CHRONIC RENAL FAILURE

Mrs. Preethi Ramesh

Senior Nursing Lecturer

BGI

CHRONIC RENAL FAILURE

DEFINITION

CRF or ESRD is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails resulting in uremia or azotemia.

END STAGE RENAL DISEASE

A clinical state or condition in which there has been an irreversible loss of renal function, and these patients usually need to accept renal replacement therapy in order to avoid life-threatening uremia.

UREMIA

Uremia is the clinical and laboratory syndrome, reflecting dysfunction of all organ systems as a result of untreated or under treated acute or chronic renal failure.

CHRONIC RENAL FAILUREEach patient is classified into one of the 5 following stages of CRF because management

and prognosis varies according to the progression of damage.

Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2)

Stage 2: Mild reduction in GFR(60-89 mL/min/1.73 m2)

Stage 3:Moderate reduction in GFR (30-59mL/min/1.73 m2)

Stage 4: Severe reduction in GFR

(15-29mL/min/1.73 m2)

Stage 5: Kidney failure

(GFR <15)

STAGES OF CRF

ETIOLOGY & RISK FACTORS

ETIOLOGY & RISK FACTORS

Decreased renal blood flow

Systemic diseases

Diabetes mellitus

Hypertension

SLE

Polyarteritis

Sickle cell disease

Amyloidosis

Glomerulonephritis

Pyelonephritis

ARF

Obstruction of the urinary tract

Hereditary lesions

Polycystic kidney disease

Infections

Vascular diseases

Medication or toxic agents

Environmental or occupational agents

Lead

Cadmium

Mercury

chromium

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS

Fluid and electrolyte disturbances

Volume expansion/ contraction

Hyper/ Hyponatremia

Hyper/ hypokalemia

metabolic acidosis

Hyperphosphotaemia

Hypocalcaemia

CLINICAL MANIFESTATIONS

Hematologic System

Anemia

Bleeding Tendencies

Infection

Metabolic changes

Waste products accumulation

Altered CHO metabolism

Elevated triglycerides

CLINICAL MANIFESTATIONS

Gastrointestinal changes

Mucosal Ulcerations

Stomatitis

Parotitis

Gingivitis

Oesophagitis

Gastritis

Colitis

CLINICAL MANIFESTATIONS

Gastrointestinal changes cont…

GI Bleeding

Diarrhoea

Constipation

Metallic Taste in mouth

Anorexia

Nausea

vomiting

CLINICAL MANIFESTATIONS

Respiratory Changes

Kussmaul Respiration

Dyspnea

Pulmonary oedema

Uremic Pleuritis

Pleural Effusion

Uremic Lung

Cough Reflex is depressed

CLINICAL MANIFESTATIONS

Cardio Vascular Changes

HTN- Leads to

CHF

Retinopathy

Encephalopathy

Nephropathy

Dysrhythmia

Peripheral Oedema

Uremic Pericarditis

CLINICAL MANIFESTATIONS

Neurologic Changes

Manifestations of peripheral neuropathy

Burning feet

Gait changes

Foot drop

Paraplegia

CLINICAL MANIFESTATIONS

Features of CNS involvement

Forgetfulness

Inability to concentrate

Short attention span

Impaired reasoning

Musculoskeletal changes

Osteomalacia

Osteitis fibrosa

Osteoporosis

Osteosclerosis

CLINICAL MANIFESTATIONS

Integumentary Changes

Yellow grey discoloration of skin

Pale

Dry and scaly

Pruritis

Bruising ,Petechial and Purpura

Hair is brittle

Nails are thin and brittle

CLINICAL MANIFESTATIONS Reproductive Changes

Women

Menstrual irregularities

Infertility

Decreased libido

Men

Impotence

Testicular atrophy

Oligospermia

Decreased libido

-Decreased sperm motility

CLINICAL MANIFESTATIONS

Endocrine Changes

Hypothyroidism

Increased GH and prolactin

Immunologic changes

Depression of human antibody formation

Decreased function of leukocytes

Depression of delayed hypersensitivity

CLINICAL MANIFESTATIONS

Psychosocial Changes

Personality and behavioral changes

Withdrawal

Depression

Anxiety

Decreased ability to concentrate

Solved mental activity

CLINICAL MANIFESTATIONSCommon symptoms when Urea is > 40 mmol/L

Malaise,

Loss of energy

loss of appetite

Insomnia

Nocturia and polyuria

Itching

Nausea, vomiting, diarrhoea

