Acute and Chronic Renal Failure

1McMurtrie/Nur 2241/Fall2012

Nursing Care of the with Nursing Care of the with Client Acute Renal FailureClient Acute Renal Failure

Christine R. McMurtrie RN, MSNChristine R. McMurtrie RN, MSN Professor, NursingProfessor, Nursing Nursing InstituteNursing Institute Brevard Community CollegeBrevard Community College 433-7538433-7538 [email protected]@brevardcc.edu


Longitudinal Section of the Longitudinal Section of the KidneyKidney


The NephronThe Nephron


Kidney FunctionsKidney Functions Maintain homeostasisMaintain homeostasis

Excretion of waste productsExcretion of waste products Fluid & Electrolyte BalanceFluid & Electrolyte Balance Acid-Base BalanceAcid-Base Balance Blood Pressure RegulationBlood Pressure Regulation Hormonal BalanceHormonal Balance


Age Related ChangesAge Related Changes Loss of glomeruliLoss of glomeruli Decreased glomerular filtration rateDecreased glomerular filtration rate Decreased production of creatinine Decreased production of creatinine


Effects of renal function Effects of renal function Changes in the ElderlyChanges in the Elderly

Altered ability to concentrate urine Altered ability to concentrate urine and compensate for Na excess or lossand compensate for Na excess or loss

Decreased response to ADHDecreased response to ADH Decreased thirst responseDecreased thirst response Decreased aldosterone levels leading Decreased aldosterone levels leading

to hypokalemiato hypokalemia Altered drug excretion & renal Altered drug excretion & renal

toxicitytoxicity


Classification of Renal Classification of Renal DiseasesDiseases

CongenitalCongenital Disorders of the glomerulusDisorders of the glomerulus Vascular DisordersVascular Disorders TraumaTrauma NeoplasmsNeoplasms


ACUTE RENAL FAILUREACUTE RENAL FAILURE Patho: Abrupt (hours to a few days) Patho: Abrupt (hours to a few days)

decrease in renal function sufficient to decrease in renal function sufficient to result in retention of nitrogenous waste result in retention of nitrogenous waste (BUN & creat) in the body(BUN & creat) in the body

Hallmark of ARF is progressive Hallmark of ARF is progressive azotemia caused by accumulation of azotemia caused by accumulation of nitrogenous end products of metabolismnitrogenous end products of metabolism


Nephron Destruction in Nephron Destruction in Acute Renal FailureAcute Renal Failure

A.A. Normal nephron. Normal nephron. BB Damage from Damage from

renal ischemia renal ischemia results in patchy results in patchy necrosis of the necrosis of the tubule. The lumen tubule. The lumen may also be blocked may also be blocked by casts.by casts.

C.C. Damage from Damage from nephrotoxic agents.nephrotoxic agents.


EtiologyEtiology Three categories of causationThree categories of causation

Prerenal - Decrease renal blood flowPrerenal - Decrease renal blood flow hypovolemia, CV failure, MI (↓CO)hypovolemia, CV failure, MI (↓CO)

dehydration, shock, trauma with bleedingdehydration, shock, trauma with bleeding Quick response & resolution with Quick response & resolution with

interventionintervention Intrarenal - Produce a renal Intrarenal - Produce a renal

parenchymal insultparenchymal insult glomerulonephritis, drugs, chemicals, diabetes, glomerulonephritis, drugs, chemicals, diabetes,

lupus, infections, ATNlupus, infections, ATN ischemic and nephrotoxicischemic and nephrotoxic Prolonged recoveryProlonged recovery

Postrenal - Obstructs urine flowPostrenal - Obstructs urine flowkidney stones, clots, tumors, neurogenic bladderkidney stones, clots, tumors, neurogenic bladderQuick response & resolution with interventionQuick response & resolution with intervention


Management: Management: Health Prevention and Promotion Health Prevention and Promotion Determine and treat the causeDetermine and treat the cause Initiate proper therapyInitiate proper therapy


ARF ProgressionARF Progression Initiating Phase Initiating Phase (onset until s & s)(onset until s & s) Oliguric Phase Oliguric Phase (onset 1-7 d; lasts 10-14 d(onset 1-7 d; lasts 10-14 d Diuretic Phase Diuretic Phase (1-3 weeks)(1-3 weeks) Recovery Phase Recovery Phase (1 wk to 1 yr)(1 wk to 1 yr)


