chronic renal failure - bangalore group of institution · irreversible loss of renal function, and...
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CHRONIC RENAL FAILURE
Mrs. Preethi Ramesh
Senior Nursing Lecturer
BGI
CHRONIC RENAL FAILURE
DEFINITION
CRF or ESRD is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails resulting in uremia or azotemia.
END STAGE RENAL DISEASE
A clinical state or condition in which there has been an irreversible loss of renal function, and these patients usually need to accept renal replacement therapy in order to avoid life-threatening uremia.
UREMIA
Uremia is the clinical and laboratory syndrome, reflecting dysfunction of all organ systems as a result of untreated or under treated acute or chronic renal failure.
CHRONIC RENAL FAILUREEach patient is classified into one of the 5 following stages of CRF because management
and prognosis varies according to the progression of damage.
Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2)
Stage 2: Mild reduction in GFR(60-89 mL/min/1.73 m2)
Stage 3:Moderate reduction in GFR (30-59mL/min/1.73 m2)
Stage 4: Severe reduction in GFR
(15-29mL/min/1.73 m2)
Stage 5: Kidney failure
(GFR <15)
STAGES OF CRF
ETIOLOGY & RISK FACTORS
ETIOLOGY & RISK FACTORS
Decreased renal blood flow
Systemic diseases
Diabetes mellitus
Hypertension
SLE
Polyarteritis
Sickle cell disease
Amyloidosis
Glomerulonephritis
Pyelonephritis
ARF
Obstruction of the urinary tract
Hereditary lesions
Polycystic kidney disease
Infections
Vascular diseases
Medication or toxic agents
Environmental or occupational agents
Lead
Cadmium
Mercury
chromium
PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS
Fluid and electrolyte disturbances
Volume expansion/ contraction
Hyper/ Hyponatremia
Hyper/ hypokalemia
metabolic acidosis
Hyperphosphotaemia
Hypocalcaemia
CLINICAL MANIFESTATIONS
Hematologic System
Anemia
Bleeding Tendencies
Infection
Metabolic changes
Waste products accumulation
Altered CHO metabolism
Elevated triglycerides
CLINICAL MANIFESTATIONS
Gastrointestinal changes
Mucosal Ulcerations
Stomatitis
Parotitis
Gingivitis
Oesophagitis
Gastritis
Colitis
CLINICAL MANIFESTATIONS
Gastrointestinal changes cont…
GI Bleeding
Diarrhoea
Constipation
Metallic Taste in mouth
Anorexia
Nausea
vomiting
CLINICAL MANIFESTATIONS
Respiratory Changes
Kussmaul Respiration
Dyspnea
Pulmonary oedema
Uremic Pleuritis
Pleural Effusion
Uremic Lung
Cough Reflex is depressed
CLINICAL MANIFESTATIONS
Cardio Vascular Changes
HTN- Leads to
CHF
Retinopathy
Encephalopathy
Nephropathy
Dysrhythmia
Peripheral Oedema
Uremic Pericarditis
CLINICAL MANIFESTATIONS
Neurologic Changes
Manifestations of peripheral neuropathy
Burning feet
Gait changes
Foot drop
Paraplegia
CLINICAL MANIFESTATIONS
Features of CNS involvement
Forgetfulness
Inability to concentrate
Short attention span
Impaired reasoning
Musculoskeletal changes
Osteomalacia
Osteitis fibrosa
Osteoporosis
Osteosclerosis
CLINICAL MANIFESTATIONS
Integumentary Changes
Yellow grey discoloration of skin
Pale
Dry and scaly
Pruritis
Bruising ,Petechial and Purpura
Hair is brittle
Nails are thin and brittle
CLINICAL MANIFESTATIONS Reproductive Changes
Women
Menstrual irregularities
Infertility
Decreased libido
Men
Impotence
Testicular atrophy
Oligospermia
Decreased libido
-Decreased sperm motility
CLINICAL MANIFESTATIONS
Endocrine Changes
Hypothyroidism
Increased GH and prolactin
Immunologic changes
Depression of human antibody formation
Decreased function of leukocytes
Depression of delayed hypersensitivity
CLINICAL MANIFESTATIONS
Psychosocial Changes
Personality and behavioral changes
Withdrawal
Depression
Anxiety
Decreased ability to concentrate
Solved mental activity
CLINICAL MANIFESTATIONSCommon symptoms when Urea is > 40 mmol/L
Malaise,
Loss of energy
loss of appetite
Insomnia
Nocturia and polyuria
Itching
Nausea, vomiting, diarrhoea
Paraesthesia
Restless leg
Bone pain
Tetany
Symptoms due to salt & water retention
Symptoms due to anaemia
Sexual dysfunction
Mental slowing, clouding of consciousness, seizures & coma
DIAGNOSTIC STUDIES
History and physical examination
Routine lab measurements
BUN
Serum Creatinine
Serum Electrolytes
Hematocrit and Hb levels
Urine Analysis
Urine Culture
Identification of Reversible Renal Disease
Renal Ultrasound
Renal Scan
C T Scan
Renal Biopsy
MANAGEMENT
Preserve the renal function and dialysis
Controlling the disease process.
