acute renal failure lecture 1 Critical care nursing_5.ppt

acute renal failure

2. The Learning outcomes
1- Define acute renal failure (ARF).
2- Explain the causes of ARF.
3- Differentiate between the three types of ARF.
4- Identify the clinical stages of ATN.
5- Discuss the clinical manifestations of ARF.
6- List the complications of ARF.
7- Develop a plan for managing ARF.

3. Acute Renal Failure (ARF)
Definition: Sudden deterioration in the
ability of the kidneys to function ( to maintain fluid,
solute, or electrolyte homeostasis). It occurs over hrs or
few days.

It is Common in ICU patients (10-20%)

4. ARF: Types, Causes and mortality
1- Primary renal (intrarenal) disease:
33%
Hemolytic uremic syndrome: 88%
Obstructive uropathy
Renal vein/artery thrombosis
Primary glomerulonephritis (RPGN)
Overall mortality: 6%
Most primary renal diseases develop RF gradually and do not
need emergent dialysis

5. Post-op heart
or other heart
failure
32%
Sepsis
17%
Cancer
related
14%
Liver
transplant or
failure
16%
Trauma
6%
Other
15%
Overall
mortality: 62%!!
Data pooled from Ped. Nephrol. 7:703, 8:334, 6:470, and 7:434

6. ARF: What are the Risk factors for mortality?
Multi-organ failure
Bacterial Sepsis
Surgery (Cardiac surgery).
Fungal sepsis
Hypotension/ vasopressors
Ventilatory support
Initiation of dialysis late in hospital course
Oliguria /anuria: with oliguric ARF, mortality is >
50% compared to < 20% with non-oliguric ARF.

7. Risk factors cont.
Advanced age
Co morbid conditions (heart failure, liver or kidney failure, diabetes)
Contrast exposure (dehydrated, diabetic)
Nephrotoxic medications (aminoglycosides, angiotensin enzyme inhibitors)
Volume depletion (especially in diabetes)
Rhabdomyolysis(is a serious syndrome due to a direct or indirect muscle
injury. It results from the death of muscle fibers and release of their
contents into the bloodstream. This can lead to complications such as renal
(kidney failure)

8. Types and causes of ARF
2- Renal
1- Prerenal 3-Postrenal

9. 1- Prerenal azotemia (failure)
 Azotemia is an elevation of blood urea nitrogen (BUN)
and serum creatinine levels. 
Causes:
Decreased circulatory volume
Hypovolemia
GI losses (V/D, ileostomy, NG drainage)
Hemorrhage (trauma, GI bleeding)
Cutaneous losses (burns)
Renal losses (diabetes insipidus or mellitus)
Loss of fluids from intravascular space
Third spacing
Septic (capillary leak) or anaphylactic shock.

10. Prerenal azotemia (failure) cont.
Decreased local blood flow to kidney
Renal artery stenosis or Renal Vein Thrombosis
(RVT)
Drug-induced renal vasoconstriction
cyclosporin, tacrolimus
Hepatorenal syndrome
Diminished cardiac output
Congestive Heart Failure (CHF)
Arrhythmias, tamponade, etc.
Cardiovascular surgery

11. Prerenal azotemia
1-Decreased
circulatory volume
A-Hypovolemia
B- Loss of fluids
2-Decreased local
blood flow to kidney
A- Renal artery
stenosis
B- Drug
C- Hepatorenal
syndrome
3- Diminished
cardiac output
A- (CHF)
B- Arrhythmias,
tamponade,etc.
C.Cardiovascular
surgery

12. 2-Postrenal Failure
Kidney stone
Ureteropelvic junction (UPJ) or Ureterovesical
junction UVJ obstruction
Bladder: as neurogenic bladder or fungus ball
Urethra: posterior urethral valve; foreign body
Iatrogenic: obstructed Foley; narcotics

13. 3- Intrinsic Acute Renal Failure
Acute tubular necrosis (ATN)
Prolonged Prerenal azotemia of any cause
Nephrotoxin-induced drugs (aminoglycosides;
amphotericin)
Primary Glomerular diseases
Hemolytic uremic syndrome
All other forms of glomerulonephritis
 Intra-renal obstruction: tumorlysis syndrome

14. Clinical course of Acute Tubular Necrosis (ATN)
I- Onset phase: (initiating)
begins with an initial insult and lasts until cell injury
occurs. It lasts from hours to days, the clinical
manifestations in this phase include
1-decreased urine output
2-increased serum Creatinine.
The major goal during this phase is to determine the cause

15. Clinical course of tubular Necrosis (ATN) cont
II- Oliguric phase or non oliguric phase (anuria)
*Oliguria = <400ml/24 hrs or <20ml/hr
*Anuria = <50ml/24 hrs
III- Diuretic phase: lasts 1-2 weeks. There is gradual increase in
urine output and may lead to volume deficits and electrolytes
imbalance.
IV- Recovery phase: lasts from months to years. Renal function
return to its normality.

