Download Chronic kidney disease

Chapter 34
Acute Renal Failure and
Chronic Kidney Disease
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Renal Failure
• Definition
– A condition in which the kidneys fail to remove
metabolic end products from the blood and regulate
the fluid, electrolyte, and pH balance of the
extracellular fluids
• Underlying causes
– Renal disease
– Systemic disease
– Urologic defects of nonrenal origin
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Types of Renal Failure
• Acute renal failure
– Abrupt in onset
– Often reversible if recognized early and treated
appropriately
• Chronic kidney disease
– End result of irreparable damage to the kidneys
– Develops slowly, usually over the course of a number
of years
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Prerenal Cases of Acute Renal Failure
• Hypovolemia
• Decreased vascular filling
• Heart failure and cardiogenic shock
• Decreased renal perfusion due to vasoactive mediators,
drugs, diagnostic agents
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Postrenal Causes of Acute Renal Failure
• Bilateral ureteral obstruction
• Bladder outlet obstruction
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Intrinsic or Intrarenal Causes of Acute
Renal Failure
• Acute tubular necrosis
– Prolonged renal ischemia
– Exposure to nephrotoxic drugs, metals, organic
solvents
– Intratubular obstruction resulting from
hemoglobinuria, myoglobinuria, myeloma light
chains, or uric acid casts
– Acute renal disease
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Phases of Acute Tubular Necrosis
• Onset or initiating phase
– Lasts hours or days
– The time from the onset of the precipitating event
until tubular injury occurs
• Maintenance phase
– Characterized by a marked decrease in the GFR
• Recovery phase
– Period during which repair of renal tissue takes place
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Question
• Congestive heart failure would be a(n)
________________ cause of renal failure.
a. Prerenal
b. Intrarenal
c. Postrenal
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Answer
a. Prerenal: The causative factor is “before” the kidney.
b. Intrarenal
c. Postrenal
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Prevention and Early Diagnosis
of Acute Renal Failure
• Assessment measures to identify persons at risk for
development of acute renal failure
– Those with preexisting renal insufficiency and
diabetes
– Elderly persons (due to the effects of aging on renal
reserve)
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Common Causes of Chronic Kidney
Disease
• Hypertension
• Diabetes mellitus
• Polycystic kidney disease
• Obstructions of the urinary tract
• Glomerulonephritis
• Cancers
• Autoimmune disorders
• Diseases of the heart or lungs
• Chronic use of pain medication
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Definition and Classification
• K/DOQI of the NKF published clinical practice guidelines
for CKD.
• Guidelines use the GFR to classify CKD into five stages
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Stages of Chronic Kidney Disease
1. Damage with normal or increased GFR
2. Mild reduction of GFR to 60–89 mL/min/1.73 m2
3. Moderate reduction of GFR to 30–59 mL/min/1.73 m2
4. Severe reduction in GFR to 15–29 mL/min/1.73 m2
5. Kidney failure with a GFR < 15 mL/min/1.73 m2 , with a
need for renal replacement therapy
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Treatment During the Renal Insufficiency
Stage of Renal Failure
• Using measures to retard deterioration of renal function
and assist the body in managing the effects of impaired
function
– Treating urinary tract infections promptly
– Avoiding medication with renal-damaging potential
– Controlling blood pressure
– Controlling blood sugar in persons with diabetes
– Stopping smoking
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Target Populations Comprising Persons
With Chronic Kidney Disease
• Persons with chronic renal insufficiency
• Persons with CKD being treated with hemodialysis
• Persons with CKD being treated with peritoneal dialysis
• Renal transplant recipients
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Question
• A GFR of _____________ best describes renal failure.
a. 60–89 mL/min/1.73 m2
b. 30–59 mL/min/1.73 m2
c. 15–29 mL/min/1.73 m2
d. <15 mL/min/1.73 m2
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
a. 60–89 mL/min/1.73 m2
b. 30–59 mL/min/1.73 m2
c. 15–29 mL/min/1.73 m2
d. <15 mL/min/1.73 m2 : This level is the result of
significantly decreased renal filtration and is the cut-off
point of renal failure.
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Factors Determining the Manifestations of
Renal Failure
• The extent of renal function present
• Coexisting disease conditions
• The type of renal replacement therapy the person is
receiving
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Clinical Manifestations of Chronic Renal
Failure
• Accumulation of nitrogenous wastes
• Alterations in water, electrolyte, and acid-base balance
• Mineral and skeletal disorders
• Anemia and coagulation disorders
• Hypertension and alterations in cardiovascular function
• Gastrointestinal disorders
• Neurologic complications
• Disorders of skin integrity
• Immunologic disorders
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Disorders of Water, Electrolyte, and
Acid-Base Balance
• Sodium and water balance
– The kidneys function in the regulation of extracellular fluid
volume.
• Potassium balance
– Approximately 90% of potassium excretion is through the
kidneys.
• Acid-base balance
– The kidneys normally regulate blood pH by eliminating
hydrogen ions produced in metabolic processes and by
regenerating bicarbonate.
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Hematologic Disorders Accompanying
Renal Failure
• Anemia
• Coagulopathies
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Cardiovascular Disorders Accompanying
Renal Failure
• Hypertension
• Heart disease
• Pericarditis
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Altered Drug Metabolism in Kidney
Disease
• CKD and its treatment can interfere with the absorption,
distribution, and elimination of drugs
– Altered drug absorption
• Antacid treatment
– Altered metabolism
• Result of less protein-bound drugs
• Increased intermediates of drug metabolism
– Alterations in dosage may be required.
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Treatment of Renal Failure
• Medical management
– Dialysis
• Hemodialysis
• Peritoneal dialysis
– Transplantation
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Treatment of Renal Failure (cont.)
• Dietary management
– Protein
– Carbohydrates, fat, calories
– Potassium
– Sodium and fluid intake
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CKD in Children
• Causes
• Manifestations
– Congenital
malformations
– Severe growth
impairment
– Inherited disorders
– Developmental delay
– Acquired diseases
– Delay in sexual
maturation
– Metabolic syndromes
– Bone abnormalities
– Development of
psychosocial problems
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CKD in the Elderly
• Normal decrease in GFR with age
– Increased detrimental effects of nephrotoxic drugs
• Greater incidence of cerebrovascular, cardiovascular, and
skeletal system effects
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Treatment Options for Chronic Renal
Failure in the Elderly and Children
• Hemodialysis
• Peritoneal dialysis
• Transplantation
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Question
• Which of the following alterations may affect drug
efficacy in a patient with CKD?
a. Loss of K+
b. Alteration in pH
c. Loss of albumin
d. Increased Ca2+
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Answer
a. Loss of K+
b. Alteration in pH
c. Loss of albumin: Loss of albumin will result in altered
drug metabolism via increased intermediates and faster
action.
d. Increased Ca2+
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