Controlling BP by diet control, weight control and medication.
Reducing dietary protein intake.
Alleviate extra renal manifestations.
Pruritis
Topical emollient and lotion.
Antihistamine.
IV Lidocaine.
MANAGEMENT
Neurological manifestations.
Safety measures to protect from injury.
Anticonvulsants.
Sedatives
Hematologic changes.
Therapy with epoetin alfa (three times a week)
supplemental iron, vitamin B12 and folic acid.
MANAGEMENT
Improve body chemistry.
Dialysis
Medications
Diet
MANAGEMENT
Dialysis
Peritoneal dialysis:
peritoneal dialysis is a type of dialysis which uses
the peritoneum in a person’s abdomen as the
membrane through which fluid & the dissolved
substances are exchanged with the blood.
Hemodialysis:
A procedure to remove fluid & waste products
from the blood & to correct the electrolyte
imbalances by using a dialysis machine & a dialyzer,
also referred to as an “artificial kidney”
MANAGEMENT
Medications
Hyperkalemia
Insulin administration – I/V
Sodium bicarbonate
Calcium Gluconate – I/V
Sodium polystrene
sulfonate(Kayexalate)
MANAGEMENT
Medications
Hypertension
Sodium and fluid restriction
Anti hypertensive drugs
Diuretics
Beta adrenergic blockers
Ca channel blockers
ACE inhibitors
MANAGEMENT
Medications
Renal osteodystrophy
Regulation of calcium, phosphorus and acidosis
Treatment of hyperparathyroidism
Calciferol
Paricalcitol (Vitamin D analog)
Calcium based phosphate binders
• Calcium acetate
• Calcium carbonate
MANAGEMENT
Medications
Anaemia
Erythropoietin – I/V subcutaneously
Epogen ( Epoetin alfa)
Parental iron
Folic Acid 1 mg daily
Diuretics
Given early to stimulate excretion of water
Vitamins
Supplemental water soluble vitamins
MANAGEMENT
Diet
Protein restriction
0.6 to 0.75 gm/kg of ideal body weight/day
1.2 to 1.3 gm/kg of ideal body weight/day once the patient starts dialysis
Water restriction
Patient not receiving dialysis – 600ml + an amount equal to the previous days urine out put
Patients on dialysis – fluid intake is adjusted so that weight gains are not more than 1 to 3 kg between dialysis
MANAGEMENT
Diet
Phosphate restriction
1000 mg/day
Phosphate rich foods are Diary products (milk, Ice
cream, cheese etc.)
Potassium restriction
2 to 4 gm/day
(Sources are – orange, banana, melons, tomatoes, beans,
legumes etc.)
MANAGEMENT
Diet
Sodium restriction
2 to 4 gm/day
(Sources are – pickled foods, canned soups, soya sauce
etc. )
Calcium
If serum ca levels are low, adequate calcium intake is
important.
Magnesium
Mild Mg restriction may be imposed
MANAGEMENT
Surgical Management
Renal Transplantation
Kidney or renal transplantation is the organ transplant of
the kidney into a patient with end stage renal disease.
NURSING MANAGEMENT
1. Risk for Decreased Cardiac Output.
2. Risk for Ineffective Protection.
3. Disturbed thought process.
4. Risk for impaired skin integrity.
5. Deficient knowledge.
6. Excess fluid volume.
7. Acute pain.
8. Impaired renal tissue perfusion.
9. Impaired urinary elimination.
10. Imbalanced nutrition less than body requirement.
11. Activity intolerance.
12. Disturbed body image.
13. Risk for injury
14. Risk for infection
15. Anticipatory grieving.
Thank youTake care of your
kidneys