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renal failure
- 2 types acute and chronic
- early detection can prevent progression of CKD from stage 1 to 5 (CKD/ESRD/ESKD)
- Increase risk:
- - ** DM
- - ** HTN
- - ** family history
- - african americans. hispanic, native am, elders
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renal failure 2
- renal impairment
- - small dec in function
- - asymptomatic
- renal insufficiency
- - 75-80% lost of nephrons
- - mild anemia, fatigue, chx in urine output, dec erythopoiten, BUN/Crt inc
- renal failure
- - > 80%
- ESRD
- - almost lost all renal function
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acute renal failure/acute kidney injury
- sudden loss of kidney's ability to excrete wastes, balance fluid & lytes
- GFR dec over houts to days, BUN & Crt inc "azotemia" dec clearance of waste products- makes you feel bad, N/V, fatigue
- common, treatable, often reversible
- - *** if recognized & tx early
- norm GFR 125
-
Acute renal failure/acute kidney injury- categories of cause
- prerenal- "to" the kidneys
- renal/intrarenal- "in" the kidney
- postrenal- "out" the kidney
-
Prerenal
- *** most common cause of AKI
- interference with blood supply- 25% of CO- if CO dec kidneys perfusion dec
- kidneys require minimum MAP 60 mmHg
- Dec GFR cayses inc proximal tubular reabsorption of Na & H2o via RAAS
-
prerenal- causes/manifestations
- Causes:
- - dehydration
- - dec BP
- - renovascular obstuction
- (think dec perfusion d/t dec blood supply)
- Manifestations:
- - dec u/o & concentrated urine
- - inc BUN: Crt ratio (20:1)
- - inc urine SG, osmo
- - absent urine protein- not tubular damage
- Treatment:
- - IV fluifs
- - may do bolus
- - need to jump start the kidneys
- - urine out put is the indicator
-
Intrarenal
- destruction of glomeruli or tubular structures
- ** ATN (acute tubular necrosis) most common due to:
- - ischemia
- - exposure to nephrotoxic agents
- - hemolysis of RBC- pluggin
- - muscle necrosis: breakdown of myoglobin
- occurs in nephrons- damage
-
Patho ATN
- causative factor leads to death of tubular epithelial cells. these cells slough off plug tubules (Hgb & myoglobin can clog tubules as well
- GFR dec, oliguria follows
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manifestations of ATN
- oliguria
- proteinuria- kidney and tubular damage
- progressively inc BUN and Crt
- "casts" in urine- kidney/tubular damage
- systemic chx- edema, wt gain, HTN
- - think holding on to water
-
Postrenal- causes and manifestations
- Causes:
- - mechanical/function al obstruction of urine
- - ureteral- calculi, stricture
- - bladder- anticholinergics, infection
- - urethral- BPH
- Manisfestation:
- - depends on obstruction site
- - ie below level of bladder causes bladder distention
- - inc BUN/Crt
- think- obstruction after the kidney, develop hydonephrosis
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diagnostic test- aki
- urine and blood studies
- US
- renal angiography
- inc BUN/Crt
- inc K
- dec Na, Hgb/Hct, Ca (bc vita D is activated in the kidney- need vita d to reabsorb)
- ABG- metabolic acidosis
- - excreting bicarb
-
phases of AKI- onset
- initial phase of injury
- immediate intervention of prevent damage
- last from hours to days
-
phases of AKI- oliguric
- < 500 ml/d
- last 10-20 d
- incr BUN/crt, lyte chx, s/s (n/v, fatigue holding on to waste)
- ** recognize oliguria & determine cause
- therapeutic fluid challenge
- longer the oliguric phase the poorer the outcome
-
phases of AKI- Diuretic
- begins when u/o inc to 500cc/24h
- may last 1-2 wks
- urine dilute w/ low SG- difficulty urine concentration
- BUN& Crt may cont to risk
- ** report massive diuresis (>3000cc/24hr)
- FVD
- urine output tells us healing is occuring
- will start to put off large amts
- @ end of phase BUN/crt normalize
-
phases of AKI- recovery
- begins when BUN stable, may last months to yr
- protect kidney from another insult
- ** avoid excessive protein intake
- may be some residual damage
- GRF 80% of what it should be
-
management- oliguric phase
- monitor I&O, wt
- careful fluid replacement
- diuretics- cautiously
- - loop diuretics
- - FVO
- with some renal function
-
management- oliguric phase 2
- lytes replacement/adjustment
- - hyperkalemia- EKG, dietary restriction, Kayexalate (pulls K in the GI), IV D50 & insulin (regular), Ca gluconate (dysrhthmia- PVC, QRS wave wide, loss p wave, high T wave, cardiac arrest)
- hyponatremia- fluid restri, esp. free H2o)
- - how much fluid to give: output past 24 hr + 600 ml
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management- oliguric dietary/dialysis
- dietary:
- - inc cal (for energy), fats, CHO
- - dec Na++, K+, +/- protein
- Dialysis:
- -w/anuria, severe acidosis
- - FVO
- remember no added salt bc it holds on to water
- protein depends on renal fx
-
management- diuretic phase
- monitor u/o, wt, orthostatic VS
- avoid repeat insult
- ** AKI may lead to CKD
-
nursing interventions
- as above and:
- oral hygiene
- help with fluid restriction
- good skin care
- good cath care
- psychological support
- complete recovery
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Chronic renal/failure/esrd
- 5th and final stage of CKD
- progressive, irreversible deterioration in renal function, with failure to maintain fluid & electrolyte balance
- affects every body system
- results fatally in uremia
- cant maintain lytes
-
common causes pf CRF
- ** DM
- un/poorly controlled HTN
- HLD, smoking
- fam hx of renal dx
- ARF
- Nsaids over use
- glomphephritis
- lysis?
