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Chapter 34 Acute Renal Failure and Chronic Kidney Disease Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Postrenal Causes of Acute Renal Failure • Bilateral ureteral obstruction • Bladder outlet obstruction Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Congestive heart failure would be a(n) ________________ cause of renal failure. a. Prerenal b. Intrarenal c. Postrenal Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a. Prerenal: The causative factor is “before” the kidney. b. Intrarenal c. Postrenal Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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) Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Definition and Classification • K/DOQI of the NKF published clinical practice guidelines for CKD. • Guidelines use the GFR to classify CKD into five stages Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Hematologic Disorders Accompanying Renal Failure • Anemia • Coagulopathies Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiovascular Disorders Accompanying Renal Failure • Hypertension • Heart disease • Pericarditis Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment of Renal Failure • Medical management – Dialysis • Hemodialysis • Peritoneal dialysis – Transplantation Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment of Renal Failure (cont.) • Dietary management – Protein – Carbohydrates, fat, calories – Potassium – Sodium and fluid intake Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Options for Chronic Renal Failure in the Elderly and Children • Hemodialysis • Peritoneal dialysis • Transplantation Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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+ Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins 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+ Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins