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Critical care Nursing

Acute Renal Failure

Dr Naiema Gaber

The Learning outcomes
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1- Define acute renal failure (ARF). 2- Explain the causes of ARF. 3- Differentiate between the three types of ARF. 4- Identify the clinical stages of ATN. 5- Discuss the clinical manifestations of ARF. 6- List the complications of ARF. 7- Develop a plan for managing ARF.

Acute Renal Failure (ARF) Definition: Sudden deterioration in the
ability of the kidneys to function ( to maintain fluid, solute or electrolyte homeostasis). It occurs over hrs or few days. It is Common in ICU patients (10-20%)

Why?

ARF: Types, Causes and mortality
1- Primary renal (intrarenal) disease: 33%
– – – – Hemolytic uremic syndrome: 88% Obstructive uropathy Renal vein/artery thrombosis Primary glomerulonephritis (RPGN)

Overall mortality: 6% Most primary renal diseases develop RF gradually and do not need emergent dialysis

2-Extra-renal causes of ARF: 67% of total
Other Trauma 15% 6% Liver transplant or failure 16% Post-op heart or other heart failure 32%

Overall mortality: 62%!!

Cancer related 14%

Sepsis 17%

Data pooled from Ped. Nephrol. 7:703, 8:334, 6:470, and 7:434

mortality is > 50% compared to < 20% with non-oliguric ARF .ARF: What are the Risk factors for mortality? Multi-organ failure Bacterial Sepsis Fungal sepsis Hypotension/ vasopressors Ventilatory support Initiation of dialysis late in hospital course Oliguria /anuria: with oliguric ARF.

angiotensin enzyme inhibitors) Volume depletion (especially in diabetes) Rhabdomyolysis. Advanced age Co morbid conditions (heart failure. surgery (cardiac surgery) . diabetes) Contrast exposure (dehydrated.Risk factors cont. diabetic) Nephrotoxic medications (aminoglycosides. liver or kidney failure.

Renal 3-Postrenal .Types and causes of ARF 1.Prerenal 2.

ileostomy. GI bleeding) » Cutaneous losses (burns) » Renal losses (diabetes insipidus or mellitus) – Loss of fluids from intravascular space » Third spacing » Septic (capillary leak) or anaphylactic shock.1.Prerenal azotemia (failure) Causes: Decreased circulatory volume – Hypovolemia » GI losses (V/D. . NG drainage) » Hemorrhage (trauma.

tamponade. etc. tacrolimus – Hepatorenal syndrome Diminished cardiac output – Congestive Heart Failure (CHF) – Arrhythmias. – Cardiovascular surgery . Decreased local blood flow to kidney – Renal artery stenosis or RVT – Drug-induced renal vasoconstriction » cyclosporin.Prerenal azotemia (failure) cont.

Loss of fluids 2-Decreased local blood flow to kidney A. CCardiovascular surgery .Hepatorenal syndrome 3.Renal artery stenosis B. etc.Arrhythmias.Drug C. tamponade.(CHF) B.Prerenal azotemia 1-Decreased circulatory volume A-Hypovolemia B.Diminished cardiac output A.

2-Postrenal Failure Kidney stone (usually UVJ) Ureteropelvic junction (UPJ) or UVJ obstruction Bladder: as neurogenic bladder or fungus ball Urethra: posterior urethral valve. foreign body Iatrogenic: obstructed Foley. narcotics .

amphotericin) Primary Glomerular diseases – Hemolytic uremic syndrome – All other forms of glomerulonephritis Intra-renal obstruction: tumor lysis syndrome .3.Intrinsic Acute Renal Failure Acute tubular necrosis (ATN) – Prolonged Prerenal azotemia of any cause Nephrotoxin-induced drugs (aminoglycosides.

Clinical course of Acute Tubular Necrosis (ATN) I. The major goal during this phase is to determine the cause . It lasts from hours to days. the clinical manifestations in this phase include 1-decreased urine output 2-increased serum Creatinine.Onset phase: (initiating) begins with an initial insult and lasts until cell injury occurs.

Clinical course of tubular Necrosis (ATN) cont – II. There is gradual increase in urine output and may lead to volume deficits and electrolytes imbalance.Diuretic phase: lasts 1-2 weeks. IV.Recovery phase: lasts from months to years. . Renal function return to its normality.Oliguric phase or non oliguric phase (anuria) *Oliguria = <400ml/24 hrs or <20ml/hr *Anuria = <50ml/24 hrs III.

gross hematuria. drug exposure ( aminoglycosides or narcotics) for bladder dysfunction . birth asphyxia Check for symptoms of primary renal disease .symptoms of CHF. sepsis.Diagnosis and Assessment of ARF In history. prodromal bloody diarrhea. Hx of strept infection. flank pain. liver disease.UTI. systemic vacuitis. seek clues regarding secondary causes .

