RENAL FAILURE

PRESENTED BY: SONIA DAGAR

 DEFINITION

 Renal failure or kidney failure is a situation in which

the kidneys fail to function adequately.
 It is characterized by the reduction in the excretory
and regulatory function of the kidney.
 If the kidney function fails, the waste products
accumulate in the blood and body leads to a
disruption in endocrine and metabolic functions as
well as fluid, electrolyte and acid-base disturbances.
 Renal failure can be:
1. ACUTE, with sudden onset of symptoms.
2. CHRONIC, occurring gradually over time.
ACUTE RENAL
FAILURE
 DEFINITION
 Acute kidney failure is the sudden and complete loss
of the ability of the kidneys to remove waste and
concentrate urine without losing electrolytes.
 AKF is a sudden decline in renal function, usually
marked by decreased glomerular filtration rate
(GFR), increased concentrations of blood urea
nitrogen (BUN), and creatinine.
 The urine output is less than 400ml per day (oliguria),
hyperkalemia, and sodium retention.
 Most common in people who are already
hospitalized.
 ETIOLOGY AND CATEGORIES

1) PRERENAL FAILURE
2) INTRARENAL FAILURE
3) POSTRENAL FAILURE
1) PRERENAL FAILURE:

 Incidence is 60-70% cases of all cases.

 Prerenal (before the kidney) failure is associate with
a decreased or interruption of blood supply to the
kidney and a drop in GFR.
 The kidneys do not receive enough blood to filter.
 It can be caused by the following condition:
 Circulatory volume depletion from dehydration,
diarrhea, vomiting, hemorrhage, burn, excessive use
of diuretics, renal-salt-wasting conditions and
glycosuria.
 Cont…

 Impaired cardiac efficiency or decreased cardiac

output.
 Flow of blood to the kidneys is disrupted
 Blood vessel carrying blood to the kidneys is
blocked or gets constricted
 Vasodilatation resulting from sepsis
 When liver fails, the level of hormone in the blood
fail.
2) INTRARENAL FAILURE:

 It occurs when there is structural damage to the

glomeruli, kidney tubules and nephrons inside the
kidney.
 Incidence is 25-40% of all cases.
 Causes of acute kidney failure include those affecting
the filtering function of the kidney, those affecting the
blood supply within the kidney, and those affecting
the kidney tissues that handles salt and water
processing.
 Conditions that damage the kidney:
 Prolonged renal ischemia
 Acute tubular necrosis
 Blood cholesterol or clots deposits in the vein and arteries
in and around the kidney
 Infection: glomerulonephritis, pylonephritis
 Hemolytic uremic syndrome
 Severe transfusion reaction
 Lupus, multiple myeloma and scleroderma
 Exposure to nephrotoxic agents such as NSAIDs, ACE
inhibitors.
3) POSTRENAL FAILURE:

 It is associated with an obstruction that blocks the flow

of urine out of the body.
 It is often caused by something blocking , elimination
of urine produced by the kidneys.
 Incidence is 5-10% of all cases.
 Cont…

 Kidney stone
 Medications
 Cancer of the urinary tract
 Bladder stone
 Enlarged prostate
 Blood clot
 Bladder cancer
 Neurological disorders of the bladder impairing its
ability to contract.
 RISK FACTORS

 Being hospitalized
 Advanced age
 Blockage in the blood vessels in arms or legs
 Diabetes
 High blood pressure
 Heart failure
 Kidney disease
 Liver disease
 PATHOPHYSIOLOGY

In response to renal injury, there is thought to be an increase

in intra-glomerular pressure with glomerular hypertrophy

Failure of renal circulation and glomerular or tubular

dysfunction

Damage tubules cannot conserve sodium normally which

activates rennin-angiotensin-aldosteron system

Sodium and fluid retention which leads to edema

 Sudden and complete loss of kidney function

Reduced blood flow to the kidney due to renal

vasoconstriction decreased the GFR and tubular
flow

Oliguria

Increased serum creatinine, BUN level and retention of

other metabolic waste (Azotemia)

Increased circulatory overload and sodium retention

 PHASES OF ACUTE RENAL
FAILURE
 Significant reduction in glomerular filtration rate (GFR) is
a result of:
1. Ischemia
2. Activation of the renin-angiotensin system
3. Tubular obstruction by cellular debries

 There are four clinical phases of ARF:

1) Onset or initiation phase
2) Oliguric phase
3) Diuresis phase
4) Recovery phase
1) ONSET OR INITIATION PHASE:

 It is the time from the onset of injury till the death of

a person.
 It begins with the underlying clinical condition
leading to tubular nacrosis e.g. hemorrhage.
 This period last from hours to days only.
2) OLIGURIC PHASE:

 This phase starts when urinary volume less than 300ml

to 400ml/24 hours.
 The persistent decrease in GFR and tubular nacrosis
characterized this phase.
 This phase last for 7-14 days but does a lot damage
to the walls and membranes of the kidney.
 Endothelial cell nacrosis and sloughing lead to tubular
obstruction and increased tubular permeability.
3) DIURESIS PHASE:

