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Renal Failure Acute and Chronic:

Renal Failure Acute and Chronic Dr. Angelo Smith M.D WHPL

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Definition :

Definition Inability of kidney to maintain homeostasis leading to a buildup of nitrogenous wastes Different to renal insufficiency where kidney function is deranged but can still support life


ARF Occurs over hours/days Lab definition Increase in baseline creatinine of more than 50% Decrease in creatinine clearance of more than 50% Deterioration in renal function requiring dialysis Anuria – no urine output or less than 100mls/24 hours Oliguria - <500mls urine output/24 hours or <20mls/hour Polyuria - >2.5L/24 hours

Acute Renal Failure:

Acute Renal Failure Persons at Risks Major surgery Major trauma Receiving nephrotoxic medications Elderly


ARF Pre renal (functional) Renal-intrinsic (structural) Post renal (obstruction)



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Pathophysiology of ischemic and toxic ARF

Acute Renal Failure:

Acute Renal Failure Stages Onset – 1-3 days with ^ BUN and creatinine and possible decreased UOP Oliguric – UOP < 400/d, ^BUN, Crest, Phos, K, may last up to 14 d Diuretic – UOP ^ to as much as 4000 mL/d but no waste products, at end of this stage may begin to see improvement Recovery – things go back to normal or may remain insufficient and become chronic


ONSET PHASE Subjective symptoms Nausea Loss of appetite Headache Lethargy Tingling in extremities


OLIGURIC PHASE vomiting disorientation, edema, ^K+ decrease Na ^ BUN and creatinine Acidosis uremic breath CHF and pulmonary edema hypertension caused by hypovolemia, anorexia sudden drop in UOP convulsions, coma changes in bowels


DIURETIC PHASE Increased UOP Gradual decline in BUN and creatinine Hypokalemia Hyponaturmia Tachycardia Improved LOC

Lab findings:

Lab findings Rising creatinine and urea Rising potassium Decreasing Hb Acidosis Hyponatraemia Hypocalcaemia

Acute Renal Failure Diagnostic Tools:

Acute Renal Failure Diagnostic Tools Urinary sediment Urinary indices Urine volume Urine electrolytes Radiologic studies



Normal Renal Ultrasound:

Normal Renal Ultrasound


TREATMENT Immediate treatment of pulmonary edema and hyperkalaemia Remove offending cause or treat offending cause Dialysis as needed to control hyperkalaemia, pulmonary edema, metabolic acidosis, and uremic symptoms Adjustment of drug regimen Usually restriction of water, Na, and K intake, but provision of adequate protein Possibly phosphate binders and Na polystyrene sulfonate

Acute Renal Failure:

Acute Renal Failure Medical treatment Fluid and dietary restrictions Maintain E-lytes D/C or change cause May need dialysis to jump start renal function May need to stimulate production of urine with IV fluids, Dopomine, diuretics, etc.

Acute Renal Failure:

Acute Renal Failure Medical treatment Hemodialysis Subclavian approach Femoral approach Peritoneal dialysis Continous renal replacement therapy (CRRT) Can be done continuously Does not require dialysate




Definition Involves progressive, irreversible loss of kidney function Defined as either presence of Kidney damage Pathological abnormalities Glomerular filtration rate (GFR) <60 ml/min for 3 months or longer

CRF - causes:

CRF - causes Glomerulonephritis – the most common cause in the past Diabetes mellitus Hypertension Tubulointerstitial nephritis are now the leading causes of CRF

Chronic Renal Failure:

Chronic Renal Failure Subjective symptoms are relatively same as acute Renal Hyponaturmia Dry mouth Poor skin turgor Confusion, salt overload, accumulation of K with muscle weakness Fluid overload and metabolic acidosis Proteinuria, glycosuria Urine = RBC’s, WBC’s, and casts

Chronic Renal Failure:

Chronic Renal Failure Cardiovascular Hypertension Arrythmias Pericardial effusion CHF Peripheral edema Neurological Burning, pain, and itching, parestnesia Motor nerve dysfunction Muscle cramping Shortened memory span Apathy Drowsy, confused, seizures, coma, EEG changes

Cardiovascular manifestations:

Cardiovascular manifestations

Chronic Renal Failure:

