Renal Failure and Treatment

1. Renal Failure andTreatment Vicky Jefferson, RN, CNN Satellite Dialysis

2. Bones can break, muscles can atrophy, glands can loaf, even the brain can go to sleep without immediate danger to survival. But -- should kidneys fail.... neither bone, muscle, nor brain could carry on. Homer Smith, Ph.D.

3. Renal Hemodynamics • Renal circulation receives 20 - 25 % of cardiac output under normal physiologic conditions. • The bodies blood volume circulates through the kidney every 6 minutes (12 times/hour).

4. Renin secretion and the regulation of volume and composition of extracellular fluid. Excretion Blood pressure control Vitamin D activation Acid-base balance regulation. Erythropoietin production Urine formation Functions of the Kidneys

5. Renin • Renin is important in the regulation of blood pressure. • It is released from the granular cells of the efferent arteriole in response to decreased arteriole blood pressure, renal ischemia, extracellular fluid depletion, increased norepinephrine, and increased urinary Na+ concentration.

6. Blood Pressure Regulation 4 mechanisms are involved • Volume control • Aldosterone effect • Renin-angiotensin-aldosterone • Renal prostaglandin

7. Prostaglandin Prostoglandins (PGs)- synthesized by most body tissues. In the kidney, PGs are synthesized in the medulla and have a vasodilating action and promote Na+ excretion. PGs counteract the vasoconstrictor effect of angiotensin and norepinephrine. Renal PGs systemically lower blood pressure by decreasing systemic vascular resistance.

8. Vitamin D • Acquired by the body through diet or through synthesis by ultraviolet radiation on the cholesterol in the skin. • The liver and the kidney make the vitamin active in the body.

9. Erythropoietin • Erythropoietin is produced and released by the kidneys in response to decreased oxygen tension in the renal blood supply that is created by the loss of red blood cells. • Erythropoietin stimulates the production of RBCs in the bone marrow. • Erythropoietin deficiency leads to anemia in renal failure.

10. RBC Synthesis & Maturation Kidney secrete Erythropoietin, it stimulates the bone marrow to produce RBC’s •  in oxygen delivery simulates release • in response the RBC count rises in 3 - 5 days • speeds the maturation of RBC’s

11. Acid Base Balance Kidneys regulate acid-base balance by stabilizing body fluid volume & flow rate to enhance the reabsorption or excretion of bicarbonate & hydrogen ions

12. Electrolyte Regulation • Sodium • Potassium • Calcium Need to Know: • Phosphate Normal Values • Magnesium Functions • Chloride Factors affect

13. Excretion of Metabolic Waste • Over 200 waste products excreted • Only 2 are used for clinical assessment • BUN • Creatinine

14. Excretion of Metabolic Waste • Over 200 waste products excreted • Only 2 are used for clinical assessment • BUN • Creatinine

15. BUN • Normal 8 - 20 mg/dl • Nitrogenous waste product of protein metabolism • Unreliable in measurement of renal function • Relevance is assessed in conjunction with Creatinine

16. Factors Affecting BUN • Urine flow • low renal perfusion • Volume depletion • Metabolic rate • Protein metabolism • Drugs

17. Creatinine • A waste product of muscle metabolism • Normal value 0.6 - 1.2 mg/dl • 2 times normal = 50% damage • 8 times normal = 75% damage • 10 times normal = 90% damage • Exception - severe muscular disease can greatly  Creatinine levels

18. Diagnostic Tools for Assessing Renal Failure • Blood Tests • BUN elevated (norm 10-20) • Creatinine elevated (norm 0.6 - 1.2) • K elevated • PO4 elevated • Ca decreased • Urinalysis • Specific gravity • Protein • Creatinine clearance

19. Diagnostic Tools • Biopsy • Ultrasound • X-Rays

20. Acute Renal Failure (ARF) • Sudden onset - hours to days • Often reversible • Severe - 50% mortality rate overall; generally related to infection.

