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 • Detoxify blood • Increase calcium absorption • calcitriol • Stimulate RBC production • erythropoietin • Regulate blood pressure and electrolyte balance • renin
Classifications • Acute versus chronic • Pre-renal, renal, post-renal • Anuric, oliguric, polyuric
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 • Pre-renal = 55% • Renal parenchymal (intrinsic)= 40% • Post-renal = 5-15%
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 • 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 Not A Field Diagnosis
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 • Hyperkalemia • Volume overload • Vascular access
Weakness Lethargy Muscle cramps Paresthesias Hypoactive DTRs Dysrhythmias Hyperkalemia Symptoms 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 • Calcium gluconate (carbonate) • Sodium Bicarbonate • Insulin/glucose • Kayexalate • Lasix • Albuterol • Hemodialysis
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 • Diabetic Nephropathy • Hypertension • Glomerulonephritis • HIV nephropathy • Reflux nephropathy in children • Polycystic kidney disease • Kidney infections & obstructions
Malaise Weakness Fatigue Neuropathy CHF Anorexia Nausea Vomiting Seizure Constipation Peptic ulceration Diverticulosis Anemia Pruritus Jaundice Abnormal hemostasis CRF Symptoms
Acute Problems in CRF • Relating to underlying disease • Relating to ESRD • Dialysis related problems
Problems Related to ESRD • Metabolic – K/Ca • Volume overload • Anemia, platelet disorder, GI bleed • HTN, pericarditis • Peripheral neuropathy, dialysis dementia • Abnormal immune function
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 • 3-4 times a week • Takes 2-4 hours • Machine filters blood and returns it to body
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
Temporary Catheter
AV Fistula & Graft
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 • 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 • Abdominal lining filters blood • 3 types • Continuous ambulatory • Continuous cyclical • Intermittent
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 • 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
Questions?
