ACUTE RENAL FAILURE
INTRODUCTION
Kidney failure is the partial or
complete impairment of kidney function. It results in an
inability to excrete metabolic waste products and water
and it contributes to disturbances of all body systems. It
can be acute or chronic.
DEFINITION
Acute renal failure is traditionally defined as a rapid
fall in the rate of glomerular filtration, which manifests
clinically as an abrupt and sustained increase in the
serum levels of urea and creatinine with an associated
disruption of salt and water homeostasis.
ETIOLOGY
❑ Prerenal causes
❑ Intrarenal or intrinsic causes
❑ Postrenal causes
Prerenal causes ;
form of ARF is because of any cause of reduced blood flow to
the kidney.
Hypovolemia: hemorrhage, severe burns, and
gastrointestinal fluid losses such as diarrhea, vomiting.
Hypotension from the decreased cardiac output: cardiogenic
shock, acute coronary syndrome.
Hypotension from systemic vasodilation: septic shock,
anaphylaxis, anesthesia
Decreased Renovascular blood flow; bilateral renal vein
thrombosis, embolism, renal artery thrombosis.
Intrinsic or intrarenal causes
❑ Intrinsic or intrarenal causes include conditions that
affect the glomerulus or tubule
Nephrotoxic injury: drugs such as aminoglycosides,
vancomycin, amphotericin
Acute interstitial nephritis: Drugs such as beta-lactam
antibiotics, penicillins, NSAIDs
Glomerulonephritis: anti-glomerular basement
membrane disease, immune complex-mediated diseases
such as SLE.
Postrenal causes
❑ Post renal causes: resulting from obstruction in urine
flow.
Benign prostatic hyperplasia
Bladder cancer
Calculi formation
Neuromuscular disorder
Prostate cancer
Spinal cord diseases
Strictures
Trauma(back, pelvis, perineum)
PATHOPHYSIOLOGY
Due to etiological factors
Inflammation of kidney glomerulus, nephrons
Kidney’s normal functioning gets altered
GFR altered inorder to compensate compromised
nephrons continue working
Exposure to associated etiology cause furtherkidney
damage
Accumulation of fluid inside the body
Decreased urine output
Edema
CLINICAL MANIFESTATIONS
Clinically acute renal failure progresses through 4
phases:
Onset phase
Oliguric(anuric) phase
Diuretic phase
Recovery phase
Onset phase :
o Duration: hours to days
o Features: common triggering events; significant blood loss,
burns, fluid loss, diabetes insipidus
-renal blood flow 25% of normal
-tissue oxygenation 25% of normal
-urine output below 0.5 ml/kg/hour
Oliguric phase:
o Duratin:8 to 14 days or longer, depending on nature of ARF
and dialysis initiation.
o Features: urine output below 400ml/day possibly as low as
100ml /day
-increase in BUN and creatinine levels
-electrolyte disturbances, acidosis, and fluid
overload(from kidney’s inability to excrete water)
Diuretic phase:
o Duration:7 to 14 days
o Features: occurs when cause of ARF is corrected.
-renal tubule scarring and edema
-increased GFR
-daily urine output above 100 ml
-possibly electrolyte depletion from excretion of
more water and osmotic effects of high BUN.
Recovery phase:
o Duration: several months to 1 year
o Features: decreased edema
-normalization of fluid and electrolyte balance
-return to GFR to 70% or 80% of normal
DIAGNOSTIC EVALUATION
History collection
Physical examination: reveals edema caused by fluid
retention.
Urinalysis: urine osmolality, sodium content and specific
gravity
Laboratory test : BUN, creatinine clearance, serum
creatinine, serum potassium
Blood test: help to reveal underlying causes of renal
failure.ABG and blood chemistries .
Kidney ultrasound
Renal scan
CT scan
Renal biopsy : histopathology of kidney
MRI or magnetic resonance angiography
PREVENTION
Continually assess renal function(urine output, laboratory
values) when appropriate .
Monitor central venous and arterial pressures and hourly
urine output of critically ill patients to detect the onset of
kidney disease as early as possible.
Pay special attention to wound, burns, and other precursors
of sepsis.
Prevent and treat infections promptly.
