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Chapter 34 Acute Kidney Injury and Chronic Kidney Disease

Renal Failure

Definition

A condition in which the kidneys fail to remove metabolic end products from the blood and regulate the fluid, electrolyte, and pH balance of the extracellular fluids

Underlying causes

Renal disease

Systemic disease

Urologic defects of nonrenal origin

Prevention and Early Diagnosis of Acute Renal Failure

Assessment measures to identify persons at risk for development of acute renal failure

Those with preexisting renal insufficiency and diabetes

Elderly persons (due to the effects of aging on renal reserve)

Types of Renal Failure

Acute Renal Failure

Abrupt in onset

Often is reversible if recognized early and treated appropriately

Chronic Renal Failure

The end result of irreparable damage to the kidneys

It develops slowly, usually over the course of a number of years.

Prerenal Cases of Acute Renal Failure

Hypovolemia

Decreased vascular filling

Heart failure and cardiogenic shock

Decreased renal perfusion due to vasoactive mediators, drugs, diagnostic agents

Postrenal Causes of Acute Renal Failure

Bilateral ureteral obstruction

Bladder outlet obstruction

Question #1

Congestive heart failure would be a(n) __________ cause of renal failure.

Prerenal

Intrarenal

Postrenal

Answer to Question #1

A. Prerenal

Rationale: Prerenal causes of acute kidney injury include profound depletion of vascular volume, impaired perfusion due to heart failure and cardiogenic shock, and decreased vascular filling because of increased vascular capacity.

Intrinsic or Intrarenal Causes of Acute Renal Failure

Acute tubular necrosis

Prolonged renal ischemia

Exposure to nephrotoxic drugs, metals, organic solvents

Intratubular obstruction resulting from hemoglobinuria, myoglobinuria, myeloma light chains, or uric acid casts

Acute renal disease

Phases of ATN

Onset or Initiating Phase

Lasts hours or days

The time from the onset of the precipitating event until tubular injury occurs

Maintenance Phase

Characterized by a marked decrease in the GFR

Recovery Phase

Period during which repair of renal tissue takes place

Common Causes of Chronic Renal Disease

Hypertension

Diabetes mellitus

Polycystic kidney disease

Obstructions of the urinary tract

Glomerulonephritis

Cancers

Autoimmune disorders

Diseases of the heart or lungs

Chronic use of pain medication

Stages of the Progression of Chronic Renal Failure #1

Diminished renal reserve

Renal insufficiency

Renal failure

End-stage renal disease (ESRD)

Stages of the Progression of Chronic Renal Failure #2

Mild reduction of GFR to 60 to 89 mL/min/1.73 m2

Moderate reduction of GFR to 30 to 59 mL/min/1.73 m2

Severe reduction in GFR to 15 to 29 mL/min/1.73 m2

Kidney failure with a GFR < 15 mL/min/1.73 m2, with a need for renal replacement therapy

Question #2

A GFR of _____________ best describes renal failure.

60 to 89 mL/min/1.73 m2

30 to 59 mL/min/1.73 m2

15 to 29 mL/min/1.73 m2

<15 mL/min/1.73 m2

Answer to Question #2

D. <15 mL/min/1.73 m2

Rationale: Less than 15 mL/min/1.73 m2 is the result of significantly decreased renal filtration and is the cut-off point of renal failure.

Clinical Manifestations of Chronic Renal Failure

Accumulation of nitrogenous wastes

Alterations in water, electrolyte, and acid–base balance

Mineral and skeletal disorders

Anemia and coagulation disorders

Hypertension and alterations in cardiovascular function

Gastrointestinal disorders

Neurologic complications

Disorders of skin integrity

Immunologic disorders

Treatment During the Renal Insufficiency Stage of Renal Failure

Using measures to retard deterioration of renal function and assist the body in managing the effects of impaired function

Treating urinary tract infections promptly

Avoiding medication with renal damaging potential

Controlling blood pressure

Controlling blood sugar in persons with diabetes

Stopping smoking

Target Populations Comprising Persons with Chronic Renal Failure

Persons with chronic renal insufficiency

Persons with renal failure being treated with hemodialysis

Persons with renal failure being treated with peritoneal dialysis

Renal transplant recipients

Factors Determining the Manifestations of Renal Failure

The extent of renal function that is present

Coexisting disease conditions

The type of renal replacement therapy that the person is receiving

Disorders of Water, Electrolyte, and Acid–Base Balance

Sodium and water balance

The kidneys function in the regulation of extracellular fluid volume.

Potassium balance

Approximately 90% of potassium excretion is through the kidneys.

Acid–base balance

The kidneys normally regulate blood pH by eliminating hydrogen ions produced in metabolic processes and regenerating bicarbonate.

Hematologic Disorders Accompanying Renal Failure

Anemia

Coagulopathies

Cardiovascular Disorders Accompanying Renal Failure

Hypertension

Heart disease

Pericarditis

Altered Drug Metabolism in Kidney Disease

CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs.

Altered drug absorption

Antacid treatment

Altered metabolism

Results of less protein-bound drugs

Increased intermediates of drug metabolism

Alterations in dosage may be required

Question #3

Which of the following alterations may affect drug efficacy in a patient with CKD?

Loss of K+

Alteration in pH

Loss of albumin

Increased Ca2+

Answer to Question #3

C. Loss of albumin

Rationale: Loss of albumin will result in altered drug metabolism via increased intermediates and faster action.

Treatment of Renal Failure #1

Medical Management

Dialysis

Hemodialysis

Peritoneal dialysis

Transplantation

Treatment of Renal Failure #2

Dietary Management

Protein

Carbohydrates, fat, calories

Potassium

Sodium and fluid intake

CKD in Children

Causes

Congenital malformations

Inherited disorders

Acquired diseases

Metabolic syndromes

Manifestations

Severe growth impairment;

Developmental delay

Delay in sexual maturation

Bone abnormalities

Development of psychosocial problems

CKD in Elderly

Normal decrease in the GFR with age

Increased detrimental effects of nephrotoxic drugs

Greater incidence of cerebrovascular, cardiovascular, and skeletal system effects

Treatment Options for Chronic Renal Failure in the Elderly and Children

Hemodialysis

Peritoneal dialysis

Transplantation