Acute Renal Failure

_____ commonly is an early manifestation of chronic renal failure.

Hypertension

most common indicator of ARF

azotemia

Disorders associated with accumulation of nitrogenous wastes

azotemia (accumulation of nitrogenous waste)- early sign of kidney failure S/s- dermatologic manifestations such as pruritus; white ash

how the levels of amniotic fluid can be used diagnostically

because amniotic fluid is comprised of fetal urine, the amount of amniotic fluid can be an indicator opf fetal renal function

Prerenal failure is manifested by a sharp decrease in urine output and a disproportionate elevation of _____ in relation to serum creatinine levels.

blood urea nitrogen

effect and prognosis for unilateral multicystic kidney D/O

- healthy kidney functions well - unilateral prognosis is good

definition of multicystic kidney

- kidney is replaced by cysts and is non-functional - kidney does not have its normal shape and is a mass of cysts

what frequently occurs with ectopic kidneys

- kinking of ureters - obstruction of normal urinary flow

what typically accompanies renal or cystic dyplasia

- other urinary tract abnormalities - frequently obstructive D/O of urine flow

S&S of ADPKD

- pain from enlarged cysts - hematuria (blood in urine) - infected cysts from UTI - renal hypertension from compression of renal vasculature and activation of renin-angiotensin mechanism - kidney stones (nephrolithiasis) - hepatic cysts (asymptomatic) - pancreatic cysts - cardiovascular abnormalities - 20% may have associated cerebral aneurysm or subarachnoid hemorrhage causing death

suspected causes of renal hypoplasia

- scaring from vascular, infectious, or other kidney disease - not developmental

characteristics of ARPKD

- small, elongated cysts form in the collecting ducts which dilate the cortical and meduallry collecting tubules

what occurs in total renal agenesis

- stillbirth - death from pulmonary hypoplasia

characteristics of ADPKD

- thousands of large cysts that develop from every segment of the nephron

characteristics of renal hypoplasia

- typically effects only one kidney - bilateral renal hypoplasia leads to progressive kidney failure

characteristics of renal dysplasia

- undifferentiated tubular structures surrounded by embryonic tissue - may be small, aplastic kidneys - may present with cysts in the abnormal tubules - one or both kidneys may be involved

effect or horseshoe kidneys

- usually none - may have effects if there is accompanying defect in the renal pelvis or obstruction of other urinary structures due to the fusion

S&S of Potter syndrome

- widely separated eyes - epicanthic folds - low set ears - broad, flat nose - receding chin - limb defects

The _____ state includes signs and symptoms of altered fluid, electrolyte, and acid-base balance; and alterations in regulatory functions.

uremic

Osteodystrophy

used to describe the skeletal complications of CKD

What must the nurse do in stage 3 of ARF

watch for dehydration and hypokalemia; isotonic polyuria

S/s of disorders of hematologic function

weakness and fatigue

The acidosis that occurs in persons with kidney failure seems to stabilize as the disease progresses, probably as a result of the tremendous buffering capacity of _____.

bone

A major concern in the treatment of acute renal failure is identifying and correcting the _____.

cause

Prerenal conditions

(type of ARF) marked decrease in renal blood flow on its way to the kidneys (ishemia)

incidence of unilateral renal agenesis, and demographic information

- 1/1000 - more often in boys - more often the left kidney

types of ADPKD

- Type I: caused by mutation of PKD1 gene, more common (85%), rapid - Type II: caused by mutations in PKD2 gene (15%)

where most ectopic kidneys are located

- above the pelvic rim or within the pelvis - may lie in the lower abdomen

what causes the destruction of normal kidney tissue in ADPKD

- apoptotic loss of renal tubular cells - inflammatory mediators

three inherited cystic kidney diseases

- autosomal dominant polycystic disease (ADPKD) - autosomal recessive polycystic kidney disease (ARPKD) - nephronophthisis-medullary cystic disease

S&S of ARPKD

- bilateral flank mass in infants - severe renal failure - impaired lung development - liver fibrosis - portal hypertension - oligohydramnios/Potter Syndrome my present - severe hypertension - prenatal death (75%) often from pulmonary hypoplasia - chronic renal failure & liver disease in those that survive the 1st year of life

characteristics of nephronophthisis-medullary cystic kidney disease

- cysts present in the cortico-medulllary border - starts in the distal tubules with basement membrane disruption - chronic, progressive tubular atrophy in the medulla and cortex - cysts are present, but chronic kidney disease and failure are related to cortical and tubular damage

