ACUTE RENAL FAILUREACUTE RENAL FAILURE

M.JANGIRM.JANGIR ICU,AAHICU,AAH

AL AINAL AIN

DEFINATIONDEFINATION Acute Renal Failure is a sudden and almost Acute Renal Failure is a sudden and almost

complete loss of kidney function caused by complete loss of kidney function caused by failure of the renal circulation or by by failure of the renal circulation or by by glomerular or tubular dysfunction.glomerular or tubular dysfunction.

OR OR

ARF is rapid beakdown of renal function ARF is rapid beakdown of renal function that occurswhen high levels of uremic that occurswhen high levels of uremic toxins accumulate in the blood.toxins accumulate in the blood.

ARFARF

Based on the amount of the urine Based on the amount of the urine that is excreted over a 24 hrs that is excreted over a 24 hrs period, Pts with ARF are separated period, Pts with ARF are separated into two groups:into two groups:

Oliguric:Pts who excrete less than Oliguric:Pts who excrete less than 400 mls per day.400 mls per day.

Nonoliguric:Pts who excrete more Nonoliguric:Pts who excrete more than 400 mls per day.than 400 mls per day.

CAUSESCAUSES

Three major categories of conditions Three major categories of conditions cause ARF:cause ARF:

Prerenal(Hypoperfusion of kidney)Prerenal(Hypoperfusion of kidney)Intrarenal or Intrinsic(Actual damage Intrarenal or Intrinsic(Actual damage

to kidney tissue)to kidney tissue)Postrenal(Obstruction to urine flow)Postrenal(Obstruction to urine flow)

PRERENAL ARFPRERENAL ARF Prerenal conditions occur due to a blood Prerenal conditions occur due to a blood

flow problem which leads to hypoperfusion flow problem which leads to hypoperfusion of kidney and a drop in GFR. The main of kidney and a drop in GFR. The main causes are:causes are:

Volume depletionVolume depletionHemorrhageHemorrhageRenal losses(Diuretics,osmotic diuretics)Renal losses(Diuretics,osmotic diuretics)GI losses(Vomiting,diarrhea,NG tubes)GI losses(Vomiting,diarrhea,NG tubes) Impaired cardiav efficiency,MI,CHFImpaired cardiav efficiency,MI,CHFCardigenic shockCardigenic shockSepsisSepsis

INTRARENAL(INTRINSIC)ARFINTRARENAL(INTRINSIC)ARF It’s due to structural damage to the glomeruli or It’s due to structural damage to the glomeruli or

kdney tubules. The main causes are:kdney tubules. The main causes are: Prolonged renal ischemiaProlonged renal ischemia Myoglobinuria(trauma,crush injuries,burns)Myoglobinuria(trauma,crush injuries,burns) Hemoglobinuria(Transfusion reactions,hemolytic Hemoglobinuria(Transfusion reactions,hemolytic

anemia)anemia) Nephrotoxic agents(NSAIDs)Nephrotoxic agents(NSAIDs) Aminoglycoside Aminoglycoside

antibiotics(gentamycin,tobamycin)antibiotics(gentamycin,tobamycin) Acute pyelonephritis,Acute glomerulonephritis)Acute pyelonephritis,Acute glomerulonephritis) Infectious processesInfectious processes

POSTRENAL ARFPOSTRENAL ARF It’s caused by an acute obstruction distal to the kidneys that It’s caused by an acute obstruction distal to the kidneys that

affects normal outflow of the urine from kidneys.The affects normal outflow of the urine from kidneys.The blockage causes pressure to build in all of the renal blockage causes pressure to build in all of the renal nephrons,eventualy the GFR decreases. The main causes nephrons,eventualy the GFR decreases. The main causes are:are:

Urinary tract obstructionUrinary tract obstruction Tubule obstruction(End chanel of renal nephrones)Tubule obstruction(End chanel of renal nephrones) CalculiCalculi TumorsTumors Benign prostate hyperplasiaBenign prostate hyperplasia StricturesStrictures Blood clots Blood clots Retroperitoneal fibrosisRetroperitoneal fibrosis

PHASES OF ARFPHASES OF ARFMainly 4 clinical phases of ARF:Mainly 4 clinical phases of ARF: Initiation period: It begins with the initial Initiation period: It begins with the initial

insult and ends when oliguria develops.insult and ends when oliguria develops.

