Renal Failure

Renal Failure NUR 3218

Renal Failure • Partial or complete impairment of kidney function • Inability to excrete waste products • Types – Acute renal failure – Chronic renal failure

Notes • Kidney disease has been on the rise & ESRD has more than doubled in the past decade • Due to diabetes, HBP & glomerulonephritis • Acute – usually sudden onset, can affect many body systems – can be reversible with aggressive care – Loss of about 50% of function

• Chronic – slower onset, affects all body systems – irreversible – Loss of about 90-95% of nephron function

• Renal insufficiency – loss of about 25% function

Acute Renal Failure • Rapid loss of kidney function – ↑ BUN & serum creatinine – Oliguria

• Types of ARF – Prerenal • Hypovolemia, ↓ CO, vascular failure

– Intrarenal (Intrinsic) • ATN (acute tubular necrosis), kidney tissue damage, nephrotoxins

– Postrenal • Obstructed urine flow

Notes • Leads to accumulation of waste products in the body • Occurs due to compromised blood flow (shock), toxins, tubular ischemia, infections & obstructions • Prerenal – from decreased blood flow or ischemia in the nephrons – conditions that cause decreased CO – Prolonged prerenal (hypoperfusion) can cause further progression of RF – Shock (septic, anaphalactic, cardiogenic), decreased CO,HF, Pulm emb, cardiac tamponade

• Intrarenal - actual tissue damage from inflammatory or immunologic processes OR from prolonged hypoperfusion causes impaired renal function – ATN, Acute glomerulonephritis, nephrotoxins (NSAID’s, antibiotics), vasculitis, hepatorenal syndrome

• Postrenal – obstruction of urine flow b/t kidney & urethra – Urethral or bladder cancer, urethral stricture, cervical cancer, Prostate enlargement

Acute Tubular Necrosis • Intrarenal condition caused by ischemia, nephrotoxins, or pigments. • ATN (exception of causes from pigments) results in 90% intrarenal ARF • Potentially reversible

Acute Renal Failure • Prerenal & Postrenal can resolve quickly with treatment of the underlying cause • Intrarenal (ATN) takes longer to resolve due to potential tissue damage • If don’t recover from ARF, can develop CRF • Clinical course follows 4 phases

Notes • PREVENTION IS THE KEY! • Often seen in ICUs. • ATNs continue to have 50% mortality rate.

Clinical Phases • Initiating Phase – Onset, Initial insult to kidney to symptoms

• Oliguric (< 400 ml/day) – Most common manifestation of ARF – Metabolic acidosis, mental changes – Fluid overload, sodium depletion, potassium build-up, low calcium, high phosphate – BUN and creatinine elevations – Variable length

Notes • See TABLE 47-2 in text and specific descriptions of manifestations on pages 1200-1201 • Initiating Phase (Onset) – gradual accumulation of nitrogenous wastes, with elevation of serum Ct & BUN – Can last hours or days

• Oliguric – decreased GFR, sudden decrease in the UO 100-400/24 hrs which does not respond to diuretics or fluid challenge – Occurs 1-7 days after causative event; depends on cause – Last about 8-15 days • Longer the duration, the less chance of recovery

– May be drowsy, disoriented or comatose

Clinical Phases • Diuretic – Kidneys begin to excrete urine, but can’t concentrate – Occurs 2-6 weeks after initial injury – May last 1-3 weeks

• Recovery – GFR ↑, BUN & Ct decrease – Outcome based upon overall health, severity of ARF & any complications – Can take up to 12 months – Vulnerable to insult during this time

Notes • Diuretic – gradual increase in GFR, indicates recovery of damaged nephrons – UO increases, can be 3-5 L/day of dilute urine • Can see hypotension from fluid loss & tachycardia

– LOC - will begin to improve

• Recovery – return to normal level of function or can develop CRF if not full recovery – - uremia may still be severe.

• ALSO, non-oliguric form of ARF. – No major decrease in urine output so less complicated – Still need to observe blood and urine components for waste product accumulation and changes in electrolyte, acid-base, and fluid balances.

