Acute renal failure.pptx

MEANING
Sudden and often temporary loss of kidney function.
DEFINITION
Acute renal failure (ARF) is an abrupt and sudden reduction in renal function resulting in the inability to excrete metabolic wastes and maintain proper fluid & electrolyte balance.
• It usually associated with oliguria (less than 500ml/day), no oliguria (greater than 800ml/day) or anuria (less than 50ml/day).
• BUN &creatinine values are elevated.
Etiology
ARF can be further divided into pre-renal, intra renal and post renal etiologies.
1) Pre- Renal causes
Are those that decrease effective blood flow to the kidney and cause a decrease in the glomerular filtration rate (GFR). Both kidneys need to be affected as one kidney is still more than adequate for normal kidney function.
 Volume depletion resulting from:
• Hemorrhage
• Renal losses (diuretics, osmotic diuresis)
• Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)
 Impaired cardiac efficiency resulting from:
• Myocardia infraction
• Heart failure
• Dysrhythmias
• Cardiogenic shock
 Vasodilation resulting from:
• Sepsis
• Anaphylaxis
• Antihypertensive medications or other medications that cause vasodilation.

2) Intrarenal causes
Refers to disease processes which directly damage the kidney itself. It can be due to one or more of the kidney’s structures including the glomeruli, kidney tubules or the interstitium.
 Prolonged renal ischemia resulting from:
• Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)
• Myoglobinuria (trauma, crush injuries, burns)
• Hemoglobinreuria (transfusion reaction, hemolytic anemia)
 Nephrotoxic agents such as:
• Aminoglycoside antibiotics (gentamycin, tobramycin)
• Radiopaque contrast agents
• Heavy metals (lead, mercury)
• Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
• NSAIDS
• ACE inhibitors
 Infections processes such as:
• Acute pyelonephritis
• Acute glomerulonephritis
3) Post renal causes
Refers to mechanical obstruction of urinary outflow, between the kidney and the urethral meatus, which includes urethral and bladder neck obstruction due to:
 Calculi formation
 Benign prostatic hyperplasia
 Tumors
 Strictures
 Trauma (to back, pelvis or perineum)
 Blood clots
Pathophysiology
The kidneys receive approximately one fourth of cardiac output; therefore, they are very sensitive to alteration in perfusion. Most cases of ARF are caused by ischemia episode. The pathophysiology of ARF is not completely understood.
 PrerenalARF, is the result of impaired blood flow that leads to hypo perfusion of the kidney which causes decreased oxygen delivery that leads to hypoxemia and ischemia due to damage the kidney and glomerular filtration rate (GFR) decreases that leads to electrolyte imbalance and increased tubular reabsorption of sodium and water.
 Intrarenal ARF is the result of actual parenchymal damage to the glomeruli or kidney

1. Acute Renal failure Presented By: SUBHASHREE MAHAPATRO FACULTY OF KIIT

2. INTRODUCTION

3. Acute renal failure ( ARF) is an abrupt and sudden reduction in renal function resulting in the inability to excrete metabolic wastes and maintain proper fluid & electrolyte balance .

4. Etiology 1)Pre- Renal causes Volume depletion resulting from: Hemorrhage Renal losses Gastrointestinal losses Impaired cardiac efficiency resulting from: Myocardia infraction Heart failure Dysrhythmias Cardiogenic shock

5. CONT… Vasodilation resulting from: Sepsis Anaphylaxis Antihypertensive medications or other medications that cause vasodilation.

6. CONT… 2) Intrarenal causes Prolonged renal ischemia resulting from: • Pigment nephropathy • Myoglobinuria • Hemoglobinreuria Nephrotoxic agents such as: • Aminoglycoside antibiotics • Radiopaque contrast agents • Heavy metals

7. CONT… • Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) • NSAIDS • ACE inhibitors Infections processes such as: • Acute pyelonephritis • Acute glomerulonephritis

8. CONT… Post renal causes Calculi formation Benign prostatic hyperplasia Tumors Strictures Trauma (to back, pelvis or perineum) Blood clots

9. Pathophysiology

10. impaired blood flow hypo perfusion of the kidney hypoxemia and ischemia GFR decreases electrolyte imbalance and increased tubular reabsorption of sodium and water Prerenal ARF

11. actual parenchymal damage to the glomeruli or kidney tubules Acute tubular necrosis GFR decreases fluid electrolyte imbalances Intrarenal ARF

12. obstruction distal to the kidney Pressure rises in the kidney tubules GFR decreases fluid electrolyte imbalance Postrenal ARF

13. Phases of Acute Renal Failure Initiating phase begins at the time of the insult and continues until the signs and symptoms become apparent. It can last hours to days .

