Renal Failure

1. Renal Failure Wendy DeMartino, MD PGY-2

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

3. 2 Kidneys 2 Ureters Bladder Urethra Anatomy

4. What do the kidneys do??

5. Kidney Function • Detoxify blood • Increase calcium absorption • calcitriol • Stimulate RBC production • erythropoietin • Regulate blood pressure and electrolyte balance • renin

8. Classifications • Acute versus chronic • Pre-renal, renal, post-renal • Anuric, oliguric, polyuric

9. 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

10. Acute Renal Failure • Pre-renal = 55% • Renal parenchymal (intrinsic)= 40% • Post-renal = 5-15%

12. 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

13. Symptoms of ARF • Decrease urine output (70%) • Edema, esp. lower extremity • Mental changes • Heart failure • Nausea, vomiting • Pruritus • Anemia • Tachypenic • Cool, pale, moist skin

14. Diagnosis of Renal Failure Not A Field Diagnosis

15. 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

16. ARF: Life Threatening Conditions • Hyperkalemia • Volume overload • Vascular access

17. Weakness Lethargy Muscle cramps Paresthesias Hypoactive DTRs Dysrhythmias Hyperkalemia Symptoms EKG?

18. Hyperkalemia & EKG • K > 5.5 -6 • Tall, peaked T’s • Wide QRS • Prolong PR • Diminished P • Prolonged QT • QRS-T merge – sine wave

22. Hyperkalemia Treatment • Calcium gluconate (carbonate) • Sodium Bicarbonate • Insulin/glucose • Kayexalate • Lasix • Albuterol • Hemodialysis

23. 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%

24. Chronic Renal Failure Causes • Diabetic Nephropathy • Hypertension • Glomerulonephritis • HIV nephropathy • Reflux nephropathy in children • Polycystic kidney disease • Kidney infections & obstructions

25. Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal hemostasis CRF Symptoms

26. Acute Problems in CRF • Relating to underlying disease • Relating to ESRD • Dialysis related problems

27. Problems Related to ESRD • Metabolic – K/Ca • Volume overload • Anemia, platelet disorder, GI bleed • HTN, pericarditis • Peripheral neuropathy, dialysis dementia • Abnormal immune function

28. 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

29. Hemodialysis • 3-4 times a week • Takes 2-4 hours • Machine filters blood and returns it to body

30. 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

31. Temporary Catheter

32. AV Fistula & Graft

33. 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

34. 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

35. Peritoneal Dialysis • Abdominal lining filters blood • 3 types • Continuous ambulatory • Continuous cyclical • Intermittent

36. 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

37. 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

38. Questions?

39. 1. The normal urinary system consists of: • two kidneys, two ureters, one urethra • two kidneys, one ureter, one bladder, one urethra • one kidney, two ureters, one bladder, one urethra • two kidneys, two ureters, one bladder, one urethra D

40. 2. The basic, functional unit of the kidney that acts to mechanically filter fluids, wastes and electrolytes is called: • Ureter • Bladder • Nephron • Trigone C

41. 3. You receive a 911 call to respond to a local residence for a report of an elderly male who is unconscious.  Upon arrival you find a 68 year old female patient who is unconscious with snoring respirations.  Your partner opens the airway and the patient begins breathing at a rate of 44 breaths per minute.  Patients daughter states her mother has ESRD and has decided she wants to die.  Patient has not had dialysis treatment for 3 weeks.  After quick assessment of ABCs what is your first priority in treating this patient? • Oxygen 15 LPM/NRBM, rapid transport • Oxygen 15 LPM/NRBM, check blood glucose, rapid transport • Have the patient’s daughter sign refusal and call in to medical control B

42. 4. You are dispatched for “Man light headed and bleeding from a shunt.”  Upon arrival you find a 38 year old male with a recent history of ARF and receives dialysis 3 times a week.  Today he was changing his shirt.  The Permcath in the right side of his chest became caught in a button hole and the red port of the catheter was sheared off.  Which of the following treatments are appropriate? • Quickly check blood pressure then clamp catheter, and then perform primary assessment. • Wrap a paper towel around catheter to soak up excess blood, apply oxygen 15 LPM/NRBM • Immediately clamp catheter close to skin level, place patient on his left side with head low and feet high, primary assessment, oxygen 15LPM/NRBM C