Initiating Phase (Hrs to Initiating Phase (Hrs to days)days)

Begins at time of insultBegins at time of insult Continues until clinical Continues until clinical

manifestations appearmanifestations appear


Oliguric PhaseOliguric PhaseOliguria = uo < 400 mL/24hOliguria = uo < 400 mL/24h

*Most common initial manifestation*Most common initial manifestation PrerenalPrerenal

No damage to renal No damage to renal tissuetissue

AutoregulationAutoregulation VasoconstrictionVasoconstriction Na & H2O retentionNa & H2O retention

Urine Urine Sp gr > 1.015 (high)Sp gr > 1.015 (high) Na < 10-20 mEq/L Na < 10-20 mEq/L

(low)(low)

IntrarenalIntrarenal Renal damageRenal damage Autoregulation failsAutoregulation fails

Can’t concentrate Can’t concentrate urine so lose Naurine so lose Na

UrineUrine Sp gr WNL (1.010)Sp gr WNL (1.010) Na > 40 mEq/L Na > 40 mEq/L

(high)(high) Ischemia or toxinsIschemia or toxins

Urine contains RBC’s Urine contains RBC’s and WBC’sand WBC’s


Clinical Manifestations Clinical Manifestations Oliguric Phase (begins 1-7 Oliguric Phase (begins 1-7

d; duration 10-14 d or d; duration 10-14 d or longer)longer) Oliguric PhaseOliguric Phase

Urinary changes – 50% experience oliguriaUrinary changes – 50% experience oliguria Fluid volume excess – JVD, bounding P, edema, htn, chf, pul Fluid volume excess – JVD, bounding P, edema, htn, chf, pul

ed, effusionsed, effusions Metabolic acidosis – Kussmaul resp, lethargy, stuporMetabolic acidosis – Kussmaul resp, lethargy, stupor Sodium balance – serum Na nml or below nmlSodium balance – serum Na nml or below nml Potassium excessPotassium excess – – leading cause of deathleading cause of death; see table 475, p. ; see table 475, p.

12021202 Hematologic disorders – pancytopenia *Infection main cause Hematologic disorders – pancytopenia *Infection main cause

of deathof death Calcium deficit and phosphate excessCalcium deficit and phosphate excess Waste product accumulation – creatinine best indicatorWaste product accumulation – creatinine best indicator Neurologic disorders – fatigue, concentration, seizures, Neurologic disorders – fatigue, concentration, seizures,

stupor, comastupor, coma


Diuretic Phase Diuretic Phase (lasts 1-3 (lasts 1-3 wks)wks)

Osmotic DiuresisOsmotic Diuresis UO 1-5 L/day (kidneys excrete)UO 1-5 L/day (kidneys excrete) Tubules cannot concentrate urineTubules cannot concentrate urine

Fluid loss Fluid loss HypovolemiaHypovolemia HypotensionHypotension

Electrolyte ImbalancesElectrolyte Imbalances Hyponatremia, hypokalemia, dehydrationHyponatremia, hypokalemia, dehydration


Recovery (up to 1 yr)Recovery (up to 1 yr) BUN & creat plateau, then decreaseBUN & creat plateau, then decrease May progress to CRFMay progress to CRF Elderly at riskElderly at risk May achieve normal kidney functionMay achieve normal kidney function


Health Health Promotion/PreventionPromotion/Prevention

Monitor high risk populationsMonitor high risk populations ElderlyElderly TraumaTrauma Surgical procedures; dyes used in dx testsSurgical procedures; dyes used in dx tests Extensive burnsExtensive burns CHFCHF SepsisSepsis OBOB Renal insufficiency due to htn, DMRenal insufficiency due to htn, DM

Monitor nephrotoxic drugs, chemicalsMonitor nephrotoxic drugs, chemicals Prevent prolonged hypotension and Prevent prolonged hypotension and

hypovolemiahypovolemia


Health PromotionHealth Promotion Medication SEMedication SE OTC DrugsOTC Drugs Chemical and Environmental Chemical and Environmental

ExposureExposure


Assessment Assessment

Diagnostic StudiesDiagnostic Studies H & P (Differential Dx)H & P (Differential Dx) UAUA Urine osmolalityUrine osmolality Renal ultrasoundRenal ultrasound Renal perfusion scanRenal perfusion scan CT scanCT scan MRIMRI

