renal failure

renal failure, ARF, CRF, ESRD

1. RENAL SYSTEM RENAL FAILURE

2. 1.Acute Renal Failure ARF is an acute and potentially reversible irritability of the kidneys to perform their normal functions to maintain homeostasis.

3. ETIOLOGY Prerenal factors osmolality is high Specific gravity <1.020  Renal perfusion Tubular function normal nonspecific symptoms: Fever Dehydration Tachycardia Ex: shock,CCF Intrarenal ARF results from injury to Kidney large amounts of calcium and uric acid excretion sodium cannot be conserved urine cannot be concentrated Symptoms: nausea/vomiting, Hypertension oliguria . Ex: HUS, GN Postrenal or obstructive delayed voiding after birth electrolyte imbalance a poor urinary stream abdominal mass Urine osmolality & sodium levels are unaffected Ex: calculi, trauma

4. PHASES Initial -Renal damage is occurring, the child may be -Asymptomatic 2. Oliguric -<1ml/kg/hr of urine -Impaired glomerular filtration -Waste cannot be remove -Uremia develops -Neurotoxicity -CCF, HTN, anemia

5. 3. Diuretic - lasts 2 weeks - cellular regeneration and healing - gradual return to normal - dehydration and electrolyte imbalance due to excess urination 4. Recovery - it takes months - if left untreated it result in fluid overload, electrolyte imbalance, uremia, coma

6. CLINICAL MANIFESTAIONS Severe oliguria / Anuria Child may be markably well / extremely sick Nausea / Vomiting Lethargy Dehydration Acidotic breathing Altered consciousness Irregular cardiac rate, rhythm Edema Hypertension

7. DIAGNOSIS Careful history taking Vomiting, diarrhea, fever, other renal disease Laboratory investigations Anemia, raised serum creatinine level, blood urea, electrolytes, pH, bicarbonate and complete blood count, reduced C3 Urine examination Protienuria, Hematuria, presence of casts USG Structural abnormalies , calculi IVP Acute tubular necrosis Radionuclide studies Evaluate GFR, renal blood flow Renal biopsy Ultimate cause

8. PATHOPHYSILOGY

9. TREATMENT Medical treatment Fluid and dietary restrictions Use of diuretics Maintain Electrolytes May need dialysis to jump start renal function May need to stimulate production of urine with IV fluids, Dopomine , diuretics, etc. Hemodialysis

10. Nursing interventions Monitor I/O, including all body fluids Monitor lab results Watch hyperkalemia symptoms: malaise, anorexia, parenthesia , or muscle weakness, ECG changes Watch for hyperglycemia or hypoglycemia if receiving TPN or insulin infusions Maintain nutrition Safety measures Mouth care Daily weights Assess for signs of heart failure Skin integrity problems

11. PROGNOSIS Mortality rate of ARF is about 20 to 40% which is influenced by the cause and duration of renal failure with severity of pathological changes. Poor prognosis is related to associated sepsis, HUS, prolonged anemia, cardiac failure, hepatic failure and respiratory failure with delayed initiation of treatment.

12. CHRONIC KIDNEY DISEASE Chronic renal failure End stage renal failure

13. 2. Chronic Renal Failure It is a permanent irreversible destruction of nephron leading to severe deterioration of renal function, finally resulting to end stage renal disease.

14. ETIOLOGY Cause below 5 years of age is mostly congenital anomalies After 5 that is acquired glomerular disease, hereditary disease Glomerular disease Congenital anomalies Obstructive uropathy Miscellaneous

15. CLINICAL MANIFESTATIONS Early symptoms Weakness Anorexia Nausea Failure to thrive Unexplained anemia Osteodystrophy Growth failure Late manifestations Gastrointestinal bleeding Pericarditis Congestive cardiac failure Altered sensorium   Indications of poor prognosis Convulsions Coma Cardiomyopathy  

16. DIAGNOSIS Blood examination Decreased hematocrit , Hb %, Na + , Ca ++ , HCO - 3 , increased K + & phosphorus Renal function test Gradual increase in BUN, uric acid & creatinine Urinalysis Variation in specific gravity, increased urine creatinine, change in total urine output X-Ray Chest, hands, knees, pelvis, spine to detect bony defect ECG, IVP, MCU, radio nuclide imaging Extent of complications Other abnormal findings Metabolic acidosis, Fluid imbalance, Insulin resistance

17. PATHOPHYSIOLOGY In the early stage of disease child remains asymptomatic. Advance renal damage will occur only in late stages. Increased numbers of nephrons are destructed at various degrees and a few remain intact but hypertrophied and functional. This leads to insufficient adjustments in fluid and electrolyte balance. As the disease progress to end stage severe reduction in number of nephrons occur and the kidney will not b able to maintain fliud and electrolyte balance. The accumulatin of various substances in blood result in complications

18. Stages of Chronic Renal Failure Diminished Renal Reserve Normal BUN, and serum creatinine absence of symptoms 2. Renal Insufficiency GFR is about 25% of normal, BUN Creatinine levels increased 3. Renal Failure GFR <25% of normal increasing symptoms 4. ESRD or Uremia GFR < 5-10% normal, creatinine clearance <5-10ml/min resulting in a cumulative effect

19. COMPLICATIONS Azotemia Metabolic acidosis Electrolyte imbalance CCF HTN Severe anemia Growth retardation Delayed or absent sexual maturation

20. MANAGEMENT Conservative management Correction of reversible component of renal dysfunction Preservation of renal function Treatment of metabolic and psycho-social problems Optimization of growth Preparation for treatment of ESRD Treat for infection, accelerated hypertension, CCF, obstruction of urine flow - to improve renal function

21. Dietary therapy Low protein diet Severe protein restriction may produce protein calorie malnutrition Diet should consist of 100 percent RDA for calories Protein should be of high biological value and should comprise 6 – 10 % of all calories Salt restriction in patients with hypertension and fluid overload Patients with salt losing nephropathy should take a liberal amount of salt and water If the GFR falls <10ml/min/1.73m 2 , potassium intake should be restricted.(hyperkalemia may develop) Vit D is essential to raise the serum calcium and suppress parathormone secretion.

22. Dialysis

23. Renal transplatation

24. NURSING MANAGEMENT Frequent monitoring Hydration and output Cardiovascular function Respiratory status Electrolytes Nutrition Mental status Emotional well being Ensure proper medication regimen Skin care Bleeding problems Care of the shunt Education to client and family

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