Acute Renal Failure
Sam Jones is a 20 year old white male. He is 6’0” ft tall and weighs 170 lbs. He is a
student in college and is involved in club basketball so he stays moderately active.
He says he has a good appetite, eats a high protein diet, but never drinks water. Sam
came to the hospital with severe pain in his stomach area and side of his back, he
then felt it in his groin. He was nauseas and vomiting and had the chills. He was
experiencing decreased appetite and fatigue. He was not urinating often and when
he did he saw blood in it. After a urinalysis, Sam was diagnosed with having
obstructive acute renal failure due to a kidney stone (uric acid stone). Sam
mentioned that his father also experienced kidney stones.
Sam’s physical examination showed pain and sensitivity in his groin/stomach/side
back area. Swelling in his hands and feet, along with some bruising. His abnormal
lab values included:
(H) Serum creatinine – a waste product made when your body breaks down
protein you eat. High levels mean kidney damage
(L) Creatinine clearance – used to estimate filtering capacity of the kidneys;
amount of creatinine in urine is compared to
amount in blood. Low levels mean kidney damage
(L) Glomerular Filtration Rate (GFR) – how well your kidneys filter wastes
from blood; speed at which kidneys
are failing. Low levels mean kidney
damage
(H) Blood Urea Nitrogen (BUN) – measure of wastes (urea – from
breakdown of protein) in blood. High
levels mean less kidney function
(H) Serum potassium – amount of potassium in blood (helps nerves/muscles
communicate – helps move nutrients into cells and
waste products out of cells). High levels mean decreased
kidney function
(L) Calcium – calcium in blood; for bone health. Low levels due to kidney failure
because kidneys control calcium/phosphorus levels – and body
cannot take in enough calcium – so takes calcium from bones
(H) Phosphorus – phosphorus in blood; for bone health & nerve/muscle function.
High levels due to kidney failure
Acute Renal Failure
a. Etiology
i. Acute renal failure (ARF) is the abrupt cessation or reduction in
glomerular filtration rate (GFR) at which blood is filtered in the glomeruli of
the kidney. Rapid loss of the kidneys' ability to remove waste (accumulation
of nitrogenous wastes) and help balance fluids and electrolytes in your body.
Characterized by oliguria (decreased urine production) and fluid &
electrolyte imbalance. If blood flow is not restored, necrosis of the cells will
occur (chronic renal failure). It is often reversible with adequate
treatment.
1. Causes:
a. Acute tubular necrosis (ATN)
b. Autoimmune kidney disease
c. Blood clot from cholesterol (cholesterol emboli)
d. Decreased blood flow due to very low blood pressure, which
can result from:
 Burns
 Dehydration
 Hemorrhage
 Injury
 Septic shock
 Serious illness
 Surgery
e. Disorders that cause clotting within the kidney’s blood
vessels
f. Infections that directly injure the kidney, such as:
 Acute pyelonephritis
 Septicemia
g. Pregnancy complications, including:
 Placenta abruptio
 Placenta previa
h. Urinary tract blockage – Kidney stone
(MedlinePlus Medical Encyclopedia, www.nlm.nih.gov)
2. 3 Major Types of Acute Renal Failure:
a. Pre-renal azotemia – conditions that reduce perfusion to the
kidney
 Severe dehydration, circulatory collapse, fluid losses
from the GI tract, or from extensive wounds such as
burns
b. Intrinsic – damage to the anatomical structure of the kidney
 After exposure to toxins such as antibiotics,
chemotherapy, or contrast dyes used in imaging tests,
infection such as glomerulonephritis, or inflammation
c. Obstructive** – blockage of the ureter or neck of the
bladder
 Kidney stones, blood clots, or a tumor
3. Four Phases of ARF
a. Initiation – when GFR declines
b. Extension – when ischemia and inflammatory damage
continue
c. Maintenance – when GFR is at its lowest level
d. Recovery – when epithelial cells regenerate
ii. Clinical Manifestations
1. Detected by a decrease in or absence or urine production or
determination of waste products (creatinine or urea) in the blood.
