1. Wendy DeMartino, MD PGY-2
Renal Failure
Wendy DeMartino, MD
PGY-2

2. Objectives Anatomy Function Acute Renal Failure (ARF)
Causes
Symptoms
Management
Chronic Renal Failure (CRF)
Dialysis

3. Anatomy
2 Kidneys
2 Ureters
Bladder
Urethra

4. What do
the kidneys do??

5. Kidney Function Detoxify blood Increase calcium absorption
calcitriol
Stimulate RBC production
erythropoietin
Regulate blood pressure and electrolyte balance
renin

8. Classifications Acute versus chronic Pre-renal, renal, post-renal
Anuric, oliguric, polyuric

9. Acute Versus Chronic Acute Chronic
sudden onset
rapid reduction in urine output
Usually reversible
Tubular cell death and regeneration
Chronic
Progressive
Not reversible
Nephron loss
75% of function can be lost before its noticeable

10. Acute Renal Failure Pre-renal = 55% Renal parenchymal (intrinsic)= 40%
Post-renal = 5-15%

12. Causes of ARF Pre-renal = Intrinsic Post-renal =
vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure
cardiac failure, liver dysfunction, or septic shock
Intrinsic
Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins
Post-renal =
prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders
neurogenic bladder
bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus

13. Symptoms of ARF Decrease urine output (70%)
Edema, esp. lower extremity
Mental changes
Heart failure
Nausea, vomiting
Pruritus
Anemia
Tachypenic
Cool, pale, moist skin

14. Diagnosis of Renal Failure
Not A Field Diagnosis

15. Acute Renal Failure Management
Make/think about the diagnosis
Treat life threatening conditions
Identify the cause if possible
Hypovolemia
Toxic agents (drugs, myoglobin)
Obstruction
Treat reversible elements
Hydrate
Remove drug
Relieve obstruction

16. ARF: Life Threatening Conditions
Hyperkalemia
Volume overload
Vascular access

17. Hyperkalemia Symptoms
EKG?
Weakness
Lethargy
Muscle cramps
Paresthesias
Hypoactive DTRs
Dysrhythmias

18. Hyperkalemia & EKG K > 5.5 -6 Tall, peaked T’s Wide QRS Prolong PR
Diminished P
Prolonged QT
QRS-T merge – sine wave

22. Hyperkalemia Treatment
Calcium gluconate (carbonate)
Sodium Bicarbonate
Insulin/glucose
Kayexalate
Lasix
Albuterol
Hemodialysis

23. Chronic Renal Failure
150–200 cases per million people = new cases each year
Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S
Mortality = 20%

24. Chronic Renal Failure Causes
Diabetic Nephropathy
Hypertension
Glomerulonephritis
HIV nephropathy
Reflux nephropathy in children
Polycystic kidney disease
Kidney infections & obstructions

25. CRF Symptoms Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea
Vomiting
Seizure
Constipation
Peptic ulceration
Diverticulosis
Anemia
Pruritus
Jaundice
Abnormal hemostasis

26. Acute Problems in CRF Relating to underlying disease Relating to ESRD
Dialysis related problems

27. Problems Related to ESRD
Metabolic – K/Ca
Volume overload
Anemia, platelet disorder, GI bleed
HTN, pericarditis
Peripheral neuropathy, dialysis dementia
Abnormal immune function

28. Dialysis ½ of patients with CRF eventually require dialysis
Diffuse harmful waste out of body
Control BP
Keep safe level of chemicals in body
2 types
Hemodialysis
Peritoneal dialysis

29. Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters
blood and
returns it to
body

30. Types of Access Temporary site AV fistula AV graft
Surgeon constructs by combining an artery and a vein
3 to 6 months to mature
AV graft
Man-made tube inserted by a surgeon to connect artery and vein
2 to 6 weeks to mature

31. Temporary Catheter

32. AV Fistula & Graft

33. What This Means For You No BP on same arm as fistula
Protect arm from injury
Control obvious hemorrhage
Bleeding will be arterial
Maintain direct pressure
No IV on same arm as fistula
A thrill will be felt – this is normal

34. Access Problems AV graft thrombosis AV fistula or graft bleeding
AV graft infection
Steal Phenomenon
Early post-op
Ischemic distally
Apply small amount of pressure to reverse symptoms

35. Peritoneal Dialysis Abdominal lining filters blood 3 types
Continuous ambulatory
Continuous cyclical
Intermittent

36. EMS Considerations Make sure the dressing remains intact
Do not push or pull on the catheter
Do not disconnect any of the catheters
Always transport the patient and bags/catheters as one piece
Never inject anything into catheter

37. Dialysis Related Problems
Lightheaded –give fluids
Hypotension
Dysrhythmias
Disequilibration Syndrome
At end of early sessions
Confusion, tremor, seizure
Due to decrease concentration of blood versus brain leading to cerebral edema