43. 5. 911 dispatch pages your department for a 72 year old female with high fever, needs to be transported to emergency room for evaluation.  Upon arrival you find an elderly female who is confused with hot dry skin and a respiratory rate of 40 BPM.  Her blood pressure is 80/40 with a pulse of 120.  The patient has a history of CRF and is on peritoneal dialysis.  You note a large tube coming from her abdomen that is connected to other tubes and large empty bags.  Patient’s daughter states that it is time to “drain mom’s dialysis water.”  Based upon your knowledge of peritoneal dialysis which of the following is an appropriate response?

44. 5 (cont). Appropriate response? • Allow the patient’s daughter to unclamp the drain tube, package the patient without disconnecting any tubes and transport the patient and all dialysis tubing intact. • Inform the patient’s daughter that you are not allowed to transport anyone on peritoneal dialysis, disconnect the tubes from the abdominal catheter, cover catheter with a plastic bag and transport. • Call Med Flight to transport patient. • Tell the patient’s daughter to disconnect all excess tubing and transport. A

45. 6. Renal failure often occurs in trauma patients who have had sustained hypotension because: • Blood pressure has no effect on kidney function. • Low blood pressure causes damage to the ureter preventing urine from draining into the bladder. • Low blood pressure prevents adequate blood flow through kidneys causing kidney tissue damage. • Low blood pressure stimulates arteries to dilate causing an increase in the amount of blood flow through the kidneys. C

46. 7. You arrive on scene for a dialysis patient with a history of kidney failure complaining of shortness of breath.  You notice the right arm has large bulging veins.  When taking a blood pressure which of the following answers best describes appropriate actions: • Take blood pressure and pulse in the left arm. • Take blood pressure in the right arm. • Take pulse in the right arm, blood pressure measurement is not necessary in dialysis patients. • Call for Med Flight. ALS ambulance agencies cannot transport patients with an AV shunt. A

47. 8. You are transporting an unconscious dialysis patient to the hospital.  The arm with is AV shunt was left dangling over the cot.  When loading in the ambulance the arm banged against the wall of the rig.  During transport you notice that there is a large hematoma over one of the veins of the arm.  The hematoma is growing quickly.  What is the most appropriate action: • Ignore it, pulsating masses in patients with AV shunts is normal. • Wrap a blood pressure cuff around the arm proximal to the injury and inflate to 20mmHG higher than SBP. • Immediately apply direct pressure over the site and maintain pressure during transport. Have your partner radio ahead to the receiving hospital to notify of condition. • Call insurance company to make sure liability insurance premiums have been paid. C

48. 9. Which of the following could potentially cause renal failure: • Hypovolemic shock • Chemical exposure • Obstruction by kidney stone • All of these D

49. References • http://www.umm.edu/ency/article/000471.htm • http://www.fpnotebook.com/REN38.htm • http://www.paems.org/eWebquiz/renal%20failure/Dialysis%20CEU.pdf • http://www.loyolaems.com/sop/4med.htm#med8 • http://www.chpnet.org/BIEM_Res/lectures.asp • http://www.emedicine.com/emerg/topic501.htm • http://g.msn.com/9SE/1?http://www.irishhealth.com/index.html?level=4&id=538&&DI=293&IG=6f0f1fd0f6854d928d14d6e96915e742&POS=22&CM=IMG&CE=22&CS=AWP&SR=22 • http://http://www.medonline.com.br/med_ed/med1/iranejm.htm • www.auburn.edu/~deruija/renal_part3/sld001.htm • file:///C:/Documents%20and%20Settings/Wendy/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/FBZ7VWDX/12.03.03-DrSturmann-Acute%26ChronicRenalFailure%5B1%5D.ppt#256,1,RENAL FAILURE • file:///C:/Documents%20and%20Settings/Wendy/Local%20Settings/Temporary%20Internet%20Files/Content.IE5/AQVFLSNN/CHRONICRENALFAILUREANDHEMODIALYSIS%5B1%5D.ppt#311,2,CHRONIC RENAL FAILURE