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Acute renal failure

Acute renal failure (ARF) is a clinical syndrome characterized by an acute fall in glomerular
filtration rate, resulting in decreased clearance of metabolic waste products from the blood. ARF
manifests as an increase in serum creatinine and BUN. Urine volume may be normal, decreased, or
increased. The exact cause of ARF and oliguria is not always known, although many times there is a
specific underlying problem. Some of the factors may be reversible if identified and treated promptly,
before kidney function is impaired. Factors include hypovolemia; hypotension; reduced cardiac output
and heart failure; obstruction of the kidney or lower urinary tract by tumor, blood clot, or kidney stone;
and bilateral obstruction of the renal arteries or veins. If these conditions are treated and corrected before
the kidneys are permanently damaged, the increased BUN and creatinine levels, oliguria, and other r signs
associated with ARF may be reversed. Renal failure can be divided into three major types: prerenal
failure, postrenal failure, and intrarenal failure. Prerenal failure is caused by inadequate renal perfusion.
The main causes are extracellular fluid volume depletion and cardiovascular disease. Prerenal conditions
do not cause permanent renal damage unless the hypoperfusion is severe enough to produce tubular
ischemia. Postrenal failure is usually the result of an obstruction somewhere distal to the kidney. Pressure
rises in the kidney tubules and eventually, the glomerular filtration rate (GFR) decreases. Intrarenal
failure is the result of actual parenchymal damage to the glomeruli or kidney tubules. Ischemia due to
decreased renal perfusion accounts for more than half of the cases of acute tubular necrosis. These
processes result in a decrease of GFR, progressive azotemia, and impaired fluid and electrolyte balance.
Certain medications, especially nonsteroidal anti-inflammatory drugs (NSAIDS) and ACE inhibitors, may
also predispose a patient to intrarenal damage. These medications interfere with the normal
autoregulatory mechanisms of the kidney and may cause hypoperfusion and eventually ischemia.
Initially, weight gain and peripheral edema may be the only symptoms of ARF. Later, as nitrogenous
products accumulate, symptoms of uremia may develop, including anorexia, nausea and vomiting,
weakness, myoclonic jerks, seizures, confusion, and coma; asterixis and hyperreflexia may be present on
examination. Chest pain), a pericardial friction rub, and findings of pericardial tamponade may occur if
uremic pericarditis is present. Fluid accumulation in the lungs may cause dyspnea and crackles on
auscultation. Many cases of ARF are reversible if diagnosed and treated early.

Usual diagnostic tests

The usual diagnostic tests include BUN, creatinine, electrolyte analysis, urine output measures,
renal ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) scans.
 Usual treatment
Treatment includes restoring normal chemical balance and preventing complications until the renal
tissues are repaired and renal function is restored. Possible causes are identified and treated. Fluid balance
is managed based on daily weights, serum and urine concentrations, fluid losses, blood pressure, and
clinical assessments. Fluid excesses are treated with mannitol, furosemide, or ethacrynic acid to initiate
diuresis and prevent subsequent renal failure. IV fluids, albumin , or blood product transfusions are used
to restore blood flow to the kidneys. Dialysis may be started to prevent complications of uremia. Sodium
bicarbonate is used to elevate plasma pH levels. Parenteral erythropoietin is used to treat reduced
erythropoietin production and prevent anemia. IV glucose and insulin or calcium glutamate are used as an
emergency and temporary measure to treat hyperkalemia. Dietary protein is limited to about 1g/kg during
oliguric phase to minimize protein breakdown and to prevent accumulation of toxic end products.
Potassium intake is limited to 40 to 60 mEq/d and Sodium intake is restricted to 2g/d. After the diuretic
phase, high-protein, high-calorie diet is given with gradual resumption of activities
.

Usual prognosis

Acute kidney failure and its immediate complications, such as water retention, high acid and potassium
levels in the blood, and increased urea nitrogen in the blood, can often be treated successfully. The overall
survival rate is about 60%. Survival is less than 50% for people who have several organs failing at the
same time. Yet, survival is about 90% for people whose kidney failure is due to decreased blood flow
because body fluids have been lost through bleeding, vomiting, or diarrhea—conditions that are reversible
with treatment.

Nursing care
Vital signs every 4hrs/ assess diagnostic test values / monitor pt response to therapy/ monitor and record I
& O/ monitor daily weights/monitor breath and heart sounds/ assess for generalized edema/ turn pt
frequently/ assist, explain, and support patient and family/ Administer antihypertensives, diuretics,
electrolyte supplements, erythropoietin, phosphate binders, and sodium bicarbonate as prescribed /
observe for signs of fatigue, pallor, and weakness