Nsg AssessmentNsg Assessment Clin Manifestations Clin Manifestations

(table 47-3, p. 1201)(table 47-3, p. 1201) VS, EKGVS, EKG I & O, wt, oral mucosaI & O, wt, oral mucosa Urine color, sp gr, Urine color, sp gr,

glucose, protein, blood, glucose, protein, blood, sedimentsediment

Skin color, edema, JVD, Skin color, edema, JVD, bruisesbruises

CV, Resp statusCV, Resp status Lab values/dx test Lab values/dx test

resultsresults


Planning Outcomes ARFPlanning Outcomes ARF Preservation of renal functionPreservation of renal function Maintanence of fluid and electrolyte Maintanence of fluid and electrolyte

and nutritional balanceand nutritional balance Decreased anxietyDecreased anxiety Adherence to medical regimen and Adherence to medical regimen and

follow-up carefollow-up care


Potential Complication: Potential Complication: arrhythmias R/T arrhythmias R/T

electrolyte imbalanceselectrolyte imbalances Insulin & D5HInsulin & D5H22OO NaHC0NaHC033 – correct acidosis – correct acidosis Calcium gluconate – prevents arrhythmiasCalcium gluconate – prevents arrhythmias DialysisDialysis Sodium Polystyrene sulfonate (Kayexalate)Sodium Polystyrene sulfonate (Kayexalate)

*DO NOT GIVE TO PT WITH PARALYTIC ILEUS*DO NOT GIVE TO PT WITH PARALYTIC ILEUS Dietary restriction K+ to 40 mEq dailyDietary restriction K+ to 40 mEq daily Phosphate and Na restrictionPhosphate and Na restriction Calcium supplements, phosphate binding agentsCalcium supplements, phosphate binding agents Cardiac monitoring, check pulse freq.Cardiac monitoring, check pulse freq.


Decreased Renal Perfusion Decreased Renal Perfusion R/T underlying problemR/T underlying problem

Treat underlying causeTreat underlying cause Prevent ATN (acute tubular necrosis)Prevent ATN (acute tubular necrosis)

Rapid blood loss replacementRapid blood loss replacement Toxicology for nephrotoxic drugsToxicology for nephrotoxic drugs

Mannitol, furosemide (SE: Tinnitus and hearing Mannitol, furosemide (SE: Tinnitus and hearing impairment with IV furosemide)impairment with IV furosemide)

Potassium replacementPotassium replacement Dopamine (low dose)Dopamine (low dose) I & 0, daily wt, renal function studies, labsI & 0, daily wt, renal function studies, labs Prevention of uremic syndrome (fig.47-5, p. 1206)Prevention of uremic syndrome (fig.47-5, p. 1206)

Sx:Sx: early -nausea, anorexia, vomitingearly -nausea, anorexia, vomiting late - stupor, convulsions, coma, bleeding late - stupor, convulsions, coma, bleeding

abnormalities, uremic pneumonitis, pericarditis, abnormalities, uremic pneumonitis, pericarditis, pleuritispleuritis


Potential complication: Metabolic Potential complication: Metabolic acidosis R/T inability to excrete H+, acidosis R/T inability to excrete H+, impaired HCO3 reabsorption, and impaired HCO3 reabsorption, and

decreased NH3 synthesisdecreased NH3 synthesis

Control of acidosisControl of acidosis Sodium bicarbonate 30-60 meq/d if bicarb Sodium bicarbonate 30-60 meq/d if bicarb

falls below 15-18 meq/Lfalls below 15-18 meq/L Monitor Kussmaul resp, lethargy, stuporMonitor Kussmaul resp, lethargy, stupor Dialysis or CRRTDialysis or CRRT


Excess Fluid Volume R/T Excess Fluid Volume R/T renal fx and fluid retention renal fx and fluid retention

Monitor cardiac function , VS, labs, sx fluid Monitor cardiac function , VS, labs, sx fluid overloadoverload

Cardiac monitoringCardiac monitoring Therapy which promotes increasing urinary Therapy which promotes increasing urinary

sodium excretionsodium excretion increase CO, diuretics (lasix, bumex, mannitol)increase CO, diuretics (lasix, bumex, mannitol) aldactone (blocks tubular effect of aldosterone)aldactone (blocks tubular effect of aldosterone)

*can cause hyperkalemia*can cause hyperkalemia I & O, daily wtI & O, daily wt *Fluid & Salt restriction (I = O + 600 mL)*Fluid & Salt restriction (I = O + 600 mL) Elevate legs, teds, scdsElevate legs, teds, scds DialysisDialysis


