Renal Failure

Wendy DeMartino, MDPGY-2

Objectives Anatomy Function Acute Renal Failure (ARF)

Causes Symptoms Management

Chronic Renal Failure (CRF) Causes Symptoms

Dialysis

Anatomy 2 Kidneys 2 Ureters Bladder Urethra

Kidney Function Detoxify blood Increase calcium absorption

calcitriol Stimulate RBC production

erythropoietin Regulate blood pressure and

electrolyte balance renin

Classifications Acute versus chronic Pre-renal, renal, post-renal Anuric, oliguric, polyuric

Acute Versus Chronic Acute

sudden onset rapid reduction in urine output Usually reversible Tubular cell death and regeneration

Chronic Progressive Not reversible Nephron loss

75% of function can be lost before its noticeable

Acute Renal Failure

Pre-renal = 55%

Renal parenchymal (intrinsic)= 40%

Post-renal = 5-15%

Causes of ARF Pre-renal =

vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure

cardiac failure, liver dysfunction, or septic shock Intrinsic

Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins

Post-renal = prostatic hypertrophy, cancer of the prostate or cervix, or

retroperitoneal disorders neurogenic bladder bilateral renal calculi, papillary necrosis, coagulated blood,

bladder carcinoma, and fungus

Symptoms of ARF Decrease urine output (70%) Edema, esp. lower extremity Mental changes Heart failure Nausea, vomiting Pruritus Anemia Tachypenic Cool, pale, moist skin

Diagnosis of Renal Failure

Acute Renal Failure Management Make/think about the diagnosis Treat life threatening conditions Identify the cause if possible

Hypovolemia Toxic agents (drugs, myoglobin) Obstruction

Treat reversible elements Hydrate Remove drug Relieve obstruction

ARF: Life Threatening Conditions Hyperkalemia Volume overload Vascular access

Hyperkalemia Symptoms Weakness Lethargy Muscle cramps Paresthesias Hypoactive DTRs Dysrhythmias

Hyperkalemia & EKG K > 5.5 -6 Tall, peaked T’s Wide QRS Prolong PR Diminished P Prolonged QT QRS-T merge –

sine wave

Hyperkalemia Treatment Calcium gluconate (carbonate) Sodium Bicarbonate Insulin/glucose Kayexalate Lasix Albuterol Hemodialysis

Chronic Renal Failure 150–200 cases per million people =

new cases each year Chronic renal failure and ESRD affect

more than 2 out of 1,000 people in the U.S

Mortality = 20%

Chronic Renal Failure Causes Diabetic Nephropathy Hypertension Glomerulonephritis HIV nephropathy Reflux nephropathy in children Polycystic kidney disease Kidney infections & obstructions

CRF Symptoms Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting

Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal

hemostasis

Acute Problems in CRF Relating to underlying disease Relating to ESRD Dialysis related problems

Problems Related to ESRD Metabolic – K/Ca Volume overload Anemia, platelet disorder, GI bleed HTN, pericarditis Peripheral neuropathy, dialysis

dementia Abnormal immune function

Dialysis ½ of patients with CRF eventually

require dialysis Diffuse harmful waste out of body Control BP Keep safe level of chemicals in body 2 types

Hemodialysis Peritoneal dialysis

Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters blood and returns it to body

Types of Access Temporary site AV fistula

Surgeon constructs by combining an artery and a vein

3 to 6 months to mature AV graft

Man-made tube inserted by a surgeon to connect artery and vein

2 to 6 weeks to mature

Temporary Catheter

AV Fistula & Graft

What This Means For You No BP on same arm as fistula Protect arm from injury Control obvious hemorrhage

Bleeding will be arterial Maintain direct pressure

No IV on same arm as fistula A thrill will be felt – this is normal

Access Problems AV graft thrombosis AV fistula or graft bleeding AV graft infection Steal Phenomenon

Early post-op Ischemic distally Apply small amount of pressure to

reverse symptoms

Peritoneal Dialysis Abdominal lining filters blood 3 types

Continuous ambulatory Continuous cyclical Intermittent

EMS Considerations Make sure the dressing remains

intact Do not push or pull on the catheter Do not disconnect any of the

catheters Always transport the patient and

bags/catheters as one piece Never inject anything into catheter

Dialysis Related Problems Lightheaded –give fluids Hypotension Dysrhythmias Disequilibration Syndrome

At end of early sessions Confusion, tremor, seizure Due to decrease concentration of blood

versus brain leading to cerebral edema