Continuing Education ActivityThe term renal failure denotes inability of the kidneys to perform excretory function leading to retention of nitrogenous waste products from the blood. Acute and chronic renal failure are the two kinds of kidney failure. When a patient needs renal replacement therapy, the condition is called end-stage renal disease (ESRD). This activity reviews the causes, pathophysiology, presentation and diagnosis of renal failure and highlights the role of the interprofessional team in its management. Show
Objectives:
Access free multiple choice questions on this topic. IntroductionThe term renal failure denotes the inability of the kidneys to perform excretory function leading to retention of nitrogenous waste products from the blood. Functions of the kidney are as follows:
Acute and chronic renal failure are the two kinds of kidney failure. Acute Renal Failure (ARF) ARF is the syndrome in which glomerular filtration declines abruptly (hours to days) and is usually reversible. According to the KDIGO criteria in 2012, AKI can be diagnosed with any one of the following: (1) creatinine increase of 0.3 mg/dL in 48 hours, (2) creatinine increase to 1.5 times baseline within last 7 days, or (3) urine volume less than 0.5 mL/kg per hour for 6 hours. [1] Recently the term acute kidney injury (AKI) has replaced ARF because AKI denotes the entire clinical spectrum from a mild increase in serum creatinine to overt renal failure. [2] Chronic Renal Failure (CRF) CRF or chronic kidney disease (CKD) is defined as a persistent impairment of kidney function, in other words, abnormally elevated serum creatinine for more than 3 months or calculated glomerular filtration rate (GFR) less than 60 ml per minute / 1.73m2. It often involves a progressive loss of kidney function necessitating renal replacement therapy (dialysis or transplantation). When a patient needs renal replacement therapy, the condition is called end-stage renal disease (ESRD). [1] CKD classified based on grade:
CKD classified based on stage:
EtiologyRenal Failure Etiopathogenesis Acute Renal Failure [3]
Chronic Renal Failure [4]
EpidemiologyThe incidence of AKI has been cited as 1% on hospital admission, 2% to 5% during hospitalization, and in as many as 37% of patients treated in intensive care units (ICUs), and in 4% to 15% of patients after cardiovascular surgery. [5] [6] [7]
PathophysiologyRenal failure pathophysiology can be described by a sequence of events that happen while during acute insult in the setting of acute renal failure and also gradually over a period in cases of chronic kidney diseases. Broadly, AKI can be classified into three groups: [9]
The pathophysiology of CRF is related mainly to specific initiating mechanisms. Over the course of time-adaptive physiology plays a role leading to compensatory hyperfiltration and hypertrophy of remaining viable nephrons. As insult continues, sub sequentially histopathologic changes occur which include distortion of glomerular architecture, abnormal podocyte function, and disruption of filtration leading to sclerosis. [10] History and PhysicalThe relevant history and physical examination findings associated with renal failure include: History
Physical examination
EvaluationPatients with renal failure have a variety of different clinical presentations as explained in the history and physical exam section. Many patients are asymptomatic and are incidentally found to have an elevated serum creatinine concentration, abnormal urine studies (such as proteinuria or microscopic hematuria), or abnormal radiologic imaging of the kidneys. The key laboratory and imaging studies to be ordered in patients with renal failure follow. Laboratory Tests
Fractional excretion of sodium (FENa) = [(UNa x PCr)/ (PNa x UCr)] x 100, where U is urine, P is plasma, Na is sodium, andCr is Creatinine. If FeNa less than 1, then likely prerenal; greater than 2, then likely intrarenal; greater than 4, then likely postrenal If the patient is on diuretics, use FEurea instead of FENa. Complete blood count, BUN, creatinine (Cr), arterial blood gases (ABGs)
Special Labs
Imaging
More advanced imaging techniques should be considered if initial tests do not reveal etiology:
Treatment / ManagementTreatment options for renal failure vary widely and depend on the cause of failure. Broadly options are divided into two groups: treating the cause of renal failure in acute states versus replacing the renal function in acute or chronic situations and chronic conditions. Below is the summary of renal failure treatment. Acute Renal Failure
General Measures
Immediate Dialysis Indications
Chronic Renal Failure
Differential Diagnosis
Complications
Consultations
Pearls and Other Issues
Enhancing Healthcare Team OutcomesThe management of kidney failure is usually done with an interprofessional team of healthcare professionals dedicated to preserving renal function. Kidney failure has enormous morbidity and mortality, costing the healthcare system billions of dollars each year. Today most hospitals have a kidney failure nurse whose job is to educate patients on the causes, detection, and prevention of kidney failure. The pharmacist also needs to regularly audit patient medications for those that are nephrotoxic. When monitoring patients with kidney failure, the nurse should note the urine output, levels of potassium, blood sugar and creatinine. Control of blood pressure and blood sugars is vital in the prevention of kidney disease. The diabetic nurse should closely monitor the renal function of all diabetics and refer patients to the nephrologist if the renal function is deteriorating. The pharmacist should emphasize the importance of medication compliance for treatment of blood pressure. These patients should have close follow up to ensure that the renal function is not deteriorating. Finally, the patient needs to be given advice on healthy eating, exercise, discontinuing tobacco and abstaining from alcohol. Kidney disease is not well managed can lead to complete renal failure, which requires dialysis.[11][12] (level V) Only through open communication between the team members can the morbidity and mortality of renal failure be lowered. Outcomes Recovery from acute renal failure depends on the cause of the disease. If the cause is reversible, the prognosis is good and leans toward a full recovery. Partial recovery of renal function may occur if the injury does not fully resolve. Severe cases of acute renal failure can result in death.
