Critical care Nursing

Acute Renal Failure

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

 ARF: Types, Causes and mortality
1- Primary renal (intrarenal) disease: 33%
Hemolytic uremic syndrome: 88%
Obstructive uropathy
Renal vein/artery thrombosis
Primary glomerulonephritis
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
Overall
mortality: 62%!!
Post-op heart
Other or other heart
Trauma 15% failure
6% 32%
Liver
transplant or
failure Cancer Sepsis
16% related 17%
14%
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, mortality is > 50%
compared to < 20% with non-oliguric ARF
Risk factors cont.
Advanced age

Co morbid conditions (heart failure, liver or kidney failure,

diabetes)

Contrast exposure (dehydrated, diabetic)

Nephrotoxic medications (aminoglycosides, angiotensin

enzyme inhibitors)

Volume depletion (especially in diabetes)

Rhabdomyolysis; surgery (cardiac surgery)

 Types and causes of ARF

1- Prerenal 2- Renal 3-Postrenal

1- Prerenal azotemia (failure)
Causes:
Decreased circulatory volume
Hypovolemia
GI losses (V/D, ileostomy, NG drainage)
Hemorrhage (trauma, 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.
Prerenal azotemia (failure) cont.
Decreased local blood flow to kidney
Renal artery stenosis
Drug-induced renal vasoconstriction
cyclosporin, tacrolimus
Hepatorenal syndrome
Diminished cardiac output
Congestive Heart Failure (CHF)
Arrhythmias, tamponade, etc.
Cardiovascular surgery
 Prerenal azotemia

1-Decreased
circulatory volume 2-Decreased local 3- Diminished
blood flow to cardiac output
kidney A- (CHF)
A-Hypovolemia A- Renal artery B- Arrhythmias,
stenosis tamponade,
B- Loss of fluids B- Drug etc.
C- Hepatorenal C-
syndrome Cardiovascular
surgery
 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
3- Intrinsic Acute Renal Failure
Acute tubular necrosis (ATN)
Prolonged Prerenal azotemia of any cause
Nephrotoxin-induced drugs
(aminoglycosides; amphotericin)
Primary Glomerular diseases
Hemolytic uremic syndrome
All other forms of glomerulonephritis
Intra-renal obstruction: tumor lysis
syndrome
Acute Renal Failure

Pathophysiology:

Acute renal failure (ARF) is a sudden and almost complete loss of kidney
function over a period of hours to days. ARF manifests with oliguria (less
than 400 mL/day of urine), anuria (less than 50 mL/day of urine), or
normal urine volume. The patient has high serum creatinine and BUN
levels (azotemia) and retention of other metabolic waste products
normally excreted by the kidneys.

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Clinical course of Acute Tubular Necrosis
(ATN)
I- Onset phase: (initiating) begins with an initial
insult and lasts until cell injury occurs. It lasts from
hours to days, the clinical manifestations in this
phase include
1-decreased urine output
2-increased serum Creatinine.
The major goal during this phase is to determine the
cause
Clinical course of tubular Necrosis (ATN) cont
II- Oliguric phase or non oliguric phase (anuria)
*Oliguria = <400ml/24 hrs or <20ml/hr
*Anuria = <50ml/24 hrs
III- Diuretic phase: lasts 1-2 weeks. There is
gradual increase in urine output and may lead to
volume deficits and electrolytes imbalance.
IV- Recovery phase: lasts from months to years.
Renal function return to its normality.
 Diagnosis and Assessment of ARF
In history, seek clues regarding secondary
causes - symptoms of CHF, liver disease, sepsis,
systemic vacuitis, prodromal bloody diarrhea;
birth asphyxia
Check for symptoms of primary renal disease
- UTI, gross hematuria, flank pain, Hx of strept
infection, drug exposure ( aminoglycosides or
narcotics) for bladder dysfunction
Assessment of ARF (Physical exam.) cont.
Subjective: Dysuria, nausea, weakness, and fatigue
Tachycardia and/or a drop in HR >15 b pm or drop in SBP
>15mmHg with orthostatics indicate = dehydration
Decreased mental status =decreased perfusion
Rales =fluid overload, CHF
Abdominal pain and distension = obstruction, UTI

