Chronic renal failure (CRF)

1. RELIANCE INSTITUTE OF NURSING
TOPIC
PRESENTED BY :-
MR. ROMAN BAJRANG
BASIC BS.C NURSING 2ND YEAR
RELIANCE INSTITUTE OF NURSING

2. INTRODUCTION
Chronic renal failure is a gradual and progressive loss of the ability
of the kidneys to function normally. The change is irreversible and is due to
loss of nephrons of the kidney. The nephrons are basic functioning unit of
the kidney and there are normally about one million nephrons in each
kidney.
The kidney is no longer able to clean toxins & waste product from
blood and concentrate the urine. When patients begin to experience
symptoms of kidney failure, most of their kidney function is lost. Simply it
can be interpreted as kidneys gradually stopping to working.
Alternative Names
Kidney failure - chronic; Renal failure - chronic; Chronic renal insufficiency;
Chronic kidney failure; Chronic renal failure

3. DEFINITION:-
Chronic kidney disease (CKD), also known as chronic renal disease, is a
progressive loss of renal function over a period of months or years. The symptoms of
worsening kidney function are unspecific, and might include feeling generally unwell
and experiencing a reduced appetite.
www.crfindia.com
Chronic kidney disease (CKD), also known as chronic renal disease, is a
progressive loss in renal function over a period of months or years.
Wikipedia, the free encyclopedia
When a patient has sustained enough kidney damage to require renal
replacement therapy on permanent basis, the patient has moved into the fifth or final
stage CKD (Chronic Kidney Disease) also referred to as Chronic Renal Failure (CRF)
or ESRD.
Brunner & Suddarth

4. STAGES
All individuals with a Glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3
months are classified as having chronic kidney disease, irrespective of the presence or
absence of kidney damage. Patients with kidney damage are at increased risk of the two
major outcomes of chronic kidney disease: loss of kidney function and development of
cardiovascular disease.[1]
Stage 1
Slightly diminished function kidney damage with normal or relatively high GFR (≥90
mL/min/1.73 m2). Kidney damage is defined as pathological abnormalities or markers
of damage, including abnormalities in blood or urine test or imaging studies.[1]
Stage 2
Mild reduction in GFR (60–89 mL/min/1.73 m2) with kidney damage. Kidney damage
is defined as pathological abnormalities or markers of damage, including abnormalities
in blood or urine test or imaging studies.[1]
Stage 3
Moderate reduction in GFR (30–59 mL/min/1.73 m2).[1] British guidelines distinguish
between stage 3A (GFR 45–59) and stage 3B (GFR 30–44) for purposes ofscreening
and referral.[4]
Stage 4
Severe reduction in GFR (15–29 mL/min/1.73 m2)[1] Preparation for renal replacement
therapy
Stage 5
Established kidney failure (GFR <15 mL/min/1.73 m2, permanent renal replacement
therapy (RRT),[1] or end stage renal disease (ESRD)

5. ETIOLOGY
 Diabetes mellitus 28%
 Hypertension 25 %
 Glomerulonephritis 21%
 Polycystic kidney disease 4%
 Others 23% – obstruction, infection etc.
Many other diseases and conditions can damage the kidneys, including:
 Autoimmune disorders (such as systemic lupus erythematosus and scleroderma)
 Birth defects of the kidneys (such as polycystic kidney disease)
 Certain toxic chemicals
 Glomerulonephritis
 Injury or trauma
 Kidney stones and infection
 Problems with the arteries leading to or inside the kidneys
 Some pain medications and other drugs (such as cancer drugs)
 Reflux nephropathy (in which the kidneys are damaged by the backward flow of
urine into the kidneys)
 Other kidney diseases
Chronic kidney disease leads to a buildup of fluid and waste products in the body. This
condition affects most bodysystems and functions, including:
 Blood pressure control
 Red blood cell production
 Vitamin D and bone health

6. PATHOPYSIOLOGY:-
Due to etiological
factors Renal
function declines
Accumulation of urea, creatinine & other waste
products
uremia
decreased GFR upto
50% increased
creatinine
increasedGlomerular capillary pressure
leads
damages ofcapillaries
focal& segmental
glomerulosclerosisglobal
glomerulosclerosis
different stages ofChronic renal Diseases

