1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 25 Renal Failure

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins When Kidneys Fail Less waste is removed More waste remains in the blood Nitrogenous compounds build up in the blood –BUN: Blood urea nitrogen –Creatinine Renal function approximated by: initial creatinine level/current creatinine level

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Renal Failure Prerenal –Decreased blood supply Shock, dehydration, vasoconstriction Postrenal –Urine flow is blocked Stones, tumors, enlarged prostate Intrinsic –Kidney tubule function is decreased Ischemia, toxins, intratubular obstruction

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which type of acute renal failure (ARF) would be most likely to accompany benign prostatic hypertrophy? a.Prerenal b.Postrenal c.Intrinsic d.Extrinsic

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Postrenal Postrenal ARF occurs when the flow of urine is blocked by kidney stones, tumors, or an enlarged prostate gland. Because the male urethra passes through the prostate, if it is enlarged, the urethra may become blocked.

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Radiocontrast Agents Can Cause ARF Giving N-acetylcysteine reduces the risk of ARF by 50% in a meta-analysis Recommended for clients at risk of renal failure who are receiving radiographic contrast media –Diabetics, clients with sepsis –Underlying vascular, renal, or hepatic disease –Receiving other nephrotoxic drugs (Kellum, J.A. [2003]. A drug to prevent renal failure? Lancet 362,589-590.)

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Scenario A man developed acute renal failure after emergency surgery for a severed left leg He came in with a serum creatinine of 1.2 mg/dL, but now it is 5.6 mg/dL His BUN is 86 mg/dL Question: Why would leg damage cause renal failure? What is his remaining kidney function?

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Urine Containing Tubular Cell Casts Casts are formed when cells are packed together in the tubule lumen They block the tubule When the mass of cells washes loose, it appears in the urine

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Scenario Mr. J is an alcoholic with kidney problems He is severely dehydrated with an infected leg ulcer, benign prostatic hypertrophy, and anemia His urine is dark and contains myoglobin and tubular cell casts His creatinine and BUN are both elevated Question: What may have caused his acute tubular necrosis?

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chronic Renal Failure Fewer nephrons are functioning Remaining nephrons must filter more –Hyperperfusion –Hypertrophy

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Development of CRF Diminished renal reserve –Nephrons are working as hard as they can Renal insufficiency –Nephrons can no longer regulate urine density Renal failure –Nephrons can no longer keep blood composition normal End-stage renal disease

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Uremia Uremia = “Urine in the Blood” Renal filtering function decreases –Altered fluid and electrolyte balance oAcidosis, hyperkalemia, salt wasting, hypertension Wastes build up in blood –Increased creatinine and BUN oToxic to CNS, RBCs, platelets Kidney metabolic functions decrease –Decreased erythropoietin –Decreased Vitamin D activation

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following renal disorders is characterized by increased BUN and creatinine levels? a.ARF b.CRF c.Uremia d.All of the above e.b and c

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer d.All of the above In each disorder listed, the ability to remove nitrogenous waste is diminished. This causes nitrogenous compounds (BUN and creatinine) to accumulate in the blood.

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Scenario A man has chronic renal failure. He has high creatinine and BUN, hyperkalemia, acidosis with normal pCO 2, and severe anemia His blood glucose has reached 340 mg/dL one hour after a hospital meal He complains of having broken two toes in the last few weeks, even though he eats a lot of dairy products for calcium

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Scenario (cont.) Question: What is the most likely cause of his chronic renal failure? What caused his anemia? Why are his bones brittle even though he eats dairy products?

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiovascular Consequences of CRF Decreased blood viscosity + Increased blood pressure + Decreased oxygen supply less erythropoietin anemia lower blood viscosity blood flows through vessels more swiftly heart rate increases

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins left ventricle dilation and hypertrophy not enough oxygen to support LV contraction angina ischemia LHF increased workload on left heart

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false. CRF leads to decreased cardiac output (CO).

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True The increased blood pressure (HTN) and hypoxemia that accompany CRF lead to increased myocardial work (the heart has to work harder to meet the metabolic demands of body tissues). Eventually the heart becomes unable to meet these metabolic demands, and CO will decrease.