16. Diagnosis and Assessment of ARF
In history, seek clues regarding secondary causes -
symptoms of CHF, liver disease, sepsis, systemic
vacuities, prodromal bloody diarrhea; birth asphyxia
Check for symptoms of primary renal disease - UTI,
gross hematuria, flank pain, History of strep infection,
drug exposure ( aminoglycosides or narcotics) for
bladder dysfunction

17. Assessment of ARF (Physical exam.) cont.
Subjective: Dysuria, nausea, weakness, and fatigue
Tachycardia and/or a drop in HR >15 b pm or drop in SBP
>15mmHg with orthostatic indicate = dehydration
Decreased mental status =decreased
perfusion

Rales =fluid overload, CHF
Abdominal pain and distension = obstruction, UTI
Itching = azotemia

18. Assessment of ARF cont.
During physical exam, look for secondary causes
Causes of decreased effective circulatory volume - CHF, ascites,
edema, sepsis
Signs of systemic illness - (vacuities, SLE): rash, arthritis,
purpura
Signs of obstructive uropathy: enlarged kidneys or bladder -
CHECK FOLEY.

19. Assessment of ARF, Labs cont.
UA:
High specific gravity = dehydration
RBCs = UTI, urolithiasis
WBCs, bacteria = UTI
Casts: RBC (glomerulonephritis), WBC (pyelonephritis),
and epithelial cells and granular casts (ischemic damage)
Electrolytes to assess for metabolic d/o
Urine Na, Creatinine
ECG to look for peaked T waves, indicates Hyperkalemia

20. Assessment for ARF cont.
 (Blood Urea Nitrogen )BUN, Cr; CBC with platelets.
Urine Analysis: hematuria, myoglobinuria,
proteinuria, RBC casts, eosinophils
Urine indices (U-osm, U-CR, U-Na )
Renal Ultra Sound (with Doppler flow to rule out
renal vein thrombosis)
Anti-DNA, ANA, renal biopsy

21. Nursing diagnosis for client having ARF
Fluid volume excess related to decreased function
Alteration in cardiac output: decreased related to fluid
volume excess.
Altered nutrition: less than body requirements related to
anorexia, nausea and vomiting.
Impairment of skin integrity related to poor nutritional
status, immobility and edema

22. Nursing diagnosis for client having ARF cont
Anxiety related to unexpressed serious illness and current
symptoms.
Activity intolerance related to fatigue, anemia, retention of
waste products and dialysis procedure.
Sleep pattern disturbance related to decreased functioning
of immune system.
Knowledge deficit, disease and it management

23. Anticipated problems
worsening the ARF
Adjust medicines for renal insufficiency
Avoid Nephrotoxins if possible
Avoid intravascular volume depletion (especially in
third-spacing or edematous patients)

24. Management of ARF
Ventilation and oxygenation
Circulation / perfusion
Fluids /electrolytes
Mobility
Protection/safety
Skin integrity
Nutrition
Comfort/ pain control
Psychological support
teaching

25. NB: Management of (ARF )
To maintain Water balance
1- Assess the Volume status
"Maintenance" is IRRELEVANT in ARF!!!
If euvolemic ( presence of the proper amount of blood
in the body), give insensible + losses + UOP
If volume overloaded,
*concentrate all meds; limit oral intake
*Need frequent check on weights and BP as well as
accurate I/O
*give insensible = 30 cc/100 kcal or 400cc/M
2
/day
*If has any UOP, Lasix + ordered drugs may be effective

26. Once ARF stabilizes, fluid replacement
should be equal to insensible losses (400)
mL /day) plus urinary or other drainage
losses to avoid hypervolemia

27. Management of ARF: General cont.
Discontinue/re-dose nephrotoxic drugs
Diet: *Eliminate potassium if serum level increased
*Oral and IV amino acids
*Provide nutrition with increased
carbohydrates to decrease catabolism.
*Total caloric intake of 35 to 50
kcal/kg/day should be maintained with
most calories provided by carbohydrates
(100 g/day).