14. CONT…. Oliguria phase In the oliguria phase, less than 400ml of urine is produced in 24 hrs. Fifty percent of those with acute kidney injury experience this, which occurs from 24 hrs. to 7 days after the initial phase. This stage can last up to 2 weeks to several months . This phase accompanied by rise in serum concentration of elements usually excreted by kidney(urea, creatinine , organic acids, and the intracellular actions-potassium & magnesium )

15. CONT.. There can be a decrease in renal function with increasing nitrogen retention even when the patient is excreting more than 2 to 3lof urine daily called nonoliguric or high output renal failure. Diuretic phase As the kidney begins to excrete waste products again, 1 to 3l/day of urine is produced. Osmotic diuresis occurs from the elevated waste products (urea), which the body is attempting to eliminate .

16. CONT…. The kidneys are not yet able to concentrate urine and so dehydration and hypotension are a concern. Monitor for hypovolemia , hyponatremia and hypotension in this phase. Serum BUN and creatinine levels are high until the end of this phase. This phase may last 1 to 3 weeks .

17. CONT…. Recovery phase In this final phase, recovery begins as the glomerular filtration rate rises . Waste products levels (BUN, creatinine ) decreases greatly within the first 2 weeks of this phase. However recovery can take up to1 year. In this that doesn’t cover renal function, chronic kidney disease occurs.

18. Clinical Manifestations 1)Urinary system – decreased urine output, proteinuria, casts, decreased specific gravity, decreased osmolality, increased urinary sodium 2)Cardiovascular system – volume overload, heart failure, hypotension(early), hypertension (after development of fluid overload), pericarditis, pericardial effusion, dysrhythmias.

19. CONT… 3)Respiratory – pulmonary edema, kussmaul respirations, pleural effusion 4)Gastrointestinal – nausea and vomiting, anorexia, stomatitis, bleeding, diarrhea, constipation 5)Hematologic – anemia (development within 48hr) increased susceptibility to infection, leukocytosis, defect in platelet functioning.

20. CONT… Neurologic – lethargy , seizures, asterixis , memory impairment Metabolic – increased BUN, creatinine , decreased sodium, increased potassium, decreased PH, bicarbonate, calcium, increased phosphate.

21. Diagnostic Evaluation A through history  Prerenal causes  Intrarenal causes  Postrenal causes Urinalysis – revels proteinuria, hematuria, casts Rising serum creatinine and BUN levels. A renal ultrasound CT scan, MRI scan Cultures of drainage

22. Management

23. Medical management Maintenance of fluid balance is based on daily weight, serial measurement of CVP, serum & urine concentration, fluid losses, blood pressure & clinical status of patient and daily intake- output measurement . Fluid excess can be detected by the clinical findings of dyspnea, tachycardia and distended neck veins. The patient’s lungs are auscultated for moist crackles.

24. Cont … Immediate goal is to retain fluid volume deficit through use of blood products and crystalloids i.e. Normal Saline, Packed RBC . The development of generalized edema is asses by examining the presacral and pretibial areas several times daily. Mannitol , furosemide (Lasix) or ethacrynic acid may be prescribed to initiate diuresis.

25. Cont …. ARF caused by hypovolemia secondary to hypoproteinemia , an infusion of albumin may be prescribed . Dialysis may be initiated to prevent complications of ARF, such as hyperkalemia, metabolic acidosis, pericarditis & pulmonary edema.

