Renal Failure Acute and Chronic DR.FAROOQ ALAM M.B.B.S-M.phil

Acute Renal Failure The kidney has a remarkable ability to recover from insult. The objectives of treatment of ARF are to restore normal chemical balance and prevent complications. The medical management includes maintaining fluid balance, avoiding fluid excesses, or possibly performing dialysis.

 Maintenance of fluid balance is based on daily body weight, serial measurements of central venous pressure, serum and urine concentrations, fluid losses, blood pressure, and the clinical status of the patient.  The parenteral and oral intake and the output, including insensible loss, are calculated and are used as the basis for fluid replacement.

Medical Management (Continued…) Because excessive administration of parenteral fluids may cause pulmonary edema, extreme caution must be used to prevent fluid overload (Characterised by dyspnea, tachycardia, distended neck veins, and crackles). Generalized edema is assessed by examining the presacral and pretibial areas several times daily. Mannitol, furosemide, or ethacrynic acid may be prescribed to initiate a diuresis and prevent or minimize subsequent renal failure.

 Adequate blood flow to the kidneys in patients with pre-renal causes of ARF may be restored by intravenous fluids or blood product transfusions.  Dialysis may be initiated to prevent serious complications of ARF, such as:  hyperkalemia, severe metabolic acidosis, pericarditis, and pulmonary edema.

Pharmacologic Therapy [Hyperkalemia] Hyperkalemia is a life- threatening condition. Therefore, the patient is monitored for: Serum potassium levels Electrocardiogram (ECG) changes (tall, tented, or peaked T waves) (next slide) Signs and symptoms (muscle weakness, diarrhea, abdominal cramps)

Pharmacologic Therapy (Continued…) Hyperkalemia may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate exchanges a sodium ion for a potassium ion in the colon (major site for potassuim exchange,decreasing K+). Sorbitol is often administered in combination with Kayexalate to induce a diarrhea-type effect.

Pharmacologic Therapy (Continued…) Administration of a retention enema requires a rectal catheter with a balloon to facilitate retention for 30 to 45 minutes. Afterward, a cleansing enema is administered to remove the Kayexalate resin as a precaution against fecal impaction. Immediate dialysis. Intravenous glucose and insulin or calcium gluconate may be used as emergency measures to treat hyperkalemia.

Nursing Management of ARF Monitoring fluid and electrolyte balance. The nurse: monitors the patient’s serum electrolyte levels and physical indicators of fluid and electrolyte imbalances. carefully screens parenteral fluids, all oral intake, and all medications to ensure that hidden sources of potassium are not inadvertently administered or consumed. monitors the patient closely for signs and symptoms of hyperkalemia.

Nursing Management of ARF (Continued…) monitors fluid status by paying careful attention to fluid intake, urine output, apparent edema, distention of the jugular veins, breath sounds, and increasing difficulty in breathing. maintains accurate daily weight, and intake and output record. reports to physician indicators of deteriorating fluid and electrolyte status, and prepares for emergency treatment.

Nursing Management of ARF (Continued…) Reducing metabolic rate. The nurse: should reduce the patient’s metabolic rate to reduce catabolism and the subsequent release of potassium and accumulation of waste products (urea and creatinine). may keep the patient on bed rest to reduce exertion and the metabolic rate during the most acute stage of ARF. should prevent or promptly treat fever and infection to decrease the metabolic rate and catabolism.

Nursing Management of ARF (Continued…) Promoting pulmonary function. The nurse: assist the patient to turn, cough, and take deep breaths frequently to prevent atelectasis and respiratory tract infection. Preventing infection. The nurse: – strictly observes aseptic technique when caring for the patient to minimise the risk of infection and increased metabolism. – avoids, when possible, inserting an indwelling urinary catheter as it is a high risk for urinary tract infection (UTI).

Chronic renal failure Treatment. Treatment focuses on controlling the symptoms, minimizing complications, and slowing the progression of the disease Three basic stages in treatment Preserve remaining nephrons Conservative treatment of uraemic syndrome Renal dialysis and transplantation.

Preserve remaining nephron function Control of hypertension and heart failure Treatment of superimposed urinary tract infection Correction of salt and water depletion Careful prescribing of drugs that are potentially nephrotoxic Dietary protein restriction Conservative management of uraemic syndrome Reduce protein intake Aluminium hydroxide to reduce intestinal phosphate absorption Vitamin D and calcium supplements to increase serum calcium Allopurinol to reduce serum uric acid Erythropoietin to correct anaemia

 Dialysis is the option for ongoing treatment, often used while waiting for a suitable transplant opportunity.  Kidney transplant, in which a functioning kidney from a donor is surgically grafted into the patient, has a good rate of success

Differences Acute renal failure Most causes of acute renal failure can be treated and the kidney function will return to normal with time. Replacement of the kidney function by dialysis (artificial kidney) may be necessary until kidney function has returned. Chronic renal failure Chronic kidney damage is usually not reversible and if extensive, the kidneys may eventually fail completely. Dialysis or kidney transplantation will then become necessary

Chronic Renal Failure Nursing care Frequent monitoring Hydration and output Cardiovascular function Respiratory status E-lytes Nutrition Mental status Emotional well being Ensure proper medication regimen Skin care Bleeding problems Care of the shunt Education to client and family

Chronic Renal Failure Transplant Must find donor Waiting period long Good survival rate – 1 year 95-97% Must take immunosuppressant’s for life Rejection Watch for fever, elevated B/P, and pain over site of new kidney

Chronic Renal Failure Post op care ICU I/O B/P Weight changes Electrolytes May have fluid volume deficit High risk for infection

Transplant Meds Patients have decreased resistance to infection Corticosteroids – anti-inflammarory Deltosone Medrol Solu-Medrol Cytotoxic – inhibit T and B lymphocytes Imuran Cytoxan Cellcept T-cell depressors - Cyclosporin

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