Period of oliguria:(UOP less than 400 Period of oliguria:(UOP less than 400 mls/24 h) It’s is accompanied by a rise in mls/24 h) It’s is accompanied by a rise in serum concentration of sustances usually serum concentration of sustances usually excreted by the kidneys(Ur,Cr,Uric acid, excreted by the kidneys(Ur,Cr,Uric acid, Pottasium and Mg)Pottasium and Mg)

Cont.. PHASES OF ARFCont.. PHASES OF ARFPeriod of diuresis: Pt. experiences a Period of diuresis: Pt. experiences a

gradually increasing UOP, which signal gradually increasing UOP, which signal that glomerular filtration has started to that glomerular filtration has started to recover.Doeward trend starts in Ur, Cr.recover.Doeward trend starts in Ur, Cr.

Period of recovery: This signals the Period of recovery: This signals the improvement of renal function and may improvement of renal function and may take from 3-12 months. Lab value returns take from 3-12 months. Lab value returns to a normal level for the Pt.to a normal level for the Pt.

RISK FACTORSRISK FACTORS

AtherosclerosisAtherosclerosis

Blood lossBlood loss

Chronic Liver DiseasesChronic Liver Diseases

Heart diseaseHeart disease

HypercalcemiaHypercalcemia

SIGNS & SYMPTOMS SIGNS & SYMPTOMS PRERENAL S&SPRERENAL S&S::

Dizziness,Headache,muscle twitching Dizziness,Headache,muscle twitching and seizuresand seizuresDry mouth,dry mucous membraneDry mouth,dry mucous membraneUremic fetor(Uremic odor in breath)Uremic fetor(Uremic odor in breath)Lethargy,N/V and diarrheaLethargy,N/V and diarrheaHypotension, TachycardiaHypotension, TachycardiaThirstThirst

Cont.. SIGNS & SYMPTOMSCont.. SIGNS & SYMPTOMSINTRARENAL(INTRINSIC) S & S:INTRARENAL(INTRINSIC) S & S:Fever,rash,arthralga(Asso. With allergic Fever,rash,arthralga(Asso. With allergic

interstitial nephritis)interstitial nephritis)Flank pain-asso. With renal artery or vein Flank pain-asso. With renal artery or vein

obstruction,severe glomerulonephritisobstruction,severe glomerulonephritisHeadache, dizziness,confusion,seizures-Headache, dizziness,confusion,seizures-

asso. With malignant HTNasso. With malignant HTNOliguria,edema,HTN,Papilledema,heart Oliguria,edema,HTN,Papilledema,heart

failurefailure Increased BUN and Cr levelsIncreased BUN and Cr levels

Cont..SIGNS & SYMPTOMSCont..SIGNS & SYMPTOMS

POSTRENAL ARF S & S:POSTRENAL ARF S & S:Difficult urination,distended bladderDifficult urination,distended bladderEdema(Fluid retention and swelling)Edema(Fluid retention and swelling)HTNHTNPain in the lower back,lower Pain in the lower back,lower

abdomen,groin,genitaliaabdomen,groin,genitaliaSevere hematuriaSevere hematuria

COMPLICATIONS OF ARFCOMPLICATIONS OF ARFDyspneaDyspneaHeart failureHeart failureEdemaEdemaVenous engorgementVenous engorgementMetabolic acidosisMetabolic acidosisHyperkalemiaHyperkalemiaInntravascular overloadInntravascular overloadUremiaUremiaConfusion, disorientation and stuporConfusion, disorientation and stupor

DIAGNOSISDIAGNOSISPhysical exam.Physical exam.Lab. Study often reveal high Ur, Cr, Lab. Study often reveal high Ur, Cr, hyperkalemia, hyperphosphatemia, hyperkalemia, hyperphosphatemia, hypocalcemiahypocalcemiaUrine analysis shows RBC and WBC, Urine analysis shows RBC and WBC, high Na, Proteinuriahigh Na, ProteinuriaSevere anemiaSevere anemiaUSG, CAT SCAN, MRIUSG, CAT SCAN, MRIRenal biopsyRenal biopsy