Imbalanced Nutrition: LBR Imbalanced Nutrition: LBR R/T altered metabolic state R/T altered metabolic state

and dietary restrictionsand dietary restrictions Adequate calories to prevent Adequate calories to prevent

catabolismcatabolism 30-35 kcal/kg body wt30-35 kcal/kg body wt CHON -0.6 g/kg, increased if catabolicCHON -0.6 g/kg, increased if catabolic 30-40% total cal from fat (fat emulsions)30-40% total cal from fat (fat emulsions)

Enteral nutrition or TPN if indicated Enteral nutrition or TPN if indicated (essential amino acids)(essential amino acids)


Risk for Infection R/T Risk for Infection R/T leukopenia, invasive lines, leukopenia, invasive lines,

uremic toxinsuremic toxins Strict aseptic techniqueStrict aseptic technique Crowd and exposure controlCrowd and exposure control Monitor local and systemic S & SMonitor local and systemic S & S Nephrotoxic drugs as last resortNephrotoxic drugs as last resort


Additional Nursing Additional Nursing Implications Acute Renal Implications Acute Renal

FailureFailure Precautions with drugsPrecautions with drugs

Avoid: antacids containing magnesium Avoid: antacids containing magnesium (Mg intoxication)(Mg intoxication)

Smaller doses for digoxin, Smaller doses for digoxin, nephrotoxic antibioticsnephrotoxic antibiotics


DialysisDialysis


Dialysis - Review definitions, benefits, Dialysis - Review definitions, benefits, procedure, preparation, patient procedure, preparation, patient

education, and complications for:education, and complications for:

Hemodialysis Hemodialysis PeritonealPeritoneal Continuous Peritoneal Continuous Peritoneal


HemodialysisHemodialysis


Vascular AccessVascular Access


Temporary Hemodialysis Temporary Hemodialysis CathetersCatheters


Right IJ Temporary HD Right IJ Temporary HD CatheterCatheter


Peritoneal DialysisPeritoneal Dialysis


Continuous Renal Continuous Renal Replacement TherapyReplacement Therapy


The EndThe End


Chronic Renal FailureChronic Renal Failure


Chronic Renal FailureChronic Renal Failure Progressive, irreversible destruction Progressive, irreversible destruction

of kidney tissue by disease which is of kidney tissue by disease which is fatal unless treated by dialysis or fatal unless treated by dialysis or transplanttransplant

Defined as kidney damage or GFR < Defined as kidney damage or GFR < 60 mL/min for > = 3 months60 mL/min for > = 3 months


Causes CRFCauses CRF Metabolic DiseasesMetabolic Diseases

*Diabetic Nephropathy*Diabetic Nephropathy *Uncontrolled hypertension*Uncontrolled hypertension InfectionInfection

UTIUTI *Glomerulonephritis*Glomerulonephritis

Urinary tract obstructionUrinary tract obstruction Exposure to nephrotoxic agentsExposure to nephrotoxic agents DehydrationDehydration Multiple myelomaMultiple myeloma


Classification Systems - Classification Systems - STAGES CRF (5) – Table 47-STAGES CRF (5) – Table 47-

6, p. 12056, p. 1205 Stage 1: Stage 1:

Asymptomatic, functions intactAsymptomatic, functions intact BUN, creat nmlBUN, creat nml GFR > = 90GFR > = 90

Dx and Tx comorbid conditionsDx and Tx comorbid conditions CVD risk reductionCVD risk reduction


Stage 2Stage 2 Mild Decrease GFR with kidney Mild Decrease GFR with kidney

damagedamage GFR 60-89GFR 60-89 Estimation of progressionEstimation of progression


Stage 3Stage 3

Moderate decrease in GFR 30-59Moderate decrease in GFR 30-59 Evaluation and treatment of Evaluation and treatment of

complicationscomplications


Stage 4Stage 4 Severe decrease GRF 15-29Severe decrease GRF 15-29 Preparation for renal replacement Preparation for renal replacement

therapytherapy


Stage 5Stage 5 Kidney Failure GFR < 15 Kidney Failure GFR < 15 Dialysis or renal replacement (if Dialysis or renal replacement (if

uremia present)uremia present)