Disorders of Hematologic Function

-8 million ppl have stage 3 and half are anemic; chronic blood loss, hemolysis -↓ in RBC production due to impaired production of erythropoietin -although platelet production often is normal in CKD, platelet function is impaired; uremia contributes to the problem

Disorders of fluid, electrolyte, and acid-base balance

-FVE (fluid volume excess) is most common; most patients in CKD do not make a lot of urine -Sodium excretion is reduced -Hyperkalemia (excess potassium)

Acute Renal Failure (ARF)

-abrupt sudden loss of renal function, reversible prolonged renal hypoperfusion can lead to ischemic tubular necrosis with significant morbidity and mortality

in stage 2 of ARF a decrease in GFR causes

-azotemia: sudden retention of urea (BUN) and creatinine -Oliguria (<400ml/day) from fluid retention due to low GFR; edema, water intoxication, and pulmonary congestion

Symptoms of prerenal conditions

-elevated BUN and creatinine -fluid overload -anura or oliguria -electrolyte disturbances (hyperkalemia) -Uremic ash on the skin (itching)

Causes of intrinsic or intrarenal conditions (ATN)

-prolonged intrarenal ishemia causing necrosis of the tubules -NSAIDS (reduce prostaglandin), chemo -intratubular obstruction -acute infectious renal disease

Prerenral conditions of ARF are reversible if treated only depending on

1) recovery of the injured cells 2) removal of the necrotic cells and intratubular casts 3) regeneration of tubular cells to restore the normal continuity of the tubular epithelium. GFR returns to normal with restoration of blood flow

Postrenal conditions: the two causes

1. Bilateral ureteral obstruction (kidney stones) 2. Bladder outlet obstruction (benign prostatic hypertrophy or BPH)

Overall Stages of AFR

1. Onset or initiating phase 2. Olguric phase 3. Diuretic phase 4. Recovery phase

Hyperkalemia results from any of these

1. failure to follow dietary potassium restriction 2. acute acidosis or trauma or infection that causes release of potassium from body tissues 3. exposure to medications that contain potassium, prevent its entry into cells, or blocks its secretion in distal nephrons

The normal glomerular filtration rate, which varies with age, gender, and body size, is approximately _____ mL/minute (1.73 mL/minute per square millimeter) for normal young healthy adults.

120 to 130

when the Kidneys begin to develop in utero

5th week of gestation

when urine formation begins in utero

9-12 weeks of gestation

tubules

Absorb/secrete between filtrate and blood -proximal convoluted -loop of Henle -distal convoluted -collecting

Define Axotemia

Accumulation of nitrogenous wastes in the blood

Intrinsic or intrarenal conditions

Acute Tubular Necrosis (ATN)

____ represents a rapid decline in kidney function sufficient to increase blood levels of nitrogenous wastes and impair fluid and electrolyte balance.

Acute renal failure

Name the most common intrarenal cause of renal failure and describe its different forms.

Acute tubular necrosis (ATN) is characterized by the destruction to tubular epithelial cells with acute suppression of renal function. ATN can be caused by a variety of conditions, including acute tubular damage due to ischemia, sepsis, nephrotoxic effects of drugs, tubular obstruction, and toxins from a massive infection. Tubular epithelial cells are particularly sensitive to ischemia and are vulnerable to toxins. The tubular injury that occurs in ATN frequently is reversible.

Sexual dysfunction in people with chronic kidney disease is thought to be multifactorial. What are thought to be causes of sexual dysfunction in people with chronic kidney disease?

Antihypertensive drugs, psychological factors, and uremic toxins. The cause of sexual dysfunction in men and women with chronic kidney disease is unclear. The cause probably is multifactorial and may result from high levels of uremic toxins, neuropathy, altered endocrine function, psychological factors, and medications (e.g. antihypertensive drugs).

Why is chronic kidney disease considered to have an insidious progression?

As kidney structures are destroyed, the remaining nephrons undergo structural and functional hypertrophy, each increasing its function as a means of compensating for those that have been lost. In the process, each of the remaining nephrons must filter more solute particles from the blood. It is only when the few remaining nephrons are destroyed that the manifestations of kidney failure become evident.

Acute renal failure occurs at a high rate in seriously ill people who are in intensive care units. What is the most common indicator of acute renal failure?

Azotemia and a decrease in the glomerular filtration rate. The most common indicator of acute renal failure is axotemia, an accumulation of nitrogenous wastes (urea nitrogen, uric acid, and creatinine) in the blood and a decrease in the glomerular filtration rate.

