Cassandra Kubes
Adult Diagnosis
Chronic Renal Failure
Definition
Chronic renal failure (CRF) is a long-term kidney disease. It’s when the kidney’s capacity to
filter waste products from the blood, defined by the glomerular filtration rate (GFR), slowly
declines. (Lewis R, 2013).
Overview
CRF can be identified by two measurements; one being a blood test of an estimated GFR, or
urine test for albumin: creatinine ratio (ACR) to identify and quantify albumin in the urine. There
are 5 different stages of CRF and they are grouped up into 3 categories; stage 1-3a: very low risk
of progressing to end stage renal disease (ESRD) but an increased risk of cardiovascular disease,
stage 3b-4: significant risk of progression to ESRD, and stage 5: at or very near ESRD. Those
with 3a CKD should be monitored annually and those with stage 3b should be monitored every
six months (Lewis R, 2013).
Facts
People over the age of 40 experience a loss of glomerular filtration rate of about 1mL/min/year.
Renal vascular disease accounts for about 27 percent of cases of end stage renal disease (ESRD)
in people over 75 (Lewis R, 2013). In older people CRF will usually remain stable and will not
progress to ESRD. It is estimated that people with stage 3a CKD have a 1 percent chance of
developing ESRD within 5 years (Lewis R, 2013).
Etiology
The risk of developing cardiovascular disease and/or ESRD increases in proportion to the
amount of albumin in the urine. Some common causes of CRF include diabetic nephropathy,
hypertensive nephropathy, renovascular disease and obstructive uropathy. Chronic renal failure
has reached its end point when the buildup of toxic substances in the blood is sufficient to cause
systemic symptoms and ultimately death. Death can be avoided however through renal
replacement therapy (RRT) (Lewis R, 2013). CRF can also be associated with polypharmacy,
hyperphosphataemia, acidosis, gout, and pruritus (Lewis R. 2013).
Treatment
There are a few different options for treatments that can be done to help slow the process of
chronic renal failure which include renal replacement therapy (RRT) where patients get
hemodialysis or instead of RRT they can do an active conservative management which can
provide a better quality of life. “Hemodialysis is a process that is used to treat patients with CRF,
whereby the waste products of metabolism and accumulated fluids are removed” (Louis F.
Small, 2010). This treatment requires patients to come into the clinic 3 times a week for 4 hours
at a time. The process is an invasive way where needles are inserted allowing the blood to run
through a machine which will remove the metabolic waste products. If one cannot undergo
hemodialysis, there is an option of peritoneal dialysis. With peritoneal dialysis, one can stay in
their home and a nurse comes in every morning and night and will initiate and terminate the
procedure for them. Complications may include shock and other reactions (Louis F. Small,
2010). The other form of treatment that one may consider if they don’t want to do dialysis is
active conservative management, “Studies have shown that the life expectancy of patients over
80 is little if they have conservative management instead of RRT” (Louis F. Small 2013). This
form of treatment aims at reducing the impact of ESRD where dietary restriction of protein to
reduce uraemic symptoms and to slow progression of CRF (Louis F. Small 2013). This type of
treatment is more for those who live with dementia and heart failure because dialysis is tougher
on their bodies.
Signs and Symptoms
Chronic renal failure is usually detected by a reduction in urine output or through blood tests that
show an increase in serum creatinine. Another way to tell may be iron deficiency and so it’s
important to check ferritin levels (Lewis R, 2013). Signs to indicate possible CRF include; eGFR
is less than 7mL/min, intractable symptoms, weight loss of more than 10 percent in 6 months,
and hypoalbuminaemis. Symptoms of ESRD include: anorexia, nausea and vomiting; pruritus,
fluid overload, restless legs, muscle cramps, and pain (Lewis R, 2013). For those who undertake
hemodialysis may experience peripheral neuropathy, joint stiffness, pain, muscle wasting,
weakness, and numerous musculoskeletal and neuromuscular complications. Some signs and
symptoms that may occur are physical, emotional, and social problems that will usually result in
different impairments and functional limitations. They may show difficulties in ambulation,
balance deficits, joint pain/stiffness, and impaired independence in activities of daily living
(ADLs) (Nussbaum & Gracia 2009).
Dialysis affecting daily life
There are many side effects from doing Renal Replacement Therapy, all of which affect their
quality of live. Dialysis affects many areas of one’s life which includes; expenses, loss of
independence, strains on relationships, work-related stress, and physiological changes and
weaknesses. There are many expenses that come along with dialysis as it would with any other
therapy but just the medication and treatment payments exceeded many patients’ limit being
$150 each time a patients goes in for dialysis. “One such hidden cost lies in the specific dietary
requirements that have to be complied with, which necessitate the buying of special food groups
that are more costly than the standard diet items of the patients” (Louis F. Small 2010). A lot of
others experience work-related stress because it takes up so much time to complete dialysis each
week and so that is taking away time to be at work. It has also affected one’s relationships
because something that they enjoyed doing before with others, they may not be able to do it
anymore because of dialysis making them fatigue easier, muscle weakness, and difficulty with
ambulation (Louis F. Small 2010).
OT Interventions
There are 3 areas to focus on when doing OT treatments with CRF patients which include:
improve functional independence and ADLs; decrease upper-extremity pain, cramping, and
stiffness; and improve trunk and upper-extremity strength and dexterity (Nussbaum & Garcia
2009). Other areas to focus on in therapy are increasing quality of life and therapeutic exercises.
Areas to assess should be range of motion (ROM), strength and sensations, also testing gait
speed, and sit-to-stand time. “Weak muscles and impaired movements could be strengthened
with therapeutic activities, resistance exercises, and neuromuscular reeducation” (Nussbaum &
Garcia, 2009). Performing resistance exercises have been shown to respond similarly to
“healthy” counterparts, showing improvements in strength, functional capacity, muscle fiber
cross-sectional area, and electromyographic activity (Nussbaum & Garcia 2009). There are
various therapeutic modalities that could be used such as ultrasound, electrical stimulation, and
soft-tissue techniques. This may help alleviate spasms and decrease pain and hypertonic
structures. Those who undergo dialysis may not want to attend occupational therapy before or
after their dialysis treatment because they become too weak or tired. However, it’ll be more
beneficial for them to receive OT during the dialysis treatment because the patient would be
more likely to participate on a regular basis because it’ll be more convenient for them. If the
patient does not want to do therapy while in dialysis, it’s important for them to know that they
have the option to do therapy at their home. “Outpatient rehabilitation programming allows for a
more unrestricted program, minimizes infection control issues, and could be more functionally
oriented (Nussbaum & Garcia, 2009). Some patients may not see the importance of attending
occupational therapy so educating the patient, focusing on the importance and specific benefits
of rehabilitation, is very important to do.
References
Lewis, R. (2013). An overview of chronic kidney disease in older people. Nursing Older People,
25(10), 31-38.
Nussbaum, J., & Garcia, R. (2009). Restorative physical and occupational therapy: a critical need
for patients with chronic kidney and end-stage renal disease. Advances In Chronic Kidney
Disease, 16(6), 529-535.
Small, L. F. (2010). QUALITY-OF-LIFE EXPERIENCES FROM THE PERSPECTIVE OF
PATIENTS RECEIVING HAEMODIALYSIS FOR CHRONIC RENAL FAILURE.
Health S A, 15(1), 1-7.