7. CLINICAL MANIFESTSTION:-
 Neurologic
Weakness and fatigue, confusion, inability to concentrate, disorientation,
Tremors, seizures, asterixis, restlessness of legs, burning of soles of feet, behavior
changes.
 Integumentary
Gray-bronze skin color; dry, flaky skin; pruritus; ecchymosis; purpura;
thin, brittle nails; coarse, thinning hair
Cardiovascular
Hypertension; pitting edema (feet, hands, sacrum); periorbital
edema; pericardial friction rub; engorged neck veins; pericarditis; pericardial effusion;
pericardial tamponade; hyperkalemia; hyperlipidemia
 Pulmonary
Crackles; thick, tenacious sputum; depressed cough reflex; pleuritic pain;
shortness of breath; tachypnea; Kussmaul-type respirations; uremic pneumonitis; “uremic
lung”
 Gastrointestinal
Ammonia odor to breath (“uremic fetor”); metallic taste; mouth
ulcerations and bleeding; anorexia, nausea, and vomiting; hiccups; constipation or
diarrhea; bleeding from gastrointestinal tract.
 Hematologic
Anemia; thrombocytopenia
 Reproductive
Amenorrhea; testicular atrophy; infertility; decreased libido
 Musculoskeletal
Muscle cramps;loss of muscle strength; renal osteodystrophy;bone
pain;
bone fractures; foot drop

8.  Electrolyte imbalance
Electrolyte balance may be upset by impaired excretion and utilization. The salt
wasting properties of some failing kidney in addition to vomiting and diarrhea may cause
hyponatremia because of dilutional effect of water retention.
Because the kidney are very efficient potassium excretors, however hyperkalemia
occur late in disease because of catabolism, potassium containing medication, trauma, blood
transfusion and acidosis contribute to potassium excess.
Hypocalamia and hyperphosphatemia occur.
 Metabolic changes:- In advancing renal failure BUN and serum creatinine level
rise as waste product of protein metabolism accompanying renal disease and
inadequate dietary intake of protein often cause hypoproteinemia.
 Immunological change:- Impairment of the immunologic system makes the
client very susceptible to infection.

9. 
DIAGNOSTIC FINDING
 Physical examination : -
 High blood pressure is almost always present during all stages
of chronic kidney disease.
 A nervous system exam may show signs of nerve damage.
 Abnormal heart or lung sounds when listening with a stethoscope.
 A urinalysis may show protein or other changes. These changes may appear
6 months to 10or more years before symptoms appear.
Tests that check how well the kidneys are working include:
 Creatinine clearance
 Creatinine levels
 BUN
 Chronic kidney disease changes the results of several other tests. Every
patient needs tohave the following checked regularly, as often as every 2 -
3 months when kidney disease gets worse:
 Albumin
 Calcium
 Cholesterol
 Complete blood count (CBC)
 Electrolytes
 Magnesium
 Phosphorous
 Potassium
 Sodium
 Causes of chronic kidney disease may beseen on:
 Abdominal CT scan
 Abdominal MRI
 Abdominal ultrasound
 Kidney biopsy
 Kidney scan

10.  This disease may also change the results of the following tests:
 Erythropoietin
 PTH
 Bone density test
 Vitamin D
GLOMERULAR FILTRATION RATE
Decreased GFR can be detected by obtaining a 24-hour
urinalysis for creatinine clearance. As Glomerular filtration decreases (due to
nonfunctioning glomeruli), the creatinine clearance value decreases, whereas the serum
creatinine and BUN levels increase.
ACIDOSIS
With advanced renal disease, metabolic acidosis occurs becausethe kidney
cannot
excrete increased loads of acid. Decreased acid secretion primarily results from inability
of the kidney tubules to excrete ammonia (NH3−) and to reabsorb sodium bicarbonate
(HCO3−). There is also decreased excretion of phosphates and other organic acids.
ANEMIA
Anemia develops as a result of inadequate erythropoietin production, the
shortened life
span of RBCs, nutritional deficiencies and the patient’s tendency to bleed, particularly
from the G.I- tract. kidney cannot excrete increased loads of acid.
CALCIUM AND PHOSPHORUS IMBALANCE
With decreased filtration through the glomerulus of the kidney, there is an increase
in the serum phosphate level and a reciprocal or corresponding decrease in the serum
calcium level. The decreased serum calcium level causes increased secretion of
parathormone from the parathyroid glands.
Other Tests
The Cockcroft-Gault formula for estimating CrCl should be used routinely as a simple
means to provide a reliable approximation of residual renal function in all patients with
chronic kidney disease. The formulas are as follows:

11.  CrCl (male) = ([140-age] X weight in kg)/(serum creatinine X 72)
 CrCl (female) = CrCl (male) X 0.85
MANAGEMENT :-
Medical :-
The goal of management is to maintain kidney function and homeostasis for as long as
possible.
OTHERTREATMENTSMAY INCLUDE:
 Special medicines called phosphate binders,to help prevent phosphorous levels from becoming too
high
 Treatment for anemia, such as extra iron in the diet, iron pills,iron through a vein (intravenous iron)
special shots of a medicine called erythropoietin, and blood transfusions
Antacids
Hyperphosphatemia and hypocalcemia are treated with aluminum-based
antacids that bind dietary phosphorus in the GI tract. Both calcium carbonate and
phosphorus binding antacids must be administered with food to be effective.
Magnesium-based antacids must be avoided to prevent magnesium toxicity.
Anti-hypertensive and Cardiovascular Agents.
Hypertension is managed by intravascular volume control and a variety of
antihypertensive Agents. Heart failure and pulmonary edema may also require treatment
with fluid restriction, low- sodium diets, and diuretic agents, inotropic agents such as
digitalis or dobutamine, and dialysis. The metabolic acidosis of chronic renal failure
usually Produces no symptoms and requires no treatment; however, sodium bicarbonate
supplements or dialysis may be needed to correct the acidosis if it causes symptoms

