acute and chronic renal failure

1. ACUTE RENAL FAILURE
&
CHRONIC RENAL FAILURE
SURENDRA SHARMA
Assist. Professor
Amity College of Nursing
Amity university, Gurgoan

2. ACUTE RENAL FAILURE
&
CHRONIC RENAL FAILURE

3. Definition
Acute renal failure is a severe deterioration of renal
function, manifested as sudden reduction of urine
excoriation (less than 1ml/kg/hr.)
Etiology
The causes of acute renal failure can be divided into
three groups, prerenal, intrarenal and postrenal
causes.

5. Prerenal
decreased renal perfusion
80%of cases
Renal
intrinsic renal disease
10%of cases
Postrenal
obstruction
10%
AcuteRenalFailure

6. Prerenal causes
These s conditions are related to the problem occur
in blood supply to the kidney either due to systemic
hypovolemia or due to renal hypoperfusion. The
important causes are hypovolemia due to diarrheal
dehydration, shock, burns, diabetic acidosis, trauma
hemorrhage, etc and CCF.

7. Intrarenal causes
Theses internsis renal; conditions are related to
problems within the kidneys and their functions,
causing reduction of GFR, renal ischemia and
tubular damage.
The important causes are:-
1. Glomerulonephritis.
2. Hemolytic uremic syndrome (HUS).
3. Renal vein thrombosis.
4. Acute tubular necrosis, (due to fluid loss,
hemorrhage, shock).
5. Sepsis.

8. Postrenal causes
These conditions are related to the problems of the
upper or lower urinary system causing obstructions
of urine flow due to obstructive uropathies. The
causes include renal calculus, PUV, bladder-neck
obstruction congenital lesion or pus collection in
urinary tract or following drug therapy
( sulfonamide).

9. Phases of ARF
Four phases of ARF are identified in children
depending upon the course of illness.
Initiating phase
This phase lasts from hours to days with features
of renal function impairment.

10. Oliguric phase
This phases lasts from 5 to 15 days but can be
prolonged for weeks. It is shorter in infants and
children (3-5 days) and longer in older children
(10-14 days). More than 3 weeks duration of oligouric
phase indicates irreversible renal damage. It depends
upon severity and duration of initial stage causing
acute Vaso -spastic nephropathy.

11. Diuretic phase
This phase lasts for few days and highly variable
with mild to severe clinical features.
Recovery phases
This phase marks the final resumption of normal
urine osmolarity, constituents and biochemical
alteration in the blood.

12. PATHOPHYSIOLOGY
Reduction of glomerular filtration rate and renal blood flow
due to renal vasoconstriction
Sodium and fluid retention which leads to edema.
Hypertension may develop due to rennin angiotension mechanism
Arteriolar constriction
Acute renal failure
Increased circulatory overload and sodium retention.

13. Clinical manifestation
Severe Oliguria or anuria.
Nausea, vomiting
Lethargy
Dehydration
Acidotic breathing
Alteration of level consciousness
Irregularities in cardiac rate and rhythm
Edema

14. DIAGNOSTIC EVALUATION
Blood examination
Shows raised serum creatinine level
Complete blood count
Blood urea
Electrolysis
pH , bi - Carbonate

15. Urine examination
proteinuria,
haematuria
presence of casts
Ultrasonography helps to detect the structural
abnormalities, calculi, etc.,
Radio-nucleotide studies can be done to evaluate
GFR and renal blood flow distribution

16. Management
Correction of dehydration
Treatment of shock and hyper kalemia
Fluid and electrolyte balance to be maintained
promptly.
Diet should be planed with low sodium, low
potassium, low phosphate and moderate protein
(0.6 to 1gm/kg).
The recommended calorie requirement is 50 to
60 cal/kg.
Liberal amount of carbohydrates and fats can be
given along with vitamin and mineral supplementation.

17.  Use of diuretics like mannitol and frusemide is
recommended by same authority.
 Steroid can also be used
 Dialysis ( peritoneal or hemodialysis is indicated in
life threatening complications
a) Persistent hyper kalemia, serum potassium
more than seven ml/eq/ lt.
b) CCF
c) Pulmonary edema
d) Neurological problem
e) Hyper phosapatemia

18. Complication
Fluid electrolyte imbalance
Hyper kalemia
Metabolic acidosis
Convulsion
Hyponatremia

19. CHRONIC RENAL FAILURE (CRF)
Definition
Chronic renal failure is a permanent irreversible
destruction of nephron leading to severe
deterioration of renal function , finally resulting to
end stage renal disease (ESRD)

20. ETIOLOGY
Glomerular diseases- glomerulonephritis, SLE,
HUS, familial nephropathy, Henoch-Schonlein
purpura, amyloidosis.
Congenital anomalies- Bilateral renal hypoplasia
or dysplasia, polycystic kidney.
Obstructive uropathy- PUJ, renal stones, PUV.
Miscellaneous- Bilateral Wilm’s tumor,
renal vein thrombosis, renal cortical necrosis, renal
tuberculosis, reflux nephropathy.