Biochemical Biochemical ConsequencesConsequences

Waste Product AccumulationWaste Product Accumulation Altered CHO metabolismAltered CHO metabolism Elevated triglyceridesElevated triglycerides Occ HypermagnesiumemiaOcc Hypermagnesiumemia Bleeding tendenciesBleeding tendencies InfectionInfection Increased cancer incidenceIncreased cancer incidence


Biochemical Biochemical ConsequencesConsequences

Sodium & WaterSodium & Water Sodium can still be reabsorbedSodium can still be reabsorbed Renal tubules lose ability to concentrate Renal tubules lose ability to concentrate

urine by reabsorbing water (sp gr 1.010)urine by reabsorbing water (sp gr 1.010) Should produce polyurea if GFR high Should produce polyurea if GFR high

enoughenough May become rapidly fluid overloaded or May become rapidly fluid overloaded or

depleteddepleted Eventually oliguria and anuria (UO < 400 Eventually oliguria and anuria (UO < 400

mL/d)mL/d)


CRF Biochem. CRF Biochem. ConsequencesConsequences

Potassium * most serious electrolyte Potassium * most serious electrolyte disturbancedisturbance GFR low, nephron loss increases, less GFR low, nephron loss increases, less

potassium is excreted, develop potassium is excreted, develop hyperkalemiahyperkalemia

Acid/Base BalanceAcid/Base Balance Loose ability to regenerate bicarbonate Loose ability to regenerate bicarbonate

and excrete hydrogen ions so develop and excrete hydrogen ions so develop metabolic acidosismetabolic acidosis


Renal OsteodystrophyRenal Osteodystrophy


CRF Biochem. CRF Biochem. ConsequencesConsequences

Calcium & Phosphate metabolismCalcium & Phosphate metabolism With increased nephron loss, have less With increased nephron loss, have less

synthesis of VIT D so less Ca reabsorbed synthesis of VIT D so less Ca reabsorbed from gut causing hypocalcemiafrom gut causing hypocalcemia

PTH levels rise in an attempt to restore PTH levels rise in an attempt to restore serum Caserum Ca

Leads to secondary hyperparathyroidism Leads to secondary hyperparathyroidism and bone loss (renal bone dystrophy)and bone loss (renal bone dystrophy)

Erythropoietin SynthesisErythropoietin Synthesis impairment leads to normochromic, impairment leads to normochromic,

normocytic anemianormocytic anemia Epogen, ProcritEpogen, Procrit *Replace folic acid if on dialysis *Replace folic acid if on dialysis

(dialyzable)(dialyzable)


Systemic Manifestations Systemic Manifestations CRFCRF

Neuro/Psychological: fatigue, lethargy, Neuro/Psychological: fatigue, lethargy, depression, poor concentration, depression, poor concentration, involuntary movements, paresthesias, involuntary movements, paresthesias, neuropathyneuropathy

CV: HTN, LVH, pericarditis, cardiac CV: HTN, LVH, pericarditis, cardiac tamponade, hyperlipidemiatamponade, hyperlipidemia

Resp: Kussmaul breathing, Dyspnea, Resp: Kussmaul breathing, Dyspnea, Pleurisy, pul ed, pneumoniaPleurisy, pul ed, pneumonia

Skin: Pruritis, purpura, pigmentation, Skin: Pruritis, purpura, pigmentation, pallor, dry, yellowish, uremic frostpallor, dry, yellowish, uremic frost


Clinical Manifestations Clinical Manifestations CRF (Cont.)CRF (Cont.)

GI: anorexia, N & V, GI bleed, peptic ulcers, GI: anorexia, N & V, GI bleed, peptic ulcers, constipation, diarrhea, metal taste in mouthconstipation, diarrhea, metal taste in mouth

GU: Nocturia, polyurea, sp gr 1.010, GU: Nocturia, polyurea, sp gr 1.010, oliguria, anuria, impotenceoliguria, anuria, impotence

Musc./Sk.: Myopathy, bone pain, renal Musc./Sk.: Myopathy, bone pain, renal osteodystrophyosteodystrophy

Heme: Normochromic, normocytic anemia, Heme: Normochromic, normocytic anemia, depressed platelet production due to uremic depressed platelet production due to uremic toxins, easy bruising and bleeding, Altered toxins, easy bruising and bleeding, Altered WBC production and functionWBC production and function


Uremia in Chronic Renal Uremia in Chronic Renal FailureFailure


Nursing Interventions Nursing Interventions CRFCRF

Prevent sodium overloadPrevent sodium overload Dietary sodium restrictionDietary sodium restriction DiureticsDiuretics

