Renal Failure is the condition in which the kidneys are unable to remove metabolic waste from the blood. Acute renal failure has an abrupt onset and is reversible. Chronic renal failure, on the other hand, is gradual, progressive and irreversible.

Cause of Acute Renal Failure

The causes for acute renal failure can be classified into three. Pre-Renal, Intra-Renal, and Post-Renal. Pre-Renal causes are cardiogenic shock, hemorrhage, excessive gastrointestinal fluid loss, dehydration, sepsis, anaphylaxis, and burns. Intra-Renal causes are acute glomerulonephritis, vasculitis, disseminated intravascular coagulation, rhabdomyolysis, metabolic imbalances, pyelonephritis, infections, toxin (aminoglycosides), NSAIDs, contrast medium, and dye. Post-Renal causes are calculi, stricture, cancer, and prostatic enlargement.

Types of Chronic Renal Failure

  1. Decreased Renal Reserve – Glomerular Filtration Rate 50%. It is asymptomatic and azotemia.
  2. Renal Insufficiency – Glomerular filtration Rate 20-50%.
  3. End-Stage Renal Disease – Glomerular Filtration Rate <5%. Uremia is present. Signs of End-Stage Renal Disease
    • Uremic fetur
    • Uremic frost – skin is yellowish due to accumulation of metabolic wastes.
    • Anemia – decreased erythopoietin
    • Decreased platelets
  4. Renal Failure – Glomerular Filtration Rate 10-20%, with positive signs.

Pathophysiology of Acute Renal Failure

The pre-renal causes can lead to hypovolemia and would then decrease renal blood flow, then acute renal failure. The intra-renal causes can lead to direct renal damage and acute tubular necrosis which then lead to acute renal failure. Post-renal causes can lead to decreased urine output or renal flow which can cause renal retention and then acute renal failure.

Stages of Acute Renal Failure

  1. Oliguric or Initiation = 1-3 weeks
    • Urine output less than 400mL per day.
    • Increased BUN, Creatinine
    • Hyperkalemia, Phosphatemia, Magnesemia
    • Hyponatremia
    • Edema
    • Hypertension
    • Metabolic acidosis = 4-6 weeks
  2. Diuretic or Maintenance
    • Normal blood pressure, creatinine, BUN
    • Negative for edema
    • Hypokalemia
  3. Recovery = 3-12 months

Management for Acute Renal Failure

  1. Treat hyperkalemia
    • Sodium bicarbonate
    • Glucose
    • Insulin
    • Calcium chloride
    • Sodium Polysterene Sulfonate (Kayexalate): For the exchange of Sodium and Potassium in the gastrointestinal tract.
  2. Treat hyperphosphatemia: Aluminum hydroxide (Amphojel)
  3. Diuretics: Furosemide, Mannitol
  4. Dopamine
  5. ACE inhibitor: Captopril
  6. Diet: Decreased Protein, increased Calcium
  7. Fluids
  8. Dialysis

Nursing Care Management for Acute Renal Failure

  1. Excess Fluid Volume
    Nursing Care Management:
    • Weight, hourly check the urine output
    • BUN, creatinine
    • Restrict fluids and sodium
    • Offer hard candies and ice chips
  2. Imbalanced Nutrition: Less Than Body Requirements
    Nursing Care Management:
    • Frequent small feedings
    • Ask the family members to join the patient in eating
    • Provide a high caloric or carbohydrate diet

Diagnostic Exam for Acute Renal Failure and Chronic Renal Failure

  1. Urinalysis – Increased white blood cell, red blood cell, casts (cellular debris), and epithelial cells.
  2. BUN, creatinine
  3. Kidney, Ureter, Bladder Ultrasound
  4. Intravenous Pyelogram
  5. Complete Blood Count – Decreased hemoglobin, hematocrit, and red blood cells.
  6. Blood Chemistry – Increased potassium, phosphorus, magnesium; decreased sodium and proteins

Management for Chronic Renal Failure

Treatment of Choice: Renal Transplantation

Dialysis

  1. Severe fluid volume
  2. Hyperkalemia
  3. Uremia
  4. Metabolic acidosis
Types of Dialysis
  • Hemo-connection: A-V Fistula is the preferred site. Nurses should watch out for disequilibrium syndrome due to increased intracranial pressure. Signs and symptoms for disequilibrium syndrome are headache and levels of consciousness changes. Nurses should also monitor for signs of infection at the site of insertion, hypotension, and chills.
  • Peritoneal dialysis – dialysing surface