21. Reduction in the renal functions.
Metabolic, endocrinal and hematological disturbances.
Damage of nephron results in hypertrophy and hyper
phosphatemia of remaining nephron.
Reduced functions of nephrons to excrete effectively
thus resulting azotemia and clinical uremia.
Impaired renal function.
Fluid overload leads to edema and hypertension.
Chronic renal failure
PATHOPHYSIOLOGY

22. Clinical manifestations
Initial polyuria or frequent passage of urine
Oliguria or anuria
Increased thirst
Decreased appetite, weakness
Low energy level
Bone pain or joint pain
Dryness and itching of skin
Hypertension and growth retardation

23. In late stage
Acidotic breathing
Nausea / vomiting
Diarrhea
Peripheral; neuropathy
Convulsions

24. DIAGNOSTIC EVALUATION
Blood examination
Decreased level of hematocrit, Hb%, Na+, Ca++, HCO-,
Increased level of K + and phosphorus.
Renal function test shows gradual increase of BUN, uric
acid and creatinine values.
Urinalysis
Variation in specific gravity increased creatinine level
in urine and change in total amount of urine output.
Chest X-ray to detect bony involvement.
ECG, IVP, MCU, Radionuclide imaging helps to detect
the extent of complications.

25. Management
At the initial stage, the management of CRF is planed
to retard the progression of the diseases by rest,
diet, supportive care and symptomatic relief.
Later, the treatment of complication, dialysis and
renal transplantation to be provided as per need.
Diet should be planed with special attention on
maintenance of calorie as per normal requirements.
Diet should contain high polyunsaturated fat and
complex carbohydrates.

26. Protein intake should be adequate
( 0.8 -1 gm/kg/day) with food items high biologic value
( egg, milk, meat, fish) .
Sodium intake needs to be allowed depending upon
the level of impairment of sodium reabsorption,
presence of edema, hypertension and azotemia.
Potassium balance to be maintain by avoiding
potassium contain food.
Dairy milk containing high phosphate need to be
avoided. But calcium supplementation is required.

27. Vitamin B1, B2, folic acid, B6 and B12
supplementation to be given. Water restriction is
usually not essential except in ESRD and fluid
overload.
Correction of acidosis to be done with sodium-bi-
carbonate.
Hypertension to be managed with antihypertensive
drugs. Infection with least toxic antibiotics.
Antihistamines is given to relief from pruritus.

28. Correction of acidosis to be done with sodium –bi-
carbonate.
Hypertension to be managed with antihypertensive
drugs.
Infection should be managed with least toxic
antibiotics.
Antihistamines is given to relief from pruritus.

29. Correction of anemia can be done with iron-folic
acid supplementation. Blood transfusion can be done.
Correction of calcium and phosphorus imbalance is
essential.
Growth hormone may be needed to correct growth
retardation.
Dialysis (peritoneal or hemodialysis) and renal
transplantation are indicated in CRF.

30. Nursing management
Through assessment of all systems are essential to
detect the problems and planning of care.
Special care to provide in relation to renal
transplant, and dialysis. Routine care should emphasize
on maintenance of fluid - electrolyte balance, skin
integrity, nutritious diet, ensuring safety from
infections and injury, assisting to cope with long-term
illness and teaching for continuation of care.

31. Complication
Azotemia
Metabolic acidosis
Electrolyte imbalance
CCF
Hypertension
Growth retardation
Delayed or absent sexual maturation

32. Nursing diagnoses
Risk of fluid electrolyte imbalance relates to
impaired renal functions
Risk for infection related to alteration of host
defense
Actively intolerance related to acute illness
Altered thought process related to CNS problem
Altered nutrition less than body requirement
related to GI disturbance
Fear and anxiety related to life threatening illness
Knowledge defecated related to management of
ARF

33. INTERVENTION
Risk of fluid electrolyte imbalance relates to
impaired renal functions
Intervention
Weigh the child daily and monitor urine output
every four hours.
Assess the child for edema measure abdominal
girth every eight hours.
Monitor and record the child’s fluid intake.
Assess the color consistency and specific
gravity of the child’s urine.

34. Risk for infection related to alteration of host
defense
Intervention
Keep the catheter drainage bag below the child’s
balder level, making sure the tubing is free from
kinks loops.
Use aseptic technique when emptying the catheter
bag.
Engorge the child to drink at least 60 ml fluid per
hour.
Administer antibiotics.

35. Actively intolerance related to acute illness
Intervention
Provide quit environment.
Provide proper nursing care.
Provide comfort slip.
Provide rest periods to follow each activity.

36. Altered nutrition less than body requirement
related to GI disturbance
Intervention
Assess the nutrition status of the child.
Provide high carbohydrate diet.
Small and frequent meals.
Restrict sodium and protein intake.

37. Fear and anxiety related to life threatening illness
Intervention
Listen to pares concerns.
Explain all procedure to the parents.
Discussion about Childs care.
Provide psychological support to the parents.

38. Knowledge defecated related to management of ARF
Intervention
Explain to the parents about the diseases.
Reassure the parents about long term effects.
Explain to the parents about sodium restricted diet.
Instruct the parents to limit the chills activity.