Review QuestionsReferences1.Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005 Nov;16(11):3365-70. [PubMed: 16177006] 2.Luo X, Jiang L, Du B, Wen Y, Wang M, Xi X., Beijing Acute Kidney Injury Trial (BAKIT) workgroup. A comparison of different diagnostic criteria of acute kidney injury in critically ill patients. Crit Care. 2014 Jul 08;18(4):R144. [PMC free article: PMC4227114] [PubMed: 25005361] 3.Friedman EA. Acute renal failure. N Engl J Med. 1996 Oct 24;335(17):1321; author reply 1321-2. [PubMed: 8992331] 4.Calderon-Margalit R, Golan E, Twig G, Leiba A, Tzur D, Afek A, Skorecki K, Vivante A. History of Childhood Kidney Disease and Risk of Adult End-Stage Renal Disease. N Engl J Med. 2018 Feb 01;378(5):428-438. [PubMed: 29385364] 5.Bagshaw SM, George C, Bellomo R., ANZICS Database Management Committe. A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients. Nephrol Dial Transplant. 2008 May;23(5):1569-74. [PubMed: 18281319] 6.Kaufman J, Dhakal M, Patel B, Hamburger R. Community-acquired acute renal failure. Am J Kidney Dis. 1991 Feb;17(2):191-8. [PubMed: 1992662] 7.Correa A, Patel A, Chauhan K, Shah H, Saha A, Dave M, Poojary P, Mishra A, Annapureddy N, Dalal S, Konstantinidis I, Nimma R, Agarwal SK, Chan L, Nadkarni G, Pinney S. National Trends and Outcomes in Dialysis-Requiring Acute Kidney Injury in Heart Failure: 2002-2013. J Card Fail. 2018 Jul;24(7):442-450. [PubMed: 29730235] 8.Garg AX, Kiberd BA, Clark WF, Haynes RB, Clase CM. Albuminuria and renal insufficiency prevalence guides population screening: results from the NHANES III. Kidney Int. 2002 Jun;61(6):2165-75. [PubMed: 12028457] 9.Lindner A, Sherrard DJ. Acute renal failure. N Engl J Med. 1996 Oct 24;335(17):1320-1; author reply 1321-2. [PubMed: 8992330] 10.Almirall J. Sodium Excretion, Cardiovascular Disease, and Chronic Kidney Disease. JAMA. 2016 Sep 13;316(10):1112. [PubMed: 27623468] 11.Ghimire S, Banks C, Jose MD, Castelino RL, Zaidi STR. Medication adherence assessment practices in dialysis settings: A survey of renal nurses' perceptions. J Clin Nurs. 2019 Feb;28(3-4):528-537. [PubMed: 30091498] 12.Soragna G, Bermond F, Fabbrini L, Rodofili A, Soragna A, Bauducco M, Panunzi A, Ramondetti A, Cerri C, Vitale C. [The "Nephrology outpatient Triage": an organizational model for the ambulatory care of patients with advanced renal disease]. G Ital Nefrol. 2018 Mar;35(2) [PubMed: 29582964] 13.Goswami S, Pahwa N, Vohra R, Raju BM. Clinical spectrum of hospital acquired acute kidney injury: A prospective study from Central India. Saudi J Kidney Dis Transpl. 2018 Jul-Aug;29(4):946-955. [PubMed: 30152434] 14.Park S, Lee S, Lee A, Paek JH, Chin HJ, Na KY, Chae DW, Kim S. Awareness, incidence and clinical significance of acute kidney injury after non-general anesthesia: A retrospective cohort study. Medicine (Baltimore). 2018 Aug;97(35):e12014. [PMC free article: PMC6392954] [PubMed: 30170408] What problem is a patient likely to experience in endPatients may experience a wide variety of symptoms as kidney failure progresses. These include fatigue, drowsiness, decrease in urination or inability to urinate, dry skin, itchy skin, headache, weight loss, nausea, bone pain, skin and nail changes and easy bruising.
Which is the treatment of choice for patients with endA kidney transplant is often the treatment of choice for end-stage renal disease, compared with a lifetime on dialysis.
How do you deal with low kidney function?What can I do to keep my kidneys healthy?. Make healthy food choices. ... . Make physical activity part of your routine. ... . Aim for a healthy weight. ... . Get enough sleep. ... . Stop smoking. ... . Limit alcohol intake link. ... . Explore stress-reducing activities. ... . Manage diabetes, high blood pressure, and heart disease.. Which complication is the most serious for a client with kidney failure?High blood pressure is one of the most destructive complications of CKD. It can lead to the development of heart disease and result in a decline in kidney function. Treatment may include diet and exercise changes as well as prescription medications to lower blood pressure.
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