Lemessa jira renal falure slide share

Acute Renal failure
By:- Lemessa Jira
7 February 2017 pp.by selam M 1

Presentation Outline
Definition
Epidemiology
A etiology
Pathogenesis
Clinical feature
Differential Diagnosis
Diagnostic modality
Medical / surgical management
Evidence based nursing intervention7 February 2017 pp.by selam M 2

objective
At the end of this session,we will be
 Define and Identify the cause of AKI and CKD
 Explain the clinical feature of AKI and CKD
 Identify the diagnostic modality of renal
failure
 Describe the treatment option for renal failure
and ESRD
 Apply evidence based nursing intervention7 February 2017 pp.by selam M 3

Anatomy & Physiology overview
 The renal and urinary systems include
kidneys, ureter, bladder and urethra
 The kidneys are paired, bean-shaped
structures located retroperitoneal (behind
and outside the peritoneal cavity)

Anatomy & Physiology ….
 Adult human kidney, weighs 113 to 170 g,
are approximately 12 cm long, 6 cm wide,
and 2.5 cm thick
( Porth & Matfin, 2009).

Kidneys and their structures
Renal capsule
 Outer membrane which incloses and
protects the kidney against infections and
trauma
Renal cortex
 The outer layer of the kidney that contains
most of the nephron 7 February 2017 pp.by selam M 7

Kidneys and their structures…
Nephrons
 Most basic microscopic structure of the kidney
 Inside each kidney there are about 1million
nephrons
 Physiological unit of the kidney used for
filtration of the blood,reabsorption and
secretion of materials 7 February 2017 pp.by selam M 8

Renal medulla
 Inner layer contains renal pyramids,
renal papillae, renal pelvis and part
of nephron
Site for salt, water and urea
absorption
(Internal medicine lecture Note)

Function of Kidneys
 Urine formation
 Regulation of electrolyte (acid–base
balance calcium and phosphorus
balance)
 Red blood cell production
 Vitamins synthesis /vit-D/

Con…
 Excretion of waste products
 Control of water balance and blood
pressure
 Secretion of prostaglandins

Common symptoms patient with renal disorder
 Pain
 Change in voiding (urinary frequency,
urgency,dysuria,hesitancy,nocturia,urinary
retention oliguria, anuria, hematuria
 Gastrointestinal symptoms
 Shortness of breath, Vital sign change

Acute Renal failure
It is a Rapid deterioration of renal
function resulting in retention of
nitrogenous wastes and inability of the
kidney to regulate fluid and electrolyte
homeostasis. (Nelson 20 ed)

Epidemiology of AKI in world
World incidence of AKI and its stages were
21.6% in adults and 33.7% in children
AKI-associated mortality rates were 23.9% in
adults and 13.8% in children
A systematic review (2004–2012)

ETHIOLOGY OF AKI
1.Pre renal2. Intrinsic Renal
3. Post-renal

Pre-renal
Most common cause of ARF
Results from decreased renal perfusion
to the kidney
Treatment of the cause restores renal
and tubular function
(Paweena S.et.al,2013).

Causes of pre renal AKI
vomiting, diarrhea, poor fluid intake,
fever, use of diuretics
hemorrhage
cardiac failure
septic shock

Intrinsic/renal
• Direct damage to the kidneys by
inflammations ,toxins, drugs, infection
Interstitial nephritis, acute glomerulo
nephritis, tubular necrosis, ischemia,
toxins

Post-renal
Sudden obstruction of urine flow due
to enlarged prostate, kidney stones,
bladder tumors or injury
Bilateral renal calculi, papillary
necrosis, coagulated blood, bladder
carcinoma 7 February 2017 pp.by selam M 20

Pathogenesis
Prerenal AKI, also called prerenal azotemia,
is characterized by
• diminished effective circulating arterial
volume, which leads to inadequate renal
perfusion and a decreased GFR.

Con…
• If the underlying cause of the renal hypo
perfusion is reversed promptly, renal
function returns to normal.
• If hypo-perfusion is sustained, intrinsic
renal parenchymal damage can develop
. ( Alobaidi et al. 2015 January ).

Intrinsic renal AKI
 It is characterized by:-renal parenchymal
damage, including sustained hypo
perfusion and ischemia
 Severe and prolonged ischemic/hypoxic
injury and nephrotoxic insult lead to
acute tubular necrosis
7 February 2017 pp.by selam 24

Con…
 An underlying feature is a rapid decline
in GFR usually associated with
decreases in renal blood flow.
 The primary causes of AKI include
ischemia, hypoxia or nephrotoxicity
(basile et.al,2014.)

con…
 Acute interstitial nephritis is another
common cause of AKI and is usually
a result of a hypersensitivity reaction
to a therapeutic agent or various
infectious agents

Postrenal AKI
Blockage in the urinary tract may cause
urine to build up in one or both kidneys.
Over time, this fluid buildup can prevent
the normal flow of urine out of the
kidney.