2. Normal urine output is 1 to 1.5 L per day. During the period when
GFR declines and reaches its lowest level, ARF patients may produce
<500 mL or urine.
3. ARF patients are likely to develop fluid and electrolyte disorders,
azotemia, and wasting. In acute renal failure, there may be problems
with increased fluid in the body (leading to swelling), increased acid
levels, raised levels of potassium, decreased levels of calcium,
increased levels of phosphate, and in later stages anemia. Bone health
may also be affected.
a. Electrolytes
b. Blood Urea Nitrogen and Creatinine
(Nutrition Therapy & Pathophysiology, p. 550)
b. Diagnostic Measures
i. Symptoms:
1. Bloody stools, breath odor, metallic taste in mouth, bruising easily,
changes in mental status or mood, decreased appetite, decreased
sensation (esp. in hands/feet), fatigue, flank pain, hand tremor, high
blood pressure, nausea/vomiting, nosebleeds, hiccups, prolonged
bleeding, seizures, shortness of breath, slow movements, swelling due
to body keeping in fluid, urination changes (little or no urine;
excessive urination at night; urination stops completely)
ii. Exams & Test:
1. Examination – check for swelling; heart murmur; crackles in the
lungs
2. *Kidney or abdominal ultrasound – preferred test for diagnosing a
blockage in the urinary tract.
3. X-ray, CT scan, or MRI of the abdomen can also tell if there is
blockage.
4. Blood tests – may help reveal the underlying cause of kidney failure.
a. Laboratory tests:
 BUN
 Creatinine clearance
 Serum creatinine
 Serum potassium
 Urinalysis
(MedlinePlus Medical Encyclopedia, www.nlm.nih.gov)
c. Treatment
i. Medical, Surgical and/or Psychological Treatment
1. Acute Renal Failure is often reversible with adequate
treatment
2. The underlying cause must be identified and treated to arrest the
progress*
3. Once the cause is found – the goal of treatment if to help the
kidneys work again and prevent fluid and waste from building up
in the body while they heal
4. Usually – a stay overnight in the hospital is required
5. May need antibiotics to treat or prevent infection
6. Diuretics (water pills) – may be used to remove fluid from the
body
7. Medicines will be given through a vein to help control blood
potassium level
8. Dialysis may be needed for some patients – can make them feel
better – may be necessary to bridge the time gap required for
treating these fundamental causes. Can save life if potassium
levels are dangerously high. Dialysis will most often be short
term – rarely the kidney damage is so great that it may be
permanently needed.
Dialysis will be used if:
a. Your mental status changes
b. If you stop urinating
c. You develop pericarditis (sac-like covering around
the heart “pericardium” becomes inflamed)
d. You cannot eliminate nitrogen waste products from
your body
9. Support groups can be beneficial – because often the stress of
having an illness can often be helped by joining a group where
members have common experiences and problems – to work
together through
(MedlinePlus)
ii. Medical Nutrition Therapy – Treatment for Client
1. Fluid Control (500 cc + urine output)
 Kidneys help control the amount of fluid that leaves your
body. With acute renal failure the kidneys are unable to
regulate the removal of fluid from your body. Too much
fluid may cause swelling, shortness of breath, or high
blood pressure.
a. Limit fluid intake
 Water, coffee, tea, sodas, soups, popsicles,
ice cream, sherbets, ice cubes, gelatin,
watery vegetables/fruits, milk, liquid
creamer, wine/beer
b. Tips:
 Drink only when thirsty
 Eat less salt – feel less thirsty
 Brush your teeth 3-4 times a day – prevent
mouth from drying out
 Suck on lemon wedge
 Chew sugarless gum or suck on sugarless
hard candy
 Measure how much fluid your favorite cup
or glass holds to be able to better monitor
fluid intake
 After measuring how much total fluid you
can drink for the day – place in a container
and drink only from it.
