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Published by: jefroc on Apr 02, 2010
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Chapter 47: Nursing Management: Acute RenalFailure and Chronic Kidney Disease
Renal failure is the partial or complete impairment of kidney function resulting in aninability to excrete metabolic waste products and water.
Renal failure causes functional disturbances of all body systems.
Renal failure is classified as acute or chronic.ACUTE RENAL FAILURE (ARF)
Acute renal failure (ARF) usually develops over hours or days with progressive elevationsof blood urea nitrogen (BUN), creatinine, and potassium with or without oliguria. It is aclinical syndrome characterized by a rapid loss of renal function with progressive azotemia.
ARF is often associated with oliguria (a decrease in urinary output to <400 ml/day).
The causes of ARF are multiple and complex. They are categorized according to similar  pathogenesis into prerenal (most common), intrarenal (or intrinsic), and postrenal causes.
Prerenal causes are factors external to the kidneys (e.g., hypovolemia) that reducerenal blood flow and lead to decreased glomerular perfusion and filtration.
Intrarenal causes include conditions that cause direct damage to the renal tissue,resulting in impaired nephron function. Causes include prolonged ischemia,nephrotoxins, hemoglobin released from hemolyzed RBCs, or myoglobin releasedfrom necrotic muscle cells. Acute tubular necrosis (ATN) is an intrarenal conditioncaused by ischemia, nephrotoxins, or pigments. ATN is potentially reversible if the basement membrane is not destroyed and the tubular epithelium regenerates.
Postrenal causes involve mechanical obstruction of urinary outflow. Common causesare benign prostatic hyperplasia, prostate cancer, calculi, trauma, and extrarenaltumors.
Clinically, ARF may progress through four phases: initiating, oliguric, diuretic, andrecovery. In some situations, the patient does not recover from ARF and chronic kidney
disease (CKD) results, eventually requiring dialysis or a kidney transplant.Oliguric Phase
Fluid and electrolyte abnormalities and uremia occur during the oliguric phase. The kidneyscannot synthesize ammonia or excrete acid products of metabolism, resulting in acidosis.
Damaged tubules cannot conserve sodium resulting in normal or below-normal levels of serum sodium. Uncontrolled hyponatremia or water excess can lead to cerebral edema. Fluidintake must be closely monitored.
Hyperkalemia is a serious complication of ARF. The serum potassium levels increase because the ability of the kidneys to excrete potassium is impaired. Acidosis worsenshyperkalemia as hydrogen ions enter the cells and potassium is driven out of the cells.
When potassium levels exceed 6 mEq/L (6 mmol/L) or dysrhythmias areidentified, treatment must be initiated immediately.
Hematologic disorders associated with ARF include anemia due to impaired erythropoietin production and platelet abnormalities leading to bleeding from multiple sources.
A low serum calcium level results from the inability of the kidneys to activate vitamin D.When hypocalcemia occurs, the parathyroid gland secretes parathyroid hormone, whichstimulates bone demineralization, thereby releasing calcium from the bones. Phosphate isalso released, leading to elevated serum phosphate levels.
The two most common causes of death in patients with ARF are infection andcardiorespiratory complications.
The best serum indicator of renal failure is creatinine because it is not significantly altered by other factors.
 Neurologic changes can occur as the nitrogenous waste products increase. Symptoms caninclude fatigue and difficulty concentrating, later escalating to seizures, stupor, and coma.
Diuretic Phase
The diuretic phase begins with a gradual increase in daily urine output of 1 to 3 L/day, butmay reach 3 to 5 L or more. The nephrons are still not fully functional. The uremia maystill be severe, as reflected by low creatinine clearances, elevated serum creatinine andBUN levels, and persistent signs and symptoms.
Recovery Phase
The recovery phase begins when the GFR increases, allowing the BUN and serumcreatinine levels to plateau and then decrease. Renal function may take up to 12 months tostabilize.Collaborative Management
Because ARF is potentially reversible, the primary goals of treatment are to eliminate thecause, manage the signs and symptoms, and prevent complications while the kidneysrecover.
Common indications for dialysis in ARF are (1) volume overload; (2) elevated potassiumlevel with ECG changes; (3) metabolic acidosis; (4) significant change in mental status;and (5) pericarditis, pericardial effusion, or cardiac tamponade.
Hemodialysis (HD) is used when rapid changes are required in a short period of time.Peritoneal dialysis (PD) is simpler than HD, but it carries the risk of peritonitis, is lessefficient in the catabolic patient, and requires longer treatment times. Continuous renalreplacement therapy (CRRT) may also be used in the treatment of ARF, particularly inthose who are hemodynamically unstable.
Prevention of ARF is primarily directed toward identifying and monitoring high-risk  populations, controlling exposure to nephrotoxic drugs and industrial chemicals, and preventing prolonged episodes of hypotension and hypovolemia.
The patient with ARF is critically ill and suffers not only from the effects of renal disease but also from the effects of comorbid diseases or conditions (e.g., diabetes, cardiovascular disease).

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