Define Creatinine

By-product of muscle metabolism

The parents of a hospitalized 4-year-old boy have just been told that their son has a chronic renal disease. The nurse is planning discharge teaching for this family. The parents inquire about treatment for their son and if kidney transplantation could occur. What would be the nurse's best response?

Chronic kidney disease is a progressive disorder that can be slowed by adherence to dietary restrictions and medication regimen. The disorder usually progresses to the point where the child needs either hemodialysis or peritoneal dialysis or a kidney transplant. All forms of renal replacement therapy are considered safe in the pediatric population, and renal transplantation is considered the best treatment for a child.

Define Uremic Encephalopathy

Decreased central nervous system activity

Define Oliguria

Decreased urine production

Anaphylactic shock is caused by?

Decreased vascular filling

The parents of a hospitalized 4-year-old boy have just been told that their son has a chronic renal disease. The nurse is planning discharge teaching for this family. What would the nurse know to include in the discharge teaching for this child and his family?

Description of the disease process; prognosis, manifestations of the disease, including physical growth and developmental delays; medication regimen, including side effects; and dietary restrictions including protein, caloric, sodium, and fluid restrictions.

CKD can result from

Diabetes Hypertension Obstruction Renal diseases (glomerulonephritis, pyleonphritis, and polycystic kidney disease)

Stage 3 and 4 ARF

Diuretic phase: - diursis (isotonic polyuria) often occurs before renal function has fully returned to normal Recovery Phase

People with chronic kidney disease have impaired immune responses to infection because of high levels of urea and metabolic wastes in the blood. What is one thing that is missing in an immune response in people with chronic kidney disease?

Failure to mount a fever with infection. Many persons with chronic kidney disease fail to mount a fever with infection, making the diagnosis more difficult.

How is chronic kidney disease classified?

Glomerular filtration rate (GFR) is used to classify chronic kidney disease into five stages, beginning with kidney damage with normal or elevated glomerular filtration rate (GFR), progressing to chronic kidney disease, and potentially, to kidney failure.

Hemorrhage and dehydration is caused by?

Hypovolemia (low volume)

What are the 2 major categories of the causes?

Hypovolemia and Decreased vascular filling

Define Salt Wasting

Impaired tubular reabsorption of sodium

Define Osteitis fibrosa

Increased bone resorption and formation

In hemodialysis, access to the vascular system is most commonly through what?

Internal arteriovenous fistula. Access to the vascular system is accompanied through the external arteriovenous shunt (i.e. tubing implanted into an artery and a vein) or, more commonly, through an internal arteriovenous fistula (i.e. anastomosis of a vein to an artery, usually in the forearm).

Prerenal conditions patho

Ishemia causes dysfunction of the tubules Drop in GFR- less fulid goes through the tubules so they reabsorb as much sodium and water as possible, so there is low urine sodium (<= 1%) and low urine output disproportionate elevation in the ratio of BUN to serum creatinine

Dietary restrictions placed on people with chronic kidney disease include limiting protein in their diet. The recommended sources of protein for people with chronic kidney disease include what source of protein?

Milk. At least 50% of the protein intake for clients with chronic kidney disease should consist of proteins with high biologic value, such as those in eggs, lean meat, and milk, which are rich in essential amino acids.

Define Prostatic hyperplasia

Most common cause of postrenal failure

Stage 2 of ARF

Oliguric Phase: characterized by a sharp decrease in urine output -decrease in GFR -HTN develops -metabolic acidosis from inability of kidneys to excrete H+

Stage 1 of ARF and symptoms seen

Onset or initiating phase -lasts hours or days, is the time from the onset of the precipitating event (ex. ischemia phase of prerenal failure or toxin exposure) until tubular injury occurs

How does renal disease cause cardiovascular disease?

People with chronic kidney disease (CKD) tend to have an increased prevalence of left ventricular ejection fraction, as in systolic dysfunction, and impaired ventricular filling, as in diastolic failure. Multiple factors lead to development of left ventricular dysfunction, including extracellular fluid overload, shunting of blood through an ateriovenous fistula for dialysis, and anemia. Coupled with the hypertension that often is present, they cause increased myocardial work and oxygen demand, with eventual development of heart failure. Congestive heart failure and pulmonary edema tend to occur in the late stages of kidney failure. Coexisting conditions that have been identified as contributing to the burden of cardiovascular disease include hypertension, anemia, diabetes mellitus, dyslipidemia, and coagulopathies. Anemia, in particular, has been correlated with the presence of left ventricular hypertrophy.

