I.

Definition

• Chronic renal failure is the end result of progressive irreversible loss of functioning renal tissue. It
usually develops gradually, possibly taking up to several years to develop. In some cases, it may occur
rapidly because of an acute disorder (e.g. unresolved acute renal failure)

II. Risk Factors

• Hypertensive nephropathy

• Diabetic nephropathy

• Chronic glomerulonephritis

• Chronic pyelonephritis

• Lupus nephritis

• Polycystic kidney disease

• Chronic hydronephrosis

III. Pathophysiology

• Decreased renal function results in an accumulation of waste products (i.e. uremia) in the
bloodstream. Uremia develops and adversely affects every system in the body.

THREE BASIC STAGES OF CHRONIC RENAL FAILURE:

Decreased renal reserve.

• During this stage, renal function is 40 to 50% of normal and homeostasis is maintained.

Renal insufficiency.
• During this stage, renal function is 20 to 40% of normal glomerular filtration rate (GFR), clearance, and
urine concentration are decreased and homeostasis is altered.

End stage renal disease.

• During this stage, renal function is less than 10% to 15% of normal; all renal functions are severely
decreased; and homeostasis is significantly altered.

In chronic renal failure, retention of sodium and water leads to edema, heart failure, and hypertension.
Conversely, episodes of diarrhea and vomiting may lead to sodium and water depletion, which can
exacerbate uremia and produce hypotension and hypovolemia.

Metabolic acidosis occurs, interfering with the kidney’s ability to excrete hydrogen ions, produce
ammonia, and conserve bicarbonate.

Decreased GFR results in:

• Increased serum phosphate

• Decreased serum calcium

• Increased parathormone but depleted bone calcium, leading to bone changes (e.g. uremic bone
disease, osteomalacia)

Erythropoietin production decreases, resulting in anemia.

Neurologic complications develop, such as:

• Altered mental function

• Personality and behavioral changes

• Convulsions

• Coma
IV. Assessment/Clinical Manifestations/Signs and Symptoms

Clinical manifestations depend on the stage of the disorder:

Increased renal reserve

• Asymptomatic as long as there is no exposure to severe physiologic or psychologic stress.

Renal insufficiency.

• Polyuria

• Nocturia

• Signs and symptoms of mild anemia

End-stage renal failure

Widespread systemic manifestations:

1)Cardiovascular

• Fluid overload, edema

• Congestive heart failure

• Electrolyte imbalance

• Metabolic acidosis

• Hypertension

• Arrhythmias

• Pericarditis, effusion, and tamponade

2)Gastrointestinal
• Anorexia, nausea, and emesis

• Stomatitis, and uremic halitosis

• Gastritis and bleeding

• Bowel problems; diarrhea

• Constipation

3)Hematopoietic

• Anemia

• Alteration coagulation

• Increased susceptibility to infection

4)Integumentary

• Pallor

• Yellowness

• Dryness

• Pruritus

• Purpura and ecchymosis

• Uremic frost (seen only in terminal or severely critically ill clients)

5)Neuromuscular

• Drowsiness, confusion, coma and irritability

• Tremors, twitching, and convulsions

• Peripheral neuropathy (Stage I – restless syndrome and paresthesias, Stage II – motor involvement,
leading to footdrop, Stage III – paraplegia)

6)Psychosocial
• Decreased mentation

• Decreased concentration

• Altered perceptions (even to the point of frank psychoses)

7)Respiratory

• Pulmonary edema

• Pneumonia or pneumonitis

• Kussmaul’s respirations

8)Skeletal

• Hypocalcemia and hyperphosphatemia

• Osteodystrophy

• Metastatic calcifications

Laboratory and diagnostic study findings

• Anemia

• Elevated blood urea nitrogen (BUN) and serum creatinine levels

• Elevated serum phosphorus level

• Decreased serum calcium level

• Decreased serum protein (particularly albumin( levels

• Low blood pH

v. Medical Management

Goal of management are to retain kidney function and maintain homeostasis for as long as
possible. All factors that contribute to ESRD and those that are reversible (e.g. obstruction) are
identified and treated.
Complications can be prevented or delayed by administering prescribed antihypertensives,
cardiovascular agents, anticonvulsants, erythropoietin (Epogen), iron supplements, phosphate-
binding agents (antacids), and calcium supplements.

