Renal Failure Lecture
Terms
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- Acute Renal Failure
- Sudden onset, affects 50% of nephrons, lasts 2-4 weeks, good prognosis
- Chronic Renal Failure
- Gradual onset, affects 90-95% nephrons, permanent damage, poor prognosis, dialysis, transplant, fatal
- Prerenal causes
- Hypovolemia, decreased cardiac output, systemic vasodialation, hypotension & hypoperfusion
- Intrarenal causes
-
Tubule/nephron damage, infection, tumors, nephrotoxins
Vascular changes, low carb diets - Nephrotoxins
-
NSAIDS (intra and prerenal)becasue the drugs affect prostaglandins.
COX 2 inhibitors
Acyclovir, mycins, IVP dye, chemo, ASA - Post renal causes
- Ureter and bladder obstruction
- Epidemiology of Acute Renal Failure
- Id patients at risk for renal disease early to help protect kidney function
- Phases of acute rental failure
-
Onset
Oliguric
Diuretic
Recovery - Onset
- Initial phase of injury to the kidney, reversal or prevention of kidney dysfunction is pssible at this stage
- Oliguric Phase
- Follows within 24 hours after the onset, urine output is less than 400 ml/24 hrs, F&E imbalance occurs, generally lasts 8-15 days
- Diuretic Phase
- Urine output increase to 4 to 5 liters per day, Bun/Creatinine improves, potential for F&E imbalance still exists, lasts approximately 10 days
- Recovery Phase
- F&E values start to stabilize, may last up to 12 months, may experience a slight decrease in kidney function
- Hyperkalemia
- > 5, s/s irritability, paresthesia, muscle weakness, ECG changes, ventrical fig, irregular pulse, hypotension, abdominal cramping, diarrhea, N/V
- TX of hyperkalemia
-
Mild 5-6 loop diurentics, dietary potassium restricted
Moderate to severe > 6.3, hemodialysis, sodium polystyrene sulfonate (Kayexalate mixed with sorbitol) - Emergency measures for hyperkalemia
-
10% calcuim gluconate IVP
Sodium bicarbonate IV
Regular insulin - Hyponatremia
- Occurs when levels < 136, develops because of water retention
- S/s of hyponatremia
- Mental status changes, Nausea, muscle twitching and abdominal cramping, muscle weakness, HA
- TX of hyponatremia
- Limit fluids, diuretics
- Metabolic Acidosis
- pH < 7.35 and serum bicarb < 22, kidneys loose the ability to secrete the hydrogen ions, bicarb ion production deminishes, lungs try to compensate by increasing the depth and rate of respirations
- S/S of metabolic acidosis
- Kussmals respiration, confusion, decreased DTR, hypotension, lethargy, dull HA, GI disturbance
- TX of Metabolic Acidosis
- Sodium Bicarb IVP, dialysis
- Complications of ARF
- Fluid & Electrolyte imbalances, pulmonary edema, cardiac arrest, CHF, hypertension, Chronic renal failure
- Chronic Renal Faiule
- Damage is progressive and irreversible, DM 40%, Hypertension 27%, Glomerulonephritis 11%
- Pathophysiology of CRF
- Hypertrophy of remaining functioning nephrons, solute load becomes greater than can be reabsorbed once 3/4 nephrons are destroyed
- S/s of Chronic Renal Failure
- Oliguria occurs resulting in retention of wast products
- Stage 1 CRF
- GFR > 90, diminished renal reserve
- Stage 2 CRF
- GFR 60-89, decreased renal reserve, kidney damage present
- Stage 3 CRF
- GFR 30-59 Renal insufficiency, metabolic wastes begin to accumulate and treatment with loop diuretics and supportive care provided
- Stage 4 CRF
- GFR 15 - 29, renal failure, response to diuretics lessen and may need dialysis
- Stage 5 CRF
- GFR < 15, end-stage renal disease
- Sensipar
- Enhances calcium receptors in parathyroid gland and suppresses PTH secretion. Only recommended for patients with dialysis.
- Hyperphosphatemia
- Serum phosphorus > 4.5, low phosphorus diet, phospate binders given with meals, Tums,
- Aluminum Toxicity
- Never use aluminum-based phosphate binders because risk of aluminum toxicity leading to anemia, osteomalacia, and encephalopathy
- Hypocalcemia
- < 9.0 die to inverse relationship with phosphorus, decreased activation of Viatamin D by the kidneys, TX Vitamin D supplements, calcuim supplements (<2000), IV clacium chloride
- Anemia
- Heep HCT between 33-36%
- TX for anemia
-
Epoetin Alfa (procrit) takes time, SE HTN, keep eye on BP
Aransep lasts longer than procrit - Other TX for anemia
- Iron fupplements, folate and Vitamin B 12
- GI disturbances
- Urea is broken down into ammonia, ulceration and bleeding can occur. Smell and tast of ammonia causes eating disorder
- TX of GI disturbance
- Vinegar mouthwashes neutralizes acid, antiacids ever 2-4 hours
- Neurologic Manifestations
- HA, Weaknses, Drowsiness, Muscle Twitching, Convulsions, Coma, Shortened attention span, peripheral neuropathy
- Cardiovascular Manifestations
- Hypertension, high cholesterol, CAD, CHF, Cardia Arrhythmias, Pericarditis, Cardiac Arrest, Edemam, Anemia, Abnormal Bleeding
- Hypertension
- Target BP is 125/75 or less. Watch serum creatinine closely and tell HCP if it increases 35% of its premedication value.
- High Cholesterol and lipids
- Use statins or lipitor to treat cholesterol
- CAD
- Modify risk factors if diabetic keep HGB A1C < 7%
- Epogen
- RBC production
- Iron Supplements
- Buildup for anemia
- Laxatives/ stool softeners
- constipation
- Diet
- Reassess every 1 - 3 months
- Type of diet
- Low protein, low potassium, low sodium, low phosphorus, limit dairy , fluid restruction 900 ml for insensible losses, high carbs
- Hemodialysis
- Involves movement of fluid and particles across a semipermeable membrane based on difussion, osmosis, and ultrafiltration
- Purpose of Dialysis
-
Restore f&E balance
Control Acid-Base balance
removes toxic substances and metabolic wastes - Peritonitis
- Elevated temperature, chills, abdomen pain or tenderness, N/V, cloudy or brown outflow of solution
- Hypovolemia
- Hypotension, tachycardia, restlessness, diaphoretic, dizziness, N/V
- Hemodialysis NI
- Hold antihypertensives prior to hemobialysis, can lead to severe hypotensive episodes, try to schedule meds around HD times, so minimal interruption will occur
- NI for vascular access device
- Assess patency Postie bruit and thrill, No BP in arm or venipuncture in access arm, assess s/s of infection, avoid compression of fistual
- Advantage of hemodialysis
- more efficient procedure, can remove toxic waste more quickly/rapidly
- Complications of Hemodialysis
- disequilibrium syndrome, Hypovolemia & shock,
- CRRT Dialysis (continuous renal replacement therapy)
- Slow, gentle process,client is unstable and critically ill and needs a slow gentle process to remove excess fluids and wastes.