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Kidney Failure

Introduction
The kidneys are bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. The kidneys are sophisticated reprocessing machines. Every day, a person's kidneys process about 200 quarts of blood to sift out about 2 quarts of waste products and extra water. The wastes and extra water become urine, which flows to the bladder through tubes called ureters. The bladder stores urine until releasing it through urination. The actual removal of wastes occurs in tiny units inside the kidneys called nephrons. Each kidney has about a million nephrons. In the nephron, a glomerulus-which is a tiny blood vessel, or capillary-intertwines with a tiny urine-collecting tube called a tubule. The glomerulus acts as a filtering unit, or sieve, and keeps normal proteins and cells in the bloodstream, allowing extra fluid and wastes to pass through. A complicated chemical exchange takes place, as waste materials and water leave the blood and enter the urinary system.

In addition to removing wastes, the kidneys release three important hormones:
y y y

Erythropoietin, or EPO, which stimulates the bone marrow to make red blood cells Renin, which regulates blood pressure Calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for normal chemical balance in the body

Why do kidneys fail? Most kidney diseases attack the nephrons, causing them to lose their filtering capacity. Damage to the nephrons can happen quickly, often as the result of injury or poisoning. But most kidney diseases destroy the nephrons slowly and silently. Only after years or even decades will the damage become apparent. Most kidney diseases attack both kidneys simultaneously

Its causes are: >Kidney stone: usually only on one side >Cancer of the urinary tract organs or structures near the urinary tract that may obstruct the outflow of urine >Bladder stone >Enlarged prostate (the most common cause in men) >Blood clot .Problems referred to as obstructive renal failure.Acute Renal Failure -is defined as an abrupt or rapid decline in renal filtration function. or blood loss >Disruption of blood flow to the kidneys y Postrenal . water pills.From vomiting. since it is often caused by something blocking elimination of urine produced by the kidneys. This condition is usually marked by a rise in serum creatinine concentration or by azotemia (a rise in blood urea nitrogen [BUN] concentration) -symptoms appear abruptly and is highly reversible Causes of acute renal failure It is caused by failure of the kidneys to perform their normal functions due to: y Prerenal . The kidneys do not receive enough blood to filter due to: >Dehydration: . diarrhea.is the most common type of acute renal failure (60%-70% of all cases).

The resulting inflammation impairs kidney function.y Renal . including infections. can be damaged by a variety of diseases.Problems with the kidney itself that prevent proper filtration of blood or production of urine Most common cause is Glomerulonephritis: The glomeruli. Pathophysiology . the initial filtration system in the kidney.

Other characteristics in the oliguric-anuric phase include: y y y y Great reduction in the glomerular filtration rate (GFR) Increased BUN/Creatinine Electrolyte abnormalities (hyperkalemia. This phase usually lasts and additional 7-14 days and is characterized by: y y y y Increase in glomerular filtration rate (GFR) Urine output as high as 2-4 L/day Urine that flows through renal tubules Renal cells that cannot concentrate urine Increased GFR in this phase contributes to the passive loss of electrolytes which requires the administration of IV crystalloids to maintain hydration. vomiting Diarrhea Abdominal pain Metallic taste in the mouth he Four Phases of Acute Renal Failure Onset Phase this period represents the time from the onset of injury through the cell death period. hyperphosphatemia and hypocalcemia) Metabolic acidosis Diuretic Phase this phase occurs when the source of obstruction has been removed but the residual scarring and edema of the renal tubules remains.Signs and Symptoms of ARF y y y y y y y y y y Decreased urine production Body swelling Problems concentrating Confusion Fatigue Lethargy Nausea. . Oliguric/Anuric Phase this phase usually lasts between 8-14 days and is characterized by further damage to the renal tubular wall and membranes. This phase can last from hours to days and is characterized by: y y y y Renal flow at 25% of normal Oxygenation to the tissue at 25% of normal Urine output at 30 ml (or less) per hour Urine sodium excretion greater than 40 mEq/L.

with postrenal failure levels usually falling within normal limits. but should only be done if the result will alter the treatment plan. Treat hyperkalemia o o o o o Sodium bicarbonate Glucose Insulin Calcium chloride Sodium Polysterene Sulfonate (Kayexalate): For the exchange of Sodium and Potassium in the gastrointestinal tract. Diagnostic Exams for ARF Laboratory Tests Lab Test Urine Specific Gravity BUN/Creatinine ratio Urine Osmolality Urine Sodium Urine Sediment (urinalysis) Fractional excretion of sodium percent (FENa) Prerenal Value Greater than 1. During this phase. This test requires urine collection for a 24 hour period with normal clearance levels being 95 ml/min to 125 ml/min. Prerenal disease levels vary depending on how long low renal flow has existed. Doppler Studies doppler scans can be effective in determining the presence and nature of renal blood flow. .010 to 1.Recovery Period Phase The recovery phase can last from several months to over a year. edema decreases. Management of ARF 1. Levels less than 50 ml/min are consistent with intrarenal disease. the renal tubules begin to function adequately and fluid and electrolyte balance are restored. Ultrasound renal ultrasound can be effective in determining existing renal failure and/or obstruction of the urinary collecting system.020 10-20:1 300-500 mOsm/kg 20 mEq/L or more Granular casts Greater than 1% Creatinine Clearance Test this is believed to be the most accurate test to determine glomerular filtration rates. Renal Biopsy renal biopsy can be effective in diagnosing intrarenal failure.020 Greater than 20:1 Greater than 500 mOsm/kg 10 mEq/L or less Hyaline casts Less than 1% Intrarenal Value 1.