Itching = azotemia
Assessment of ARF cont.
During physical exam, look for secondary causes
Causes of decreased effective circulatory volume -
CHF, ascites, edema, sepsis
Signs of systemic illness - (vasculitis, SLE): rash,
arthritis, purpura
Signs of obstructive uropathy: enlarged kidneys or
bladder - CHECK FOLEY.
Assessment of ARF, Labs cont.
UA:
High specific gravity = dehydration
RBCs = UTI, urolithiasis
WBCs, bacteria = UTI
Casts: RBC (glomerulonephritis), WBC
(pyelonephritis), and epithelial cells and granular casts
(ischemic damage)
Electrolytes to assess for metabolic d/o
Urine Na, Creatinine
ECG to look for peaked T waves, indicates Hyperkalemia
Assessment for ARF cont.
BUN, Cr; CBC with platelets.
Urine Analysis: hematuria, myoglobinuria,
proteinuria, RBC casts, eosinophils
Urine indices (U-osm, U-CR, U-Na )
Renal Ultra Sound (with Doppler flow to rule
out renal vein thrombosis)
Renal biopsy
Nursing diagnosis for client having ARF
Fluid volume excess related to decreased
function
Alteration in cardiac output: decreased related
to fluid volume excess.
Altered nutrition: less than body requirements
related to anorexia, nausea and vomiting.
Impairment of skin integrity related to poor
nutritional status, immobility and edema
Nursing diagnosis for client having ARF cont
Anxiety related to unexpressed serious illness
and current symptoms.
Activity intolerance related to fatigue,
anemia, retention of waste products and
dialysis procedure.
Sleep pattern disturbance related to decreased
functioning of immune system.
Knowledge deficit, disease and it
management
Anticipated problems
worsening the ARF
Adjust medicines for renal
insufficiency
Avoid Nephrotoxins if possible
Avoid intravascular volume
depletion (especially in third-
spacing 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
 NB: Management of (ARF )
To maintain Water balance
1- Assess the Volume status
"Maintenance" is IRRELEVANT in ARF!!!
If euvolemic, give insensible + losses + UOP
If volume overloaded,
*concentrate all meds; 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).
Management of ARF: General cont

Foley catheterization for accurate output

Daily weight, monitor BP, labs
Correct easy bleeding with DDAVP,- (1-deamino-8-D-
arginine vasopressin),estrogen, and cryoprecipitate
Prednisone in acute interstitial nephritis may help
Mannitol - alkaline diuresis in Rhabdomyolysis
Management: Prerenal
Goal is to restore BP and intravascular volume
Fluid deficit:
Fluid bolus with 500ml, recheck fluid status,
repeat.
Monitor vital signs and electrolytes
Normal or increased fluid status:
CHF: monitor O2 status. Lasix 20-80mg IV.
Monitor diuresis, potassium status, daily
weight
Management: Postrenal
Place Foley, note residual. If >400ml and
discomfort is relieved, leave catheter in
place.
If Foley in place, Fluds with 20-30ml saline
Consider stones or mass obstruction
Daily weights, strict I/O
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.
Aminoglycosides:
higher risk: elderly, volume depletion, >5 days, large doses,
preexisting liver disease, and preexisting renal insufficiency.
Correct preexisting volume depletion and monitor drug levels
Indications for renal replacement therapy
Volume overload
Pulmonary edema, CHF, refractory HTN
Hyperkalemia
Hyperphosphatemia
Uremic side-effects: pericarditis, pleuritis
Metabolic acidosis
Mental changes
Modes of renal replacement therapy
Peritoneal dialysis - also gentle and don't need
heparinization but slow and catheter may leak or
not work.

Hemodialysis - very fast, but need big lines and

systemic heparinization; causes hemodynamic
instability and uremic dysequilibrium symptoms
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).
Complications of ARF cont.
Anemia is common, caused by
increased red blood cell (RBC) loss
and decreased RBC production.

Platelet dysfunction may occur

secondary to the uremia and present as
gastrointestinal (GI) bleeding.
 Special Cases
Elderly:
Elderly more susceptible to ARF (3.5 X more
common)
Creatinine clearance dependent on age
Evolution to acute tubular necrosis more common
Pregnancy:
Infected uterus
Toxemia and related obstetric complications.
Pregnant patients only group with a sharp drop in ARF
mortality (1.7%)
Pediatric: Congenital anomalies (e.g.,urethral valves,
etc)
Nursing Management of ARF
Monitoring fluid and electrolyte balance. The nurse:

monitors the patients serum electrolyte levels and physical indicators of

fluid and electrolyte imbalances.
carefully screens parenteral fluids, all oral intake, and all medications to
ensure that hidden sources of potassium are not inadvertently
administered or consumed.
monitors the patient closely for signs and symptoms of hyperkalemia .
monitors fluid status by paying careful attention to fluid intake, urine
output, apparent edema, distention of the jugular veins, breath sounds, and
increasing difficulty in breathing.
maintains accurate daily weight, and intake and output record.
reports to physician indicators of deteriorating fluid and electrolyte status,
and prepares for emergency treatment.

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Nursing Management of ARF (Continued)
Reducing metabolic rate. The nurse:
should reduce the patients metabolic rate to reduce catabolism and the
subsequent release of potassium and accumulation of waste products (urea
and creatinine).
may keep the patient on bed rest to reduce exertion and the metabolic rate
during the most acute stage of ARF.
should prevent or promptly treat fever and infection to decrease the
metabolic rate and catabolism.

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 Nursing Management of ARF (Continued)
Promoting pulmonary function. The nurse:

assist the patient to turn, cough, and take deep breaths frequently to
prevent atelectasis and respiratory tract infection.
Preventing infection. The nurse:
strictly observes aseptic technique when caring for the patient to minimise
the risk of infection and increased metabolism.
avoids, when possible, inserting an indwelling urinary catheter as it is a
high risk for urinary tract infection (UTI).

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