Common Manifestations Associated with Acute and Chronic Renal Failure Acute Renal Failure: Initiation Phase: Few manifestations Maintenance Phase: 1) Urinary Changes: a) Output less than 20cc/ hr. b) Casts, RBCs, WBCs. c) Specific gravity of 1.010 same as plasma. Kidney can no longer concentrate urine. 2) Fluid Volume Excess: a) Fluid retention b) Distended neck veins c) Bounding pulse d) Edema e) CHF and pulmonary edema 3) Metabolic Acidosis: a) Kidney cannot excrete acid metabolites. b) Bicarbonate level decreases because bicarbonate is used to buffer hydrogen ions. Also there is defective reabsorption and regeneration. c) Kussmaul respiration to blow off CO2. 4) Sodium Excess: a) Sodium is retained b) leading to excess fluid volume, hypertension, and CHF. 5) Potassium Excess: a) Kidney cannot excrete K therefore high serum K levels. b) If failure is associated with tissue injury higher K levels may exist. c) Acidosis enhances K movement from intracellular to extracellular fluid. d) K levels above 6 mEq/L must be treated immediately to prevent cardiac dysthymias. Earliest sign is high peaked T waves on EKG. 6) Calcium Deficit: a) Decreased absorption from GI tract because of increased phosphate levels and increased excretion by the kidney. b) Usually asymptomatic because acidosis keeps what little calcium there is ionized. c) Azotemia: BUN and serum creatinine elevated 7) Confusion, disorientation, agitation or lethargy, hyper refexia, seizuresm anorexia, nausea, vomiting, absent bowel sounds and other manifesttions associated with azotemia and uremic syndrome. Recovery Phase: 1) Diuresis 2) Serum creatinine, BUN, potassium, and phosphate levels remain gigh and may continue to rise in spite of increasing urine output. Recovery m ay take up to a year. Chronic Renal Failure: 1) Diminished Renal Reserve: Absence of symptoms 2) Renal Insufficiency: Easy fatigue and weakness are common symptoms. Headaches, nocturia and polyuria occur. 3) Renal Failure: Increasing azotemia, edema metabolic acidosis, hypercalcemia and uremia. Oliguria with proteinuria, casts, pyuria, and hematuria, then anuria. 4) End Stage Renal Failure: kidney atrophy and fibrosis; overt uremia Physiological Effects of Azotemia and Uremia on Body Systems: Metabolic Disturbances: Azotemia: a) BUN and serum creatinine increase and creatinine clearance decrease. b) BUN influenced by protein intake, fever, and catabolic rate. c) Serum creatinine and creatinine clearance are better indicators of renal function than BUN. d) As BUN increases nausea, vomiting, diarrhea, and headaches occur. e) Uric acid levels increase leading to gouty arthritis. Actual incidence of gout is low. Carbohydrate Intolerance: a) Cells become insensitive to insulin leading to hyperinsulinism, hyperglycemia, and abnormal glucose metabolism. b) Insulin and glucose metabolism improve but do not return to normal with dialysis. c) Diabetics often require less insulin before. Elevated Triglycerides: a) Hyperinsulinemia stimulates hepatic pro- duction of triglycerides. b) Increase in triglycerides (type IV) leads to increased atherosclerosis. Electrolyte Imbalances: Potassium Excess: a) Kidneys cannot excrete. b) Acidosis causes shift from intracellular to extracellular. Metabolic Acidosis: a) Kidney cannot excrete NH3 and reabsorb and regenerate bicarbonate. b) Plasma bicarb usually stabilizes around 16 to 20 mEq/L. because of demineraization from the bone. c) Kussmaul respirations may occur but less prevalent than in acute. Magnesium: Excreted by the kidneys and is usually not a problem unless the client takes large amounts of milk of magnesia or antacids containing magnesium. Sodium Excess or Deficit: Excess usually develops in late stages. Hematological System: Anemia: a) Main cause is decreased erythropoietin by the kidney resulting in decreased erythropoiesis by the bone marrow. b) Additional causes are nutritional defi- ciencies, hypersplenism, decreased RBC life span and GI bleeding. c) Dialysis dialyzes folic acid, traumatizes RBCs, and blood may be lost in the dialyzer. Bleeding Tendencies: Uremia impair platelet aggregation and impairs release of platelet factor. Infection: a) Uremia decreases cellular and humoral immunity causing lymphopenia and lymphoid atrophy. b) Uremia also decreases chemotaxis causing neutrophils and monocytes to ignore an inflammation. c) Limited protein intake causes limited WBC production. Cardiovascular System: Hypertension: Caused by fluid retention and sometimes increased renin production may lead to atherosclerosis, intrarenal arterial spasm, CHF, retinopathy, and encephalopathy. Cardiac Arrhythmias: Caused by hyperkalemia, hypocalcemia, and decreased coronary artery perfusion. Pericarditis: Caused by edema may progress to hemorrhagic effusion and cardiac tamponade. M.I. and CVA are the leading cause of death for clients on dialysis. Respiratory System: Uremic pneumonitis: Show up as interstitial edema on X-ray. Thick tenacious sputum. Gastrointestinal Tract: Urea causes an inflammation of the mucosa. Ulcerations throughout the tract are caused by the increased ammonia produced by the bacterial breakdown of urea. Urine odor on breath and metallic taste. Constipation is a frequent complaint because of the aluminum antacids taken to lower phosphate levels. Neurological System: Cause unknown. Attributed to nitrogenous wastes. General Depression of the CNS: Apathy, lethargy inability to concentrate, convulsions and coma. Peripheral Neuropathy: May describe as bugs crawling on legs, burning sensations and eventually motor involvement such as foot drop, weakness, atrophy, and paralysis. Dialysis may or may not halt or reduce symptoms. Musculoskeletal System: Renal Osteodystrophy Phosphate is not excreted by the kidney. Calcium phosphate is formed leading to a drop in the serum calcium levels. The low serum calcium level stimulates a rise in parathyroid hormone eventually leading to demineralization of the bone. Normally the kidney metabolizes vitamin D which is either ingested or formed in the skin. Vit. D is necessary for calcium absorption from the GI tract. In failure the kidney does not metabolize Vit. D and calcium absorption is impaired. The above factors contribute to: a. Osteomalacia: Lack of mineralization of newly formed bones. b. Osteitis fibrosa: The calcium reabsorbed from the bone is replaced with fibrous tissue. c. Metastatic calcification: Calcium phosphate is deposited in soft tissues such as blood vessels, joints, lungs, myocardium and eyes (uremic red eye). Arterial calcification in the fingers and toes may cause gangrene. Integumentary System: Yellow color of the skin is caused by the uremia.. Pallor is caused by anemia. Dryness is caused by a decrease in oil gland activity. Puritis is caused by a combination of dry skin, calcium phosphate deposits on the skin, and sensory neuropathy. May also by caused by urea crystals on the skin which is called uremic frost. Petechiae and ecchymosis are due to clotting abnormalities. Reproductive System: Decrease in hormone levels cause decrease in libido and infertility. Amenorrhea and anovulation in women and low sperm count and loss of testicular consistency in men. Usually improves with dialysis. Endocrine System: Unexplained hypothyroidism.