12. Anti-seizure Agents
Neurologic abnormalities may occur, so the patient must be observed for early
evidence of slight twitching, headache, delirium, or seizure activity. Intravenous
diazepam (Valium) or phenytoin (Dilantin) is usually administered to control seizures.
The side rails of the bed Should be padded to protect the patient.
Erythropoietin
Anemia associated with chronic renal failure is treated with recombinant human
erythropoietin (Epogen). Anemic patients (hematocrit less than 30%) present with
nonspecific symptoms, such as malaise, general fatigability, and decreased activity
tolerance. Epogen therapy is initiated to achieve a hematocrit of 33% to 38%, which
generally alleviates the symptoms of anemia. Epogen is administered either
intravenously or subcutaneously 3 times a week. It may take 2 to 6 weeks for the
hematocrit to rise; therefore, Epogen is not indicated for patients who need immediate
correction of severe anemia.
Blood volume expander
Dopamine administer in low doses byintravenous infusion, increase renal blood flow.
Diuretics If restoration of renal blood flow does not improved urinary output, a potent
loop diuretic suchas
furosemide (lasix) or an osmotic diuretic such as mannitol may be given with intravenous
fluids.
DIALYSIS :-
In dialysis, blood is separated from a dialysis solution (dialysate) by a
semipermeable membrane.
Each type of dialysis may be used to relieve symptom of renal failure temporarily
until the client regain kidney function or to sustain life in the client with the irreversible
kidney disease. In the letter case, the dialysis must continue for the rest of the client’s
life unless successful kidney transplantation is done.
Dialysis is usually accomplished through both ultra filtration and diffusion. When

13. dialysis is used as a substitute for kidney function, the semi permeable membrane used
is either the peritoneal membrane (for peritoneal dialysis) or an artificial membrane (for
Hemodialysis).
A specially prepared electrolyte solution called dialysate is placed in a
compartment on
one side of the membrane while the clients’ blood is on the other side.
There are two types of dialysis:
1. Hemodialysis;a procedurein which blood passes through a semi permeable
membrane filter outside the body.
2. Peritoneal dialysis;which uses the peritoneum surrounding the abdominal
cavity.
TYPES OF PERITONEAL DIALYSIS:- There are three types of peritoneal dialysis-
a) Continuous ambulatory peritoneal dialysis. (CAPD)
b) Continuous cycle peritoneal dialysis. (CCPD)
c) Intermittent peritoneal dialysis. (IPD)
SURGICAL MANAGEMENT:-
Kidney transplantation is a surgical management of CRF. It is the surgical
implantation of a human kidney from one person to another, is performed for client with
irreversible kidney failure. Appendix presents a sample clinical pathway for client
undergoing kidney transplantation.
Selection of the transplant recipient is based on careful evaluation the client’s
medical, immunologic, psychological and social statuses. The decision is usually made
by the client. Significant others, and physician working together. Recipient selection is
usually from the group less than 70 years of age who have an estimated life
expectancy of 2 years or more and in whom the transplant will improve the quality of
life.
The transplant kidney surgically placed extra peritoneal the iliac fossa. The
renal artery is anastmosed to the recipient’s hypogastric artery and the renal vein to the

14. recipient’s iliac vein.
Usually the kidney begins to function immediately. Sometime adequate
functioning is delayed a few days. Hemodialysis may be performed until good function
is established.
NUTRITIONAL THERAPY
When patient have chronic kidney disease, he need to make changes in his diet, including:
 Limiting fluids
 Eating a low-protein diet (this may be recommended)
 ing salt, , and other electrolytes
 Getting enough calories
CARBOHYDRATES
 If pt is overweight or have diabetes, he may need to limit the amount of carbohydrates.
 Fruits, breads, grains, and vegetables. These foods provide energy, as well as
fiber, minerals, and vitamins.
 High-calorie desserts such as candies, sugar, honey, and jelly pies, cakes, or cookies
FATS
 Fats can be a good source of calories. Make sure to use monounsaturated and
polyunsaturated fats (olive oil, canola oil, safflower oil) to help protect your
arteries
PROTEIN
 Low-protein diets may be helpful before patient starts dialysis. He should take
moderate- protein diet (1 gram of protein per kilogram of body weight per day).
 Once patient starts dialysis, he will need to eat more protein. In fact, a high-
protein diet with fish, poultry, pork, or eggs at every meal may be recommended.
This will help to replace muscles and other tissues that he lose.
 People on dialysis should eat 8 - 10 ounces of high-protein foods each