Control htn (diuretics, beta blockers, ace Control htn (diuretics, beta blockers, ace inhibitors) and anemia (Epogen, Procrit)inhibitors) and anemia (Epogen, Procrit)

Control hyperkalemia (Kayexalate)Control hyperkalemia (Kayexalate) Control hyperphosphatemia with oral calcium Control hyperphosphatemia with oral calcium

based phosphate binders to sequester ingested based phosphate binders to sequester ingested phosphate in the gut (Tums, PhosLo, Renagel)phosphate in the gut (Tums, PhosLo, Renagel)

Vit D supplements, (Calcitrol, Calcifediol, Vit D supplements, (Calcitrol, Calcifediol, Rocaltrol)Rocaltrol)


Nursing Interventions Nursing Interventions CRFCRF

Anemia – erythropoetin and iron Anemia – erythropoetin and iron replacementreplacement

Avoid Dig, Aminoglycosides, Avoid Dig, Aminoglycosides, Meperidine, NSAIDSMeperidine, NSAIDS


National Renal Diet National Renal Diet

Established for pre-ESRD, hemodialysis, Established for pre-ESRD, hemodialysis, & PD & PD

Goals: Decrease build-up of urea Goals: Decrease build-up of urea and nitrogenous wastesand nitrogenous wastes Delay progression of renal diseaseDelay progression of renal disease prevent wasting and malnutritionprevent wasting and malnutrition

restriction of protein to prevent restriction of protein to prevent accumulation of nitrogenous wastesaccumulation of nitrogenous wastes


Diet in CRF – Diet in CRF – Table 47-8, p. Table 47-8, p. 12121212

Comparison of diets for ESRD, PD, Comparison of diets for ESRD, PD, HD, ESRDHD, ESRD

ESRDESRD CHON (0.6-1 g/kg/d)CHON (0.6-1 g/kg/d) Unrestricted for fluidUnrestricted for fluid Individualized for K, Na, PhosphorusIndividualized for K, Na, Phosphorus If Phosphorus restriction (avoid organ If Phosphorus restriction (avoid organ

meats, fish, poultry, milk, milk products, meats, fish, poultry, milk, milk products, whole grains, nuts, eggs, dried beans)whole grains, nuts, eggs, dried beans)


Diet in CRFDiet in CRF PDPD

CHON – 1.2-1.3 g/kg (nml diet .8 g/kg)CHON – 1.2-1.3 g/kg (nml diet .8 g/kg) No added salt in diet (2-4 gm)No added salt in diet (2-4 gm) Phosphorus restriction same as HD <= Phosphorus restriction same as HD <=

17 g17 g Fluid unrestricted if wt & B/P controlledFluid unrestricted if wt & B/P controlled


Diet in CRFDiet in CRF HDHD

CHON – 1.1-1.4 g/kgCHON – 1.1-1.4 g/kg Sl less than PDSl less than PD

Individualized Phosphorus restrictionIndividualized Phosphorus restriction Sodium – based on body wt & B/PSodium – based on body wt & B/P Fluid = 0utput previous 24 hr + Fluid = 0utput previous 24 hr +

insensible lossinsensible loss(600 mL) (600 mL)


Electrolyte Imbalances in Electrolyte Imbalances in the Pt with Renal Fxthe Pt with Renal Fx

Hyperkalemia - impaired excretion of KHyperkalemia - impaired excretion of K Sx: Irritability, nausea, diarrhea, abd cramps, Sx: Irritability, nausea, diarrhea, abd cramps,

dysrhythmias, ECG changesdysrhythmias, ECG changes Hyponatremia - water retention (sodium Hyponatremia - water retention (sodium

leaves vascular compartment and moves to leaves vascular compartment and moves to interstitial space) interstitial space) Sx: Nausea, vomiting, headache, CNS involvement Sx: Nausea, vomiting, headache, CNS involvement

causing lethargy, confusion, seizures, & comacausing lethargy, confusion, seizures, & coma Hyperphosphatemia - decreased excretion of Hyperphosphatemia - decreased excretion of

phosphate in urinephosphate in urine Sx: Hyperreflexia, paraesthesias, tetany (same sx Sx: Hyperreflexia, paraesthesias, tetany (same sx

as hypocalcemia)as hypocalcemia)


Dietary Goals:Dietary Goals: Encourage foods low in K and NaEncourage foods low in K and Na

avoid salt substitutes and processed avoid salt substitutes and processed foodsfoods