Con…
In adults sudden obstruction of urine
flow occurs due to enlarged prostate,
kidney stones, bladder tumors or injury
account for the majority of cases of AKI
(OD, et al 2013)

Prerenal
 There may be history of volume loss from
vomiting, diarrhea, or blood loss and may
present with dehydration , hypotension ,
tachycardia , pallor , and decreased urine
output,
 Sudden onset and reversible
Clinical presentation

Renal
 Hematuria, edema, and hypertension
indicates a glomerular etiology for AKI.
 Presence of rash
 History of prolonged exposure to
nephrotoxic medication

Post renal
• History of interrupted urinary stream
and palpable bladder or kidney suggest
obstructive uropathy.
• Abdominal colic pain, hematuria and
dysuria suggest urinary tract calculi.

Diagnosis
 History and
 Physical examination

Con…
Cardiovascular examination
 Murmurs
 Pericardial friction rub
 Increased jugulovenous distention
Pulmonary examination
 Crepitation sound

Con…
Abdomen
Abdominal or costovertebral angle
tenderness - Nephrolithiasis, renal artery
or renal vein thrombosis
distended bladder – Urinary obstruction
( P, et al 2009)

BUN, Serum cr level and electrolyte
Urinary indices may be useful in differentiating
prerenal AKI from intra renal AKI.
Ultrasound - evaluates renal size, able to detect
masses, obstruction, stones
Renal biopsy - Patient in whom the etiology is
not identified 7 February 2017 pp.by selam M 35
Laboratory investigation

DDX for AKI
Chronic Kidney Disease
Acute Tubular Necrosis
Azotemia
Hyperkalemia
Hypertensive Emergencies
Lupus nephritis
(Harison 19th ed)
7 February
2017 pp.by selam M 36

Complication of AKI
Metabolic
• Hyponatremia
• Hyperkalemia
• Hypocalcemia, hyperphosphatemia
• Hyperuricamia
• Metabolic acidosis 7 February 2017 pp.by selam M 37

Con…
Cardiovascular
CHF
Hypertension
Arrhythmias
Pericarditis
Pulmonary edema

Con…
Neurologic
Coma and Seizures
Hematologic
 Anemia and Coagulopathies & bleeding
diathesis

Management of acute renal failure
Treat the cause
 If hypotension, correct hypotension with
fluid, and monitor urine output hourly
Initiation of renal replacement therapy
when indicated
TREATMENT

Con…
 Elimination of nephrotoxic agents eg,
NSADS
If the cause is post renal obstruction, e.g.
ureteric stone, BOO, remove by means of
Open Surgery
(Surgery lecture note)

Indications for dialysis
 Anuria/UO <100ml/24/
 Oliguria (uo<400ml/24hr)
 Volume overload with evidence of
hypertension and/or pulmonary edema
 Severe metabolic acidosis unresponsive
to medical management

Con…
 Uremia
 Blood urea nitrogen >100-150 mg/dL
 Calcium: phosphorus imbalance, with
hypocalcemic tetany that cannot be
controlled by other measures

• Nutrition is of critical importance a patient
who develop AKI. In most cases, sodium,
potassium, and phosphorus should be
restricted.
• Protein intake should be moderately restricted
while maximizing caloric intake to minimize
the accumulation of nitrogenous wastes7 February 2017 pp.by selam M 44
Nutrition

con…
• The recommended energy provide target of
20–30 kcal/kg/day and a protein target of
1.5 g/kg/day, in the absence of RRT.
• In case of RRT, an increase in protein supply
maximum 1.7 g/kg/day suggested
[KDIGO 2O12 guideline]

Prevention of AKI
Adequate hydration
Maintenance of adequate mean arterial
pressure
Minimizing nephrotoxin exposure

con…
2 GFR <60 mL/min/1.73 m2 for ≥3 months,
with or without the other signs of kidney
damage described above
(Arveiler D, et al. 2012)

Reference
 Kasper L., Braunwald E., Harrison’s principles of Internal medicine,
16th Edition, Gout,
 Myers R. Allen, National Medical Series for independent Study
(NMS) 3rd edition Medicine,
 Fiaccadori E, Parenti E, Maggiore U. Nutritional support in acute
kidney injury. J Nephrol. 2008;21:645–56
 KIDIGO 2012,Guideline
 oca et.al. chronic kidney disease after acute kidney injury.
epidemiological research center,2012.
 Tamiru .et al. Survival patterns of patients on maintenance
hemodialysis for end stage renal disease in Ethiopia: BMC
Nephrology 2013,14 :127 7 February 2017 pp.by selam M 48

Lemessa jira renal falure slide share

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