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Patho CRF
- progressive renal function dec with deterioration and destruction of nephrons
- as total GFR fails, serum BUN/crt inc
- remaining nephrons hypertrophy- try to work harder and harder
- kidneys cant concentrate urine adequately
- large volume of urine made
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patho CRF
- tubules gradually lost ability to reabsorb lytes-acidosis, inc PO4 (phosphate inreverse relationship with Ca), K+, Mg, dec Ca
- as renal damage cont & functioning # nephrons dec, GFR dec more
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patho CRF
- body is unable to rid itself of H2O, salt, and other wastes
- anemia and htn develops- reabsorbing fluid
- w/GFR < 10-20 ml/min, clinical uremia seen
- result of CRF is uremia & death unless tx
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diagnostic test CKD
- dec NA++. Ca++, Ph
- inc K+, PO4, mg, BUn/crt
- U/A- proteinuria
- dec urine creatinin clearance- 24 hrs
- CBC- normochromic normocytic anemia- MCV, MCH, MHCH norm
- elev trig
- dec plat- risk for petechia
- metabolic acidosis- dec ph, bicarb
- may have chx in BS- DM must need less insulin bc not excreting
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diagnostic test CKD 2
- KUB, IVP, CT
- renal angiography
-
management-CKD conservative
- maintain/restore fluid balance
- - Na++/fluid restriction (daily u/o + 600 ml)
- - diuretics- loop need some renal fx
- - antihtn
- - strict I&O, daily wt
- assess FVO
- 1L of fluid- 1Kg
- remember 1 kg- 2.2 lbs
-
management- CKD electrolyte balance
- K+ diet restriction, kayexalate
- PO4- dietary restriction- 800-1000 mg/d
- phosphate binders if diet not successful
- - amophogel, CaCO3, Ca gluconate, sevelamer (renagel)
- Ca++= calcitriol, calcitonin- surpress parathyroid hormone- pt ca in bloodstream
- mg++ avoid laxatives, anacids w/mg (mile of mg)
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management- ckd metabolic acidosis
- symptoms if serum bicarb < 15 mEq/L
- H/A, malaise, change in resp, to stupor coma
- treated with IV bicarb or dialysis
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management CKD- diet
- protein restriction= at least 50 % high (not too much) but eggs, diary, fish
- inc CHO, fats, cal for energy
- Na++, K+ restriction- watch seasonings
- PO4 restrictions (most foods have both po4 and ca)
- water soluble vitas, high iron foods
- K- orange juice, banana, protein
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management- anemia, htn
- anemia-- if Hct is < 30, to dec S&S
- Epogen ** primary tx- viscosity clots
- - IV/Sc
- - 2-6 wks before improvement seen
- Blood infusion
- HTN
- antihtn
- ace-i, ca channel blockers and statins (hld dec chol)
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Management ckd integumentary
- dec itching
- uv light
- soothing skin lotions-temporary
- coping
- stress management
- support groups
- skin issue
- grayish
- look sick
- pale- anemia
- uremic frost- crystals- form on skin itchy
- petechia- dec plat
-
management ckd more aggressive
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dialysis
- eliminates wastes, lytes, water
- hemodialysis or peritoneal (artifical kidney)
- either may temp or permanent
- "artificial kidney"- semipermable membrane thru which dialysis occurs ultrafiltration & diffusion
- dialysate- specially prepared lyte solution that runs on other side of membrane
- remind- trying to replace kidney that is not working
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dialysis indications
- S&S progressive uremia
- BUN > 99mg/dl, Crt >10
- toxic level certain meds
- - cant excrete meds
- significant acidosis dec ph, dec GFR (norm 125) < 10
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peritoneal dialysis
- dialysate insilled at regular intervals into peritoneal cavity
- wastes, excess fluid, lytes pass thru via osmosis & diffusion (peritoneum- artificial kidney)
- drained at regular intervals
- you have to have intact peritonum - can't have abd surgeries, multi obesity with large walls
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peritoneal dialysis 3
- fill
- - room temp sterile dialystate- hypertonic pull solution
- dwell
- - remain in abd- diffusion & osomosis 2-8 hrs
- drain
- - by gravity into sterile bag or pump
- pt will have feeling of fullness
- solution clear- yellowish
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