renal failure, ARF, CRF, ESRD

1. RENAL SYSTEM
RENAL FAILURE

2. 1.Acute Renal Failure
ARF is an acute and potentially
reversible irritability of the kidneys
to perform their normal functions to
maintain homeostasis.

3. ETIOLOGY
Prerenal factors
osmolality is high
Specific gravity <1.020
Renal perfusion
Tubular function normal
nonspecific symptoms:
Fever
Dehydration
Tachycardia
Ex: shock,CCF
Intrarenal ARF
results from injury to
Kidney
large amounts of calcium
and uric acid excretion
sodium cannot be
conserved
urine cannot be
concentrated
Symptoms:
nausea/vomiting,
Hypertension
oliguria.
Ex: HUS, GN
Postrenal or obstructive
delayed voiding after
birth
electrolyte imbalance
a poor urinary stream
abdominal mass
Urine osmolality &
sodium levels are
unaffected
Ex: calculi, trauma

4. PHASES
1. Initial
-Renal damage is occurring, the child may be
-Asymptomatic
2. Oliguric
-<1ml/kg/hr of urine
-Impaired glomerular filtration
-Waste cannot be remove
-Uremia develops
-Neurotoxicity
-CCF, HTN, anemia

5. 3. Diuretic
- lasts 2 weeks
- cellular regeneration and healing
- gradual return to normal
- dehydration and electrolyte imbalance due
to excess urination
4. Recovery
- it takes months
- if left untreated it result in fluid
overload, electrolyte
imbalance, uremia, coma

6. CLINICAL MANIFESTAIONS
• Severe oliguria/ Anuria
• Child may be markably well / extremely sick
• Nausea / Vomiting
• Lethargy
• Dehydration
• Acidotic breathing
• Altered consciousness
• Irregular cardiac rate, rhythm
• Edema
• Hypertension

7. DIAGNOSIS
• Careful history taking
Vomiting, diarrhea, fever,
other renal disease
• Laboratory investigations
Anemia, raised serum
creatinine level, blood urea,
electrolytes, pH,
bicarbonate and complete
blood count, reduced C3
• Urine examination
Protienuria, Hematuria,
presence of casts
• USG
Structural abnormalies,
calculi
• IVP
Acute tubular necrosis
• Radionuclide studies
Evaluate GFR, renal blood
flow
• Renal biopsy
Ultimate cause

8. PATHOPHYSILOGY

9. TREATMENT
• Medical treatment
–Fluid and dietary restrictions
–Use of diuretics
–Maintain Electrolytes
–May need dialysis to jump start renal
function
–May need to stimulate production of urine
with IV fluids, Dopomine, diuretics, etc.
–Hemodialysis

10. Nursing interventions
• Monitor I/O, including all body fluids
• Monitor lab results
• Watch hyperkalemia symptoms:
malaise, anorexia, parenthesia, or muscle weakness, ECG
changes
• Watch for hyperglycemia or hypoglycemia if receiving TPN or
insulin infusions
• Maintain nutrition
• Safety measures
• Mouth care
• Daily weights
• Assess for signs of heart failure
• Skin integrity problems

11. PROGNOSIS
Mortality rate of ARF is about 20 to 40%
which is influenced by the cause and duration
of renal failure with severity of pathological
changes. Poor prognosis is related to
associated sepsis, HUS, prolonged
anemia, cardiac failure, hepatic failure and
respiratory failure with delayed initiation of
treatment.

12. CHRONIC KIDNEY DISEASE
• Chronic renal failure
• End stage renal failure

13. 2. Chronic Renal Failure
It is a permanent irreversible
destruction of nephron leading to
severe deterioration of renal
function, finally resulting to end
stage renal disease.

14. ETIOLOGY
• Cause below 5 years of age is mostly
congenital anomalies
• After 5 that is acquired glomerular
disease, hereditary disease
Glomerular disease
Congenital anomalies
Obstructive uropathy
Miscellaneous

15. CLINICAL MANIFESTATIONS
Early symptoms
• Weakness
• Anorexia
• Nausea
• Failure to thrive
• Unexplained
anemia
• Osteodystrophy
• Growth failure
Late manifestations
• Gastrointestinal
bleeding
• Pericarditis
• Congestive
cardiac failure
• Altered
sensorium
Indications of poor
prognosis
• Convulsions
• Coma
• Cardiomyopathy

16. DIAGNOSIS
• Blood examination
Decreased hematocrit, Hb%, Na+, Ca++, HCO-
3, increased K+
& phosphorus
• Renal function test
Gradual increase in BUN, uric acid & creatinine
• Urinalysis
Variation in specific gravity, increased urine creatinine,
change in total urine output
• X-Ray
Chest, hands, knees, pelvis, spine to detect bony defect
• ECG, IVP, MCU, radio nuclide imaging
Extent of complications
• Other abnormal findings
Metabolic acidosis, Fluid imbalance, Insulin resistance

17. PATHOPHYSIOLOGY
In the early stage of disease child remains
asymptomatic. Advance renal damage will occur only in
late stages.
Increased numbers of nephrons are destructed at
various degrees and a few remain intact but
hypertrophied and functional. This leads to insufficient
adjustments in fluid and electrolyte balance. As the
disease progress to end stage severe reduction in
number of nephrons occur and the kidney will not b
able to maintain fliud and electrolyte balance. The
accumulatin of various substances in blood result in
complications

18. Stages of Chronic Renal Failure
1. Diminished Renal Reserve
Normal BUN, and serum creatinine absence of
symptoms
2. Renal Insufficiency
GFR is about 25% of normal, BUN Creatinine levels
increased
3. Renal Failure
GFR <25% of normal increasing symptoms
4. ESRD or Uremia
GFR < 5-10% normal, creatinine clearance
<5-10ml/min resulting in a cumulative effect

19. COMPLICATIONS
• Azotemia
• Metabolic acidosis
• Electrolyte imbalance
• CCF
• HTN
• Severe anemia
• Growth retardation
• Delayed or absent sexual maturation

20. MANAGEMENT
• Conservative management
Correction of reversible component of renal
dysfunction
Preservation of renal function
Treatment of metabolic and psycho-social
problems
Optimization of growth
Preparation for treatment of ESRD
Treat for infection, accelerated hypertension,
CCF, obstruction of urine flow - to improve renal
function

21. •Dietary therapy
• Low protein diet
• Severe protein restriction may produce protein calorie
malnutrition
• Diet should consist of 100 percent RDA for calories
• Protein should be of high biological value and should comprise 6 –
10 % of all calories
• Salt restriction in patients with hypertension and fluid overload
• Patients with salt losing nephropathy should take a liberal amount
of salt and water
• If the GFR falls <10ml/min/1.73m2, potassium intake should be
restricted.(hyperkalemia may develop)
• Vit D is essential to raise the serum calcium and suppress
parathormone secretion.

22. • Dialysis

23. • Renal transplatation

24. NURSING MANAGEMENT
• Frequent monitoring
– Hydration and output
– Cardiovascular function
– Respiratory status
– Electrolytes
– Nutrition
• Mental status
– Emotional well being
• Ensure proper medication regimen
• Skin care
• Bleeding problems
• Care of the shunt
• Education to client and family