28. Foley catheterization for accurate output
Daily weight, monitor BP, labs
Correct easy bleeding with DDAVP,
estrogen, and cryoprecipitate
Prednisone in acute interstitial nephritis may help
Mannitol - alkaline diuresis in Rhabdomyolysis

29. Management: Prerenal
 The goal is to restore BP and intravascular
volume
Fluid deficit:
Fluid bolus with 500ml, recheck fluid status,
repeat.
Monitor vital signs and electrolytes
Normal or increased fluid status:
CHF: monitor O2 status. Lasix 20-80mg IV.
Monitor diuresis, potassium status, daily
weight

30. Management: Postrenal
Place Foley, note residual. If >400ml and discomfort is
relieved, leave catheter in place.
If Foley in place, Floods with 20-30ml saline
Consider stones or mass obstruction
Daily weights, strict I/O

31. Management: Renal
Hyperkalemia:
Continuous cardiac monitoring
Kayexalate 15 to 30g in 50-100ml 20% sorbitol PO q 3-4
hours or in 200ml 20% sorbitol PR q 4 hours
Dialysis for failed kidneys: can remove 30-60 mEq/hr
Contrast dye:
Creatinine peaks within 72 hours with slow recovery
over 7 to 14 days with appropriate therapy.
Aminoglycosides:
higher risk: elderly, volume depletion, >5 days, large
doses, preexisting liver disease, and preexisting renal
insufficiency.
Correct preexisting volume depletion and monitor
drug levels

32. Indications for renal replacement therapy
( Dialysis )
Volume overload
Pulmonary edema, CHF, refractory HTN
Hyperkalemia
Hyperphosphatemia
Uremic side-effects: pericarditis, pleuritis
Metabolic acidosis
Mental changes

33. Modes of renal replacement therapy
Peritoneal dialysis - also gentle and don't need
heparinization but slow and catheter may leak or
not work.
Hemodialysis - very fast, but need big lines and
systemic heparinization; causes hemodynamic
instability and uremic dysequilibrium symptoms

34. Complications of ARF
Death (50%)
Sepsis infection (leading cause of
mortality)
Hypertension exacerbated by fluid
overload: Use antihypertensive that
do not decrease renal blood flow).

35. Complications of ARF cont.
Anemia is common, caused by
increased red blood cell (RBC) loss and
decreased RBC production.
Platelet dysfunction may occur
secondary to the uremia and present as
gastrointestinal (GI) bleeding.

36. Special Cases
Elderly:
Elderly more susceptible to ARF (3.5 X more
common)
Creatinine clearance dependent on age
Evolution to acute tubular necrosis more
common
Pregnancy:
Infected uterus
Toxemia and related obstetric complications.
Pregnant patients only group with a sharp drop
in ARF mortality (1.7%)
Pediatric: Congenital anomalies
(e.g.,urethral valves, etc)

37. Dialysis

38. Kidneys – Facts and Function
•The kidneys have three main functions:
1- Control concentrations of body fluids,
2- Rid the body of unwanted soluble waste
3- Regulate a proper acid-alkaline environment in the body for
proper chemical reactions Even small variances may result
in death.

39. Kidney Failure
•Kidney failure, or renal failure, occurs when the kidneys fail to function
adequately.
1- Acute renal failure - Definition
•Acute renal failure (ARF) occurs when a rapid loss of renal function results in
poor urine production, electrolyte disturbance, and fluid balance disturbance
2- Chronic Renal Failure - Definition
•Chronic renal failure (CRF) or chronic kidney disease (CKD) occurs when a
progressive loss of kidney function occurs over a period of months to years.

40. Dialysis - Definition

•Dialysis is an artificial process used to remove water and waste
substances from the blood when the kidneys fail to function properly.
•It generally works through osmosis and filtration of fluid across a
semipermeable membrane with the use of a dialysate.
• Principle :Dialysis works on the principles of the diffusion of solutes
and ultrafiltration of fluid across a semi-permeable membrane.
•Diffusion describes a property of substances in water. Substances in
water tend to move From an area of high concentration To an area of
low concentration.

41.  
Semipermeable Membrane
•A semipermeable membrane is a thin layer of material that contains various sized
holes, or pores. Smaller solutes and fluid pass through the membrane, but the
membrane blocks the passage of larger substances (for example, red blood cells, large
proteins).
 Dialysate –:
•Dialysate is a Solution containing ultra pure water and chemicals (electrolytes) that
passes through the artificial kidney to remove excess fluids and wastes from the blood.
Urea and other waste products, potassium, and phosphate diffuse into the dialysis
solution. Concentrations of sodium chloride are similar to those of normal plasma to
prevent loss.