2-4 g/d K and sodium restriction2-4 g/d K and sodium restriction 1 g NaCl = 400 mg Na1 g NaCl = 400 mg Na

Avoid foods high in phosphorusAvoid foods high in phosphorus Restrict P to 1 G/dRestrict P to 1 G/d nuts, anchovies, organ meat, bran, nuts, anchovies, organ meat, bran,

cheese, dairy products, poultry cheese, dairy products, poultry


Phosphorus/Ca- (moves Phosphorus/Ca- (moves in opposition to Ca)in opposition to Ca)

Encourage Low phos foods and Ca Encourage Low phos foods and Ca supplements supplements

Hyperphosphatemia occurs with Hyperphosphatemia occurs with hypocalcemia (tetany)- Nml hypocalcemia (tetany)- Nml phosphate 2.5-4.5phosphate 2.5-4.5 Avoid vegetarian diets (high in Avoid vegetarian diets (high in

Phosphates)Phosphates) Tetany SX: muscle cramps, paresthesias, Tetany SX: muscle cramps, paresthesias,

convulsions, calcification in soft tissueconvulsions, calcification in soft tissue


Diet CRFDiet CRF Calcium carbonate or calcium Calcium carbonate or calcium

acetate (bind phosporus)acetate (bind phosporus) Calcium supplements (dairy products Calcium supplements (dairy products

are restricted)are restricted) Vitamin D (lose ability to produce Vit Vitamin D (lose ability to produce Vit

D)D) Give Vit DGive Vit D

RocaltrolRocaltrol CalcijexCalcijex


AnemiaAnemia Fe supplements (FeTinic)Fe supplements (FeTinic)

Tarry stools, constipation, GI irritationTarry stools, constipation, GI irritation Do not take at same time as phosphate Do not take at same time as phosphate

bindersbinders Folic acid – RBC formation and dialysisFolic acid – RBC formation and dialysis Epogen (EPO), Procrit Epogen (EPO), Procrit

(adverse effects= htn, increased blood (adverse effects= htn, increased blood viscosity, iron deficiency)viscosity, iron deficiency)


DyslipidemiaDyslipidemia Goal to keep LDL’s less than Goal to keep LDL’s less than

100mg/dl and triglycerides below 100mg/dl and triglycerides below 200 mg/dl200 mg/dl StatinsStatins fobratesfobrates


Drug Excretion & Drug Excretion & NephrotoxicityNephrotoxicity

Drugs Excreted by KidneysDrugs Excreted by Kidneys DigoxinDigoxin Narcotic AnalgesicsNarcotic Analgesics

Meperidine (converted to normeperidine)Meperidine (converted to normeperidine) OxycodoneOxycodone MSMS

Nephrotoxic DrugsNephrotoxic Drugs NSAIDSNSAIDS Amnoglycosides – Vanc, GentAmnoglycosides – Vanc, Gent PNCPNC TetracyclinesTetracyclines


Nsg Management CKDNsg Management CKD See Care Plan Lewis pp 1180-1181See Care Plan Lewis pp 1180-1181


Treatment Options CKDTreatment Options CKD DialysisDialysis

HemodialysisHemodialysis Peritoneal DialysisPeritoneal Dialysis

Continuous Renal Replacement Continuous Renal Replacement TherapyTherapy

Kidney TransplantationKidney Transplantation


Renal TransplantationRenal Transplantation Review indications for Review indications for

transplantation, patient preparation, transplantation, patient preparation, patient education, postoperative patient education, postoperative care, immunosuppression, rejection, care, immunosuppression, rejection, and management following and management following transplantationtransplantation

70% Cadavers donors70% Cadavers donors 30% LRD30% LRD


Pre-opPre-op Supportive Care for both donor & recipientSupportive Care for both donor & recipient H & PH & P Continue dialysisContinue dialysis Immunosuppressive therapy to prevent Immunosuppressive therapy to prevent

rejection (can occur hours to years after rejection (can occur hours to years after transplantation)transplantation) Azathioprine (Imuran)Azathioprine (Imuran) PrednisonePrednisone Cyclosporine (Sandimmune)Cyclosporine (Sandimmune)


