lemessa jira renal falure slide share

May 1, 2023 pp.by selam M 1

Acute Renal failureBy:- Lemessa Jira

Presentation Outline Definition

Epidemiology

A etiology

Pathogenesis

Clinical feature

Differential Diagnosis

Diagnostic modality

Medical / surgical management

Evidence based nursing interventionMay 1, 2023 pp.by selam M 2

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objectiveAt 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 intervention

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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)

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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).

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Kidneys and their structuresRenal 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

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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

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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)

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Function of Kidneys Urine formation Regulation of electrolyte (acid–base balance calcium and phosphorus balance)

Red blood cell production Vitamins synthesis /vit-D/

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

Secretion of prostaglandins

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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

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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)

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Epidemiology of AKI in worldWorld 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)

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ETHIOLOGY OF AKI

1.Pre renal 2. Intrinsic Renal

3. Post-renal

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Pre-renalMost common cause of ARFResults from decreased renal perfusion to the kidney

Treatment of the cause restores renal and tubular function

(Paweena S.et.al,2013).

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Causes of pre renal AKI

vomiting, diarrhea, poor fluid intake, fever, use of diureticshemorrhage cardiac failureseptic shock

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Intrinsic/renal• Direct damage to the kidneys by inflammations ,toxins, drugs, infection

Interstitial nephritis, acute glomerulo nephritis, tubular necrosis, ischemia, toxins

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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

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PathogenesisPrerenal AKI, also called prerenal azotemia, is characterized by

• diminished effective circulating arterial volume, which leads to inadequate renal perfusion and a decreased GFR.

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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 ).

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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

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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.)

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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

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Postrenal AKIBlockage 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.

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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)

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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

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Renal Hematuria, edema, and

hypertension indicates a glomerular etiology for AKI.

Presence of rash History of prolonged exposure

to nephrotoxic medication

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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.

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Diagnosis History and Physical examination

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

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Con…Abdomen Abdominal or costovertebral

angle tenderness - Nephrolithiasis, renal artery or renal vein thrombosis

distended bladder – Urinary obstruction

( P, et al 2009)

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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, stonesRenal biopsy - Patient in whom the etiology is not identified

Laboratory investigation

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DDX for AKIChronic Kidney DiseaseAcute Tubular NecrosisAzotemiaHyperkalemiaHypertensive EmergenciesLupus nephritis (Harison 19th ed)

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Complication of AKIMetabolic

• Hyponatremia • Hyperkalemia• Hypocalcemia,

hyperphosphatemia • Hyperuricamia • Metabolic acidosis

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Con…Cardiovascular

CHFHypertension Arrhythmias PericarditisPulmonary edema

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Con…

Neurologic Coma and Seizures Hematologic

Anemia and Coagulopathies & bleeding diathesis

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Management of acute renal failureTreat the cause If hypotension, correct hypotension with fluid, and monitor urine output hourly

Initiation of renal replacement therapy when indicated

TREATMENT

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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) May 1, 2023

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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

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Con… Uremia Blood urea nitrogen >100-150

mg/dL Calcium: phosphorus imbalance,

with hypocalcemic tetany that cannot be controlled by other measures

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• 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 wastes

Nutrition

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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]

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Prevention of AKIAdequate hydrationMaintenance of adequate mean arterial pressure

Minimizing nephrotoxin exposure

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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)

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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

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