Renal Failure (Acute and Chronic) Vasa Recta

- detects change in blood volume

Renal System
- triggers release of renin
1. Excretion
- remove waste from blood stream Renin
- Triggers release of angiotensin
2. Regulation
Angiotensin
Vasa Recta - Potent vasoconstrictor
- Sensitive to changes of blood volume - BP dependent on circulating blood volume and
- Regulatory function SVR

Urine Output Aldosterone

- 1 to 2mL/kg/hr - End product of RAAS mechanism
- Great indicator of acute renal failure - Effects on collecting tubules
- Reabsorb water and sodium
Anuria – absence of urine
Oliguria – less than normal 3. Balancing of pH and electrolytes
- Reabsorption of electrolytes (homeostasis)
Acute Renal Failure Phases
1. Oliguric Phase Bicarbonate (HCO3)
2. Anuric Phase - Buffer solution
3. Diuretic Phase - Acidic = bind with excess hydrogen ions and
4. Onset Phase carbon ions (prevent forming of carbonic acid)

Chronic Renal Failure Stage Carbonic Acid

- 5 stages - Metabolic acidosis
- Dependent on urine output and glomerular
filtration rate 4. Helps with bone health via calcium and
phosphorus
Function of Renal System - Renal failure has problem with vitamin D
1. Removal of waste product synthesis (drop in calcium level)
- Different method of filtration (osmosis, diffusion) - Bone demineralization (compensatory mechanism
- Primarily circulation to increase calcium level)
- Excretion of creatinine and BUN - Rigid and fragile bones

Nephron – functional unit of kidney Vitamin D

- needed for calcium absorption
Creatinine – more sensitive indicator of kidney
damage Renal Anatomy and Physiology

BUN – affected by dietary intake and strenuous Filtration

physical activity
2. Regulation of Blood Volume, Pressure and RBC
- triggers release of hormone (erythropoietin)
- RAAS mechanism (detects by vasa recta)
Erythropoietin
- stimulate bone marrow to produce RBC
- Dialysis patient (ANEMIA)
- Primary method of blood cleaning
- don’t contain large molecules (RBC and CHON)
- (+) RBC and CHON = GFR problem
- Normal: water, NaCl, potassium, HCo3, glucose,
amino acids, creatinine and urea
- 90ml/min/1.32m2 (mostly reabsorb)
Proximal Convoluted Tubule Furosemide (Lasix)
- Potassium, NaCl, Water, amino acids and glucose - Loop diuretic
and bicarbonate - Potassium wasting diuretics
- 65% NaCl and water is reabsorb - Loop of henle
- 100% amino acids and glucose is reabsorb
- 90% HCO3 is reabsorb Renal Failure
- Secretions: uric acid, organic acids (antibiotics) - Drop in kidney function
- prevents
Loop of Henle - repeated UTI and pyelonephritis
- Concentration of urine
- reabsorbing water in the descending loop (highly Note:
water permeable) -should prevent irreversible damage
- reabsorbing 25% NaCl in ascending loop - Cell death decreases kidney function

Distal Convoluted Tubule Acute Renal Failure or Acute Tubular Necrosis

- Reabsorbing 5% NaCl - AKA: Acute Kidney Injury (AKI)
- Water reabsorption - Sudden onset
- Secretion: hydrogen and potassium - result of nephrotoxic and ischemic renal injuries
- Reversible
Collecting Duct
- reabsorb 5% NaCl Causes of ARF
- reabsorb water and urea 1. Pre-renal
- Renal hypoperfusion
Excretion - Dehydration
- Water - Disrupted blood flow (surgey, blood loss, burns,
- NaCl infection)
- Potassium - Sepsis = hypotension (body will shut down the
- HCO3 system that is not critical for survival)
- Creatinine and urea
2. Intra-renal (leading cause)
Note: - Direct damage with kidney tissues
- Creatinine and urea NOT secreted and reabsorb - Damage within the kidneys
along the nephron (marker of GFR) - Nephrotoxic agents (NSAIDS)
- 2 major hormones controls the rate of water - Autoimmune diseases (SLE)
excretion (aldosterone and ADH) in presence of - Direct trauma
dehydration - Acute glomerulonephritis (SLE)
- Albumin and glucose NOT excreted under normal - Acute tubular necrosis
condition (large molecules) - Acute interstitial nephritis (allergic reaction and
- Different types of diuretics acts on different parts infection)
of nephron - Vascular

Aldosterone 3. Post-renal
- Acts on distal tubule - Obstruction after the kidney
- RAAS mechanism - Ureters
- Renal stones and BPH (common cause)
Anti-Diuretic Hormone (ADH) - Urine backflow (vesicoureteral reflux)
- AkA: vasopressin
- Posterior pituitary gland Note:
- Post-renal and pre-renal could lead to intra-renal
Losing of Albumin
- Check for edema (bipedal)
- Albuminuria = PIH/ (eclampsia)
Stages of ARF - Fruity odor breath (chronic)
1. Onset Phase
- With triggering events Acute MI or CVA
- Urine output: <0.5mL/kg/hr - Associated problem