 It is marked by increased urine secretion of more than

400ml/24 hours.
 This phase may last days or weeks.
 The patient is closely monitored for dehydration in this
phase.
4) RECOVERY PHASE:

 It begins with the recovery of the GFR and tubular

function to such an extent that BUN and serum
creatinine stabilizes.
 It may continue over 3 to 12 months and more
nephrons regain function.
 CLINICAL MENIFESTATIONS
 Patient may appear critically ill or lethargic
 Decreased urine production
 Dark colored urine
 Foamy and bubbly urine and getting up at night to
urinate
 Skin and mucous membrane are dry from dehydration
 Azotemia
 Oliguria or anuria
 Edema or fluid retention
 Cont…
 Hypertension and rapid heart rate
 Flank pain (between the ribs and hips)
 Shortness of breath
 Metabolic acidosis
 Feeling dizzy when stand up
 Anemia and platelet dysfunction
 Increased susceptibility to second infection
 General malaise and fatigue
 Tachycardia and dysrhythmia
 Cont…

 Fluid and electrolyte imbalance

 Anorexia
 Nausea, vomiting
 Diarrhea and constipation
 Stomatitis, bleeding, hemastasis, abdominal pain
 Headache, drowsiness, irritability, confusion
 Seizures and coma
 Peripheral neuropathy
 DAIGNOSTIC EVALUATIONS

 Blood test
 Urine tests
 Electrocardiogram
 Imaging tests
 Kidney biopsy
 MANAGEMENT

1. Pharmacologic therapy
2. Fluid and electrolyte replacement
3. Nutritional therapy
4. Dialysis
CHRONIC RENAL
FAILURE
 DEFINITION

 It is a rapid progressive deterioration or loss of

renal function in which the body’s ability to
maintain metabolic and fluid and electrolyte
balance fails, resulting in uremia or azotemia
over a period of months.
 The final stage of chronic kidney disease is
called end-stage renal disease (ESRD).
ETIOLOGY AND RISK FACTORS

 A family history of kidney disease

 Chronic glomerulonephritis (inflammation of glomeruli)
 Diabetes mellitus
 High blood pressure
 Long term infection e.g. pyelonephritis
 Polycystic kidney disease (cyst in the kidneys)
 Nephrotoxic agents: long term aminoglycoside
therapy
 Cont…

 Autoimmune disorders such as systemic lupus,

erythematosus and scleroderma
 Injury or trauma
 Kidney stones and infection
 Reflux nephropathy
 Certain toxic chemicals: cadmium, mercury
 PATHOPHYSIOLOGY
Due to etiological factors renal functions declines

Nephron damage is progressive; damaged nephron

cannot function and do not recover

Decreased glomerular filtration rate

Remaining nephrons undergo changes to compensate

for those damaged nephrons.
Compensatory excretion continues as GFR diminished

Filtration of more contrated blood by the remaining

nephrons

Damage of nephron results in hypertrophy and hyper

phosphatemia of remaining nephron

Urine may contain abnormal amounts of protein, RBCs,

white blood cells or casts
Increased serum creatinine, BUN level and retention of
urea and other niterogenous waste
(uremia and azotemia)

Further damage of the nephrons 80-90% damage, GFR

10-20%

Chronic renal failure

 CLINICAL MENIFESTATIONS

 NEUROLOGICAL
SYSTEM:
 Cognitive impairment  Disorientation
 Personality change  Tremors
 Asterixis  Restlessness of legs
 Seizures  Burning of sole of feet
 Confusion and behavior change
 Inability to concentrate
 GESTROINTESTINAL
SYSTEM:
 Nausea and vomiting  Constipation
 Food distaste  Diarrhea
 Ammonia odor to breath  Bleeding from GI tract
 Mouth ulceration and
bleeding
 Anorexia
 Hiccups
 CARDIOVASCULAR  PULMONARY SYSTEM:
SYSTEM:
 Chest pain  Fluid in lungs
 Pericardial effusion  Breathing difficulty
 Hypertension  Uremic pneumonitis
 Pitting edema  Depressed cough reflex
 Hyperkalemia and  Pleuritic pain
hyperlipidemia
 Pericardial temponade
 Other symptoms:

 Oliguria  Low level of sexual

 General ill feeling and interest and impotence
fatigue  Amenorrhea
 Headaches  Sleep problems such as
 Weight loss without trying insomnia, restless leg
to lose weight syndrome and obstructive
 Bone pain sleep apnea.
 Muscle twitching or
cramps
 DIAGNOSTIC EVALUATIONS
 Anemia (low red blood cell count)
 High level of parathyroid hormone
 Hypocalcaemia (low blood level of calcium)
 Hyperphosphatemia (high blood level of phosphate)
 Hperkalemia (high blood level of potassium)
 Hyponatremia (low blood level of sodium)
 Low blood level of bicarbonate
 Low plasma pH (blood acidity)
 Imaging studies such as ultrasound, CT scan
 Renal biopsy
MANAGEMENT