Nursing and Collaborative Management • PREVENTION IS KEY!! – Health promotion – Avoid dehydration – Avoid conditions that cause ARF

• History – Early recognition of renal problems • Autoimmune conditions • Infections

– Monitor lab values – Awareness of nephrotoxic substances • Drug history

Notes • TEXT gives long list of causes of ARF • Are numerous clinical conditions that can lead to ARF • Avoid dehydration – esp in FL & in the summer for children and older adults • Infections – streptococcal especially • Nephrotoxic – NSAID’s, tylenol, antibiotics like amphoteracin B, vancomycin, tetracycline – aminiglycosides like gentamicin – antineoplastics like cisplatin & methotrexate – Other things like pesticides & fungicides & heavy metals & X-ray dyes (especially in older adults) • Careful matching of blood products

Clinical Manifestations of ARF • Azotemia - accumulation of nitrogenous waste products in the blood • Uremia - syndrome of renal failure as it affects other body systems

Notes • AZOTEMIA – accumulation of nitrogenous waste in the blood – measured by BUN & Ct • Uremia - urinary, cardiovascular, respiratory, GI, Hematologic, neurologic, and metabolic changes (See Table 47-3) in text

Diagnostic Tests • Serum BUN & creatinine, electrolytes, anemia • Metabolic acidosis • Creatinine clearance • Urinalysis • Renal ultrasound, CT scan, IVP

Notes • Acute & Chronic lab values are very similar • CT & BUN will gradually increase – see metabolic acidosis – Remember Ct is better indicator of renal function b/c not affected by hydration or catabolism

• • • • • • •

Serum potassium – will increase as renal fx declines Serum phosphorus – will be increased Serum calcium decreased Can also see anemia if decreased erythropoietin Creatinine clearance – decreased b/c GFR is decreased Urine – will have RBC’s casts, myoglobin KUB – an enlarged kidney may indicate obstruction

• IVP – especially dangerous with decreased renal function because of dye

Nursing Diagnosis • Excess fluid volume r/t compromised regulatory mechanisms • Imbalanced nutrition: Less than body requirements r/t dietary restrictions • Ineffective protection r/t abnormal blood profiles

Nursing & Collaborative Care • Ensure adequate intravascular volume & adequate cardiac output • Pharmacology – Volume replacement – Loop diuretics – Low-dose dopamine – Kayexalate (if hyperkalemia) – Sodium bicarbonate (if metabolic acidosis) – Avoid NSAID’s & ace inhibitors – Use nephrotoxic drugs sparingly

Notes • Maintain renal perfusion!!! • Goals aimed at treating the underlying cause & preserving as much kidney fx as possible • Treatment varies some based on the clinical phase in • Volume – fluid challenges to increase renal blood flow • May or may not be prescribed with diuretics • Low dose dopamine to increase blood flow to the kidney & increases BP • Some type of invasive monitoring to know fluid & pressure status • Ace inhibitors – used to help ARF from nephrotoxic ATN

Nursing & Collaborative Care • Fluid Balance – Assess edema, CHF, & pulmonary edema – Accurate I & O, daily weights – Restrict fluid if hyponatremic – Problems that occur • Hyperkalemia • Hyponatremia • Metabolic acidosis

Notes •

Careful monitoring of labs and working with dietician

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Assess edema, CHF, & pulmonary edema

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Provide adequate nutrition w/o placing a stress on the kidney

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Accurate I & O, daily weights (1 kg = 1000 ml fluid)

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If fluid is restricted, it can be calculated as the UO + 600 ml.

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Restrict fluid if hyponatremic –

Problems that occur • • •

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Hyperkalemia Hyponatremia – may be dilutional with actual high levels of sodium Metabolic acidosis

Adequate calories, high carb, low Na, low K, low phosphorus, low protein

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Know foods that should be avoided

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– High K – apricots, artichokes, bananas, etc – High Na - bouillon, canned soups, preserved meats, cheeses, olives, pickles, etc – High phos – dried beans & peas, eggs, fish, organ meats, nuts & seeds TPN/enteral feedings if unable to tolerate oral

Nursing & Collaborative Care • Nutrition – Adequate calories to prevent catabolism – Monitor protein intake – Restrict potassium, phosphate, & sodium – Give calcium supplements/phosphate binding agents

Notes • Adequate calories from carbs and fats - calories average 30 – 35 kcal/kg of body weight • - 30-40% total calories from fat • • Protein intake depends upon degree of catabolism - control nitrogenous waste production • - limit starvation ketosis • - about 0.6 – 2 grams/kg/day • - can add essential Amino Acid supplements • • Restrict potassium, phosphate, and sodium - potassium and sodium depends on plasma levels and symptoms of • edma, hypertension, and CHF - limit phoshates and give calcium supplements and/or phosphate• binding agents

Nursing & Collaborative Care – Treat elevated potassium levels • Regular insulin IV • Sodium bicarbonate • Calcium gluconate IV • Dialysis • Kayexalate (sodium polystyrene sulfonate) • Dietary restriction of potassium