ACE inhibitor: Captopril 6. Dopamine 5. -may be used if the patient in AKF is stable and not in immediate crisis. Peritoneal Dialysis -is often the best treatment option for infants and children. Hemofiltration -also called continuous renal replacement therapy (CRRT). a filter known as a dialyzer (or artificial kidney). increased Calcium 7. Treat hyperphosphatemia: Aluminum hydroxide (Amphojel) 3. 9. or dialysis circuit. continuous blood filtration therapy used to control acute kidney failure in critically ill patients. and a dialysis machine that monitors and maintains blood flow and administers dialysate. . Dialysis -involves circulating the patient's blood outside of the body through an extracorporeal circuit (ECC).2. Dialysate is a sterile chemical solution that is used to draw waste products out of the blood. -a catheter is surgically implanted into the peritoneum and dialysate is infused. During the treatment. Mannitol 4. the waste products from the bloodstream enter the peritoneum and binds with the dialysate. Diet: Decreased Protein. The dialysate after some period of time is drained and is replaced with a clean dialysate. -uses when patients are too weak to withstand the rapid filtration rates of hemodialysis 10. Fluids 8. The ECC is made up of plastic blood tubing. Diuretics: Furosemide. is a slow.

Weight. hourly check the urine output BUN.Nursing Care for ARF 1. creatinine Restrict fluids and sodium Offer hard candies and ice chips Imbalanced Nutrition: Less Than Body Requirements Nursing Care Management: y y y Frequent small feedings Ask the family members to join the patient in eating Provide a high caloric or carbohydrate diet . Excess Fluid Volume Nursing Care Management: y y y y 2.

73m2 More than 90 60-89 30-59 15-29 Less than 15 (or dialysis) *GFR is glomerular filtration rate. Use of analgesics regularly over long durations of time can cause analgesic nephropathy Atherosclerosis) leading to the kidneys causes a condition called ischemic nephropathy. which is the leading cause of kidney disease in the United States. which can cause kidney failure Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease wherein both kidneys have multiple cysts. Causes of CRD y Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy. waste and toxic substances in the body that are normally excreted by the kidney.Chronic Renal Failure -Chronic kidney disease occurs when one suffers from gradual and usually permanent loss of kidney function over time. High blood pressure Glomerulonephritis is the inflammation and damage of the filtration system of the kidneys. y y y y y . there is an accumulation of water. a measure of the kidney's function. -With loss of kidney function. Stages of Chronic Kidney Disease Stage 1 2 3 4 5 Description Slight kidney damage with normal or increased filtration Mild decrease in kidney function Moderate decrease in kidney function Severe decrease in kidney function Kidney failure GFR* mL/min/1.

y Obstruction of the flow of urine by stones. hypocalcemia. or cancers may also cause kidney disease. hyponatremia Normochromic normocytic anemia Twenty-four hour urine collection for total protein y y . an enlarged prostate. low serum bicarbonate. Signs and Symptoms y y y y y Lethargy Weakness shortness of breath generalized swelling may occur Metabolic acidosis y Inability to excrete potassium and rising potassium levels in the serum (hyperkalemia) is associated fatal heart rhythm disturbances (arrhythmias) including ventricular tachycardia and ventricular fibrillation Uremia Pericarditis Hypocalcemia y y y y Laboratory Studies y y Elevated serum urea and creatinine Hyperkalemia. strictures (narrowings). hyperphosphatemia.

The four goals of therapy are to: y y y y Slow the progression of disease Treat underlying causes and contributing factors Treat complications of disease Replace lost kidney function Strategies for slowing progression and treating conditions underlying chronic kidney disease include the following: y y y Control of blood glucose Control of high blood pressure Diet .Imaging Studies y y y y y y Plain abdominal x-ray Intravenous pyelogram Renal ultrasound Renal radionuclide scan CT scan MRI Treatment Regimen There is no cure for chronic kidney disease.

Salt restriction: Limit to 4-6 grams a day to avoid fluid retention and help control high blood pressure Fluid intake: Excessive water intake does not help prevent kidney disease. Potassium restriction: This is necessary in advanced kidney disease because the kidneys are unable to remove potassium Phosphorus restriction: Decreasing phosphorus intake is recommended to protect bones. alkalizing agents. dairy products and meats) 6. erythropoietin. folic acid supplements) 4. Encourage intake of high biologic value protein (eggs. Administer prescribe medications ( ion exchange resin.Patient Education Regarding Diet Modification y Protein restriction: Decreasing protein intake may slow the progression of chronic kidney disease. Encourage adequate rest . antibiotics. Encourage self-management such a blood pressure monitoring and glucose monitoring 3. Proper assessment for risk factors that might cause a rapid decline 2. y y y y Surgical Treatment for CRF y y y Kidney Transplant Hemodialysis Peritoneal Dialysis Nursing Supportive Management 1. Maintain strict fluid control 5.