Renal Failure
Gail l Lupica PhD, RN,
CNE
Nurs 211

The renal system works together with
the body’s urinary system to collect the
body’s waste products and expel them as
urine.
•
One kidney is located on each side of
the abdomen, near the lower back.
•
The kidneys filter about 45 gallons of
fluid each day.
•
The functional unit of the kidney is the
nephron. Each kidney contains about 1
million nephrons.
Functions of the Renal System

Maintenance of fluid balance:


The kidneys maintain the fluid balance in the body by
regulating the amount and makeup of fluid inside and
outside (mainly) the cells.
The kidneys are continuously exchanging water,
(plus sodium, potassium, chloride, and other ions
across their cell membranes.)
• Two hormones play a key role in the kidney’s ability to maintain
fluid balance in the body
Functions of the Renal System
• 1.
ADH: controls the collecting tubules permeability to water
according to the osmoreceptor’s ability to sense high
concentration of solute in the plasma. (In other words when the
plasma is concentrated, ADH is secreted to hold on to
more water. When the plasma is dilute, ADH is not secreted so
the permeability to water changes in the collecting tubules, and
water is released.)
• 2.
Aldosterone: regulates water reabsorption in the distal
tubules by increasing sodium reabsorption and
therefore water reabsorption when released from the adrenal
cortex. (It is released as the final response in the renin angiotensin
aldosterone system.) The presence of Aldosterone also helps
increase the excretion of potassium.
Functions of the Renal System>
Failure


When the kidneys fail:
Patients retain fluid and you see:
Peripheral edema
Pulmonary edema
Decreased urine output
Hypertension
Functions of the Renal System
The regulation of acid-base
balance:
The kidneys regulate acid base balance by:
 Excreting just enough hydrogen ions to keep
the ph of the blood in the normal range.
 Manufacturing bicarbonate (a base) as
needed to maintain ph between 7.35-7.45.
Functions of the Renal System>
Failure

When the kidneys fail:
Metabolic acidosis
results.

• Patients may develop Kussmaul
respirations.—what’s that?
Functions of the Renal System

The secretion of
erythropoietin:
 The kidneys secrete erythropoietin when
the oxygen supply in the tissue blood drops.
This hormone prompts the bone marrow to
produce more RBCs.
Functions of the Renal System>
Failure

When the kidneys fail:
The patient becomes anemic.
(Remember also they are anemic due to the increased
destruction of RBCs & PLTS by the uremic toxins,
and even due to their bleeding tendency secondary to their
low PLTS.)
Functions of the Renal System
Maintenance of electrolyte balance:
The kidneys function to regulate electrolyte
concentrations.
 When the kidneys fail, electrolyte levels are
not maintained:
K+, Na, Phosphate, Ca+

Functions of the Renal System>
Failure

Potassium:
Hypokalemia may occur…

•
with vomiting or excessive diarrhea in early renal failure
when uremic toxins begin to circulate.
in the diuretic phase of acute renal failure as the kidney is
unable to conserve water and electrolytes. ……………….
ARRYTHMIAS, NAUSEA, and LETHARGY occur.

Hyperkalemia occurs with….. decreased renal
excretion of potassium both in the oliguric phase of
acute renal failure and in end stage renal disease.
Hyperkalemia could lead to life threatening ARRYTHMIAS!!
Functions of the Renal System>
Failure

Sodium:

Hyponatremia also occurs in the diuretic phase of acute
renal failure when the kidneys cannot conserve sodium or water.
MUSCLE WEAKNESS, CONFUSION, and ABDOMINAL
CRAMPING occur.