Uremia pericarditis is a disorder that accompanies chronic kidney disease (CKD). What are its presenting signs and symptoms?

Pericardial friction rub, chest pain with respiratory accentuation, and fever without infection. Uremic pericarditis resembles viral pericarditis in its presentation. This includes all potential complications, up to and including cardiac tamponade. The presenting signs include mild to severe chest pain with respiratory accentuation and a pericardial friction rub. Fever is variable in the absence of infection and is more common in dialysis than uremic pericarditis. Shortness of breath and thromboangiitis are not indicative of uremic pericarditis.

Define Isosthenuria

Polyuria with urine that is almost isotonic with plasma

____ failure results from obstruction of urine outflow from the kidneys.

Postrenal

pathology of oligohyrdraminos

Potter syndrome

_____ failure, the most common form of acute renal failure, is characterized by a marked decrease in renal blood flow.

Prerenal

Define Uremia

Presence of excessive amounts of urea in the blood

Neuromuscular disorders can be triggered by chronic kidney disease (CKD). For those clients on dialysis, approximately two-thirds suffer from what peripheral neuropathy?

Restless leg syndrome is a manifestation of peripheral nerve involvement and can be seen in as many as two-thirds of patients on dialysis.

The glomerular filtration rate is considered to be the best measure of renal function. What is used to estimate the glomerular filtration rate?

Serum creatinine. In clinical practice, glomerular filtration rate is usually estimated using the serum creatinine concentration.

Acute tubular necrosis is the most common cause of intrinsic renal failure. One of the causes of ATN is ischemia. What are the most common causes of ischemic ATN?

Severe hypovolemia, Burns, and overwhelming sepsis. Ischemic acute tubular necrosis occurs most frequently in persons who have major surgery, severe hypovolemia, overwhelming sepsis, trauma, and burns.

How is anemia related to chronic kidney disease?

The anemia of chronic kidney disease (CKD) is due to several factors including chronic blood loss, hemolysis, bone marrow suppression due to retained uremic factors, and decreased red cell production due to impaired production of erythropoietin and iron deficiency. The kidneys are the primary site for the production of the hormone erythropoietin, which controls red blood cell production. In renal failure, erythropoietin production usually is insufficient to stimulate adequate red blood cell production by the bone marrow.

What are the clinical manifestations of chronic kidney disease?

The manifestations of chronic kidney disease (CKD) include an accumulation of nitrogenous wastes; alterations in water, electrolytes, 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; and disorders of immunologic function. The point at which these disorders make their appearance and the severity of the manifestations are determined largely by the extent of renal function that is present and the coexisting disease conditions.

Chronic kidney disease impacts many systems in the body. What is the number one hematologic disorder caused by chronic kidney disease (CKD)?

The number one hematologic disorder that accompanies chronic kidney disease is anemia.

Describe the progression of acute tubular necrosis (ATN).

The onset or initiating phase, which lasts for hours or days, is the time from the onset of the precipitating event until tubular injury occurs. The maintenance phase of ATN is characterized by a marked decrease in the glomerular filtration rate (GFR), causing sudden retention of endogenous metabolites, such as urea, potassium, sulfate, and creatinine that normally are cleared by the kidneys. Fluid retention gives rise to edema, water intoxication, and pulmonary congestion. If the period of oliguria is prolonged, hypertension frequently develops and, with it, signs of uremia. The recovery phase is the period during which repair of renal tissues take place. Its onset usually is heralded by a gradual increase in urine output and a fall in serum creatinine, indicating that the nephrons have recovered to the point at which urine excretion is possible.

Define Hemodialysis

Use of artificial kidney to filter blood

Microalbuminuria (proteinuria) refers to?

albumin excretion >normal range but below the range normally detected by tests of total protein exrecretion in the urine (ppl with CKD need to get screened for this)

Glomerular Filtration Rate (GFR)

amount of filtrate formed each minute

when kidneys begin to function in utero

approximately week 8 of gestation

Neuropathy is caused by ______ and _____ of nerve fibers, possibly caused by uremic toxins.

atrophy, demyelination

S&S of nephronophthisis-medullary cystic kidney disease

caused by inability to concentrate urine (tubular disruption): - polyuria - polydipsia (thirst) - enuresis (bed-wetting) other presentations: - salt-wasting - growth retardation - anemia - progressive renal insufficiency - some may present with ocular lesions, oculo-motor abnormalities, retinitis pigmentosa - may have liver fibrosis - may have cerebellar abnormalities - progressive azotemia (nitrogen/urea buildup in the blood), renal failure, death

effects & prognosis for bilateral multicystic kidney D/O

causes: - oligohydramnios and Potter Syndrome - pulmonary hypoplasia - renal failure DEATH - poor prognosis