38. Questions?

39. 1. The normal urinary system consists of:
two kidneys, two ureters, one urethra
two kidneys, one ureter, one bladder, one urethra
one kidney, two ureters, one bladder, one urethra
two kidneys, two ureters, one bladder, one urethra D

40. 2. The basic, functional unit of the kidney that acts to mechanically filter fluids, wastes and electrolytes is called: C
Ureter
Bladder
Nephron
Trigone

41. 3. You receive a 911 call to respond to a local residence for a report of an elderly male who is unconscious.  Upon arrival you find a 68 year old female patient who is unconscious with snoring respirations.  Your partner opens the airway and the patient begins breathing at a rate of 44 breaths per minute.  Patients daughter states her mother has ESRD and has decided she wants to die.  Patient has not had dialysis treatment for 3 weeks.  After quick assessment of ABCs what is your first priority in treating this patient? B
Oxygen 15 LPM/NRBM, rapid transport
Oxygen 15 LPM/NRBM, check blood glucose, rapid transport
Have the patient’s daughter sign refusal and call in to medical control

42. 4. You are dispatched for “Man light headed and bleeding from a shunt
4. You are dispatched for “Man light headed and bleeding from a shunt.”  Upon arrival you find a 38 year old male with a recent history of ARF and receives dialysis 3 times a week.  Today he was changing his shirt.  The Permcath in the right side of his chest became caught in a button hole and the red port of the catheter was sheared off.  Which of the following treatments are appropriate? C
Quickly check blood pressure then clamp catheter, and then perform primary assessment.
Wrap a paper towel around catheter to soak up excess blood, apply oxygen 15 LPM/NRBM
Immediately clamp catheter close to skin level, place patient on his left side with head low and feet high, primary assessment, oxygen 15LPM/NRBM

43. dispatch pages your department for a 72 year old female with high fever, needs to be transported to emergency room for evaluation.  Upon arrival you find an elderly female who is confused with hot dry skin and a respiratory rate of 40 BPM.  Her blood pressure is 80/40 with a pulse of 120.  The patient has a history of CRF and is on peritoneal dialysis.  You note a large tube coming from her abdomen that is connected to other tubes and large empty bags.  Patient’s daughter states that it is time to “drain mom’s dialysis water.”  Based upon your knowledge of peritoneal dialysis which of the following is an appropriate response?

44. 5 (cont). Appropriate response?
Allow the patient’s daughter to unclamp the drain tube, package the patient without disconnecting any tubes and transport the patient and all dialysis tubing intact.
Inform the patient’s daughter that you are not allowed to transport anyone on peritoneal dialysis, disconnect the tubes from the abdominal catheter, cover catheter with a plastic bag and transport.
Call Med Flight to transport patient.
Tell the patient’s daughter to disconnect all excess tubing and transport. A

45. 6. Renal failure often occurs in trauma patients who have had sustained hypotension because:
Blood pressure has no effect on kidney function.
Low blood pressure causes damage to the ureter preventing urine from draining into the bladder.
Low blood pressure prevents adequate blood flow through kidneys causing kidney tissue damage.
Low blood pressure stimulates arteries to dilate causing an increase in the amount of blood flow through the kidneys.

46. 7. You arrive on scene for a dialysis patient with a history of kidney failure complaining of shortness of breath.  You notice the right arm has large bulging veins.  When taking a blood pressure which of the following answers best describes appropriate actions: A
Take blood pressure and pulse in the left arm.
Take blood pressure in the right arm.
Take pulse in the right arm, blood pressure measurement is not necessary in dialysis patients.
Call for Med Flight. ALS ambulance agencies cannot transport patients with an AV shunt.

47. 8. You are transporting an unconscious dialysis patient to the hospital.  The arm with is AV shunt was left dangling over the cot.  When loading in the ambulance the arm banged against the wall of the rig.  During transport you notice that there is a large hematoma over one of the veins of the arm.  The hematoma is growing quickly.  What is the most appropriate action: C
Ignore it, pulsating masses in patients with AV shunts is normal.
Wrap a blood pressure cuff around the arm proximal to the injury and inflate to 20mmHG higher than SBP.
Immediately apply direct pressure over the site and maintain pressure during transport. Have your partner radio ahead to the receiving hospital to notify of condition.
Call insurance company to make sure liability insurance premiums have been paid.

48. 9. Which of the following could potentially cause renal failure:
Hypovolemic shock
Chemical exposure
Obstruction by kidney stone
All of these D

49. References http://www.umm.edu/ency/article/000471.htm  
file:///C:/Documents%20and%20Settings/Wendy/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/FBZ7VWDX/ DrSturmann-Acute%26ChronicRenalFailure%5B1%5D.ppt#256,1,RENAL FAILURE
file:///C:/Documents%20and%20Settings/Wendy/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/AQVFLSNN/CHRONICRENALFAILUREANDHEMODIALYSIS%5B1%5D.ppt#311,2,CHRONIC RENAL FAILURE