42. •In
 medicine, a shunt is a hole or a small passage
which moves, or allows movement of,
 fluid from one
part of the
 body to another. The term may describe
either
 congenital or acquired shunts; and acquired
shunts (sometimes referred to as
 iatrogenic shunts)
may be either
 biological or mechanical.

45. Catheter (shunt)Types:
•Catheters are usually found in two general varieties, tunneled
and non-tunneled.
1-Non-tunnelled catheter access is for short-term access Up to
about 10 days. Often for one dialysis session only. Catheter
emerges from the skin at the site of entry into the vein.

46. • 2-Tunnelled access involves a longer catheter Tunneled” under
the skin From the point of insertion in the vein exit site some
distance away placed in the internal jugular vein Exit site is
usually on the chest wall. The tunnel acts as a barrier to
invading microbes, and as such, tunneled catheters are designed
for short- to medium-term access (weeks to months only),
because infection is still a frequent problem.

47. Catheter Problems
1- Infection (frequent)
•tunneled catheters are designed for short-to medium-term
access weeks to months only
•Venous Stenosis (serious)
•Foreign body in the vein
2- Venous stenosis
•Results in scarring and narrowing of vein
3- Can cause problems with severe venous congestion in the area
drained by the vein

48. How dialysis is performed
•There are two main types of dialysis: haemodialysis and peritoneal
dialysis.
1-Haemodialysis
 involves diverting blood into an external machine, where
it's filtered before
 being returned to the body
2- Peritoneal dialysis
 involves pumping dialysis fluid into the space inside
your abdomen (tummy)
 to draw out waste products from the blood
passing through vessels
 lining the inside of the abdomen.

49. Hemodialysis: Preparing for treatment
•Before haemodialysis start,
 will usually need to have a special blood
vessel created in patient arm, called an arteriovenous fistula (AV fistula).
This blood vessel is created by connecting an artery to a vein.
•Joining a vein and an artery together makes the blood vessel larger and
stronger. This makes it easier to transfer your blood into the dialysis
machine and back again.
•The operation to create the AV fistula is usually carried out
 around
four
to eight
 weeks before haemodialysis begins.
This allows the tissue and
skin surrounding the fistula to heal.
•If blood vessels are too narrow to create an AV fistula, an alternative
procedure known as an AV graft may be recommended.
 A piece of
synthetic tubing (graft) is used to connect the artery to the vein.
•As a short-term measure, or in an emergency, you may be given a neck
line. This is where a small tube is inserted into a vein in your neck.

50. •Most people need three sessions
of haemodialysis a week, with
each session lasting around four
hours. This can be done in
hospital
•Two thin needles will be inserted
into AV fistula or graft and taped
into place. One needle will slowly
remove blood and transfer it to a
machine called a dialyser or
dialysis machine.

51. The haemodialysis process
•The dialysis machine is made up of a series of membranes that act as filters and a special liquid
called dialysate.
•The membranes filter waste products from blood, which are passed into the dialysate fluid.
The
 used dialysate fluid is pumped out of the dialyser and the filtered blood is passed back into
your body through the second needle.
•During your dialysis sessions, you will sit or lie on a couch, recliner or bed. You will be able to
read, listen to music, use your mobile phone or sleep.
•Haemodialysis isn't painful, but
 some people feel a bit sick and dizzy, and may have muscle
cramps during the procedure. This is caused by the rapid changes in blood fluid levels that occur
during the treatment.
•After the dialysis session, the needles are removed and a plaster is applied to prevent bleeding. If
you were treated in hospital, you can usually go home shortly afterwards.

52. Peritoneal dialysis
•There are two main types of peritoneal dialysis:
1- continuous ambulatory peritoneal dialysis (CAPD) 
–
where blood is filtered several times during the day
2- automated peritoneal dialysis (APD)
 – where a machine
helps filter blood during the night as patient sleep
•Both
 treatments can be done at home once patient trained
to carry them out himself.

53. Preparing for treatment
•Before have CAPD or APD, an opening will need to be made in
abdomen. This will allow the dialysis fluid (dialysate) to be pumped
into
 the space inside your abdomen (the peritoneal cavity).
•An incision is usually made just below belly button. A thin tube called
a catheter is inserted into the incision and the opening will normally be
left to heal for a few weeks before treatment starts.
•The catheter is permanently attached to abdomen, which some people
find difficult.

54. Dialysis and pregnancy
•Becoming pregnant while on dialysis
 can sometimes be
dangerous for the mother and baby.
•It's possible to have a successful pregnancy while on
dialysis, but will probably need to be monitored more
closely at a dialysis unit and may need more frequent or
longer treatment sessions.