renal failure

RENAL SYSTEMRENAL FAILURE

1.Acute Renal Failure

ARF is an acute and potentially reversible irritability of the kidneys to perform their normal functions to maintain homeostasis.

ETIOLOGYPrerenal factors osmolality is highSpecific gravity <1.020Renal perfusionTubular function normal

nonspecific symptoms:FeverDehydrationTachycardia

Ex: shock,CCF

Intrarenal ARFresults from injury to

Kidneylarge amounts of calcium

and uric acid excretionsodium cannot be

conserved urine cannot be

concentrated

Symptoms:nausea/vomiting,Hypertensionoliguria.

Ex: HUS, GNPostrenal or obstructivedelayed voiding after

birthelectrolyte imbalancea poor urinary stream abdominal mass

Urine osmolality & sodium levels are unaffected

Ex: calculi, trauma

PHASES1. Initial

-Renal damage is occurring, the child may be -Asymptomatic

2. Oliguric-<1ml/kg/hr of urine -Impaired glomerular filtration-Waste cannot be remove-Uremia develops-Neurotoxicity-CCF, HTN, anemia

3. Diuretic- lasts 2 weeks- cellular regeneration and healing- gradual return to normal- dehydration and electrolyte imbalance due to excess urination

4. Recovery- it takes months- if left untreated it result in fluid overload, electrolyte imbalance, uremia, coma

CLINICAL MANIFESTAIONS• Severe oliguria/ Anuria• Child may be markably well / extremely sick• Nausea / Vomiting• Lethargy• Dehydration• Acidotic breathing• Altered consciousness• Irregular cardiac rate, rhythm• Edema• Hypertension

DIAGNOSIS• Careful history taking

Vomiting, diarrhea, fever, other renal disease

• Laboratory investigationsAnemia, raised serum creatinine level, blood urea, electrolytes, pH, bicarbonate and complete blood count, reduced C3

• Urine examinationProtienuria, Hematuria, presence of casts

• USGStructural abnormalies, calculi

• IVPAcute tubular necrosis

• Radionuclide studiesEvaluate GFR, renal blood flow

• Renal biopsyUltimate cause

PATHOPHYSILOGY

TREATMENT• Medical treatment– Fluid and dietary restrictions–Use of diuretics–Maintain Electrolytes –May need dialysis to jump start renal

function–May need to stimulate production of urine

with IV fluids, Dopomine, diuretics, etc.–Hemodialysis

Nursing interventions• Monitor I/O, including all body fluids• Monitor lab results• Watch hyperkalemia symptoms: malaise, anorexia,

parenthesia, or muscle weakness, ECG changes • Watch for hyperglycemia or hypoglycemia if receiving TPN or

insulin infusions • Maintain nutrition• Safety measures• Mouth care• Daily weights• Assess for signs of heart failure• Skin integrity problems

PROGNOSIS

Mortality rate of ARF is about 20 to 40% which is influenced by the cause and duration of renal failure with severity of pathological changes. Poor prognosis is related to associated sepsis, HUS, prolonged anemia, cardiac failure, hepatic failure and respiratory failure with delayed initiation of treatment.

CHRONIC KIDNEY DISEASE

• Chronic renal failure

• End stage renal failure

2. Chronic Renal Failure

It is a permanent irreversible destruction of nephron leading to severe deterioration of renal function, finally resulting to end stage renal disease.

ETIOLOGY

• Cause below 5 years of age is mostly congenital anomalies

• After 5 that is acquired glomerular disease, hereditary diseaseGlomerular diseaseCongenital anomaliesObstructive uropathyMiscellaneous

CLINICAL MANIFESTATIONSEarly symptoms• Weakness• Anorexia• Nausea• Failure to thrive• Unexplained

anemia• Osteodystrophy• Growth failure

Late manifestations

• Gastrointestinal bleeding

• Pericarditis• Congestive

cardiac failure• Altered

sensorium

Indications of poor

prognosis• Convulsions• Coma• Cardiomyopathy

DIAGNOSIS• Blood examination

Decreased hematocrit, Hb%, Na+, Ca++, HCO-3, increased K+

& phosphorus• Renal function test

Gradual increase in BUN, uric acid & creatinine• Urinalysis

Variation in specific gravity, increased urine creatinine, change in total urine output

• X-RayChest, hands, knees, pelvis, spine to detect bony defect

• ECG, IVP, MCU, radio nuclide imagingExtent of complications

• Other abnormal findingsMetabolic acidosis, Fluid imbalance, Insulin resistance

PATHOPHYSIOLOGYIn the early stage of disease child remains

asymptomatic. Advance renal damage will occur only in late stages.

Increased numbers of nephrons are destructed at various degrees and a few remain intact but hypertrophied and functional. This leads to insufficient adjustments in fluid and electrolyte balance. As the disease progress to end stage severe reduction in number of nephrons occur and the kidney will not b able to maintain fliud and electrolyte balance. The accumulatin of various substances in blood result in complications

Stages of Chronic Renal Failure1. Diminished Renal Reserve

Normal BUN, and serum creatinine absence of symptoms

2. Renal Insufficiency GFR is about 25% of normal, BUN Creatinine

levels increased3. Renal Failure

GFR <25% of normal increasing symptoms4. ESRD or Uremia

GFR < 5-10% normal, creatinine clearance <5-10ml/min resulting in a cumulative effect

COMPLICATIONS

• Azotemia• Metabolic acidosis• Electrolyte imbalance• CCF• HTN• Severe anemia• Growth retardation• Delayed or absent sexual maturation

MANAGEMENT• Conservative managementCorrection of reversible component of renal

dysfunctionPreservation of renal functionTreatment of metabolic and psycho-social

problemsOptimization of growthPreparation for treatment of ESRDTreat for infection, accelerated hypertension,

CCF, obstruction of urine flow - to improve renal function

•Dietary therapy• Low protein diet• Severe protein restriction may produce protein calorie

malnutrition• Diet should consist of 100 percent RDA for calories• Protein should be of high biological value and should comprise 6

– 10 % of all calories• Salt restriction in patients with hypertension and fluid overload• Patients with salt losing nephropathy should take a liberal amount

of salt and water• If the GFR falls <10ml/min/1.73m2, potassium intake should be

restricted.(hyperkalemia may develop)• Vit D is essential to raise the serum calcium and suppress

parathormone secretion.

• Dialysis

• Renal transplatation

NURSING MANAGEMENT• Frequent monitoring – Hydration and output– Cardiovascular function– Respiratory status– Electrolytes – Nutrition

• Mental status– Emotional well being

• Ensure proper medication regimen• Skin care• Bleeding problems• Care of the shunt• Education to client and family

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