Renal Failure 2013 v.1.1
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Transcript of Renal Failure 2013 v.1.1
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Renal Failure
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Acute Renal Failure (ARF)
is a rapid loss of renal function
due to damage to the kidneys
Can lead to potentially fatal conditions
Including metabolic acidosis; fluid and
electrolyte imbalances
Can be seen in both outpatient andinpatient clients
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ARF
A widely accepted criterion:
!" or greater increase in serum creatinineabo#e baseline
(normal is less than $ mg%dl)
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&atients may ha#e normal or abnormal
urine output
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&athophysiology
&athogenesis is not always known
'ome cases may be re#ersible:
$hypo#olemia
hypotension
*reduced cardiac output and heart failure
+obstruction of the kidney or lower urinary tract
by tumor, blood clot, or kidney stone
bilateral obstruction of the renal arteries or
#eins
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&athophysiology
If treated and corrected before the kidneys are
permanently damaged, the increased -./and creatinine le#els, oliguria, and other signs
may be re#ersed
Renal stones are not common causes of ARF
but some types may increase its risk
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Categories
&rerenal (hypoperfusion of kidney)
Intrarenal (actual damage to kidneytissue)
&ostrenal (obstruction to urine flow)
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&rerenal ARF
0ccurs in 1!" to 2!" of cases
the result of impaired blood flow3
3that leads to hypoperfusion of the
kidney and a decrease in the 4FR
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Intrarenal ARF
the result of actual parenchymal damage tothe glomeruli or kidney tubules
Acute tubular necrosis (A5/) is the mostcommon type of intrinsic ARF
Characteristics of A5/ are:
intratubular obstructiontubular back leak
6asoconstriction
changes in glomerular permeability
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Those processes result in:
a decrease of 4FR
progressi#e a7otemia
and fluid and electrolyte imbalances
C89, 9, F, 5/, and cirrhosis can lead to
A5/
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&ostrenal ARF
.sually result from obstruction
5he pressure rises in the kidney tubulesand e#entually decreasing 4FR
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Causes of &rerenal ARF
VOLUME DEPLETO! resulting from:emorrhage
Renal losses (diuretics, osmotic diuresis)4astrointestinal losses (#omiting, diarrhea, nasogastricsuction)
MP"#ED $"#D"$ E%%$E!$& resulting from:yocardial infarctioneart failure9ysrhythmiasCardiogenic shock
V"'ODL"TO!resulting from:'epsisAnaphyla
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Causes of Intrarenal ARF
P#OLO!(ED #E!"L '$)EM" resulting from:&igment nephropathy (associated with the breakdown
of blood cells containing pigments that inturn occlude kidney structures)yoglobinuria (trauma, crush in=uries, burns)emoglobinuria (transfusion reaction, hemolytic anemia)
!EP)#OTO*$ "(E!T' such as:Aminoglycoside antibiotics (gentamicin, tobramycin)Radiopa>ue contrast agentsea#y metals (lead, mercury)'ol#ents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
/onsteroidal anti?inflammatory drugs (/'AI9s)Angiotensin?con#erting en7yme inhibitors (AC@ inhibitors)
!%E$TOU' P#O$E''E' such as:Acute pyelonephritis
Acute glomerulonephritis
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&ostrenal ARF
U#!"#& T#"$T O+'T#U$TO!,
including:
Calculi (stones)
5umors
-enign prostatic hyperplasia
'trictures
-lood clots
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9ecreased 4FR
0bstruction4lomerular
inflammation9amage to
nephrons
9ecreased
renal
perfusion
ARF
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9@CR@A'@9
4FR
9ecreased
fluid e
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ypo
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&hases
$ Initiation period
0liguric period
* 9iuresis period+ Reco#ery period
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$ Initiation period
begins with the initial insult
and ends when oliguria de#elops
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0liguria &eriod
,-- ml. The minimum amount of urineneeded to rid the body of normal metabolicwaste products
In this phase uremic symptoms first appear andlife?threatening conditions such as hyperkalemiade#elop
/onoliguric form has enough urine output nutdecreased renal function(nephroto
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9iuresis phase
marked by a gradual increase in urine output/
which signals that glomerular filtration has started toreco#er
aboratory #alues stabili7e and e#entuallydecrease
Renal function may still be markedly abnormal
.remic symptoms may still be present
BA5C 0.5 F0R 9@9RA5I0/DDD(may increase uremic symptoms)
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reco#ery period
'ignals the impro#ement of renal function
may take * to $ months
aboratory #alues return to the patientEs normal
le#el
Although a permanent $" to *" reduction in
the 4FR is common, it is not clinically
significant
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Clinical anifestations
6ariesay include '%'< since many organs may be affected
Altered urine output
@dema or dry skin
&atient may apear critically ill and lethargic
C/' '%'< include:
9rowsinessheadache,
muscle twitching
sei7ures
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Assessment and 9iagnostic Findings
-./, Creatinine, /4A (blood and urine)
.rinalysis (hematuria, low spec gra#ity)
Inability t concentrate urine (one of earliestsigns)
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Assessment and 9iagnostic Findings
If w% prerenal a7otemia: decreased amount of
/a in the urine (less than ! m@>%) normal
urinary sediment
intrarenal a7otemia: usually ha#e urinary
sodium le#els greater than +! m@>% with
urinary casts and other cellular debris
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.ltrasound
C5 scan
RI
Creatinine clearance
'erum electrolytesC-C
A-4
@C4
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&re#enting Acute Renal Failure
$ &ro#ide ade>uate hydration to patients at riskfor dehydration including:
.-efore, during, and after surgery
.&atients undergoing intensi#e diagnosticstudies
re>uiring fluid restriction and contrast agents
.&atients with neoplastic disorders or disordersof metabolism (eg, gout) and those recei#ingchemotherapy
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&re#ent and treat shock promptly
(blood and fluid replacements)
* onitor central #enous and arterial
pressures and hourly urine output ofcritically ill patients
(to detect A'A&)
+ 5reat hypotension promptly
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Continually assess renal function
(urine output, laboratory #alues)
1 @nsure proper blood transfusion
2 &re#ent and treat infections promptly(Infections can produce progressi#e renal
damage)
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&ay special attention to wounds, burns, and
other precursors of sepsis%infection
G 5o pre#ent infections from ascending in the
urinary tract
gi#e meticulous catheter careRemo#e catheters as soon as possible
$! &re#ent to
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A#oid prolonged use of /'AI9Es
may cause interstitial nephritis
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Radiocontrast?induced nephropathy (CI/) is a
ma=or cause of hospital?ac>uired ARF:
Limit e0posure
4i#ing !1acetylcysteine 2%luimucil3 andsodium bicarbonate 2!a)$O43 before and
during procedures reduces ris5
but prehydration with saline (/'') is
considered the most effecti6e method to
pre6ent $!
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4erontologic care
0lder people are more #ulnerable to to
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edical anagement
5reat underlying cause
anage symptoms
&re#ent complications
aintain fluid balance
&rerenal a7otemia: increase perfusion
Intrarenal a7otemia: supporti#e therapy
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edical anagement
9iureticsannitol (0smitrol)Furosemide (asi
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edical anagement
&eritoneal 9ialysis &9
emodialysis 9
Continuous Renal Replacement 5herapy
CRR5
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For e
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/ursing Careonitor o#erall status
onitor electrolytes
Reduca metabolic rate-ed rest
5reat fe#er and infection
&ulmonary function
&re#ent infection
&ro#iding skin care
&sychosocial support