ACUTE AND CHRONIC RENAL FAILURE
• The end-products of pharmacological agents
are mainly excreted via the kidneys and
therefore depend on the effective functioning
of the kidneys and entire urinary system to
prevent toxaemia.
• In addition, overuse of drugs especially self
medication can impair kidney function.
Cont…
• Renal failure is when the kidneys fail to
function normally with a resultant rise in
blood levels of urea and creatinine.
• Urinary output usually is decreased.
• This occurs suddenly (acute) or over a period
of time of months or years (chronic).
ACUTE RENAL FAILURE
• Acute renal failure (ARF) is a sudden and
almost complete loss of kidney (decreased
glomerula filtration rate) over a period of
hours to days or a sudden and severe
interruption of the kidney function.
CAUSES
• The aetiology of ARF is divided into three
major categories:
Pre renal causes (hypo perfusion of the kidney)
• This refers to causes outside the kidneys that
reduce renal blood flow and lead to hypo
perfusion of the kidney and a drop in
glomerular filtration rate.
• Common pre renal clinical situations are:
Cont…
• Hypovolaemia (volume-depletion) states such as
in haemorrhage, dehydration, vomiting and
inappropriate use of diuretics.
• Impaired cardiac performance which leads to
decreased cardiac output such as in myocardial
infarction, heart failure or cardiogenic shock.
• Systemic vasodilatation or decreased peripheral
resistance due to sepsis, anaphylaxis, acidosis and
neurologic injury.
Cont…
• Hypotension due to shock and cardiac failure.
• Renal vascular obstruction due to thrombosis of
renal arteries, bilateral renal vein thrombosis and
embolism.
Cont…
Intra renal causes (intrinsic or renal causes)
• These are the result of actual parenchymal
damage to the glomeruli or kidney tubules.
Examples include:
• Conditions such as burns, crush injuries, and
severe trauma – In these conditions, myoglobin
(a protein released from muscle when injury
occurs) and haemoglobin are liberated, causing
renal toxaemia, ischaemia or both.
Cont…
• Nephrotoxicity agents such as amino glycoside
antibiotics e.g. gentamycin; radio opaque contrast
agents; heavy metals e.g. lead and mercury;
solvents and chemicals e.g. ethylene glycol and
arsenic; NSAIDS and angiotensin-converting
inhibitors (ACE inhibitors).
Cont…
• The commonest are NSAIDS and ACE
inhibitors,these medications interfere with the
normal auto regulatory mechanisms of the
kidneys and may cause hypo perfusion and
eventually ischaemia.
• Nephrotoxicity may also result from herbal
remedies and conditions such as HIV
infections
Cont…
• Infectious processes such as acute
pyelonephritis, acute glomerulonephritis,
toxaemia of pregnancy, malignant
hypertension and systemic lupus
erythromatous
Cont…
Post renal causes
• These are usually the result of an obstruction distal
to the kidney.
• This results in mechanical obstruction of urinary
outflow.
• As the flow of urine is obstructed, urine refluxes
into the renal pelvis causing pressure to rise in the
kidney tubules.
• Eventually, the glomerular filtration rate decreases.
Common causes are:
Cont…
• Renal calculi
• Tumours such as bladder and prostate cancer
• Strictures
• Blood clots
• Others include trauma (to back, pelvis or
perineum) and spinal cord disease.
Cont…
• Pre renal causes account for 60-70%, intrinsic
causes account for 25-40% whereas post renal
causes account for 5-10% of the cases.
PATHOPHYSIOLOGY
• The pathophysiology of acute renal failure is not
completely understood. However, the possible
pathologic processes involved in acute tubular
necrosis are:
• Renal vasoconstriction – Hypovolaemia and
decreased renal blood flow stimulate rennin
release, which activates the renin-angiotensin-
aldosterone system and results in constriction of
the peripheral arteries and renal afferent
arterioles.
Cont…
• With decreased renal blood flow, there is
decreased capillary pressure and glomerular
filtration rate (GFR), as well as tubular
dysfunction and ends with oliguria.