Prevent and treat shock promptly with blood and fluid
replacement.
Provide adequate hydration to the patients at risk for
dehydration .
Take precautions to ensure that appropriate blood is given to
correct patient to avoid transfusion reactions.
To prevent infections, provide meticulous care during
procedures like catheterizations.
Treat hypotension promptly
Provide drugs safely.
MEDICAL MANAGEMENT
❑ Treatments to balance the amount of fluids
❖ intravenous (IV) fluids is administered.
❖ Diuretics like Lasix ,mannitol are prescribed to cause your
body to expel extra fluids.
❑ Medications to control blood potassium.
❖ calcium, glucose or sodium polystyrene sulfonate (Kionex)
to prevent the accumulation of high levels of potassium in
your blood.
❖ Kionex increases fecal potassium excretion through
binding of potassium in the lumen of the gastrointestinal
tract. Binding of potassium reduces the concentration of
free potassium in the gastrointestinal lumen, resulting in a
reduction of serum potassium levels.
❑ Medications to restore blood calcium levels. If the levels
of calcium drop too low, then an infusion of calcium.
❑ Dialysis to remove toxins from your blood. If toxins build
up in blood, dialysis help to remove toxins and excess
fluids from body while kidneys heal. Dialysis may also help
remove excess potassium from body. During dialysis, a
machine pumps blood out of body through an artificial
kidney (dialyzer) that filters out waste. The blood is then
returned to body. Two methods of dialysis are:
Hemodialysis
Peritoneal dialysis
NUTRITIONAL THERAPY
✔ 30-35 kcal/day and 0.8-1 g of protein /kg of desired body weight
to prevent breakdown of body protein.
✔ Dietary fat intake increased so that patient receives at least 30%
to 40 % of total calories from fat . Fat emulsion IV given as
nutritional supplement.
✔ Avoid products with added salt. Lower the amount of sodium
you eat each day by avoiding products with added salt, including
many convenience foods, such as canned foods pickles and fast
foods.
✔ Other foods with added salt include salty snack foods, canned
vegetables, and processed meats and cheeses should be avoided.
NURSING MANAGEMENT
NURSING DIAGNOSIS
❖ Excess fluid volume related to decreased urine output,
dietary excess, and retention of sodium and water
❖ Imbalanced nutritional status less than body requirement
related to anorexia, nausea, vomiting, dietary restrictions
and altered oral mucus membranes
❖ Activity intolerance related to fatigue, anemia, retention of
waste products and dialysis procedure
❖ Deficit knowledge regarding condition and treatment
❖ Risk for situational low self esteem related to dependency,
role changes, change in body image
NURSING INTERVENTION
Monitor fluid and electrolyte balance. The nurse monitors
the patient’s fluid and electrolyte levels and physical
indicators of potential complications during all phases of the
disorder.
Reducing metabolic rate. Bed rest is encouraged and fever
and infection are prevented or treated promptly.
Promoting pulmonary function. The patient is assisted to
turn, cough, and take deep breaths frequently to prevent
atelectasis and respiratory tract infection.
Preventing infection. Asepsis is essential with invasive
lines and catheters to minimize the risk of infection and
increased metabolism.
Providing skin care. Bathing the patient with cool water,
frequent turning, and keeping the skin clean and well
moisturized and keeping the fingernails trimmed to avoid
excoriation are often comforting and prevent skin
breakdown.
Provide safety measures. Patient with CNS involvement
may be dizzy or confused.
COMPLICATIONS
Hypervolemia
Hyperkalemia
Metabolic acidosis
Uremia
Hyperurecemia
Hypocalcaemia, hyperphosphatemia
Recovery phase of ARF
-polyuria
-hypernatremia,hypokalemia,hypomagnesemia,
hypophosphatemia
CONCLUSIO
Nthe kidneys suddenly can't filter
ARF is a condition in which
waste from the blood. Acute renal failure develops rapidly
over a few hours or days. It may be fatal. It's most common in
those who are critically ill and already hospitalised.
Symptoms include decreased urinary output, swelling due to
fluid retention, nausea, fatigue and shortness of breath.
Sometimes symptoms may be subtle or may not appear at all.