26. Pharmacologic therapy elevated potassium levels may be reduced by administering cation – exchange resins (sodium polystyrene sulfonate ) orally or by retention enema. Sorbitol may be administered in combination with kayexalate to induce a diarrhea – type effect

27. Cont … If the patient is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), iv dextrose 50%, insulin & calcium replacement may be administered to shift potassium back into the cells. Diuretic agents are often used to control fluid overload. Adult dose: 20-80 mg PO/IV once. Vasodilators- Dopamine, in small doses causes selective dilatation of the renal vasculature, enhancing renal perfusion. Adult dose: 2-5 mcg/kg/min.

28. Cont … Alkalinizer -Sodium Bicarbonate, Increases plasma bicarbonate, which buffers Hydrogen ion concentration; reverses acidosis. Adult Dose: Initial dose IV bolus 1 mEq /kg, then infuse 2-5 mEq /kg over 4-8 hr depending on CO2, pH . Many medications are eliminated through kidneys, dosages must be reduced when a patient has ARF, like ACE inhibitors, antibiotic (especially aminoglycosides), digoxin

29. Nutritional therapy Replacement of dietary proteins is individualized to provide the maximum benefit and minimize uremic symptoms . Caloric requirements are met with high carbohydrate meals, because carbohydrates have a protein – sparing effect.

30. Cont …. Foods & fluids containing potassium or phosphorous (e.g. bananas, citrus fruits & juices, coffee) are restricted . Following the diuretic phase, the patient is placed on a high-protein, high caloric diet & is encouraged to resume activities gradually.

31. Nursing Management

32. Assessment The nurse monitors for complications, participates in emergency treatment of fluid and electrolyte imbalances . Assess the patient’s progress and response to treatment, and provides physical and emotional support . Assess understanding of cause of renal failure. Its consequences & its treatment . Assess nutritional status.

33. Nursing Diagnosis- 1 Excess fluid volume related to compromised regulatory mechanism as evidence by intake greater than output and increased blood pressure. Goal Maintain fluid volume and absence of edema.

34. Intervention Assess skin, face, and dependent areas for edema. Evaluate degree of edema . Accurately record intake and output. Monitor urine specific gravity. Weight daily at same time of day, on same scale, with same equipment and clothing. Monitor vital signs and auscultate lung and heart sounds.

35. Nursing Diagnosis- 2 Risk for decreased cardiac output as evidence by fluid overload, electrolyte imbalance. Goal Maintain cardiac output.

36. Intervention Monitor vital signs and observe ECG. Assess skin color of skin, mucous membranes, and nail beds and capillary refill. Auscultate heart sounds. Maintain bed rest or encourage adequate rest and provide assistance with care and desired activities.

37. Nursing Diagnosis- 3 Imbalanced nutrition less than body requirements related to dietary restrictions to reduce nitrogenous waste products as evidence by physical examination. Goal Maintain weight as indicated by individual situation, free from edema.

38. Intervention Assess and document dietary intake. Provide frequent, small feedings. Give patient a list of permitted foods or fluids and encourage involvement in menu choices. Offer frequent mouth care. Give gums, hard candy, and breath mints between meals. Weight daily and record it. Provide high calorie, low to moderate protein diet. Include complex carbohydrate and fat sources to meet caloric needs.

39. Nursing Diagnosis- 4 Risk for infection related to invasive procedures (e.g., urinary catheterization) or changes in dietary intake. Goal Experience no sign/symptoms of infection.

40. Intervention Assess skin integrity. Promote good hand washing by patient and staff. Use aseptic technique when caring and manipulating IV and invasive lines. Provide routine catheter care and promote meticulous perineal care. Encourage deep breathing, coughing, frequent position changes.

41. Prevention Identify patients with preexisting renal disease. Initiate adequate hydration before, during and after any procedure requiring NPO status. Avoid exposure to nephrotoxins Monitor chronic analgesics use Prevent and treat shock with blood and fluid replacement

42. Cont … Monitor urinary output and CVP hourly in critically ill patients Schedule diagnostic studies requiring dehydration Pay special attention to draining wounds, burns and so forth Avoid infection Take every precaution to make sure that the right person receives the right blood to avoid complication.

43. Complication

44. Recent studies .

45. BIBLIOGRAPHY