2. Phosphorus (maintain serum value within normal limits)
 When kidney function declines, the body has a difficult
time keeping phosphorus and calcium in balance. As a
result, the body cannot get rid of excess phosphorus.
a. Low phosphorus diet
 High phosphorus foods (Avoid): cola
drinks, peanut butter, cheese, sardines,
chicken/beef liver, nuts, caramels, beer,
ice cream
 Low phosphorus foods (Choose): broccoli,
non-dairy substitutes
b. Phosphate binder
3. Potassium (2 grams/2000 mg)
 The kidneys are responsible for helping to keep the
correct amount of potassium in your body. High levels of
potassium are very dangerous.
 Most foods contain potassium. Serving size will
determine which as low, moderate, or high potassium
levels.
a. Low potassium diet
 High potassium foods (Avoid): bananas,
broccoli, chocolate, oranges, potatoes,
coffee, cantaloupe, tomatoes, salt
substitutes, prunes, mushrooms, bran
products, raisins, greens, apricots
 Low potassium foods (Choose): apples,
beans (green), rice, grapes, cucumber,
noodles, pears, onions, watermelon,
lettuce, cereal, cranberries, carrots, bread
products, cherries
 (See attached sheet for complete list)
4. Protein (80 grams)
 Protein is needed to maintain muscles, aid in building
resistance to infections, and repair/replace body tissue. As
protein is broken down in the body, waste products called
urea are formed. As kidney function declines, urea builds
up in the blood.
 Eating too much protein may cause urea to build up too
quickly – this will cause a sick feeling.
 Eating less protein may be helpful in reducing your blood
urea levels.
 Need both high quality and low quality protein in diet –
choose wisely
a. Low protein diet
 High protein foods (Eat less): meat,
poultry, milk products, eggs
 Low protein foods (Eat more): fresh
beans (pinto, kidney, navy), grains,
vegetables
5. Sodium (2 grams/2000 mg)
 Sodium is needed for many functions such as controlling
muscle contractions, balancing fluids, and controlling
blood pressure. Healthy kidneys remove excess sodium in
the urine. As kidney function declines, sodium and fluids
may accumulate in your body. May cause swelling in
eyes, hands, and/or feet/ankles.
 To keep sodium level in balance – limit sodium in diet.
a. Low sodium diet
 High sodium foods: table salt,
bouillon cubes, potato chips, nuts,
bacon, cold cuts, cheese,
canned/dehydrated/instant soups,
canned vegetables, processed meals
 Low sodium alternatives: season
with a variety of spices like garlic or
oregano, use lemon
(Medical College of Wisconsin)
iii. Prognosis
1. Acute renal failure is often reversible with adequate treatment.
Once the underlying cause is determined, a renal diet and dialysis
(in some cases) can aid the kidneys during healing and treatment
until they are stable enough to work on their own.
2. However, patients with acute renal failure have a higher risk of
acquiring chronic renal failure in the future.
References
Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology.
“Acute Kidney Failure.” MedlinePlus. U.S. National Library of Medicine. 24 January
2013. www.nlm.nih.gov
“Kidney Disease.” Fresenius Medical Care. 2012. Fresenius Medical Care Holdings, Inc.
www.ultracare-dialysis.com
“Kidney Stones.” Mayo Clinic. 2013. Mayo Foundation for Medical Education and
Research. www.mayoclinic.com
“Lab Values Explained: Measures of Kidney Function.” Life Options. A Program of
Medical Education Institute, Inc. 2013. www.lifeoptions.org/kidneyinfo
“Diet: The Role of the Renal Diet” Kidney Patient Guide. September 2012.
www.kidneypatientguide.org
“Kidney Disease and Diet.” Academy of Nutrition and Dietetics. 2013.
www.eatright.org
“Management of Acute Renal Failure.” American Academy Family Physician. 2005.
www.aafp.org
“Diet for Renal Patient.” Medical College of Wisconsin. 2013. www.mcw.edu
“Kidney Disease.” The National Kidney Foundation. 2013. www.kidney.org