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Renal Failure

Wendy DeMartino, MD PGY-2

Objectives

Anatomy Function Acute Renal Failure (ARF)


Causes Symptoms Management

Chronic Renal Failure (CRF)

Causes Symptoms

Dialysis

Anatomy

2 Kidneys 2 Ureters Bladder Urethra

Kidney Function
Detoxify blood Increase calcium absorption

calcitriol erythropoietin

Stimulate RBC production

Regulate blood pressure and electrolyte balance

renin

Classifications
Acute versus chronic Pre-renal, renal, post-renal Anuric, oliguric, polyuric

Acute Versus Chronic

Acute

sudden onset rapid reduction in urine output Usually reversible Tubular cell death and regeneration Progressive Not reversible Nephron loss

Chronic

75% of function can be lost before its noticeable

Acute Renal Failure

Pre-renal = 55% Renal parenchymal (intrinsic)= 40%

Post-renal = 5-15%

Causes of ARF

Pre-renal =

vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure cardiac failure, liver dysfunction, or septic shock Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins

Intrinsic

Post-renal =

prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders neurogenic bladder bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus

Symptoms of ARF

Decrease urine output (70%) Edema, esp. lower extremity Mental changes Heart failure Nausea, vomiting Pruritus Anemia Tachypenic Cool, pale, moist skin

Diagnosis of Renal Failure

Acute Renal Failure Management


Make/think about the diagnosis Treat life threatening conditions Identify the cause if possible

Hypovolemia Toxic agents (drugs, myoglobin) Obstruction

Treat reversible elements

Hydrate Remove drug Relieve obstruction

ARF: Life Threatening Conditions


Hyperkalemia Volume overload Vascular access

Hyperkalemia Symptoms

Weakness Lethargy Muscle cramps Paresthesias Hypoactive DTRs Dysrhythmias

Hyperkalemia & EKG


K > 5.5 -6 Tall, peaked Ts Wide QRS Prolong PR Diminished P Prolonged QT QRS-T merge sine wave

Hyperkalemia Treatment
Calcium gluconate (carbonate) Sodium Bicarbonate Insulin/glucose Kayexalate Lasix Albuterol Hemodialysis

Chronic Renal Failure


150200 cases per million people = new cases each year Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S Mortality = 20%

Chronic Renal Failure Causes


Diabetic Nephropathy Hypertension Glomerulonephritis HIV nephropathy Reflux nephropathy in children Polycystic kidney disease Kidney infections & obstructions

CRF Symptoms

Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting

Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal hemostasis

Acute Problems in CRF


Relating to underlying disease Relating to ESRD Dialysis related problems

Problems Related to ESRD


Metabolic K/Ca Volume overload Anemia, platelet disorder, GI bleed HTN, pericarditis Peripheral neuropathy, dialysis dementia Abnormal immune function

Dialysis
of patients with CRF eventually require dialysis Diffuse harmful waste out of body Control BP Keep safe level of chemicals in body 2 types

Hemodialysis Peritoneal dialysis

Hemodialysis
3-4 times a week Takes 2-4 hours Machine filters blood and returns it to body

Types of Access

Temporary site AV fistula

Surgeon constructs by combining an artery and a vein 3 to 6 months to mature Man-made tube inserted by a surgeon to connect artery and vein 2 to 6 weeks to mature

AV graft

Temporary Catheter

AV Fistula & Graft

What This Means For You


No BP on same arm as fistula Protect arm from injury Control obvious hemorrhage

Bleeding will be arterial Maintain direct pressure

No IV on same arm as fistula A thrill will be felt this is normal

Access Problems
AV graft thrombosis AV fistula or graft bleeding AV graft infection Steal Phenomenon

Early post-op Ischemic distally Apply small amount of pressure to reverse symptoms

Peritoneal Dialysis
Abdominal lining filters blood 3 types

Continuous ambulatory Continuous cyclical Intermittent

EMS Considerations
Make sure the dressing remains intact Do not push or pull on the catheter Do not disconnect any of the catheters Always transport the patient and bags/catheters as one piece Never inject anything into catheter

Dialysis Related Problems


Lightheaded give fluids Hypotension Dysrhythmias Disequilibration Syndrome

At end of early sessions Confusion, tremor, seizure Due to decrease concentration of blood versus brain leading to cerebral edema

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