Hypernatremia occurs with decreased renal
excretion of sodium. This will occur in the end stages of
renal disease and the person will be on a sodiumrestricted diet. ……DRY MUCOUS MEMBRANES, and
OLIGURIA occurs.
Functions of the Renal System>
Failure
Calcium:

Hypocalcemia occurs for two reasons:
• 1.
A hyperphosphatemia occurs because of a decreased
excretion of phosphate.
• There is an inverse relationship between phosphate and Calcium, so a
hypocalcemia occurs. ( These electrolytes are regulated by the parathyroid
gland, so when the phosphate level rises out of control due to the kidneys
inability to excrete it, the parathyroid hormone (from the gland) is over
secreted and starts to get Calcium from the bones, due to a depletion in the
serum) OSTEOPOROSIS, OSTEODYSTROPHY (bone disease), AND
TETANY occurs.
Functions of the Renal System>
Failure
Hypocalcemia
 2.
The kidneys normally secrete an
active form of vitamin D (2-3 DPG),
which help the intestines absorb calcium.
When there’s decreased absorption,
there’s hypocalcemia.
You tube . com

chvostek's sign and trousseau's sign
Functions of the Renal System
Maintenance of blood pressure:
The kidneys help regulate blood pressure by producing
and secreting the enzyme renin
in response to an actual or perceived decline in extra
cellular fluid volume. (Angiotensinogen) turns Renin
into angiotensin I which is converted into
angiotensin II (by an enzyme), the most potent
vasoconstrictor in the body.
Angiotensin II raises arterial blood pressure by…
RENIN…
1. Increasing peripheral vasoconstriction
2. Stimulating Aldosterone secretion
Aldosterone promotes the reabsorption of sodium and
water to correct the fluid deficit and/or inadequate
blood flow (renal ischemia)
Functions of the Renal System>
Failure

When the kidneys fail:
Patients are often
HYPERTENSIVE.
Functions of the Renal System
The collection and elimination of
metabolic waste such as urea and
creatinine:
The kidney’s job is to excrete the waste products of metabolism.
Urea is a byproduct of protein metabolism. It is not as adequate an indicator
of renal disease as elevated creatinine levels are because urea (BUN)
levels elevate with an increased protein intake, trauma, dehydration etc..
Serum creatinine levels are an accurate indicator of renal
function/dysfunction. The urinary excretion should equal the amount
produced by the body (by skeletal muscle catabolism).
Functions of the Renal System>
Failure
When the kidneys fail:
 The patient suffers from an overload of these
circulating uremic toxins.
All body systems may be affected.


the CNS is affected by the uremic toxins.
Drowsiness, poor memory, inability to concentrate, seizures, and
even come may result.

GI distress may result such as nausea, vomiting,
abdominal distension, diarrhea, and constipation.
Functions of the Renal System>
Failure
• Pericarditis may result as pericardium is
inflamed due to the buildup of these uremic
wastes. A pericardial friction rub and pain may
result.

Pruritis may result as the excretory
function of the skin attempts to excrete the
waste products. A uremic frost may be notable
on skin and collect on eyebrows. Skin may
become a pale yellowish color, as urochrome
pigments are present.

Anemia and thrombocytopenia occur
because the uremic toxins destroy RBCs
Acute Renal Failure:
Etiology:
Acute renal failure is defined as loss of functional
ability of the kidney. It has a sudden onset and is
reversible.
 It may be classified as:
• 1.
• 2.
• 3.
Prerenal
Renal (intrarenal) Causes
Postrenal
Classifications of ARF



Prerenal failure results from conditions that
diminish blood flow to the kidneys. (hypovolemia,
hypotension, poor cardiac output states)
Renal (intrarenal) failure results from
damage to the filtering structures of the kidneys.
(trauma, disease, antibiotics, pesticides)
Postrenal failure results from bilateral
obstruction of urine outflow. (ureteral obstruction,
bladder obstruction, urethral obstruction)
Pre-renal- renal artery not
getting the job done…
Diseases affect basement membrane which leads
to nephrotic syndrome= proteinuria
Pyelonenritis
Intra-renal fx
Bladder/uretal stones- post renal fx.
Acute Renal Failure- Phases
Phases:
 The course of acute renal failure is characterized by
three phases.

