RENAL FAILURE Kidney failure (Renal Failure) A condition in which the kidneys stop working and are not

t able to remove waste and extra water from the blood or keep body chemicals in balance. Acute Renal Failure -Is a sudden decline in renal function, usually marked by increased concentrations of blood urea nitrogen (BUN; azotemia) and creatinine; oliguria (less than 500 ml of urine in 24 hours); hyperkalemia; and sodium retention. Risk Factors Being hospitalized, especially for a serious condition that requires intensive care Advanced age Blockages in the blood vessels in your arms or legs (peripheral artery disease) Diabetes High blood pressure Heart failure Kidney diseases Liver diseases

Acute Renal Failure Symptoms rapid onset of oliguria with rise in nitrogenous waste (azotemia), BUN, and creatinine that is usually reversible. Changes in urine output Sudden weight gain Headache Nausea and vomiting Elevated BP Changes in LOC Uremic smell (halitosis) Dry itchy purpuric skin Increased potassium, BUN, creatinine Decreased pH, Hct, and Hgb Hyperkalemia is the most dangerous imbalance because of its effect in cardiac activity Hyponatremia is an effect of dilution rather than a true lack of sodium

Causes of Acute Renal Failure 1. Pre Renal Cause from factors outside of kidneys - circulatory collapse, cardiovascular disorders, hypovolemia, severe vasoconstriction 2. Intra Renal Cause - renal parenchyma failure or disease, nephrotic damage (due to poisons, antibiotics); blood transfusion reaction; acute pyelonephritis. 3. Post Renal Cause - obstruction in collecting system: renal calculi, prostatic tumor, gynecological or urological problems. Phases of Acute Renal Failure 1. Oliguric Phase - decrease urine output (<400 ml for 24 hours) caused by acute renal ischemia and tubular necrosis. This retains waste products and leads to metabolic acidosis. - last for 1 to 8 weeks

2. Diuretic Phase - return of GFR and level of BUN signal diuretic phase (1,000 to 2,000 ml per day of urine output that may cause dehydration). 3. Recovery Phase - return to pre-renal failure activity level - recovery last for 3 to 12 months Complication of ARF -include dysrhythmias, increased susceptibility to infection, electrolyte abnormalities, GI bleeding due to stress ulcers, and multiple organ failure. Untreated ARF can also progress to chronic renal failure, endstage renal disease, and death from uremia or related causes. Diagnostic Evaluation: Urinalysis shows proteinuria, hematuria, casts. Urine chemistry distinguishes various forms of ARF(prerenal, postrenal, intrarenal). Serum creatinine and BUN levels are elevated; arterial blood gas (ABG) levels, serum electrolytes may be abnormal. Renal ultrasonography estimates renal size and rules out treatable obstructive uropathy. Imaging tests Abdominal ultrasound. Computed tomography (CT) scan. Abdominal X-ray or a spiral CT scan, which may be used if a kidney stone is suspected. Nursing Interventions: Monitor 24-hour urine volume to follow clinical course of the disease. Monitor BUN, creatinine, and electrolyte. Monitor ABG levels as necessary to evaluate acid-base balance. Weigh the patient to provide an index of fluid balance. Measure blood pressure at various times during the day with patients in supine, sitting, and standing positions. Adjust fluid intake to avoid volume overload and dehydration. Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. Have resuscitation equipment available in case of cardiac arrest. Watch for urinary tract infection, and remove bladder catheter as soon as possible. Employ intensive pulmonary hygiene because incidence of pulmonary edema and infection is high. Provide meticulous wound care. Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories. Institute seizure precautions. Provide padded side rails and have airway and suction equipment at the bedside. Encourage and assist the patient to turn and move because drowsiness and lethargy may reduce activity. Explain that the patient may experience residual defects in kidney function for a long time after acute illness. Encourage the patient to report routine urinalysis and follow-up examinations. Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism.

Chronic kidney failure -occurs when disease or disorder damages the kidneys so that they are no longer capable of adequately removing fluids and wastes from the body or of maintaining the proper level of certain kidney-regulated chemicals in the bloodstream.