• Ischaemia alters glomerular epithelial cells
and decreases glomerular capillary
permeability.
• This reduces blood flow and leads to tubular
dysfunction.
Cont…
• When tubules are damaged, interstitial
oedema occurs, and necrotic epithelial cells
accumulate in the tubules.
• The debris lowers the GFR by obstructing the
tubules and intra tubular fluid flow.
SIGNS AND SYMPTOMS
• Clinically, acute renal failure progress through
four (4) phases
• Intrarenal disease with acute tubular necrosis
has a prolonged course of recovery because of
the actual parenchyma damage.
• The phases are:
Initiating phase
• This begins at the time of the insult and
continues until the signs and symptoms
become apparent or significant.
• It can last hours to days.
Oliguric phase- 8-15 days
• This follows within one day of the onset and
the duration is dependent upon the type of
the toxic injury and duration of ischaemia.
• The major problems in this phase are the
inability to excrete fluid loads, regulate
electrolytes and excrete metabolic waste
products.
Cont…
• Uraemic symptoms first appear when the
urine output is less than 400 mls/24 hours as a
result of increased serum urea nitrogen and
creatinine.
Cont…
• Later, life threatening conditions such as
hyperkalaemia occurs when urine output is less
than 30 mls/hr because of the inability to
regulate electrolytes. Fluid overload also
occurs. The symptoms at this stage include;
• dysarythmias,
• Kussmaul’s respirations (rapid, deep breathing),
• CCF
Cont…
• pulmonary oedema
• Jugular vein distension with bounding pulse
• hypertension
• Fatigue and bleeding
Diuretic phase (2-6 wks)
• The diuretic phase begins with the gradual
increase in daily urine output of 1 to 3 litres
per day, but may reach 3 to 5 litres or more
per day.
• Urine production is increased because of high
urea concentration in the glomerular filtrate
that causes osmotic diuresis and inability of
the tubules to concentrate the urine.
Cont..
Symptoms include;
• urine output of up to 4-5 litres per day
• postural hypertension
• tachycardia, improving mental alertness and activity
• weight loss, thirst, Dry mucous membranes and
decreased skin turgor
• These last for 2-6 weeks after onset of oliguria but
the duration varies accordingly
Recovery phase
• This begins when the glomerular filtration rate
increases, allowing serum creatinine to stabilize and
then decrease.
• Major improvements occur in the first 1 to 2 weeks
of this phase but renal function may take up to 12
months to stabilize.
• The major symptom is decreased energy levels
which last for 3-12 months.
MEDICAL MANAGEMENT
INVESTIGATIONS
History
• Investigate each symptom. The key symptoms
are anorexia, fatigue, nausea and vomiting,
mental status changes, pruritus, shortness of
breath if fluid overload is present.
• Assess also for oliguria and passage of stones
in the urine.
Cont…
• Past health history e.g. diabetes mellitus or
cerebral vascular accident which can lead to a
neurogenic bladder, recent surgery or
procedures which have predisposed the
patient to ischaemia, endocarditis or
exposure to contrast media.
• Determine also whether the patient has been
taking nephrotoxic agents or has been
exposed to environmental toxins.
Cont…
• Review of the systems, for example;
– Pulmonary system symptoms which could lead to
vasculitis.
– Cardiac system (symptoms of cardiac failure,
prosthetic valve or valvular disease which could
lead to decreased renal function).
– Gastrointestinal tract (diarrhea, vomiting or poor
intake which could lead to hypovolaemia).
Cont…
– Genitourinary (prostate enlargement leading to
obstruction).
– Musculoskeletal (bone pain in the elderly which
could be due to prostate cancer or prolonged
immobilization).
Cont…
– Musculoskeletal (bone pain in the elderly which
could be due to prostate cancer or prolonged
immobilization).
– Skin (rash which could be due allergic interstitial
nephritis or systemic lupus erythromatous.
Cont…
• Physical examination – may reveal the
following:
• Vital signs – increased temperature due to
possible infection, hypertension or
hypotension due to depletion of fluid volume
or sepsis and weight loss or gain due to
hypovolaemia or hypervolaemia.