The oliguric phase occurs at the onset of symptoms
and could last as long as eight weeks. It is characterized
by a decreased urine output …(less than
400ml in 24 hours). The kidney is trying to
conserve sodium and water, and therefore hypervolemia,
edema, weight gain, pulmonary edema, and elevated blood
pressure occur. The BUN and creatinine rise thereby
causing uremic signs and symptoms. (nausea, changes in
mental acuity, fatigue, pericarditis)
Acute Renal Failure- Phases

The diuretic phase is marked by urine
output that can range from 1-5 L/day. The
kidney has lost its ability to conserve water.
Hypovolemia, (fluid) weight loss,
hypokalemia, hyponatremia all can result.
The BUN and creatinine begin to level out.
May last 7-14 days.
Acute Renal Failure- Phases

The recovery phase is reached when
the BUN and creatinine have returned to
normal. This phase can last from 3-12
months.
Acute Renal Failure- Diagnostic
Findings:
Laboratory data and other assessments reveal the
following:
.....(In the oliguric phase)
1.
2.
3.
4.
Decreased or absent urinary output
Increased BUN, creatinine, sodium,
potassium, chloride
Decreased calcium (high phos),
bicarbonate (acidosis), H/H (anemic)
Metabolic acidosis
Acute Renal Failure Management




What do you think is done to manage fluid
overload?
What do you think is used to manage the
hypertension?
What do you think is used to manage the
anemia?
Fluid restriction may be based on the previous day’s
output plus 400-500ml for insensible losses.)
(
Chronic Renal Failure-irreversible
Chronic renal failure is a progressive and
irreversible deterioration of kidney
function. Eventually, in end stage renal disease there
is less than 20% of nephron function
left.
Any diseases involving the kidney could progress to chronic
renal failure. (Acute renal failure could
terminate in chronic renal failure if left
untreated. )
Examples of causes ….include renal calculi, polycystic kidney disease,
and Diabetes Mellitus.
Chronic Renal Failure- Clinical
Manifestations:
 Uremic
Signs and Symptoms
 Electrolyte Disturbances, acid
base imbalances, and
anemias
 Fluid Volume Excess:
Chronic Renal FailureManagement
Diet…
 Protein?
 Sodium?
 Potassium?
 Fluid?
Chronic Renal FailureManagement
Drug therapy
 Which drugs are used to treat the patient in ESRD in
the following areas? Please provide specific
examples.







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Fluid overload & edema?
Blood pressure?
Nausea and vomiting?
Gastric acid secretions?
Constipation?
Anemia?
Itching /Pruritis?
Hyperphosphatemia?
Chronic Renal Failure- Emergency
Management of Hyperkalemia
Emergency measures:
• Hyperkalemia
1.
2.
3.
4.
Any more??????
Chronic Renal Failure- Emergency
Management
Cardiac tamponade
Pleural effusions
Pulmonary edema
Chronic Renal Failure Management:
Dialysis
Dialysis is a treatment used to:
• Restore fluid and electrolyte balance
• Correct Acid-base im balance
• Remove wastes like BUN &
creatinine
• Remove toxic materials from the
body.
Dialysis – three principles

It is based on three principles:
Diffusion: which is the movement of
particles across a semipermeable membrane from
areas of higher concentration to lower concentration.
This clears solutes from the body.
• 2.
Osmosis: which is the movement of
fluid across a semipermeable membrane from an
area of lesser solute concentration to an area of greater
solute concentration.
• 3.
Ultrafiltration: which is the movement of
fluid across a semipermeable membrane as a result
of an artificially created pressure gradient.
• 1.
Dialysis
Goals of Dialysis:
 To remove metabolic waste
products Like what?
 To maintain safe concentrations of
electrolytes (Especially potassium!!)
Why?
 To correct acid-base imbalances
Which one?
 To remove excess fluids
There are two types of dialysis available
 1. Peritoneal
Dialysis
 2. Hemodialysis
Peritoneal Dialysis
This method involves the instillation of a hypertonic
solution into the peritoneal cavity where it
remains for a prescribed period of time, until it is
drained. The amount of time the Dialysate remains
in the peritoneal cavity depends upon the type of
peritoneal dialysis used.
Fluids and solutes are transferred from the
bloodstream into the peritoneum when dialysate
solution is instilled into the peritoneal cavity. The
principles of osmosis and diffusion are carried
out.
Peritoneal Dialysis
In intermittent peritoneal dialysis:
 2 liters of dialysate is instilled into the
peritoneal cavity every night at bedtime. It is
allowed to drain after 5-7 hours. During
the day the abdomen remains empty.
Peritoneal Dialysis


Other methods leave the dialysate in the peritoneal cavity
(dwell time) for as little as 30 minutes.