Paraesthesia

Restless leg

Bone pain

Tetany

Symptoms due to salt & water retention

Symptoms due to anaemia

Sexual dysfunction

Mental slowing, clouding of consciousness, seizures & coma

DIAGNOSTIC STUDIES

History and physical examination

Routine lab measurements

BUN

Serum Creatinine

Serum Electrolytes

Hematocrit and Hb levels

Urine Analysis

Urine Culture

Identification of Reversible Renal Disease

Renal Ultrasound

Renal Scan

C T Scan

Renal Biopsy

MANAGEMENT

Preserve the renal function and dialysis

Controlling the disease process.

Controlling BP by diet control, weight control and medication.

Reducing dietary protein intake.

Alleviate extra renal manifestations.

Pruritis

Topical emollient and lotion.

Antihistamine.

IV Lidocaine.

MANAGEMENT

Neurological manifestations.

Safety measures to protect from injury.

Anticonvulsants.

Sedatives

Hematologic changes.

Therapy with epoetin alfa (three times a week)

supplemental iron, vitamin B12 and folic acid.

MANAGEMENT

Improve body chemistry.

Dialysis

Medications

Diet

MANAGEMENT

Dialysis

Peritoneal dialysis:

peritoneal dialysis is a type of dialysis which uses

the peritoneum in a person’s abdomen as the

membrane through which fluid & the dissolved

substances are exchanged with the blood.

Hemodialysis:

A procedure to remove fluid & waste products

from the blood & to correct the electrolyte

imbalances by using a dialysis machine & a dialyzer,

also referred to as an “artificial kidney”

MANAGEMENT

Medications

Hyperkalemia

Insulin administration – I/V

Sodium bicarbonate

Calcium Gluconate – I/V

Sodium polystrene

sulfonate(Kayexalate)

MANAGEMENT

Medications

Hypertension

Sodium and fluid restriction

Anti hypertensive drugs

Diuretics

Beta adrenergic blockers

Ca channel blockers

ACE inhibitors

MANAGEMENT

Medications

Renal osteodystrophy

Regulation of calcium, phosphorus and acidosis

Treatment of hyperparathyroidism

Calciferol

Paricalcitol (Vitamin D analog)

Calcium based phosphate binders

• Calcium acetate

• Calcium carbonate

MANAGEMENT

Medications

Anaemia

Erythropoietin – I/V subcutaneously

Epogen ( Epoetin alfa)

Parental iron

Folic Acid 1 mg daily

Diuretics

Given early to stimulate excretion of water

Vitamins

Supplemental water soluble vitamins

MANAGEMENT

Diet

Protein restriction

0.6 to 0.75 gm/kg of ideal body weight/day

1.2 to 1.3 gm/kg of ideal body weight/day once the patient starts dialysis

Water restriction

Patient not receiving dialysis – 600ml + an amount equal to the previous days urine out put

Patients on dialysis – fluid intake is adjusted so that weight gains are not more than 1 to 3 kg between dialysis

MANAGEMENT

Diet

Phosphate restriction

1000 mg/day

Phosphate rich foods are Diary products (milk, Ice

cream, cheese etc.)

Potassium restriction

2 to 4 gm/day

(Sources are – orange, banana, melons, tomatoes, beans,

legumes etc.)

MANAGEMENT

Diet

Sodium restriction

2 to 4 gm/day

(Sources are – pickled foods, canned soups, soya sauce

etc. )

Calcium

If serum ca levels are low, adequate calcium intake is

important.

Magnesium

Mild Mg restriction may be imposed

MANAGEMENT

Surgical Management

Renal Transplantation

Kidney or renal transplantation is the organ transplant of

the kidney into a patient with end stage renal disease.

NURSING MANAGEMENT

1. Risk for Decreased Cardiac Output.

2. Risk for Ineffective Protection.

3. Disturbed thought process.

4. Risk for impaired skin integrity.

5. Deficient knowledge.

6. Excess fluid volume.

7. Acute pain.

8. Impaired renal tissue perfusion.

9. Impaired urinary elimination.

10. Imbalanced nutrition less than body requirement.

11. Activity intolerance.

12. Disturbed body image.

13. Risk for injury

14. Risk for infection

15. Anticipatory grieving.

Thank youTake care of your

kidneys