• Mouth – signs of dehydration.
Cont…
• Neck – distended jugular veins with visible
bounding pulse due to fluid overload.
• Pulmonary system – signs of congestive heart
failure; and crackles in the lungs
• Heart – heart murmurs or signs of congestive
heart failure.
• Abdomen – bladder distension suggesting
urethral obstruction.
• Pelvis – pelvic mass.
Cont…
• Rectum – prostate enlargement.
• Skin – rash of interstitial nephritis or splinter
haemorrhages; and loss of skin turgor due to
dehydration.
• Haematologic –signs of anaemia.
• Neurological – lethargy, memory impairment
Cont…
• Urinalysis – urine amount is reduced initially. If
the cause is pre renal, the specific gravity is
high whereas for intrinsic causes, the specific
gravity may be normal. There are urine
sediments containing abundant cells, casts or
proteins suggesting intrinsic causes.
• Renal ultrasound provides information about
the anatomy and physiology of the kidneys.
• Blood for urea, nitrogen and creatinine levels.
Cont…
• Serum for electrolyte levels e.g. there may be
hyperkalaemia, high phosphate concentrations and
low calcium levels.
• Full blood count may reveal anaemia due to
reduced erythropoietin production, uraemic gastric
intestinal lesions and reduced red blood cell life
span.
• Computed Tomography (CT) scan and magnetic
resonance imaging (MRI) can identify masses and
vascular anomalies.
TREATMENT
• Since acute renal failure is potentially
reversible, the primary goals of treatment are;
• To eliminate the cause
• To manage the signs and symptoms
• To prevent complications while the kidneys
recover
• Therefore, the treatment starts with
treatment of the precipitating cause.
Conservative management
• Hypovolaemia is treated with hypotonic solutions
such as saline.
• If hypovolaemia is due to blood or plasma loss,
packed red blood cells and isotonic saline are
administered.
• Volume replacement rates must match volume
losses on a 1:1 basis.
Cont…
• Various therapies are used to manage potassium
levels e.g. regular insulin administration
intravenously.
• This causes potassium to move into the cells.
Ensure that glucose is given concurrently to prevent
hypoglycaemia.
• Other drugs that may be given are sodium
bicarbonate which correct acidosis and causes shift
of potassium into cells as well as loop diuretics such
as lasix (up to 320 mg/day) to produce diuresis.
cont...
• Renal failure from nephrotoxins or ischaemia is
treated with agents that increase renal blood flow
such as low-dose dopamine, mannitol and loop
diuretics.
• Inflammatory states as in acute
glomerulonephritis are treated with
glucocorticosteroids.
Cont…
• Dietary restriction. Dietary proteins are limited to
about 1g/kg during the oliguric phase to minimize
protein breakdown and to prevent accumulation of
toxic end products.
• Foods and fluids containing potassium or
phosphorus (bananas, citrus fruits and juices,
coffee) are restricted.
• Potassium intake is usually restricted to 40-60
mEq/day and sodium is usually restricted to 2g/day
Cont…
• The elevated serum phosphate level is
controlled with phosphate-binding agents
such as aluminium hydroxide which decrease
the absorption of phosphate from the
intestinal tract
Cont…
• Adjustments of medications that are
commonly eliminated through the kidneys
such as antibiotics especially aminoglycosides,
digoxin, angiotensin-converting enzyme
inhibitors and medications containing
magnesium.
Dialysis
• This is required when conservative management
is not effective.
• It is a process by which waste products in the
blood are filtered through a semi-permeable
membrane.
• There are two (2) methods that are used, that is,
peritoneal dialysis and haemodialysis. However,
haemodialysis is the method of choice when
rapid changes are required in a short time.
NURSING CARE
Environment
• Nurse the patient in a clean, quiet and well
ventilated environment.
Observations
• This is a very ill patient; observe that meals taken
and drugs excreted by the kidneys should be
[Link] should be checked frequently
because cardiac function may be affected by
retention of fluid or hypertension which may have
been the cause.
Cont…
• Respirations observed for signs of pulmonary
oedema or depth and volume. If volume is
high it is a sign of acidosis.