Notes • See Table 47-5

Nursing & Collaborative Care • Promote Rest

– Anemia contributes to fatigue – Increase activity/ambulation as condition improves

• Prevent Injury & Infection

– Electrolyte imbalance & uremia may contribute to mental confusion – Good skin care, measures to relieve pruritus – Aseptic technique for all invasive lines

• Assist with Patient & Family Coping

– Mental changes – ARF explanations – Medications, diet, infections, follow-up care

Notes • Pruritis occurs because of uremic deposits in the skin

Gerontologic Considerations • Older adult more susceptible to ARF • Consider differences in treatment, e.g. diuretics • Higher mortality rate due to infection, GI hemorrhage, or MI

Collaborative Care • Temporary dialysis therapies – Hemodialysis • Special vascular access, Vas-Cath

– Peritoneal dialysis • Tenkoff catheter

– Hemofiltration - CRRT

Notes •

Vascular access – preferred site is subclavian vein or jugular over the femoral – b/c infection, mobility & visualization – Can be used immediately – Special catheter with 2 lumens – outflow & inflow

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PD – abd catheter has to be placed – uses the peritoneum as the dialysis membrane – Slower process, some pts may not tolerate the large amount of fluid introduced into the abdomen

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Hemofiltration – CRRT – Continuous renal replacement therapy procedures that are better tolerated by critically ill pts for removing waste products, uses a dialysate solution, but is better tolerated, need to be hospitalized & require intensive are nursing – – double lumen dialysis catheter inserted in the subclavian or jugular

Chronic Renal Failure Presence of kidney damage or glomerular filtration rate (GFR) less than 60 ml/min for 3 months or longer

Notes • Normal GFR is 125 ml/min • Measured by Urine Creatinine Clearance

Chronic Renal Failure • Progressive, irreversible destruction of the nephrons of both kidneys • Occurs over months to years, determined by severity of symptoms & preservation of function • Deteriorates to End Stage Renal Disease (ESRD) & will need dialysis or transplant • Uremic syndrome- systemic & lab manifestations of ESRD

Notes • Disease is usually a slow process occurring over years of damage – *Diabetes – see most in obesity, sedentary, family history, Native Americans – *Hypertension – African Americans likely to have HTN – *Glomerulonephritis – Systemic Diseases • Sickle cell • Scleroderma • SLE

– Polycystic disease

• *Most frequent causes

Etiology of Chronic Renal Failure • Born with over 2 million nephrons, kidney failure after 85%-90% lost • African Americans with hypertension • Native Americans with diabetes • Incidence increasing • Insurance companies & Medicare now pay for ESRD treatment

Notes • Causes – are due to many different diseases • Incidence is on the rise – Greater in persons over 65 & with a risk factor

Chronic Renal Failure - Terms • Diminished Renal Reserve – Renal function declines – Creatinine clearance declines – Ct & BUN normal – Nocturia & polyuria

• Renal Insufficiency – GFR continues to decline – Ct & BUN begin to elevate – Medical management

• End-Stage Renal Disease – Excessive waste build-up

Notes • CRF – Terms often heard– NOT Current Stage Guidelines – SEE TABLE 47-6 for STAGES of Chronic Kidney Disease – Diminished renal reserve, but not metabolic wastes in blood – a healthy kidney is able to compensate • See more nocturia & polyuria b/c the kidney is less able to concentrate urine

– Renal Insufficiency - kidney is now unable to compensate & see waste accumulate & the kidney beginning to be unable to handle the body’s needs • Elevated uric acid, phosphorus • Care is medical management here with medications, managing fluid, BP, electrolytes, & diet • Always progresses to stage III – just depends upon how fast the progression is • May have this for years

– End – Stage Renal Disease - excessive build-up of waste products in the blood & kidney can no handle • More severe fluid & electrolyte imbalances • Without treatment, is fatal

Clinical Effects of ESRD

Notes • Can develop slowly over months to years • Urea is the end product of protein metabolism, so BUN & Ct will elevate • Kidney normally excretes K+, so if function declines, then potassium will accumulate • Bones will demineralize d/t high phos & low ca – stimulates parathyroid hormone, which releases Ca

Clinical Effects of ESRD • Regulatory Functions – – – – – – – –

Waste product accumulation (BUN, Ct) Anemia because ↓ erythropoietin Metabolic acidosis Hyperkalemia Abnormal fluid & sodium balance (HBP) Hyperuricemia Hyperphosphatemia, hypocalcemia Glucose intolerance

• Cardiac System – HBP  LV hypertrophy  CHF – Cardiac arrhythmias – Uremic pericarditis