15. Top 15 Healthy Foods for People with Kidney Disease
1. Red bell peppers
9. Raspberries
10. Strawberries
CALCIUM AND PHOSPHOROUS
 Calcium and phosphorous, two other important minerals in the body, are also
monitored closely.
 Patient will need to limit the amount of dairy foods, because they contain large
amounts of phosphorous. This includes milk, yogurt, cheese, tub margarine,
butter, cream cheese, heavy cream, ricotta cheese, brie cheese, sherbet, and
nondairy whipped toppings.
 Fruits and vegetables contain only small amounts of phosphorous, but may
contain large amounts of potassium.
 Patient may need to take calcium supplements to prevent bone disease, and
vitamin D to control the balance of calcium and phosphorous in his body.
SALT OR SODIUM
 Reducing sodium in diet helps control high blood pressure, keeps from being
thirsty, and prevents body from holding onto extra fluid

IRON
 Patients with advanced kidney failure also have anemia and usually need extra iron.
 Many foods contain extra iron (liver, beef, pork, chicken, lima and kidney beans,
iron-fortified cereals).
2. Cabbage
7. Cranberries
8. Blueberries
11. Cherries
12. Red grapes
13. Egg whites
14. Olive oil
3. Apples
4. Cauliflower
5. Garlic
6. Onions

16. Possible Complications
 Anemia
 Bleeding from the stomachor intestines
 Bone, joint, and muscle pain
 Changes in blood sugar
 Damage to nerves of the legs and arms (peripheral neuropathy)
 Dementia
 Fluid buildup around the lungs (pleural effusion)
 Heart and blood vessel complications
o Congestive heart failure
o Coronary artery disease
o High blood pressure
o Pericarditis
o Stroke
 High phosphorous levels
 High potassium levels
 Hyperparathyroidism
 Increased risk of infections
 Liver damage or failure
 Malnutrition
 Miscarriages and infertility
 Seizures
 Swelling (edema)
 Weakening of the bones and increased risk of fractures
PREVENTION
 Treating the condition that is causing the problem may help prevent or
delay chronic kidney disease.
 Other tips for protecting the kidneys and preventing heart disease and
stroke:
 Do not smoke.
 Eat meals that are low in fat and cholesterol.
 Get regular exercise (talk to your doctor or nurse before starting to

17. exercise).
 Take drugs to lower your cholesterol, if needed.
 Keep your blood sugar under control.
 Avoid eating too much salt or potassium.
 Always talk to your kidney doctor before taking any over-the-
counter medicine, vitamin, or herbal supplement. Make sure all of
the doctors you visit know you have chronic kidney disease.
 Everyone with chronic kidney disease should be up-to-date on
important vaccinations, including:
 H1N1 (swine flu) vaccine
 Hepatitis A vaccine
 Hepatitis B vaccine
 Influenza vaccine
 Pneumococcal polysaccharide vaccine (PPV)
Nursing Management
The patient with chronic renal failure requires astute nursing care to avoid the
complications of reduced renal function and the stresses and anxieties of dealing with a
life-threatening illness. Examples of potential nursing diagnoses for these patients
include the following:
o Excess fluid volume related to decreased urine output, dietary excesses, and
retention of sodium and water
o Imbalanced nutrition: less than bodyrequirements related to anorexia, nausea and
vomiting, dietary restrictions, and altered oral mucous membranes
o Deficient knowledge regarding condition and treatment regimen
o Activity intolerance related to fatigue, anemia, retention of waste products, and
dialysis procedure
o Low self-esteem related to dependency, role changes, changes in bodyimage,
and sexual dysfunction.

18. SUMMARY:-
Chronic Kidney Disease (CKD), also known as Chronic Renal Disease,
orESRD, is a progressive, irreversible deterioration in renal function in
which the body’s ability to maintain metabolic and fluid and electrolyte
balance fails, resulting in uremia or azotemia (retention of urea and other
nitrogenous wastes in the blood).

19. BIBLIOGRAPHY
1. Brunner and Suddharth’s, Medical Surgical Nursing,
Volume -1,11th edition, page no: 1762.
2. Joyce .m. black, Medical Surgical Nursing, Volume-1, 7th
edition , page no:714
3. Lewis Medical Surgical Nursing, 4th edition, Mosby
publication, page no: 94.
4. Phipps Medical Surgical, 8th edition, Mosby publication, page
no: 256-258.
5. Website: http://www.wikipedia.com/tss.
Website