CHF Abdominal pain and distension = obstruction. and fatigue Tachycardia and/or a drop in HR >15 b pm or drop in SBP >15mmHg with orthostatics indicate = Decreased mental status dehydration perfusion Rales =fluid overload.Assessment of ARF (Physical exam. Subjective: Dysuria. nausea. weakness. UTI Itching = azotemia =decreased .) cont.

Assessment of ARF cont. SLE): rash. ascites. . During physical exam. edema. arthritis.CHECK FOLEY. look for secondary causes – Causes of decreased effective circulatory volume CHF. sepsis – Signs of systemic illness . purpura – Signs of obstructive uropathy: enlarged kidneys or bladder .(vasculitis.

indicates Hyperkalemia – – – – . WBC (pyelonephritis). Labs cont. urolithiasis WBCs. and epithelial cells and granular casts (ischemic damage) Electrolytes to assess for metabolic d/o Urine Na. bacteria = UTI Casts: RBC (glomerulonephritis). UA: High specific gravity = dehydration RBCs = UTI.Assessment of ARF. Creatinine ECG to look for peaked T waves.

ANA. Urine Analysis: hematuria. renal biopsy . BUN.Assessment for ARF cont. U-Na ) Renal Ultra Sound (with Doppler flow to rule out renal vein thrombosis) Anti-DNA. Cr. eosinophils Urine indices (U-osm. CBC with platelets. proteinuria. U-CR. RBC casts. myoglobinuria.

Nursing diagnosis for client having ARF Fluid volume excess related to decreased function Alteration in cardiac output: decreased related to fluid volume excess. Impairment of skin integrity related to poor nutritional status. Altered nutrition: less than body requirements related to anorexia. immobility and edema . nausea and vomiting.

Nursing diagnosis for client having ARF cont Anxiety related to unexpressed serious illness and current symptoms. disease and it management . Knowledge deficit. Activity intolerance related to fatigue. retention of waste products and dialysis procedure. Sleep pattern disturbance related to decreased functioning of immune system. anemia.

Anticipated problems worsening the ARF – Adjust medicines for renal insufficiency – Avoid Nephrotoxins if possible – Avoid intravascular volume depletion (especially in thirdspacing or edematous patients) .

Management of ARF Ventilation and oxygenation Circulation / perfusion Fluids /electrolytes Mobility Protection/safety Skin integrity Nutrition Comfort/ pain control Psychological support teaching .

*concentrate all meds. give insensible + losses + UOP – If volume overloaded.Assess the Volume status – "Maintenance" is IRRELEVANT in ARF!!! – If euvolemic.NB: Management of (ARF ) To maintain Water balance 1. limit oral intake *Need frequent check on weights and BP as well as accurate I/O *give insensible = 30 cc/100 kcal or 400cc/M2/day *If has any UOP. Lasix + ordered drugs may be effective .

Once ARF stabilizes. fluid replacement should be equal to insensible losses (400) mL /day) plus urinary or other drainage losses to avoid hypervolemia .

.Management of ARF: General cont.  Discontinue/re-dose  nephrotoxic drugs Diet: *Eliminate potassium if serum level increased *Oral and IV amino acids *Provide nutrition with increased carbohydrates to decrease catabolism. *Total caloric intake of 35 to 50 kcal/kg/day should be maintained with most calories provided by carbohydrates (100 g/day).

monitor BP. and cryoprecipitate Prednisone in acute interstitial nephritis may help Mannitol .alkaline diuresis in Rhabdomyolysis . labs Correct easy bleeding with DDAVP.Management of ARF: General cont Foley catheterization for accurate output Daily weight. estrogen.

– Monitor vital signs and electrolytes Normal or increased fluid status: – CHF: monitor O2 status. recheck fluid status. – Monitor diuresis. Lasix 20-80mg IV.Management: Prerenal Goal is to restore BP and intravascular volume Fluid deficit: – Fluid bolus with 500ml. repeat. potassium status. daily weight .

note residual. If Foley in place. leave catheter in place. If >400ml and discomfort is relieved. strict I/O .Management: Postrenal Place Foley. Fluds with 20-30ml saline Consider stones or mass obstruction Daily weights.

Aminoglycosides: – higher risk: elderly. preexisting liver disease. and preexisting renal insufficiency. – Correct preexisting volume depletion and monitor drug levels . >5 days.Management: Renal Hyperkalemia: – Continuous cardiac monitoring – Kayexalate 15 to 30g in 50-100ml 20% sorbitol PO q 3-4 hours or in 200ml 20% sorbitol PR q 4 hours – Dialysis for failed kidneys: can remove 30-60 mEq/hr Contrast dye: – Creatinine peaks within 72 hours with slow recovery over 7 to 14 days with appropriate therapy. volume depletion. large doses.

Indications for renal replacement therapy Volume overload – Pulmonary edema. pleuritis Metabolic acidosis Mental changes . CHF. refractory HTN Hyperkalemia Hyperphosphatemia Uremic side-effects: pericarditis.

causes hemodynamic instability and uremic dysequilibrium symptoms . but need big lines and systemic heparinization.very fast. Hemodialysis .Modes of renal replacement therapy Peritoneal dialysis .also gentle and don't need heparinization but slow and catheter may leak or not work.