PREVENTIONPREVENTION Provide adequate hydration to Pts at risk for Provide adequate hydration to Pts at risk for

dehydration:dehydration: *Surgical Pts :before, during and after surgery*Surgical Pts :before, during and after surgery *Pts undergoing intensive diagnostic studies *Pts undergoing intensive diagnostic studies

requiring fluid requiring fluid restriction and contrast agentsrestriction and contrast agents *Pts with disorders of metabolism (Gout) and *Pts with disorders of metabolism (Gout) and

those receiving chemotherapythose receiving chemotherapy Prevent and treat shock promptly with blood and Prevent and treat shock promptly with blood and

fluid replacementfluid replacement Monitor critically ill Pts for CVP,ABP and hrly UOP Monitor critically ill Pts for CVP,ABP and hrly UOP

to detect early onset of renal failureto detect early onset of renal failure

Cont.. PREVENTIONCont.. PREVENTIONManage hypotension promptlyManage hypotension promptlyContinually asses renal function (UOP, Lab values)Continually asses renal function (UOP, Lab values)Follow proper blood transfusion protocols to avoid Follow proper blood transfusion protocols to avoid transfusion reactionstransfusion reactionsPrevent and treat infection promptlyPrevent and treat infection promptlyPay special attention to wounds, burns and other Pay special attention to wounds, burns and other causes of sepsiscauses of sepsisProper care of indwelling cathetersProper care of indwelling cathetersClosely monitor allClosely monitor allmediations metabolized or excreted by the mediations metabolized or excreted by the kidneys for dosage, duration and blood levels to kidneys for dosage, duration and blood levels to prevent toxic effects.prevent toxic effects.

MANAGEMENTMANAGEMENTMaintenance of fluid and electrolytes. Ion Maintenance of fluid and electrolytes. Ion exchange resins (Na polysterene exchange resins (Na polysterene sulfonate) to control hyperkalemia.sulfonate) to control hyperkalemia.IV fluids and diuretics: adequate blood IV fluids and diuretics: adequate blood flow to the kidneys in some Pts may be flow to the kidneys in some Pts may be restored by IV fluids and medications. restored by IV fluids and medications. Mannitol, ferusemide may be prescribed to Mannitol, ferusemide may be prescribed to initiate a diuresis and prevent subsequent initiate a diuresis and prevent subsequent renal failure.renal failure.Correction of acidosis and elevated Correction of acidosis and elevated phosphate levels: Serial ABG, appropriate phosphate levels: Serial ABG, appropriate resp. ventilatory measures resp. ventilatory measures

Cont.. MANAGEMENTCont.. MANAGEMENT

Appropriate antibiotics to treat Appropriate antibiotics to treat infection.infection.

Dietary proteins are limited to Dietary proteins are limited to approximately 1gm/kg during the approximately 1gm/kg during the oliguric phase to minimize protein oliguric phase to minimize protein breakdown and to prevent breakdown and to prevent accumulation of toxic end products. accumulation of toxic end products.

Cont.. MANAGEMENTCont.. MANAGEMENTDIALYSIS:DIALYSIS:Dialysis may be initiated to prevent Dialysis may be initiated to prevent

serious complications of ARF, such as serious complications of ARF, such as hyperkalemia, pericarditis and hyperkalemia, pericarditis and seizures.seizures.

Dialysis corrects many biochemical Dialysis corrects many biochemical abnormalities, allows for abnormalities, allows for liberalization of fluid, protein and Na liberalization of fluid, protein and Na intake.intake.

NURSING MANAGEMENTNURSING MANAGEMENTClose monitoring of fluid and electrolytes Close monitoring of fluid and electrolytes balance.balance.Reduce metabolic rate by adequate bed Reduce metabolic rate by adequate bed rest to reduce catabolism and subsequent rest to reduce catabolism and subsequent release of K+ and accumulation of release of K+ and accumulation of endogenous waste products.endogenous waste products.Promote pulmonary function by frequent Promote pulmonary function by frequent deep breaths, cough to prevent atelectasis deep breaths, cough to prevent atelectasis and respiratory infectin.and respiratory infectin.Avoiding infection by practicing aseptic Avoiding infection by practicing aseptic techniques in invasive lines care.techniques in invasive lines care.

Cont.. NURSING MANAGEMENTCont.. NURSING MANAGEMENT

Provide meticulous skin care as dry Provide meticulous skin care as dry and edematous skin more prone to and edematous skin more prone to breakdown. Turn Pt frequently to breakdown. Turn Pt frequently to prevent skin breakdown.prevent skin breakdown.Follow strict aseptic techniques with Follow strict aseptic techniques with Pts who are on dialysis to prevent Pts who are on dialysis to prevent infection.infection.Provide psychological support to Pt Provide psychological support to Pt and family.and family.

THANKS FOR YOUR THANKS FOR YOUR ATTENTIONATTENTION