depression and anxiety which may require mental health consultation Encourage to talk about their fears and concerns

37. Teach to take low protein diet Teach about signs of infection or worsening renal condition - weight gain, headache, hypertension, flank pain, decreased urine output, sore throat, or flu like symptoms Instruct the patient that the child can pursue activities as tolerated Encourage caregivers to teach the child to stay away from the other children who have signs of infections Encourage caregivers to teach the child hand washing especially in school where there are many people Allow the child to decide whether teachers should know about the patient’s renal condition Refer to resource groups

38. prevention Provide adequate hydration to at risk patients e.g. pre and post op pts , pts on fluid restriction, patients with cancerous conditions and those receiving chemotherapy Prevent and treat shock promptly with blood and fluids Monitor intake and output on critically ill patients including arterial and central venous pressures Treat hypotension promptly

39. Prevention … Continually monitor renal function- urine output, creatinine , urea and electrolytes Proper screening of blood to avoid transfusion reactions which can precipitate renal failure Prevent and treat infections promptly because they can progressively damage kidneys Care for wounds, burns which can act as port of entry for bacterias Carry out meticulous care of patients with indwelling catheters Carefully monitor for drug effects and interactions for those drugs excreted by kidneys. Ensure accurate dosage of drugd