Dietary intervention is needed, with careful regulation of protein intake, fluid intake to balance
fluid losses, and sodium intake and with some restrictions of potassium.

Adequate intake of calories and vitamins is ensured. Calories are supplied with carbohydrates
and fats to prevent wasting.

Protein is restricted; protein must be of high biologic value (dairy products, eggs, meats)

Vitamin supplementation

Fluid allowance is 500 to 600 mL of fluid or more than the 24-hour urine output

Pharmacologic Management
• Hyperphosphatemia and hypocalcemia are treated with aluminum-based antacids or calcium
carbonate; both must be given with food
• Hypertension is managed by intravascular volume control and antihypertensive medication
• Heart failure and pulmonary edema are treated with fluid restriction, low-sodium diet, diuretics,
inotropoic agents (eg. Digitalis or dobutamine) and dialysis
• Metabolic acidosis is treated, if necessary, with sodium bicarbonate supplements or dialysis.
• Hyperkalemia is treated with dialysis; medications are monitored for potassium content; patient
is placed on potassium-restricted diet; Kayexalate is administered as needed.
• Patient is observed for early evidence of neurologic abnormalities (eg. Slight twitching,
headache, delirium, or seizure activity)
• The onset of seizures, type, duration and general effect on patient are recorded; physician is
notified immediately and patient is protected from injury with padded side rails. Intravenous
diazepam (Valium) or phenytoin (Dilantin) is administered to control seizures.
• Anemia is treated with recombinant human erythropoietin (Epogen); hematocrit is monitored
frequently
• Heparin is adjusted as necessary to prevent clotting of dialysis lines during treatments.
• Serum iron and transferring levels are monitored to assess iron states (iron is necessary for
adequate response to erythropoietin)
• Blood pressure and serum potassium levels are monitored
• Patient is referred to a dialysis and transplantation center early in the course of progressive
renal disease. Dialysis is initiated when patient cannot maintain a reasonable lifestyle with
conservative treatment.

VI. Nursing Diagnosis

• Excess fluid volume related to decreased urine output, dietary excess, and retention of sodium
and water.
• Imbalanced nutrition: less than body requirements related to anorexia, nausea and vomiting,
dietary restriction and altered oral mucous membranes
• Deficient knowledge regarding condition and treatment regimen

VII. Nursing Management

Provide conservative therapy, as indicated.

• Maintain strict fluid control; daily fluid intake should equal 500 ml (insensible loss) plus the
amount of the previous 24 hours urine output; daily weight; and strict intake and output
• Encourage intake of high biologic value protein foods such as eggs, dairy products, and meats
(causes positive nitrogen balance needed for growth and healing)
• Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between meals.
• Encourage alternating activity with rest. Encourage independence as much as possible.
• Assess the client and family’s response to chronic illness. Encourage therapeutic conversations
to help cope with chronic illness.
• Provide symptomatic treatment.
• Be prepared to identify and treat complications, which include hyperkalemia, pericarditis,
pericardial effusion, pericardial tamponade, hypertension, anemia, and bone disease.

Administer prescribed medication, which may include ion exchange resin, alkalizing agents,
antibiotics, erythropoeitin, folic acid supplements, iron supplements, phosphate-binding agents,
calcium supplements, histamine receptor antagonists, and proton-pump inhibitors.

Prepare the client for peritoneal dialysis, if indicated.

• Assist with the procedure as instructed, maintaining septic technique and monitoring for signs
and symptoms of peritonitis. (rigid, boardlike abdomen, fever, cloudy peritoneal fluid)

Prepare the client for and assist with hemodialysis, if indicated.

• Provide proper shunt care, and assess for possible complications. (bleeding due to
heparinization, hypovolemia, hypotension due to excessive water removal, dialysis
disequilibrium syndrome (headache, confusion, and seizures) due to rapid removal of urea from
plasma.)

Prepare the client for kidney transplantation, if indicated.

• Provide postoperative care for any client who has undergone major surgery with special
attention to catheter patency and adequacy, intake and output, fluid replacement, and protection
from infection.
• Monitor for signs and symptoms of complications such as:

1)Graft rejection (fever, elevated white blood cell count, electrolyte abnormalities, abnormal
renogram)
2)Infection stemming from immunosuppressive therapy (sepsis pneumonia, wound infection, and
urinary tract infection)