Sometimes an automatic cycler is used and other times
the dialysate is timed manually.

Smaller amounts than 2 liters of dialysate may be used at
first until the client adjusts.)
Dialysate concentrations can be 1.5% or 4.25%
Peritoneal Dialysis


A thick catheter is used to gain access to the
peritoneal cavity.
The catheter can be used for long term or
temporary use.
• Tenckhoff
• Gore-Tex
• Column-disc
Peritoneal Dialysis
Peritonitis:
 Meticulous aseptic technique must be maintained
during handling of the catheter, tubing, and dialysate
solution.
What do you think the clinical evidence of
peritonitis would be?
Peritoneal Dialysis
Catheter related complications:
 Displacement or obstruction may
occur. Obstruction may be due to the adherence
of the catheter tip to the omentum, or to
exudates present due to infection, or to
malposition of the catheter. Peristalsis facilitates
outflow, so constipation can reduce catheter
flow.
Peritoneal Dialysis


Fibrin clot formation may be a problem
inside the catheter so heparin is often added to
the dialysate.
Bowel perforation may occur
especially in those who are malnourished.
……What do you think your first clue would to
tell if this complication has occurred?
Peritoneal Dialysis
Dialysis related complications:
 Pain: This may be due to rapid instillation of
dialysate, incorrect dialysate temp or ph,
dialysate accumulation under the diaphragm,
or excessive suction during outflow.
 Fluid and electrolyte imbalance may occur.
 Hyperglycemia Why do you think this
could occur?
You tube

peritoneal dialysis in renal failure

#8 Sam Scarce
Hemodialysis
In hemodialysis toxin-filled blood is removed
from the patient via some type of vascular access
site, pumped through a dialyzer, and then returned
to the client.
 The dialyzer has a blood compartment and a
dialysate compartment. The two compartments are
separated by a semipermeable membrane. Toxins
and wastes diffuse across the membrane from the
blood to the dialysate.
Hemodialysis -Vascular access
Sites
Various vascular access sites may be used:
 Internal Arteriovenous Fistulas: This
involves a surgical creation of an arteriovenous
anastomosis to provide easy access to blood. This is
used for clients requiring chronic dialysis.
An artery is anastomosed to a vein so that there is an
opening (fistula) between the artery and vein. The
flow of arterial blood causes the vein to become
engorged, and therefore usable in the dialysis
procedure. These fistulas require 6 weeks to be
mature enough for use. Other dialysis approaches
are used until then.
Hemodialysis -Vascular access
Sites
Internal Arteriovenous
Grafts:

An artificial graft is made to create an artificial vein for
blood flow. One end of the graft if anastomosed to an
artery, tunneled under the skin and then anastomosed to a
vein. It can be used two weeks after insertion.
Hemodialysis -Vascular access
Sites
External Arteriovenous
Shunts:

An external arterial cannula is connected to the dialyzer.
Blood returns through the venous cannula. When not
connected to the hemodialyzer, the cannulas are connected
to each other.
Hemodialysis-Vascular access
Sites
Femoral or Subclavian
Vein:

These catheters are temporary sources of vascular
access, and must be replaced frequently.
Hemodialysis
Schedule:

Hemodialysis must be continued intermittently for
a client’s lifetime if they have ESRD. A typical
treatment is 3-4 hours of treatment, 3-4 days a
week.
Hemodialysis
Complications of Hemodialysis:

Hypovolemic shock

Blood loss

Electrolyte imbalance

Air embolus
Hemodialysis on you tube
hemodialysis procedure video
Hemo Dialysis (Labs, H/H, Cautions)
Nursing Students