Notes •

Can develop slowly over months to years

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Urea is the end product of protein metabolism, so BUN & Creatinine will elevate

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Kidney normally excretes potassium, so if function declines, then potassium will accumlate

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Bones will demineralize due to high phosphorus and low calcium – stimulates parathyroid hormone, which releases Ca

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Hyperlipidemia occurs causing cardiac problems – from impaired fat metabolism – leads to increased triglycerides, increased cholesterol, increased LDL

Clinical Manifestations • Respiratory System – Dyspnea, tachypnea – Kussmaul's respirations – Uremic pleuritis/lung

• GI System – Mucosal ulcerations – Metallic taste in mouth – N, V, D, C, – Anorexia – Weight loss, malnutrition – GI bleeding

Notes • CRF causes changes to ALL body systems – primarily effects of those things related to fluid volume, electrolyte, acid-base & the build up of nitrogenous waste • RESPIRATORY – d/t metabolic acidosis – Kussmaul's esp if severe metabolic acidosis – Can develop “uremic lung” – type of pneumonia due to elevated uric acid

• GI – excessive ammonia from uremia irritates the GI mucosa & causes ulcerations – Ulcerations can place the pt at risk for bleeding from them if they become severe – Constipation is due to the fluid limitations, activity limitations

Clinical Manifestations • Cardiovascular – Hypertension, peripheral edema – CHF – Arrhythmias – Cardiomyopathy – Uremic pericarditis

• Hematology – Anemia

Notes • CV – effects related to excess volume – Arrhythmia – electrolyte imbalances

• HEME – anemia b/c of decreased EPO production by the kidneys – also deficient in iron – Bleeding from the GI tract

Clinical Manifestations • Neurological System – ↑ as CRF progresses – CNS depression (lethargy, inability to concentrate, declining mental ability, seizures) – Peripheral neuropathy, paresthesias – Cerebral swelling

• Integumentary System – ↑ skin pigment – Uremic frost – Hair & nails dry & brittle

Notes •

NEURO – develop a uremic encephalopathy b/c uremic toxins damage the axons – also is from the build-up of waste products – General CNS depression which will continue to progress if untreated – Peripheral neuropathy – see changes in sensation, may complain of “restless leg syndrome” or “feeling bugs crawling inside of legs” – Muscle weaknesses, diminished DTR’s – Asterixis can occur

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SKIN – increased pigment due to urochrome being deposited in the skin, which has a yellowish-grey coloration – Just darker in dark skinned clients – The uremia causes prurutis – May also see uremic frost – when urea crystallizes on the skin, see most when the BUN is very high & pt has refused or dialysis has been w/d

Clinical Manifestations • Urinary – Decreased or absent urine output – + for protein, heme & casts

• Musculoskeletal – Muscle weakness, bone pain – Renal osteodystrophy – Uremic deposits in the eye

Notes • URINE – unless it is the early stages, their may be high UO of dilute, unconcentrated urine esp at night • MS – renal osteodystrophy from the abnormalities in calcium & phosphorus – bones become thin & weak & can have pathological fxs – Eye – may burn & water from irritation

Clinical Manifestations • Reproductive System – Infertility, ↓ libido – ↓ hormone levels, amenorrhea

• Psychological Changes – Personality & behavioral changes – Body image alterations – Anxiety, depression, & grief

Geriatric Considerations of Renal Failure • GFR rate declines every 10 years after age 50 • Older adults are more likely to have other chronic conditions that contribute to RF • Have difficulty performing PD & have difficulty getting to HD appointments • Often need community resources for assistance

Chronic Renal Failure Diagnostic Tests • Serum creatinine, BUN • Urinalysis • 24-hour urine – Creatinine clearance (= GFR)

• • • •

KUB, ultrasound, CT Renal scan, angiogram Renal biopsy Serum electrolytes

Notes See Textbook discussion Causes extreme changes in some blood values Can also calculate the GFR & CrCl Other studies would be included to monitor the effects on the other body systems, there are just the RF ones • X-rays can be done – but of limited value • • • •

Nursing Diagnosis for Renal Failure • Excess Fluid Volume r/t compromised regulatory mechanism • Activity Intolerance r/t weakness, metabolic alterations • Imbalanced Nutrition: Less than body requirements r/t restricted diet, anorexia • Impaired skin integrity r/t prurutis of uremia • Ineffective Protection r/t hyperkalemia • Risk for Infection r/t uremic toxins, chronic disease • Fatigue r/t anemia, disease state