21. Characteristics of ARF • Homeostatic functions affected most • Electrolyte imbalances • Volume regulation • Blood pressure control • Endocrine functions affected lease • Require time to evolve • Renal size is preserved • Evidence of acute illness or insult exists

22. Acute Renal Failure (ARF) • Sudden fall in glomerular filtration rate (GFR) • Retention of nitrogenous (BUN and creatinine) and other wastes • Hours to days • About 5% of all hospitalizations • About 20% of ICU admissions • Mortality 50 – 80% • Independent risk factor for death – 5x increase risk

23. Chronic Renal Failure • Slow progressive renal disorder related to nephron loss, occurring over months to years • Culminates in End Stage Renal Disease

24. Characteristics of Chronic Renal Failure • Cause & onset often unknown • Loss of function precedes lab abnormalities • Lab abnormalities precede symptoms • Symptoms (usually) evolve in orderly sequence • Renal size is usually decreased

25. Causes of Chronic Renal Failure • Diabetes • Hypertension • Glomerulonephritis • Cystic disorders • Developmental - Congenital • Infectious Disease

26. Causes of Chronic Renal Failure • Neoplasms • Obstructive disorders • Autoimmune diseases • Lupus • Hepatorenal failure • Scleroderma • Amyloidosis • Drug toxicity

27. Glomerular Filtration RateGFR • 24 hour urine for creatinine clearance • Can estimate creatinine clearance by: 140 – {age x weight (kg)} 72 x serum creatinine

28. Stages of Chronic Renal FailureOld System • Reduced Renal Reserve • Renal Insufficiency • End Stage Renal Disease (ESRD)

29. Stages of Chronic Renal FailureNKF Classification System Stage 1: GFR > 90 ml/min despite kidney damage

30. Stages of Chronic Renal FailureNKF Classification System Stage 2: Mild reduction (GFR 60 – 89 ml/min) 1. GFR of 60 may represent 50% loss in function. 2. Parathyroid hormones starts to increase.

31. During Stage 1 - 2 • No symptoms • Serum creatinine doubles • Up to 50% nephron loss

32. Stages of Chronic Renal FailureNKF Classification System Stage 3:Moderate reduction (GFR 30 – 59 ml/min) 1. Calcium absorption decreases 2. Malnutrition onset 3. Anemia secondary to Erythropoietin deficiency 4. Left ventricular hypertrophy

33. Stages of Chronic Renal FailureNKF Classification System Stage 4: Sever reduction (GFR 15 – 29 ml/min) 1. Serum triglycerides increase 2. Hyperphosphatemia 3. Metabolic acidosis 4. Hyperkalemia

34. During Stage 3 - 4 • Signs and symptoms worsen if kidneys are stressed • Decreased ability to maintain homeostasis

35. During stages 3 - 4 • 75% nephron loss • Decreased: glomerular filtration rate, solute clearance, ability to concentrate urine and hormone secretion • Symptoms: elevated BUN & Creatinine, mild azotemia, anemia

36. Stages of Chronic Renal FailureNKF Classification System Stage 5: Kidney failure (GFR < 15 ml/min) 1. Azotemia

37. During Stage 5 • Residual function < 15% of normal • Excretory, regulatory and hormonal functions severely impaired. • metabolic acidosis • Marked increase in: BUN, Creatinine, Phosphorous • Marked decrease in: Hemoglobin, Hematocrit, Calcium • Fluid overload

38. During Stage 5 • Uremic syndrome develops affecting all body systems • can be diminished with early diagnosis & treatment • Last stage of progressive CRF • Fatal if no treatment

39. What happens when the kidneys don’t function correctly?

40. Manifestations of CRF -Nervous System • Mood swings • Impaired judgment • Inability to concentrate and perform simple math functions • Tremors, twitching, convulsions • Peripheral Neuropathy • restless legs • foot drop

41. Manifestations of CRFSkin • Pale, grayish-bronze color • Dry scaly • Severe itching • Bruise easily • Uremic frost

42. Manifestations of CRFEyes • Visual blurring • Occasional blindness

43. Manifestations of CRF Fluid - Electrolyte - pH • Volume expansion and fluid overload • Metabolic Acidosis • Electrolyte Imbalances • Hyperkalemia

44. Manifestations of CRFGI Tract • Uremic fetor • Anorexia, nausea, vomiting • GI bleeding

45. Manifestations of CRF Hematologic • Anemia • Platelet dysfunction

46. Manifestations of CRF Musculoskeletal • Muscle cramps • Soft tissue calcifications • Weakness • Related to calcium phosphorous imbalances

47. Calcium-Phosphorous Balance

48. Manifestations of CRFHeart - Lungs • Hypertension • Congestive heart failure • Pericarditis • Pulmonary edema • Pleural effusions

49. Manifestations of CRF Endocrine - Metabolic • Erythropoietin production decreased • Hypothyroidism • Insulin resistance • Growth hormone decreased • Gonadal dysfunction • Parathyroid hormone and Vitamin D3 • Hyperlipidemia

50. Treatment Options • Hemodialysis • Peritoneal Dialysis • Transplant • Nothing