RejectionRejection Mechanism of action of Mechanism of action of

T cytotoxic lymphocyte T cytotoxic lymphocyte activation and attack of activation and attack of renal transplanted renal transplanted tissue. The tissue. The transplanted kidney is transplanted kidney is recognized as foreign recognized as foreign and activates the and activates the immune system. T immune system. T helper cells are helper cells are activated to produce IL-activated to produce IL-2, and T cytotoxic 2, and T cytotoxic lymphocytes are lymphocytes are sensitized. After these sensitized. After these T cytotoxic cells T cytotoxic cells proliferate, they attack proliferate, they attack the transplanted kidneythe transplanted kidney


Immunosuppressive Immunosuppressive therapytherapy

Suppress proliferation of cells within Suppress proliferation of cells within immune systemimmune system

Nsg. ResponsibilitiesNsg. Responsibilities Monitor WBC (fever), platelets (bleeding Monitor WBC (fever), platelets (bleeding

gums, bruising, petechiae, joint pain, gums, bruising, petechiae, joint pain, hematuria, black or tarry stools), pul hematuria, black or tarry stools), pul function (cyclophosphamines can cause function (cyclophosphamines can cause pul fibrosis)pul fibrosis)

Monitor renal and liver function studiesMonitor renal and liver function studies Administer meds with food to avoid GI Administer meds with food to avoid GI

effectseffects Give antacidsGive antacids Encourage po fluidsEncourage po fluids Monitor I & O, hand-washing, prevent Monitor I & O, hand-washing, prevent

infection (MRSA)infection (MRSA)


Patient Teaching – Patient Teaching – Immunosuppressive Immunosuppressive

TherapyTherapy Avoid large crowds and exposure to infectionAvoid large crowds and exposure to infection Report fever, chills, sore throat, fatigue, Report fever, chills, sore throat, fatigue,

malaisemalaise Use contraceptives to prevent birth defectsUse contraceptives to prevent birth defects Avoid aspirin, ibuprofen to prevent bleedingAvoid aspirin, ibuprofen to prevent bleeding Females may stop having periods while on Females may stop having periods while on

cyclophosphamide; menses resumes after cyclophosphamide; menses resumes after drug is discontinueddrug is discontinued

If on cyclophosphamide, report coughing or If on cyclophosphamide, report coughing or difficulty breathingdifficulty breathing


Postoperative CarePostoperative Care Indwelling urinary catheter; measure Indwelling urinary catheter; measure

hourly, maintain closed system; foley out hourly, maintain closed system; foley out after 2-3 days (monitor voiding)after 2-3 days (monitor voiding)

Fluid replacement cc/ccFluid replacement cc/cc VS, arterial pressure, PWP (Diuresis can VS, arterial pressure, PWP (Diuresis can

occur immediately after transplantation)occur immediately after transplantation) DiureticsDiuretics Monitor lytes and urinary function testsMonitor lytes and urinary function tests


Postoperative Postoperative ComplicationsComplications

Hemorrhage (Swelling of operative site, Hemorrhage (Swelling of operative site, increased abd girth, shock, changes in VS, increased abd girth, shock, changes in VS, LOCLOC

Failure of the ureteral anastomosis Failure of the ureteral anastomosis (leakage of urine into peritoneal cavity – (leakage of urine into peritoneal cavity – abd swelling, tenderness, decreased uoabd swelling, tenderness, decreased uo

Renal artery thrombosis (abrupt htn, Renal artery thrombosis (abrupt htn, reduced GFR)reduced GFR)

Infection from immunosupporession Infection from immunosupporession (change in LOC, cloudy or malodorous (change in LOC, cloudy or malodorous urine, purulent incisional drainage)urine, purulent incisional drainage)


Discharge TeachingDischarge Teaching Emotional support – allow controlEmotional support – allow control MedicationsMedications Monitor VS and daily wtMonitor VS and daily wt Sx of rejection to be reported immediately:Sx of rejection to be reported immediately:

Swelling and tenderness of graft site, fever, Swelling and tenderness of graft site, fever, joint aching, weight gain, decreased urinary joint aching, weight gain, decreased urinary outputoutput

Dietary Dietary Restricted carbohydrate and increased CHONRestricted carbohydrate and increased CHON Sodium restrictionSodium restriction


Discharge TeachingDischarge Teaching CorticosteroidsCorticosteroids

Report cushingoid effects: Report cushingoid effects: Wt gainWt gain Fat redistributionFat redistribution HyperglycemiaHyperglycemia Sodium and water retentionSodium and water retention


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Date post:	16-Apr-2017
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Acute and Chronic Renal Failure

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