Cystoclysis Treatment
- 3 way catheter - Treat cause
- monitor lab values (electrolytes, BUN, creatinine,
2. Oliguric or Anuric Phase ABG, RBC)
- <400mL/day or <100mL/day - Daily weighing (edema)
- Increase BUN and creatinine - Nephrologist consultation with OTC drugs
- Electrolyte imbalance - Treat complications
- Acidosis - Acute dialysis (fistula, jugular, femoral)
- Fluid overload and shifting (3rd space)
- Last 8-14 days or longer Chronic Renal Failure (CRF)
- Graduation in dialysis (irreversible damage) - Gradual progression
- Irreversible damage
3. Diuretic Phase - HPN and DM
- AKI is corrected - Increase pressure damages blood vessels
- Tubule scarring and edema - ARF
- Increase GFR - HPN = Glumerulosclerosis (thickening), sclerosis
- Urine output >400mL - Diabetic Nephropathy = mesangial expansion,
- Electrolyte depletion podocytopathy, glomerular basement thickening,
- Last 7-14 days sclerosis
- Polycystic kidney disease (similar appearance
4. Recovery Phase with liver cirrhosis)
- decreased edema
- Normal fluid and electrolytes Mesangail Expansion – fibrosis within kidneys
- GFR 70-80% normal
- Last months to year Sclerosis – abnormal hardening of tissues

Diagnosis Method Stages of CRF

1. Serum creatinine level - Based on GFR
- >0.3mg/dL within 48hrs
- Normal: 0.6-1.2mg/dL 1. Stage 1
- >90mL/min GFR (normal) with kidney damage
2. Urine Volume
- <0.5mL/kg/hr for 6hrs Note:
- GFR not always equal to urine output
Clinical Manifestation - GFR located in bow man’s capsule
- Oliguira (decrease GFR)
- Edema (bipedal, periorbital, anasarca/general) 2. Stage 2
- periorbital (common with pedia) - GFR 60-89mL/min
- anasarca (pitting edema)
- Fatigue/ tired (accumulation of urea) 3. Stage 3
- Azotemia (accumulation of nitrogenous waste in - Moderate kidney function
brain) - GFR 30-59mL/min
- Nausea
- SOB or chest pain or pressure 4. Stage 4
- Confusion - Severe kidney function
- Seizure or coma - GFR 15-29 mL/min
- HPN (>200mm Hg systolic BP)
5. Stage 5 - Vitamin D = regulatory function
- Kidney failure or ESRD - Anemia = erythropoietin or blood transfusion
- Dialysis or RRT (renal replacement therapy)
- GFR <15mL/min Note:
- Blood transfusion without HD machine RISK for
Treatment fluid volume overload
1. Renal Replacement Therapy (RRT) - Dialysis adjunct with blood transfusion to prevent
- Hemodialysis congestion
- Peritoneal Dialysis
Nursing Responsibilities (ARF or CRF)
Hemodialysis - Diet: Low CHON, sodium, phosphorus
- AV fistula (surgically connection between artery - avoid citrus (rich in phosphorus)
and vein) - restricted fluid intake and activity
- AV fistula begin in wrist until it goes to antecubital - Care with dialysis access site (jugular or femoral)
fossa - Risk sepsis (aseptic technique with central line
- Advantageous than peritoneal dialysis catheters)
- 2-4hrs - Compliance to treatment (refer to social service in
- More accurate and reliable filtering system financially incapable)
- Closely monitor by RN - Adjustment of medication dosage (renal doses)
- Dialyzer is replaceable (expensive)
Clinical Manifestations
Fistula Nursing Consideration - Sodium and water retention = edema and HPN
- Never take BP and extraction procedure in same - Vomiting and diarrhea (dangerous due to
location with fistula restricted fluid intake)
- Fistula 1 month before it matures or used as - Hyperkalemia = muscle weakness, ECG changes
access point and fibrillation
- (+) Bruit and thrills = patent fistula - Non-functional sodium potassium pump =
- Thrills = palpated potassium retention (potassium sparring diuretics
- Bruit = auscultated and ace inhibitors aggravates the problem)
- (-) Bruit and fistula = cannot use or ruptured fistula - Metabolic acidosis = bone decalcification
- Dialysis adjunct with heparin (to prevent clotting in - decreased calcitriol (active Vit. D) = hypocalcemia
fistula) = secondary parathyroidism = osteodystrophy
- Ligation (tali) = to stop bleeding - Hyperphosphatemia
- Uremia = neurological sx = hiccups, cramps, N&V,
Peritoneal Dialysis reproductive problem, hyperpigmentation
- No need for hemodialysis machine - Decreased angiotensin = hypotension
- using dialysate - Anemia
- Trocar (surgically create access) - Renal osteodystrophy (decreased calcitriol or
- Ambulatory (may perform at home) Vit.D)
- >4hrs (longer)
Note:
Dialysate - Vitamin D need for calcium absorption (without it
- Dialysis solution calcium intake is useless coz’ cannot utilize by
- infuse into peritoneal space body)
- Replacement for dialyzer

2. Renal Transplant
- Gold standard treatment
- Disadvantage = organ procurement and cost
- Maintenance meds

3. Palliative Treatment