Complications of ARF Death (50%) Sepsis infection (leading cause of mortality) Hypertension exacerbated by fluid overload: Use antihypertensive that do not decrease renal blood flow). .

Anemia is common.Complications of ARF cont. Platelet dysfunction may occur secondary to the uremia and present as gastrointestinal (GI) bleeding. . caused by increased red blood cell (RBC) loss and decreased RBC production.

5 X more common) – Creatinine clearance dependent on age – Evolution to acute tubular necrosis more common Pregnancy: – Infected uterus – Toxemia and related obstetric complications..g.Special Cases Elderly: – Elderly more susceptible to ARF (3. – Pregnant patients only group with a sharp drop in ARF mortality (1.7%) Pediatric: Congenital anomalies (e.urethral valves. etc) .

Review questions 1-Intrarenal acute renal failure can be due to a.antibiotics and radiocontrst dye administration d-obstructed Foley catheter and prostate hypertrophy (c) .dehydration and increased cardiac output b.calculi in the ureters and hypovolimic shock c.

and vascular volume overload major potential problems a-onset b-oliguric c-diuretic d-recovery . infection. gastrointestinal bleeding.(b) 2-During which phase of acute tubular necrosis (ATN) are Hyperkalemia.

(c) 3.decreased red blood cell production »d-an inability of platelets to function properly .decreased RBC survival »b-impaired white blood cell function »c.Decreased erythropoietin production in renal failure results in »a.

then headache. and a purpuric rash on his legs. abdominal pain. vomiting. He had not voided for 24 hours. What is the diagnosis? ARF? What the lab. Investigations that confirm the diagnosis? . edema. knee pain.Clinical Case #1 Ali is a 15 year old male who presented with URI (upper Respiratory Infection) symptoms.

Albumin was 3.Physical exam and labs BP was 152/94. BUN and Creatinine were 76 and 8. Indicate hypertension A urinalysis revealed hematuria and proteinuria.0.1 indicate ARF . Heart and lung exams were normal.

He’s fluid overloaded and hypertensive – he doesn’t need any fluid How were the maintenance calculations derived? – What goes into the formula? – Insensible + UOP = maintenance=400 cc only . What percent “maintenance” should you run his IV at? – NO FLUIDS .Fluid management in ARF (Clinical Case #1) This kid weighs 70 kg.

He’s NPO though. If this kid had an albumin of 1. what fluids would you give him? – Bolus of NS like any other dehydrated kid – but cautiously Now you have the kid euvolemic by exam but still has no UOP. so what fluid rate should you run now? – Insensible loss 400 cc+ UOP = maintenance = 400 cc .Fluid management in ARF (Clinical Case #1) cont.0 and mucus membranes were very dry.

etc Goal is to prevent stroke or congestive heart failure . nitropruside. clonidine.. need to directly vasodilate (calcium channel blockers.2-Hypertension management (Clinical Case #1) High blood pressure could be from volume overload or from intrinsic renal disease If has volume overload.

14 Calcium 5.3%.3 Hematocrit 30.5.Back to Ali (Clinical case #1) K+ 6. Phosphorus 9. Bicarb. low bicarb.8. Platelets 280K Interpret this results. = Metabolic Acidosis .

3-Acidosis management (Clinical case #1) Correct bicarbonate which is < 15 Acidosis makes the kids feel terrible watch -sodium and fluid overload -lowering ionized calcium levels (by increasing binding of calcium to albumin) .

leukemia) Uremic PLT's do not function well.4-Anemia and uremic bleeding management (Clinical Case #1 ) Anemia results from lack of renal erythropoietin production + increased loss Underlying disorder may also cause hemolysis or decreased RBC production (sepsis. so have increased bleeding: treatment will causes transient improvement in PLT function. .

5 .2 cc/kg/hour On clinical exam she has very moist mucus membranes BUN and Creatinine are 110 and 0.Clinical Case #2 Samira. Albumin is 3. neutropenia and thrombocytopenia UOP (Urinary output) is 1.7. is a 10 year-old with acute lymphocytic leukemia receiving chemotherapy Has fever.

so NO! Why is BUN so high? .Assessment of clinical case #2 Is she in renal failure? Creatinine is normal.

fever. BUN may be increased disproportionately with blood products. . increased catabolism as in case of treatment with steroids. excess amino acids in bleeding.Use of plasma BUN: Cr ratio In pre-renal BUN :Cr > 20 usually However.

are therre any Other symptoms 4.Foley d.by hour c.is there any changes in vital signs? . last 24 hours? Oliguria = <400ml/24 hrs or <20ml/hr Anuria = <50ml/24 hrs 2.(c) Mr.does he has Recent surgery? 3. salem hasn’t peed all night long!” How is UO measured? a-By shift b.urinating on own? For more information write three more questions 1-What is the trend over last 2-3 hours vs.

Any questions??? .