Detailed Description on Renal Failure (ARF; CRF; Dialysis)

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1. RENAL FAILURE Dr. SHAIK KAREEMULLA Associate Professor Department of Pharmacy Practice MMCP (MMDU)

2. ACUTE RENAL FAILURE Acute Renal F ailure (ARF) defined as decrease in glomerular filtration rate (GFR) that occur hours to weeks or even months, associated with accumulation of waste products like urea and creatinine. Changes in either serum creatinine (Scr) or urine output (UOP) values are considered as primary criteria for diagnosing Acute Renal Failure by majority of the physicians. Classification system for ARF has been proposed and is being validated . Components of the system include GFR and UOP values.

3. RIFLE acronyms includes Risks of dysfunction , Injury to kidneys, Failure of kidneys , Loss of function and End stage kidney disease . CLINICAL PRESENTATIONS Signs & symptoms are subtle (difficult to detect) & varied. Outpatients do not suffer with acute distress while Hospitalized patients suffer with ARF symptoms after a catastrophic (extremely harmful) event . Outpatients suffer from change in urinary habits , weight gain and flank pain . Other Signs include Edema , Colored or Foamy urine and Orthostatic Hypotension.

4. SYMPTOMS Water and electrolyte imbalance. Fatigue. Oliguria. SOB. Excessive acid in urine. Nausea. Confusion. Weakness. Irregular heart beat. Fluid retention that leads to swelling of feet, legs and ankles.

5. RISK FACTORS Advanced age. Pre existing renal parenchymal disease. Diabetes Mellitus. COMPLICATIONS Chronic Renal Failure. Ischemic parenchymal injury. R enal azotemia (Excess nitrogenous waste products in urine). Electrolyte imbalance. Metabolic acidosis. Pulmonary edema. Hypertensive crisis. Urinary tract infections.

6. Acute kidney injury type Typical % cases Common etiology Pre-renal 40 to 80 Decreased renal perfusion Intra renal (including ATN) 10 to 50 Renal parenchymal injury Post renal <10 Urinary tract obstruction

7. ETIOPATHOGENESIS Causes for ARF includes Pre-renal , Intra-renal and Post-renal . 1) Pre-renal causes Pre-renal diseases cause sudden decrease in blood flow to nephrons. Renal ischemia results in functional disorders and depression of Glomerular Filtration Rate . Pre-renal causes are Inadequate cardiac output, Hypovolaemia , and Vascular diseases that reduces perfusion of kidneys .

8. 2) Intra-renal causes Intra-renal diseases associates with the diseases of renal tissues. It includes the following: Acute Tubular Necrosis due to Ischaemia . Acute Tubulo -Interstitial Nephritis. Diseases of Glomeruli. Effect of a Nephrotoxin . Pyelonephritis . Vascular diseases of arteries and arterioles within Kidneys.

9. 3) Post-renal causes Post-renal diseases occurs due to obstruction to the flow of urine along the renal tract . Obstruction to urine flow occurs due to presence of mass tissue within the lumen and also due to presence of external compression in the parts of lower urinary tract like ureter, urinary bladder or urethra . Acute Renal Failure originating from Pre-renal and Post-renal diseases eventually leads to Intra-renal diseases.

10. CHRONIC RENAL FAILURE Chronic Kidney D isease (CKD) is a progressive loss of function over several months to years, and is characterized by gradual replacement of normal kidney structure with interstitial fibrosis. CKD is categorized by the level of kidney function , based on glomerular filtration rate (GFR ), into stages 1 to 5 , with each increasing number indicating a more advanced stage of the disease , as defined by a declining GFR . This classification system from the National Kidney Foundation’s Kidney Dialysis Outcomes and Quality Initiative ( K/DOQI) also accounts for structural evidence of kidney damage.

11. CKD stage 5 , previously referred to as end-stage renal disease (ESRD ), occurs when the GFR falls below 15 mL/min per 1.73 m2 body surface area . The patient with stage 5 CKD requiring chronic dialysis or renal transplantation for relief of uremic symptoms is said to have ESRD. CLINICAL PRESENTATIONS CKD development and progression is insidious . Patients with stage 1 or 2 CKD usually do not have symptoms or metabolic derangements seen with stages 3 to 5 , such as anemia , secondary hyperparathyroidism , cardiovascular disease , malnutrition, fluid and electrolyte abnormalities that are more common as kidney function deteriorates .