Regardless of cause, _____ represents a loss of functioning kidney nephrons with progressive deterioration or glomerular filtration, tubular reabsorptive capacity, and endocrine functions of the kidneys.

chronic kidney disease

what frequently happens to the functioning kidney in unilateral renal agenesis

compensatory hypertrophy of the functioning kidney

agenesis

complete failure of an organ to develop during gestation

what can result from reduced amniotic fluid levels

compression on the fetus, causing: - impaired lung development - impaired development of fetal structures

In clinical practice, glomerular filtration rate is usually estimated using the serum _____ concentration.

creatinine

term for renal dysplasia with cysts in the tubules

cystic dyplasia

Chronic renal failure can produce _____ or fluid _____, depending on the pathology of the kidney disease.

dehydration, overload

renal dysplasia

developmental abnormality of kidney structures

Cardiovascular Function and CDK

early identification and aggressive treatment of hypertension has been shown to slow the progression of renal impairment in many types of the kidney disease: salt and water restriction and the use of anti-hypertensive medications to control blood pressure

term for kidneys that develop outside of normal location

ectopic kidneys - may effect one or both kidneys

dysgenesis

failure of an organ to develop normally during gestation

what is the main constituent of amniotic fluid

fetal urine

glomerulus

filtration; ball of capillaries encased by Bowman's Capsule in the nephron and serving as the site of filtration in the vertebrate kidney

nephron

functional units of kidneys (1million in each kidney); glomerulus and tubules

Normal aging is associated with a decline in the _____ and subsequently with reduced homeostatic regulation under stressful conditions.

glomerular filtration rate

Increased excretion of low-molecular-weight globulins is a marker of ____ disease, and excretion of ____ a marker of chronic kidney disease.

tubulointerstitial, albumin

Anorexia, nausea, and vomiting are common in patients with _____, along with a metallic taste in the mouth that further depresses the appetite.

uremia

common type of ectopic kidneys involving fusion of the two kidneys at one end

horseshoe kidney - usually joined at the lower pole

renal function

kidneys activate vitamin D without this we cannot absorb calcium; Filter, reabsorb, and excrete electrolytes, metabolic by-products and drugs

definition of renal hypoplasia

kidneys do not develop to full size

term for reduced amounts of amniotic fluid

oligohydramnios

The term renal _____ is used to describe the skeletal complication of chronic kidney disease.

osteodystrophy

Low-bone turnover osteodystrophy

osteomalacia is characterized by a slow rate of bone formation and defects in bone mineralization

Treatment of CKD: diet

patient is on strict K+, sodium, protein (nitrogen) and fluids

Disorders of calcium and phosphorous balance and bone disease

phosphate excretion is impaired: -causing serum phosphate levels to ↑ and serum calcium levels to ↓ (since they are inversely related) - the drop in serum calcium, stimulates parathyroid hormone (PTH) release, with a resultant ↑ in calcium resorption of bone and osteodystrophy

Treatment of hyperphosphatemia

phosphate-bind antacids may be prescribed

Disorders of drug elimination

phosphate-binding antacids to control hyperphosphatemia and hypocalcemia interferes with the absorption of some drugs

The causes of acute renal failure commonly are categorized as _____, _____, or ______.

prerenal, intrinsic, postrenal

Azotemia

refers to elevations in nitrogenous wastes (BUN, creatinine)

Uremia

refers to the symptoms associated with elevated nitrogenous waste products ex. itching (uremic ash)

what does the nurse need to do in stage 2 of AFR

restrict fluids

In chronic renal failure, the kidneys lose the ability to regulate _____ excretion.

sodium

S/S of Acute Tubular Necrosis

the patient's GFR does not increase after restoration of renal blood flow because of tubular necrosis

Peritoneal dialysis

treatment of CKD -fluid instilled in abdomen through catheter by patient at home -retained 3-4 hours, drained and reinstalled. -requires catheter in abdomen

Hemodialysis

treatment of CKD 3 times a week at a dialysis clinic paid for by Medicad connected to machine requires fistula

Because of their high metabolic rate, the _____ cells are most vulnerable to ischemic injury.

tubular epithelial

High-bone turnover osteodystrophy

↓ in bone density with ↑ formation of porous coarse fibered bone