Renal Failure Acute and Chronic

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Renal FailureAcute and Chronic

• DR.FAROOQ ALAM
• M.B.B.S-M.Phil

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Acute Renal Failure

• Identifying and correcting the causes
  Fluid and dietary restrictions
• Maintaining water and electrolyte balance
• Supplying adequate calories
• May need dialysis to jump start renal function
• May need to stimulate production of urine with IV
  fluids, Dopomine, diuretics, etc.

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Acute Renal Failure

• The kidney has a remarkable ability to recover
  from insult. The objectives of treatment of ARF
  are to restore normal chemical balance and
  prevent complications.
• The medical management includes maintaining fluid
  balance, avoiding fluid excesses, or possibly
  performing dialysis.

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Maintenance of fluid balance is based on daily
body weight, serial measurements of central
venous pressure, serum and urine concentrations,
fluid losses, blood pressure, and the clinical
status of the patient. The parenteral and oral
intake and the output, including insensible loss,
are calculated and are used as the basis for
fluid replacement.
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Medical Management (Continued)

• Because excessive administration of parenteral
  fluids may cause pulmonary edema, extreme caution
  must be used to prevent fluid overload
  (Characterised by dyspnea, tachycardia, distended
  neck veins, and crackles) . Generalized edema is
  assessed by examining the presacral and pretibial
  areas several times daily. Mannitol, furosemide,
  or ethacrynic acid may be prescribed to initiate
  a diuresis and prevent or minimise subsequent
  renal failure.

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Adequate blood flow to the kidneys in patients
with prerenal causes of ARF may be restored by
intravenous fluids or blood product
transfusions. Dialysis may be initiated to
prevent serious complications of ARF, such as
hyperkalemia, severe metabolic acidosis,
pericarditis, and pulmonary edema.
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Pharmacologic TherapyHyperkalemia

• Hyperkalemia is a life-threatening condition.
  Therefore, the patient is monitored for
• Serum potassium levels
• Electrocardiogram (ECG) changes (tall, tented, or
  peaked T waves) (next slide)
• Signs and symptoms (muscle weakness, diarrhea,
  abdominal cramps)

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Peaked T waves
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Pharmacologic Therapy (Continued)

• Hyperkalemia may be reduced by administering
  cation-exchange resins (sodium polystyrene
  sulfonate Kayexalate) orally or by retention
  enema. Kayexalate exchanges a sodium ion for a
  potassium ion in the colon (major site for
  potassuim exchange). Sorbitol is often
  administered in combination with Kayexalate to
  induce a diarrhea-type effect.

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Pharmacologic Therapy (Continued)

• Administration of a retention enema requires a
  rectal catheter with a balloon to facilitate
  retention for 30 to 45 minutes. Afterward, a
  cleansing enema is administered to remove the
  Kayexalate resin as a precaution against fecal
  impaction.
• Immediate dialysis.
• Intravenous glucose and insulin or calcium
  gluconate may be used as emergency measures to
  treat hyperkalemia.

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Nursing Management of ARF

• Monitoring fluid and electrolyte balance. The
  nurse
• monitors the patients serum electrolyte levels
  and physical indicators of fluid and electrolyte
  imbalances.
• carefully screens parenteral fluids, all oral
  intake, and all medications to ensure that hidden
  sources of potassium are not inadvertently
  administered or consumed.
• monitors the patient closely for signs and
  symptoms of hyperkalemia (Slide 12).

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Nursing Management of ARF (Continued)

• monitors fluid status by paying careful attention
  to fluid intake, urine output, apparent edema,
  distention of the jugular veins, breath sounds,
  and increasing difficulty in breathing.
• maintains accurate daily weight, and intake and
  output record.
• reports to physician indicators of deteriorating
  fluid and electrolyte status, and prepares for
  emergency treatment.

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Nursing Management of ARF (Continued)

• Reducing metabolic rate. The nurse
• should reduce the patients metabolic rate to
  reduce catabolism and the subsequent release of
  potassium and accumulation of waste products
  (urea and creatinine).
• may keep the patient on bed rest to reduce
  exertion and the metabolic rate during the most
  acute stage of ARF.
• should prevent or promptly treat fever and
  infection to decrease the metabolic rate and
  catabolism.

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Nursing Management of ARF (Continued)

• Promoting pulmonary function. The nurse
• assist the patient to turn, cough, and take deep
  breaths frequently to prevent atelectasis and
  respiratory tract infection.
• Preventing infection. The nurse
• strictly observes aseptic technique when caring
  for the patient to minimise the risk of infection
  and increased metabolism.
• avoids, when possible, inserting an indwelling
  urinary catheter as it is a high risk for urinary
  tract infection (UTI).

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Chronic renal failure

• Chronic renal failure represents progressive and
  irreversible destruction of kidney structures,
  leading to the accumulation of metabolic
  products, drugs and poisons, and disorders of
  water, electrolyte, acid-base balance, and renal
  endocrine function.

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Treatment.

• Treatment focuses on controlling the symptoms,
  minimizing complications, and slowing the
  progression of the disease
• Three basic stages in treatment
• Preserve remaining nephrons
• Conservative treatment of uraemic syndrome
• Renal dialysis and transplantation
• .

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Preserve remaining nephron function Control of
hypertension and heart failure Treatment of
superimposed urinary tract infection Correction
of salt and water depletion Careful prescribing
of drugs that are potentially nephrotoxic
Dietary protein restriction Conservative
management of uraemic syndrome Reduce protein
intake Aluminium hydroxide to reduce intestinal
phosphate absorption Vitamin D and calcium
supplements to increase serum calcium
Allopurinol to reduce serum uric acid
Erythropoietin to correct anaemia
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Dialysis is the option for ongoing treatment,
often used while waiting for a suitable
transplant opportunity Kidney transplant, in
which a functioning kidney from a donor is
surgically grafted into the patient, has a good
rate of success
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Differences

• Acute renal failure Most causes of acute renal
  failure can be treated and the kidney function
  will return to normal with time. Replacement of
  the kidney function by dialysis (artificial
  kidney) may be necessary until kidney function
  has returned.
• Chronic renal failureChronic kidney damage is
  usually not reversible and if extensive, the
  kidneys may eventually fail completely. Dialysis
  or kidney transplantation will then become
  necessary

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Another diagnostic clue that helps differentiate
CRF and ARF is gradual rise in serum creatinine
(over several months or years) as opposed to a
sudden increase in the serum creatinine (several
days to weeks).
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Chronic Renal Failure

• Nursing care
• Frequent monitoring
• Hydration and output
• Cardiovascular function
• Respiratory status
• E-lytes
• 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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Chronic Renal Failure

• Transplant
• Must find donor
• Waiting period long
• Good survival rate 1 year 95-97
• Must take immunosuppressants for life
• Rejection
• Watch for fever, elevated B/P, and pain over
  site of new kidney

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Chronic Renal Failure

• Post op care
• ICU
• I/O
• B/P
• Weight changes
• Electrolytes
• May have fluid volume deficit
• High risk for infection

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Transplant Meds

• Patients have decreased resistance to infection
• Corticosteroids anti-inflammarory
• Deltosone
• Medrol
• Solu-Medrol
• Cytotoxic inhibit T and B lymphocytes
• Imuran
• Cytoxan
• Cellcept
• T-cell depressors - Cyclosporin

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THANK YOU

• Any questions???