12. Uremic symptoms (fatigue, weakness, SOB, mental confusion , nausea , vomiting , bleeding and anorexia ) are generally absent in stages 1 and 2 , minimal during stages 3 and 4 , and common in patients with stage 5 CKD who may also experience itching , cold intolerance , weight gain , and peripheral neuropathies. PATHOPHYSIOLOGY Susceptibility factors increase the risk for kidney disease but do not directly cause kidney damage . Susceptibility factors include advanced age , reduced kidney mass and low birth weight , racial or ethnic minority , family history , low income or education, systemic inflammation and dyslipidemia.

13. Initiation factors initiate kidney damage and can be modified by drug therapy . Initiation factors include diabetes mellitus, hypertension , autoimmune diseases, polycystic kidney disease and drug toxicity . Progression factors hasten decline in kidney function after initiation of kidney damage . Progression factors include glycemia in diabetes, hypertension, proteinuria, smoking . Most progressive nephropathies share a final common pathway to irreversible renal parenchymal damage and ESRD. Key pathway elements include loss of nephron mass , glomerular capillary hypertension and proteinuria.

14. eNOS : endothelial Nitric Oxide Synthase ET: Endothelin ICAM-1:  Intercellular Adhesion M olecule-1 PG : Prostaglandins

15. DIALYSIS The movement of fluid and molecules across a semi permeable membrane from one compartment to another compartment. Dialysis does not correct renal dysfunction. Dialysis helps to replace renal function when kidneys failed. Dialysis Corrects fluid/electrolyte imbalances. Dialysis remove waste products.

16. Initiated when: U remia can no longer be managed. Immediately should be done if: Patients unresponsive to diuretics (fluid overload ). Patients suffering from pericarditis. Patients suffering from uncontrolled hypertension. Patients suffering from neurologic manifestations. Patients having GFR less than 15 ml/minute.

17. TYPES OF DIALYSIS Hemodialysis. Peritoneal Dialysis. Hemofiltration/Continuous Renal Replacement Therapy (CRRT ) DIALYSATE: A balanced mix of electrolytes and water. Closely resembles human plasma. Need not be sterile in hemodialysis, but should be sterile during peritoneal dialysis. Usually warmed to approximately 100 ° F.

18. Common electrolytes included: Potassium. Sodium chloride. Magnesium. Calcium. Glucose. Bicarbonate or acetate added to buffer (to stabilize existing metabolic acidosis ).

19. PRINCIPLE INVOLVED: Diffusion: Movement of solutes from an area of greater concentration to an area of lesser concentration. Osmosis: Movement of fluid from an area of lesser concentration to an area of greater concentration. Ultrafiltration (water & fluid removal): Movement of fluid across a semi permeable membrane as a result of an artificially created pressure. It helps in controlling weight loss during dialysis .

20. HEMODIALYSIS Uses a machine and an artificial kidney to remove excess fluid and waste products from the blood. R egulate Blood Pressure & do not regulate hormonal functions. Preferred method and is indicated when immediate removal of water and toxins is needed. Blood pumped out via the vascular access. Passes through a filter (dialyzer ). Semi-permeable pores allows small substances (creatinine, urea, water) to pass but does not allow passage of blood, protein, bacteria, then blood is returned once filtered.

21. Internal Arteriovenous Fistula (AVF ): Fistula made between radial artery and basilic vein. Provides arterial blood flow via the vein. Works best if patient has healthy veins. Advantages: Low complication rate. Can be used indefinitely. No dressing. Allows freedom of movement .

22. Internal Arteriovenous Graft (AVG) Primary used in CRF & elderly. Synthetic graft which provides a bridge between artery and vein. Needs 3-6 weeks for healing. Advantages : Decreased risk of bleeding/clotting. Can be used indefinitely. No dressing. Allows freedom of movement.

23. AVF OR AVG complications : Clotting/thrombosis. Stenosis (Abnormal narrowing of passageway). Infections. Steal syndrome (inflow & outflow of blood during dialysis). Cold hand/fingers. Numbness/tingling of fingers. May resolve after 6 weeks. Increased risk of heart failure .

24. Nursing Interventions: Do not measure BP, do not draw blood & do not administer injections. Monitor for clotting. Monitor for arterial steal syndrome. Monitor site for infection and bleeding. Do not do such activities that compresses the blood vessels. Maintain occlusive dressing that stops bleeding. Do not use catheter other than dialysis techniques. Do not sit for more than 45 degrees or lean forward.