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Renal Failure. Wendy DeMartino, MD PGY-2. Objectives. Anatomy Function Acute Renal Failure (ARF) Causes Symptoms Management Chronic Renal Failure (CRF) Causes Symptoms Dialysis. 2 Kidneys 2 Ureters Bladder Urethra. Anatomy. What do the kidneys do??. Kidney Function.

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renal failure

Renal Failure

Wendy DeMartino, MD

PGY-2

objectives
Objectives
  • Anatomy
  • Function
  • Acute Renal Failure (ARF)
    • Causes
    • Symptoms
    • Management
  • Chronic Renal Failure (CRF)
    • Causes
    • Symptoms
  • Dialysis
anatomy
2 Kidneys

2 Ureters

Bladder

Urethra

Anatomy
slide4

What do

the kidneys do??

kidney function
Kidney Function
  • Detoxify blood
  • Increase calcium absorption
    • calcitriol
  • Stimulate RBC production
    • erythropoietin
  • Regulate blood pressure and electrolyte balance
    • renin
classifications
Classifications
  • Acute versus chronic
  • Pre-renal, renal, post-renal
  • Anuric, oliguric, polyuric
acute versus chronic
Acute Versus Chronic
  • Acute
    • sudden onset
    • rapid reduction in urine output
    • Usually reversible
    • Tubular cell death and regeneration
  • Chronic
    • Progressive
    • Not reversible
    • Nephron loss
  • 75% of function can be lost before its noticeable
acute renal failure
Acute Renal Failure
  • Pre-renal = 55%
  • Renal parenchymal (intrinsic)= 40%
  • Post-renal = 5-15%
causes of arf
Causes of ARF
  • Pre-renal =
    • vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure
    • cardiac failure, liver dysfunction, or septic shock
  • Intrinsic
    • Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins
  • Post-renal =
    • prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders
    • neurogenic bladder
    • bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus
symptoms of arf
Symptoms of ARF
  • Decrease urine output (70%)
  • Edema, esp. lower extremity
  • Mental changes
  • Heart failure
  • Nausea, vomiting
  • Pruritus
  • Anemia
  • Tachypenic
  • Cool, pale, moist skin
diagnosis of renal failure
Diagnosis of Renal Failure

Not A Field Diagnosis

acute renal failure management
Acute Renal Failure Management
  • Make/think about the diagnosis
  • Treat life threatening conditions
  • Identify the cause if possible
    • Hypovolemia
    • Toxic agents (drugs, myoglobin)
    • Obstruction
  • Treat reversible elements
    • Hydrate
    • Remove drug
    • Relieve obstruction
arf life threatening conditions
ARF: Life Threatening Conditions
  • Hyperkalemia
  • Volume overload
  • Vascular access
hyperkalemia symptoms
Weakness

Lethargy

Muscle cramps

Paresthesias

Hypoactive DTRs

Dysrhythmias

Hyperkalemia Symptoms

EKG?

hyperkalemia ekg
Hyperkalemia & EKG
  • K > 5.5 -6
  • Tall, peaked T’s
  • Wide QRS
  • Prolong PR
  • Diminished P
  • Prolonged QT
  • QRS-T merge – sine wave
hyperkalemia treatment
Hyperkalemia Treatment
  • Calcium gluconate (carbonate)
  • Sodium Bicarbonate
  • Insulin/glucose
  • Kayexalate
  • Lasix
  • Albuterol
  • Hemodialysis
chronic renal failure
Chronic Renal Failure
  • 150–200 cases per million people = new cases each year
  • Chronic renal failure and ESRD affect more than 2 out of 1,000 people in the U.S
  • Mortality = 20%
chronic renal failure causes
Chronic Renal Failure Causes
  • Diabetic Nephropathy
  • Hypertension
  • Glomerulonephritis
  • HIV nephropathy
  • Reflux nephropathy in children
  • Polycystic kidney disease
  • Kidney infections & obstructions
crf symptoms
Malaise

Weakness

Fatigue

Neuropathy

CHF

Anorexia

Nausea

Vomiting

Seizure

Constipation

Peptic ulceration

Diverticulosis

Anemia

Pruritus

Jaundice

Abnormal hemostasis

CRF Symptoms
acute problems in crf
Acute Problems in CRF
  • Relating to underlying disease
  • Relating to ESRD
  • Dialysis related problems
problems related to esrd
Problems Related to ESRD
  • Metabolic – K/Ca
  • Volume overload
  • Anemia, platelet disorder, GI bleed
  • HTN, pericarditis
  • Peripheral neuropathy, dialysis dementia
  • Abnormal immune function
dialysis
Dialysis
  • ½ of patients with CRF eventually require dialysis
  • Diffuse harmful waste out of body
  • Control BP
  • Keep safe level of chemicals in body
  • 2 types
    • Hemodialysis
    • Peritoneal dialysis
hemodialysis
Hemodialysis
  • 3-4 times a week
  • Takes 2-4 hours
  • Machine filters

blood and

returns it to

body

types of access
Types of Access
  • Temporary site
  • AV fistula
    • Surgeon constructs by combining an artery and a vein
    • 3 to 6 months to mature
  • AV graft
    • Man-made tube inserted by a surgeon to connect artery and vein
    • 2 to 6 weeks to mature
what this means for you
What This Means For You
  • No BP on same arm as fistula
  • Protect arm from injury
  • Control obvious hemorrhage
    • Bleeding will be arterial
    • Maintain direct pressure
  • No IV on same arm as fistula
  • A thrill will be felt – this is normal
access problems
Access Problems
  • AV graft thrombosis
  • AV fistula or graft bleeding
  • AV graft infection
  • Steal Phenomenon
    • Early post-op
    • Ischemic distally
    • Apply small amount of pressure to reverse symptoms
peritoneal dialysis
Peritoneal Dialysis
  • Abdominal lining filters blood
  • 3 types
    • Continuous ambulatory
    • Continuous cyclical
    • Intermittent
ems considerations
EMS Considerations
  • Make sure the dressing remains intact
  • Do not push or pull on the catheter
  • Do not disconnect any of the catheters
  • Always transport the patient and bags/catheters as one piece
  • Never inject anything into catheter
dialysis related problems
Dialysis Related Problems
  • Lightheaded –give fluids
  • Hypotension
  • Dysrhythmias
  • Disequilibration Syndrome
    • At end of early sessions
    • Confusion, tremor, seizure
    • Due to decrease concentration of blood versus brain leading to cerebral edema