• Blood pressure should be checked to know the
general condition of the patient.
• If there is a rise above normal may indicate as
a sign of urea in blood where hypertension is
not the cause of renal failure.
Cont…
• Temperature should be checked every 4 hours
if it is normal because a sudden rise in
temperature may occur because these
patients are susceptible to infection
• Observe for muscular twitching, disorientation
and increased drowsiness and report
immediately to the doctor if is going into
ureamic state, cerebral oedema may preceed
coma.
Cont…
Fluid and Nutrition
Correct hypovolaemia by oral or iv route to maintain
cardiac output for adequate perfusion of kidneys.
Fluids limited to 500mls per day and amount equal
to urinary output in 24hours. 500mls fluid loss will be
through skin and lungs. The type of fluid given will
depend on laboratory results. Maintain an accurate
fluid balance record of intake and output
Watch for signs of dehydration in diuretic phase
Cont…
Monitor urinary output and specific gravity
Explain to the patient why you are restricting fluids and
[Link] potassium intake
Restrict protein intake to avoid further rise in urea to
reduce accumulation of urea and creatinine about 125g of
protein per day.
Adequate nutrition with 2000 Kcal per day and vitamins.
Give adequate carbohydrates
Limit dietary protein intake during oliguric phase to 60g
per day to prevent rises in blood urea. A normal diet is
resumed as recovery begins.
Electrolyte balance
• Frequent estimation of blood potassium and other
electrolytes (urea, creatinine etc.) will be carried
out
• Evaluation for potassium intoxication by
assessment of serum potassium levels and ECG.
Acculation may occur during the uric phase. Iv
calcium supplement is given if hypocalcaemia
develops
• Calcium gluconate (IV) is used as emergency
measure to correct hperkalaemia
Rest
• Patient’s activities are minimized to avoid
increasing metabolic production of wastes.
• This is done to conserve energy.
• Resume activities slowly to resume renal
function.
Hygiene
Mouth care is done frequently to stimulate
salivation. Patient may have sores, rinse mouth with
antiseptic. Lubricate lips with Vaseline. Squeeze
lemon juice in water and rinse mouth with saline.
Bath patient daily to remove waste which may be
excreted through the skin and also for comfort
Do pressure area care and apply Vaseline on bone
prominences.
Do 2 hourly turnings and exercise to prevent deep
vein thrombosis
Prevention of infection
• Patients are susceptible to infection therefore,
nurse patient in a sideward to protect them from
diseases. If infection is present give antibiotics.
Tetracycline is contraindicated because it has a
marked catabolic effect rising uric levels.
• Utilize aseptic method during dialysis
• Avoid use of indwelling catheters
• Turn patient and encourage her to cough to
prevent pulmonary infections
Emotional support
• Explain the disease to the patient, answer
questions truthfully that recovery is 50%
Chances and give support care.
• Explain the type of treatment, heamodialysis
or peritoneal dialysis and explain the
prognosis.
• Involve relatives in the nursing care.
Nursing care cont…
Position
• Nurse patient in bed with rails to prevent injury
when twitching, due to accumulation of toxins.
Medication
• Lasix but if the urinary output is not
satisfactorily.
• Drugs containing potassium and sodium must
not be given to the patient.
Preparation for discharge
Advise patient and family on resuming activities gradually
and that there is a need for extra rest.
Dietary restriction like low salt intake if patient is fat, advise
to lose [Link] infections if sick seek medical advice
promptly
Observe review dates to monitor progress and reinforce on
need of continuation of treatment like urinalysis (first sample
in the morning) in order to prevent progression of disease to
chronic renal failure. If not employed, refer to social worker
Advise to come to the hospital when ill and never take
unprescribed drugs
Prevention of acute renal failure
Prevent and treat shock with blood and fluid
replacement-avoid prolong periods of dehydration
Take every precaution to ensure that the right patient
received the right blood transfusion
Monitor urinary output in all critically ill patients to
detect onset of renal failure
Avoid use of nephrotoxins
Avoid use of indwelling catheters
Initiate adequate hydration
Prevent sepsis ( e. g. burns, drains etc.)
