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Chapter 34 Acute Renal Failure and Chronic Kidney Disease
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Renal Failure Definition
A condition in which the kidneys fail to remove metabolic end products from the blood and regulate the fluid, electrolyte, and pH balance of the extracellular fluids Underlying causes Renal disease Systemic disease Urologic defects of nonrenal origin
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Types of Renal Failure Acute renal failure Abrupt in onset
Often reversible if recognized early and treated appropriately Chronic kidney disease End result of irreparable damage to the kidneys Develops slowly, usually over the course of a number of years
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Prerenal Cases of Acute Renal Failure
Hypovolemia Decreased vascular filling Heart failure and cardiogenic shock Decreased renal perfusion due to vasoactive mediators, drugs, diagnostic agents
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Postrenal Causes of Acute Renal Failure
Bilateral ureteral obstruction Bladder outlet obstruction
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Intrinsic or Intrarenal Causes of Acute Renal Failure
Acute tubular necrosis Prolonged renal ischemia Exposure to nephrotoxic drugs, metals, organic solvents Intratubular obstruction resulting from hemoglobinuria, myoglobinuria, myeloma light chains, or uric acid casts Acute renal disease
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Phases of Acute Tubular Necrosis
Onset or initiating phase Lasts hours or days The time from the onset of the precipitating event until tubular injury occurs Maintenance phase Characterized by a marked decrease in the GFR Recovery phase Period during which repair of renal tissue takes place
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Question Congestive heart failure would be a(n) ________________ cause of renal failure. Prerenal Intrarenal Postrenal
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Answer Prerenal: The causative factor is “before” the kidney.
Intrarenal Postrenal
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Prevention and Early Diagnosis of Acute Renal Failure
Assessment measures to identify persons at risk for development of acute renal failure Those with preexisting renal insufficiency and diabetes Elderly persons (due to the effects of aging on renal reserve)
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Common Causes of Chronic Kidney Disease
Hypertension Diabetes mellitus Polycystic kidney disease Obstructions of the urinary tract Glomerulonephritis Cancers Autoimmune disorders Diseases of the heart or lungs Chronic use of pain medication
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Definition and Classification
K/DOQI of the NKF published clinical practice guidelines for CKD. Guidelines use the GFR to classify CKD into five stages
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Stages of Chronic Kidney Disease
Damage with normal or increased GFR Mild reduction of GFR to 60–89 mL/min/1.73 m2 Moderate reduction of GFR to 30–59 mL/min/1.73 m2 Severe reduction in GFR to 15–29 mL/min/1.73 m2 Kidney failure with a GFR < 15 mL/min/1.73 m2 , with a need for renal replacement therapy
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Treatment During the Renal Insufficiency Stage of Renal Failure
Using measures to retard deterioration of renal function and assist the body in managing the effects of impaired function Treating urinary tract infections promptly Avoiding medication with renal-damaging potential Controlling blood pressure Controlling blood sugar in persons with diabetes Stopping smoking
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Target Populations Comprising Persons With Chronic Kidney Disease
Persons with chronic renal insufficiency Persons with CKD being treated with hemodialysis Persons with CKD being treated with peritoneal dialysis Renal transplant recipients
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Question A GFR of _____________ best describes renal failure.
60–89 mL/min/1.73 m2 30–59 mL/min/1.73 m2 15–29 mL/min/1.73 m2 <15 mL/min/1.73 m2
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Answer 60–89 mL/min/1.73 m2 30–59 mL/min/1.73 m2 15–29 mL/min/1.73 m2
<15 mL/min/1.73 m2 : This level is the result of significantly decreased renal filtration and is the cut-off point of renal failure.
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Factors Determining the Manifestations of Renal Failure
The extent of renal function present Coexisting disease conditions The type of renal replacement therapy the person is receiving
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Clinical Manifestations of Chronic Renal Failure
Accumulation of nitrogenous wastes Alterations in water, electrolyte, and acid-base balance Mineral and skeletal disorders Anemia and coagulation disorders Hypertension and alterations in cardiovascular function Gastrointestinal disorders Neurologic complications Disorders of skin integrity Immunologic disorders
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Disorders of Water, Electrolyte, and Acid-Base Balance
Sodium and water balance The kidneys function in the regulation of extracellular fluid volume. Potassium balance Approximately 90% of potassium excretion is through the kidneys. Acid-base balance The kidneys normally regulate blood pH by eliminating hydrogen ions produced in metabolic processes and by regenerating bicarbonate.
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Hematologic Disorders Accompanying Renal Failure
Anemia Coagulopathies
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Cardiovascular Disorders Accompanying Renal Failure
Hypertension Heart disease Pericarditis
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Altered Drug Metabolism in Kidney Disease
CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs Altered drug absorption Antacid treatment Altered metabolism Result of less protein-bound drugs Increased intermediates of drug metabolism Alterations in dosage may be required.
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Treatment of Renal Failure
Medical management Dialysis Hemodialysis Peritoneal dialysis Transplantation
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Treatment of Renal Failure (cont.)
Dietary management Protein Carbohydrates, fat, calories Potassium Sodium and fluid intake
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CKD in Children Causes Congenital malformations Inherited disorders
Acquired diseases Metabolic syndromes Manifestations Severe growth impairment Developmental delay Delay in sexual maturation Bone abnormalities Development of psychosocial problems
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CKD in the Elderly Normal decrease in GFR with age
Increased detrimental effects of nephrotoxic drugs Greater incidence of cerebrovascular, cardiovascular, and skeletal system effects
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Treatment Options for Chronic Renal Failure in the Elderly and Children
Hemodialysis Peritoneal dialysis Transplantation
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Question Which of the following alterations may affect drug efficacy in a patient with CKD? Loss of K+ Alteration in pH Loss of albumin Increased Ca2+
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Answer Loss of K+ Alteration in pH
Loss of albumin: Loss of albumin will result in altered drug metabolism via increased intermediates and faster action. Increased Ca2+
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