Chronic Renal Failure GI Stomatitis Ulcers Pancreatitis Uremic fetor Vomiting consitpation Respiratory ^ chance of infection Pulmonary edema Pleural friction rub and effusion Dyspnea Kussmaul’s respirations from acidosis

Chronic Renal Failure:

Chronic Renal Failure Endocrine Stunted growth in children Amenorrhea Male impotence ^ aldosterone secretion Impaired glucose levels R/T impaired CHO metabolism Thyroid and parathyroid abnormalities Hemopoietic Anemia Decrease in RBC survival time Blood loss from dialysis and GI bleed Platelet deficits Bleeding and clotting disorders – purpura and hemorrhage from body orifices , ecchymoses

Chronic Renal Failure:

Chronic Renal Failure Skeletal Muscle and bone pain Bone demineralization Pathological fractures Blood vessel calcifications in myocardium, joints, eyes, and brain Skin Yellow-bronze skin with pallor Puritus Purpura Uremic frost Thin, brittle nails Dry, brittle hair, and may have color changes and alopecia


Uremia  i s clinical syndrome that results from profound loss of renal function  c ause(s) of it remains unknown  r erers generally to the constellation of signs and symptoms associated with CRF, regardless of cause  presentations and severity of signs and symptoms of uremia vary and depend on  the magnitude of reduction in functioning renal mass  rapidity with which renal function is lost


Uremia the most likely candidates as toxins in uremia are the by–products of protein and amino acid metabolism Urea – represents some 80% of the total nitrogen excreted into the urine Guanidino compunds: guanidine, creatinine, creatin, guanidin-succinic acid) Urates and other end products of nucleic acid metabolism Aliphatic amines Peptides Derivates of the aromatic amino acids: tryptophan, tyrosine, and phenylalanine

Metabolic acidosis:

Metabolic acidosis Metabolic acidosis of CRF is not due to overproduction of endogenous acids but is largely a reflection of the reduction in renal mass , which limits the amount of NH 3 (and therefore HCO 3 - ) that can be generated


INVESTIGATIONS BUN – indicator of glomerular filtration rate and is affected by the breakdown of protein. Normal is 10-20mg/dL. When reaches 70 = dialysis Serum creatinine – waste product of skeletal muscle breakdown and is a better indicator of kidney function. Normal is 0.5-1.5 mg/dL. When reaches 10 x normal, it is time for dialysis Creatinine clearance is best determent of kidney function. Must be a 12-24 hour urine collection. Normal is > 100 ml/min

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K+ - The kidneys are means which K+ is excreted. Normal is 3.5-5.0 ,mEq/L. maintains muscle contraction and is essential for cardiac function. Both elevated and decreased can cause problems with cardiac rhythm Hyperkalemia is treated with IV glucose and Na Bicarb which pushes K+ back into the cell.

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Ca With disease in the kidney, the enzyme for utilization of Vit D is absent Ca absorption depends upon Vit D Body moves Ca out of the bone to compensate and with that Ca comes phosphate bound to it. Normal Ca level is 4.5-5.5 mEq/L Hypocalcemia = tetany Treat with calcium with Vit D and phosphate Avoid antacids with magnesium


OTHER ABNORMAL FINDINGS Metabolic acidosis Fluid imbalance Insulin resistance Anemia Immunological problems


MANAGEMENT Medical treatment IV glucose and insulin Na bicarb, Ca, Vit D, phosphate binders Fluid restriction, diuretics Iron supplements, blood, erythropoietin High carbs, low protein Dialysis - After all other methods have failed

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Hemodialysis Vascular access Temporary – subclavian or femoral Permanent – shunt, in arm Care post insertion Can be done rapidly Takes about 4 hours Done 3 x a week

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Peritoneal dialysis Semipermeable membrane Catheter inserted through abdominal wall into peritoneal cavity Cost less Fewer restrictions Can be done at home Risk of peritonitis 3 phases – inflow, dwell and outflow Automated peritoneal dialysis Done at home at night Maybe 6-7 times /week CAPD Continuous ambulatory peritoneal dialysis Done as outpatient Usually 4 X/d

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

What we can do at home:

What we can do at home Potassium restriction 2 to 4 g High-potassium foods should be avoided Oranges Bananas Tomatoes Green vegetables Phosphate restriction 1000 mg/day Foods high in phosphate Dairy products Most foods high in phosphate are also high in calcium

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