Risk Factors Diabetes most common cause of chronic kidney disease worldwide; obesity is an additional factor for diabetes Hypertension systolic hypertension is of particular concern. Beginning at around age 50, systolic blood pressure rises and continues to rise with age. Autoimmune disease Systemic infection Urinary stones or lower urinary tract obstruction Exposure to certain toxic drugs cyclosporins and other immunosuppressive agents and corticosteriods

Types of Chronic Renal Failure 1. Reduced Renal Reserve high BUN but there is no clinical symptoms 2. Renal Insufficiency mild azotemia with impaired urine concentration with nocturia 3. Renal Failure severe azotemia, acidosis, impaired urine dilution, severe anemia, electrolyte imbalance 4. End-Stage Renal Failure deranged excretory and regulatory mechanism; and distinctive groupings of symptoms Signs and symptoms: swelling, usually of the lower extremities fatigue weight loss loss of appetite nausea or vomiting a change in urination (change in volume and frequency) change is sleep pattern headaches itching difficulties in memory and concentration

Complications: o o o o o Cardiovascular disease hypertension may also contribute to the development and increase the risk of stroke Anemia when kidneys are damaged there is a decrease in erythropoietin, a hormone that stimulates production of red blood cells Bone disease disorders of calcium and phosphorus metabolism may develop early Malnutrition alteration of the bodys response to insulin as well as other metabolic functions (such as erythropoietin formation and vitamin D metabolism) Decreased functional status and well-being includes complex regimen, adverse effects and the possible or actual loss of job and income

Medical Management: Peritoneal dialysis Hemodialysis Kidney Transplantation

PREOPERATIVE CARE

Assess knowledge and feelings about the procedure, answering questions and clarifying information as needed. Listen and address concerns about surgery, the source of the donor organ, and possible complications. Addressing concerns and reducing preoperative anxiety improve postoperative recovery. Continue dialysis as ordered. Continued renal replacement therapy is necessary to manage fluid and electrolyte balance and prevent uremia prior to surgery.

 Administer immunosuppressive drugs as ordered before surgery. Immunosuppression is initiated before transplantation to prevent immediate graft rejection. POSTOPERATIVE CARE Maintain urinary catheter patency and a closed system. Catheter patency is vital to keep the bladder decompressed and prevent pressure on suture lines. A closed drainage system minimizes the risk for urinary tract infection. Measure urine output every 30 to 60 minutes initially. Careful assessment of urine output helps determine fluid balance and transplant function. Acute tubular necrosis (ATN) is a common early complication, usually due to tissue ischemia during the period between removal of the kidney from the donor and transplantation. Oliguria is an early sign. Monitor vital signs and hemodynamic pressures closely. Diuresis may occur immediately, resulting in hypovolemia, low cardiac output, and impaired perfusion of the transplanted kidney. Maintain fluid replacement, generally calculated to replace urine output over the previous 30 or 60 minutes, milliliter for milliliter. Fluid replacement is vital to maintain vascular volume and tissue perfusion. Administer diuretics as ordered. Loop and/or osmotic diuretics such as furosemide or mannitol may be used to promote postoperative diuresis. Remove the catheter within 2 to 3 days or as ordered. Encourage to void every 1 to 2 hours and assess frequently for signs of urinary retention following catheter removal. The bladder may have atrophied prior to surgery, reducing its capacity. Urinary retention places stress on suture lines and increases the risk of infection. Monitor serum electrolytes and renal function tests. These tests are used to monitor graft function and fluid and electrolyte status. Electrolyte imbalances may develop as the transplanted kidney begins to function and diuresis occurs. Elevated serum creatinine and BUN levels may be early signs of rejection or graft failure. Nursing Management Proper assessment for risk factors that might cause a rapid decline Encourage self-management such a blood pressure monitoring and glucose monitoring Administer prescribe medications ( ion exchange resin, alkalizing agents, antibiotics, erythropoietin, folic acid supplements) Maintain strict fluid control Encourage intake of high biologic value protein (eggs, dairy products and meats) Encourage adequate rest