Acute renal failure

1. NCM 106: Acute Biologic Crisis
ACUTE RENAL FAILURE

2. Acute Renal Failure
• It is a rapid loss of renal function
due to the damage of the
kidneys.
• It is a syndrome of varying
causation that results in sudden
decline in renal function

3. Pathophysiology:
Prerenal, Intrarenal, Post renal causes
↓
Hypoperfusion of the kidneys
↓
Alteration in kidney function
↓
Decreased glomerular filtration rate
↓
Retention of fluids and urinary sediments
↓
Increase in serum concentration of renal substances
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Kidney damage

4. Categories:
A. Prerenal Azotemia
- It is the result of impaired blood flow
that leads to hypoperfusion of the kidney
and a decrease in the GFR.
B. Intrarenal/ Intrinsic Renal failure
- It is the result of actual parenchymal
damage to the glomeruli or kidney tubules
C. Post renal Azotemia
- It occurs when urinary flow from both
kidneys, or a single functioning kidney, is
obstructed

5. Phases of Acute Renal Failure
I. Onset/Initiation
- begins with the initial insult and ends when oliguria
develops
II. Oliguric-Anuric phase
- accompanied by an increase in serum
concentration of substances usually excreted by the
kidneys (urea, creatinine, uric acid, organic acids and
intracellular cations- potassium and magnesium).
III. Diuretic Phase
- Marked by a gradual increase in urine output.
IV. Recovery phase
- Improvement of renal function

6. Clinical Manifestations
• Lethargy
• Hypovolemia- causes prerenal disease
a. Dehydration- dry skin and mucous membranes
• Hypervolemia- result from intrinsic or post renal disease
a. Hyperkalemia
b. Arrythmias
c. Rales
• Azotemia
a. Nausea and vomiting
b. Body malaise
c. Altered sensorium
d. Pericardial effusion/ pericardial friction rub

7. Clinical Manifestations
• CNS-
a. Encephalopathic changes- asterixis and confusion
a. Drowsiness
b. Headache
c. Muscle twitching
d. Seizures
• Non-specific diffuse abdominal pain and ileus
• Platelet dysfunction- bleeding

8. Assessment and Diagnostic Findings
• Urine assessment
a. Scanty to normal volume
b. Hematuria may be present
c. Low specific gravity
d. Unconcentrated urine
e. Prerenal Azotemia- decreased sodium and
normal urinary sediment and other cellular debris
f. Intrarenal Azotemia- increased sodium with urinary
casts
• Renal UTZ/ CT or MRI
• BUN
• Serum Creatinine levels

9. • Electrolyte imbalances
Hyperkalemia
Increase phosphate levels
Hypocalcemia
• Metabolic acidosis
• Anemia

10. Prevention:
1. Obtain a careful history to identify exposure to
nephrotoxic agents or environmental toxins.
2. Patients should be monitored closely for
changes in the renal function.
3. Provide adequate managements depending on
its cause to prevent further occurrence of
complications

11. Medical Management:
Objectives of treatment:
1. Restore normal chemical balance
2. Prevent complications until repair of renal tissue and
restoration of renal function can occur.
• 1. Eliminate underlying cause.
• 2. Maintain fluid balance basing on patient’s daily body
weight, serial measurements of CVP, serum and urine
concentrations, fluid losses, BP and clinical status of the
patient.
a. Fluid replacement
b. Assess for fluid excess

12. Medical Management:
c. Administer medications that will initiate diuresis as
ordered:
• mannitol (Osmitrol)
• furosemide (Lasix)
• ethacrynic acid (Edecrin)
d. IV fluids or transfusions of blood products
e. Dialysis may be initiated to prevent complications
 Hemodialysis
 Peritoneal dialysis
 Continuous Renal replacement Therapies (CRRTs)

13. Pharmacologic Therapy
1. Manage Hyperkalemia promptly
• Kayexalate- orally or retention enema
• Sorbitol in combination with Kayexalate
• IV dextrose 50%, insulin and calcium
replacement
• Albuterol sulfate (Ventolin HFA) by nebulizer
2. Treat severe acidosis and increase in
phosphate levels
• Sodium bicarbonate therapy
• Phosphate-binding agents (Calcium or
lanthanum carbonate)

14. Nutritional therapy
1. High-protein diet
2. High-carbohydrate meal
3. Restrict foods and fluids that are high in potassium and
phosphorus
Nursing Management:
1. Monitoring Fluid and Electrolyte Imbalance
- Monitor serum electrolyte levels and physical indicators
of complications during all phases of the disorder.
- Parenteral fluids, all oral intake and all medications are
screened carefully to ensure that hidden sources of
potassium are not inadvertently administered or
consumed.

15. Nursing Management:
1. Monitoring Fluid and Electrolyte Imbalance
- Monitor patient’s cardiac function and musculoskeletal
status to signs of hyperkalemia.
- MIO and weigh daily accurately
2. Reducing Metabolic Rate
- Bed rest to reduce exertion and metabolic rate during
the most acute stage.
- Prevent infection and fever.
3. Promoting Pulmonary Function
- Assist patient to turn, cough and take deep breaths
frequently to prevent atelectasis and respiratory tract
infection.

16. Nursing Management:
4. Prevent Infection
- Asepsis should be thoroughly practiced with handling of
invasive lines and catheters to minimize the risk of
infection and increase in metabolism.
5. Providing Skin care
- Meticulous skin care should be performed to prevent
breakdown as a result of edema.
- Bath the patient with cool water.
- Frequently turn the patient and keep the skin clean and
well-moisturized.
6. Providing Psychosocial Support
- The patient and the family should be given assistance,
thorough explanation and support during the lengthy
treatment.

17. NCM 106: Acute Biologic Crisis Lecture Series
ACUTE RENAL FAILURE
Cygnette S. Lumbo, RN,MN