Notes • Many ND could be included in the list – these relate to the primary problems seen, but their could be others depending upon the health status of the individual pt

Nursing & Collaborative Care • Administer prescribed medications – Antihypertensives • ACE or ARB • BB or Ca channel blockers

– Antidiabetic agents – Electrolytes to correct imbalances, kayexealate – Phosphate binding agents – Erythropoietin – Caution with digixon preparations & other drugs with kidney clearance

Notes •

See Text, pp. 1209-1211

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Conservative measures are always tried first with dialysis being the last resort • Aimed at slowing the progression of the CRF & preventing complications – Especially those pts with DM & HBP

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Control BP – antihypertensive & diuretics – – – –

Weight loss if obese Therapeutic lifestyle – exercise, smoking cessation, avoid alcohol Beta blockers decrease the incidence of cardiac mortality ACE – decrease proteinuria & delay progression of CRF, also ARB, angio rec inh -

Notes • Control BS – monitor & keep bs under control • Hyperkalemia – another problem of CRF – can give IV glucose & insulin to move K out of the cell or can give Kayexelate – a cation exchange resin – give PO or as a retention enema; dialysis • Phosphate binding – tums or Remegel to bind with ph – want aluminum free phosphate binder • EPO – to get Hct between 30-35%, very effective in helping to improve fatigue • Drugs to avoid – drugs excreted by the kidney are always a concern - & doses may have to be adjusted – – – – – –

Includes primarily Dig, antibiotics, & pain meds Dig adjust dose down Aminoglycosides, penicillin &tetracycline – have to adjusted down NEVER give Demerol b/c liver changes then kidney has to excrete NEVER give NSAID’s b/c they cause renal vasoconstriction Avoid or only use in very small amounts as prescribed - Tylenol

Nursing & Collaborative Care • Nutrition & Fluid Balance – Protein restriction – Sodium restriction – Protein restriction – Avoid salt substitutes, foods high in potassium – Limit fluid intake – Restrict phosphorus – Comply with dietary restrictions

Notes • See Table 47-8 in text • Protein metabolism is the primary cause of uremia, so protein should be limited in CKD, 0.6 – 0.75 g/kg of ideal body weight) (unless on dialysis) but not avoided when creatinine clearance is 25 ml/min or less. or will develop negative nitrogen balance & lose muscle & become malnurished – Chronic renal insufficiency – 0.6 – 0.8 g/kg of body weight/day – Dialysis – 1.2 – 1.3 g/kg of ideal body weight/day – 50% protein should be high biologic value containing all of the essential amino acides – Evaluated & calculated based upon individual needs & type of dialysis being used

Notes • Sodium restriction – 2-4 g/day depending on edema and HTN - esp when little or no urine output as it will contribute to edema – Also BP, weight. & if on dialysis is factored in

• Potassium restriction – 2-4 g (39 mg = 1 mEq) • Fluid will also depend upon the UO & type of dialysis • Phosphorus – limited (1000 mg/day) but is primarily in foods that are high in protein – May need calcium supplements, foods with calcium • Use calcium or aluminum based antacids

Nursing & Collaborative Care • Prevent infection & injury – Meticulous skin care • Pruritis

– Avoid places/persons with infections

• Stool softeners • Activities to lessen bleeding • Monitor for confusion, falls

Notes • Skin – attention to any breaks in skin – vascular access or PD catheter site – Pruritis – d/t urate crystal excreted thru the skin, sometimes uremic frost • Avoid soaps, lotions that may be irritating • May need antipuritics, such as Benadryl

• Monitor H & H, stools for occult blood, avoid aspirin products

Collaborative Care & Nursing Management of CRF • Promote comfort, rest & sleep – Tend to have a number of chronic complaints, not acute pain – Cool room temperature at night – Rest periods as needed – Fatigue – Epogen or Procrit

• Promote coping – – – –

Noncompliance is an issue, also depression Social problems, relationships, vocation Adjustments to dialysis Implications for the future

Collaborative Care & Nursing Management of CRF • Dialysis is initiated when GFR is less than 10-15 ml/min (severe kidney impairment) • Movement of fluid & particles across a semipermeable membrane • Removes waste & toxic material • Sustains body function for both acute & chronic RF • Can also be used to remove drugs & poisons from the body, to correct serious metabolic imbalances

Notes • Selection of dialysis is based upon a number of factors, lab values + clinical manifestations • Begins when conservative approaches no longer work • Type of dialysis is determined by the physician based upon patient factors – Adv & disadv to both – Diet and fluid amounts more difficult before dialysis initiated; hemodialysis more restrictive than peritoneal