COMPLICATIONS
• Hyperkalaemia
• Convulsions
• Comma – due to uraemia
• Confusion, disorientation- due to uraemia
• Cardiac arrest
ROLES OF A NURSE
Nurse must be alert and knowledgeable about the
condition.
Recognize or observe for potassium toxicity like
generalized muscular weakness, shallow breathing,
numbness of limbs and around the mouth and
increased pulse and low BP.
Never give fluids or food rich in potassium or sodium
In increased levels of potassium, give sodium
bicarbonate because increased potassium levels
leads to cardiac impairment.
Cont…
Cardiac insufficiency check pulse rate which is usually
weak
Pulmonary oedema check for dyspnoea and rised blood
preesure which is associated with cardiac involvement
Convulsions occur with severe headache, muscular
twitching due to ureamia
Put patient in padded railed bed to prevent injury and
observe for signs of coma- increased drowsness and
look toxic due to increased urea may progress into
disorientation and ureamic coma.
CHRONIC RENAL FAILURE
Usually the end result of a gradually progressive loss
of renal function due to diseases of the kidneys
where the nephrons are destroyed. Chronic renal
failure progresses through the following stages:
Reduced renal reserves(glomerular filtration rate)
35% to 50% of normal
Renal insufficiency (GFR 20-35% of normal
Renal failure GFR 20 to 25% of normal
End stage renal disease GFR less than 20% of normal
Causes
• Main cause is chronic glomerulonephritis
• Diabete mellitus
• Hypertension
• Chronic pyelonephritis
• Obstructive processes such as calculi
• Nephrotoxic agents such as long-term
aminoglycosides
SIGNS AND SYMPTOMS
Symptoms usually occur by the time the GFR is 20 to
35% of normal
Patient’s history may include a disease that cause
renal failure
Renal :
Hyponatraemia, Dry mouth, Fatigue, Nausea
Loss of skin turgor, Confusion, decrease in urine
output,very dilute urine, muscle weakness and
irregular pulse due to accumulation of potassium
Cardiovascular
• When the cardiovascular system is involved
there will be:
• Hypertension
• Irregular pulse
• Peripheral oedema
• Cardiac arrythmias
Cont…
Respiratory
• Pneumonia, Pleuritic pain, metabolic acidosis
and pulmonary oedema
GI
• Gum ulceration and bleeding, Parotitis, Patient
complain of hiccups, metallic taste in the
mouth,Anorexia,Nausea and vomiting and
abdominal pain.
Cont…
• Skin
• Yellowish bronze colour due to jaundice
• Skin is dry and scaly with purpura
• Ecchymosis
• Petechiae
• Brittle finger nails
• Hair is brittle may change colour
• Severe itching due to bile pigments deposited on
the skin.
Neurologic
• Alterations in the level of consciousness
• Shortened memory, Drowsiness\Irritability
• Coma, Seizures
• Muscle crumps
• Bilateral footdrop
• Pain, burn and itching in the legs
• Flaccid paralysis
Cont…
Endocrine
• Growth retardation in children
• Infertility in adults, Decreased libido,
Amenorrhea in women, Impotence in men
• Purpura,GI bleeding,Heamorrhage from body
orifices, Ecchymosis and Petechiae
• All of these are due to thrombocytopenia and
platelet defects
Musculoskeletal
• History of pathological fractures
• Bone and muscle pain due to calcium-
phosphorus imbalance and parathyroid
hormone imbalance
INVESTIGATIONS
• Blood studies show;
• Elevated urea nitrogen, serum creatinine, sodium
and potassium levels.
• Decreased arterial PH and bicarbonate levels
• Low haemoglobin and haematocrit
• Low RBC, Increased blood glucose
• X-ray studies show reduced kidney size
• Renal scan show size of the kidney
• Renal biopsy for histological identification
TREATMENT
• Conservative treatment aims to correct
specific symptoms
• Low protein diet reduces the production of
end-products of protein metabolism
• High calorie diet to prevent ketoacidosis
• Restrict sodium and potassium
THE END
