Renal Failure I

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How does the kidney regulate endocrine function?

Renin = BP
Erytrhopoetine= RBC prod.
Ca+/Phosphorus balance = activate Vit D, incr Ca+ absorption=Calcitrol

Why do we have to urinate when we are cold?

vasoconstriction pushes excess fluid out to keep body warm and gets rid of that fluid via urine

__________ will produce concentrated urine _______ will produce dilute urine

diaphoresis + eating salty food= conc.
drinking and cold weather = dilute

kidneys can't remove urea
wastes accumulate disrupting endocrine/metabolic fx
systemic diesase

Renal Failure

sudden onset
rapid reduction in urine output
reversible
tubular cell death and regeneration

acute renal failure

progressive
not reversible
nephron loss

Chronic renal failure

True or False
We can loose up to 75% of function before we notice kidney failure

True

occurs when the kidneys are unable to excrete the daily load of toxins in the urine

ARF

<400mL/day of urine

Oliguria

<50mL/day of urine

Anuria

Oliguria + anuria + high serum creatinine + high BUN levels =

ARF

High levels of BUN

Azotemia

What is the most cause of acute renal failure?

Acute tubular necrosis r/t shock or chemicals

Perfusion, filtration and water balance (shock) are___________ problems

Prerenal

Selective reabsorption and water balance are ________ problems

Renal

Urine collection, storage and elimination are ______ problems

Postrenal

Vascular supply effects

Perfusion = Prerenal

Problems with the glomerulus causes

Filtration problems=Prerenal

Issues in the tubules cause

Selective reabsorption, secretion, excretion=Renal

Problems between the collecting ducts and the bladder cause

urine collection and storage problems=postrenal

Urination and micturition effect

elimination=postrenal

_____________ is a classic reason for drop in GFR is an early sign of___________

HTN
hypoperfusion of the kidneys

What is the key to determining how much perfusion is getting to the kidney?

MAP <80 = rapid decline

MAP=

(CO X SVR) + CVP

What causes renal artery obstruction and contributes to hypoperfusion of the kidneys?

Tumor
Blood clot
Aneruysm
Pregnancy Pressure

Vomiting, diarrhea, poor fluid intake, fever, diruetics and HF all contribute to _______________

shock = hypoperfusion of kidneys

What causes cardiogenic shock?

Hemorrhage
MI
HF
Sepsis
Anaphylaxis

Nephron & Microcirculation are implicated in ____________ problems

intrarenal problems

Actual parenchymal damage to the glomeruli, interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia and toxins cause problems where?

Intrarenal

What causes tubular necrosis?

Burns
Crush injuries
Infx
nephrotoxic agents

In burns and crush injuries ___________ is released causing renal toxicity, ishemia or both

myoglobin
(released from muscle injury)

GFR, Tubular reabsorption and tubular secretion are considered _____________

intrarenal

Common genetic kidney disease that becomes symptomatic after 30 with hematuria, chronic UTI's and HTN

Polycystic disease

Presents as hematuria, smokers have 2x the risk, metastasizes to lung & bone

Renal cell carcinoma

obstruction somewhere distal to the kidney is considered

postrenal

If the psi rises in the kidney tubules and affects the GFR its considered

postrenal

Neurogenic bladder as seen in MS, ALS, DMD and Quads

postrenal

What are common causes of psi rise in the tubules?

Calculi (stones)
Tumors (prostate/cervix/bladder)
BPH
Bilateral renal alculi
Strictures
Blood clots

What causes calculi?

Calcium
Infx
Uric acid

What are the sx's of calculi?

PAIN
hematuria

Who is at risk for calculi?

People with higher Ca+ levels
Electrolyte imbalances
Gout
Infections

Secondary to constant UTI's which causes acute neutrophilic inflamm exudates and small abscesses

acute pyelonephritis

What are the sx's of acute pyelonephritis?

Flank pain
fever
High WBC
Pyuria

Water in the kidneys d/t blockage

Hydronephrosis

From most to least what area of the kidneys cause acute renal failure?

Pre-renal = 55%
Renal parenchymal (intrinsic) = 40%
Post-renal= 5-15%

What is normal output?

30mL/hr
1mg/Kg/hr

What is normal urine replacement?

output + 600mL per 24hrs

<400mL/day urine output

oliguric

>500mL/day urine output

nonoliguric

very little or no urine output

Anuric

What are the major systemic disease that cause kidney failure?

HTN
Diabetes
Rhabdomyolosis (ETOH, heat stroke, cocain, siezures, low Phosphate, DVT/VTE)

BUN is a measure of

products of protein breakdown

Serum creatinine is a measure of

muscle breakdown compares blood with urine

What is normal serum creatinine?

0.7-1.3mg/dL =men
0.6-1.1mg/dL=women

What is a normal GFR?

90-120mL/min/1.73 (m^2)

What is GFR affected by?

AGE
creatinine measurement
gender
height
race
weight

What is a normal BUN?

6-20mg/dL

What causes low BUN?

malnutrition
overhydration
liver failure
low protein diet

What causes excessive proteint levels in GI tract?

CHF
Hypotension

If the kidneys aren't perfused what goes up and why?

BUN
b/c can't clear proteins

high metabolic rate = high fluid need and larger % of body weight that is water is characteristic of

infants and children

Who has larger fluid turnover, losses and fluid requirement/Kg?

infants and children

True or False
We have larger ECF volume until 2years of age

True

lower GFR, drug clearance, shorter tubules, less response to ADH

kids

less ability to conserve and remove excess water, difficulty conserving/excreting NaCL

kids

less ability to handle acid load and difficulty secreting solute load

kids

What are the percent body weight as fluid for
Adults
Newborn
Pre-term infant

55%
75-80%
90%

What is the water/Kg in
Adult
Infant

Adult=550mL/Kg
Infant=750mL/Kg

What is the proportion of ECF in
Adult
Newborn

adult=33%
newborn=50%

Infant water loss is ____ that of an adult

2x

What is the water turnover in an
adult
infant

1/5 = adult
1/2 = infant

What are s's of pediatric moderate volume deficit?

BP= normal or low
Pulse=increase
No tears
Depressed fontanels

50-90mL/Kg fluid loss + gray skin + poor turgor + very dry mucous membranes + oliguria + 2-3sec cap refill

Moderate volume deficit in children

What indicates mild vol. deficit in children?

<50mL/Kg
pale skin
decr turgor
dry mucous membranes
decr output
BP=normal
Puls=normal or increased
cap refill=<2sec
drawn facial expression

Shock + change in LOC, elevated BUN, K+, Creatinine =

Severe vol deficit resulting in acidosis

What kind of fluid loss is considered severe for children?

>100mL/Kg

mottled skin + very poor turgor + parched membranes + oliguria + azotemia

Severe vol deficit in children

Low BP, rapid thready pulse and cap refill >3 sec

evidence of severe vol deficit in children

What changes as we age in respect to kidney fx?

lower/decreased:
Neprons
Renal blood flow
GFR
ability to concerntrate urine
cardiac fx

less able to adjust vol, secrete solute load, bladder elasticity, weaker sphincter, decr bladder capacity, BPH

geronotological differences in fluid balance/renal fx

hypoperfusion AEB ^BUN, ^ Creatinine, decr output, urine NaCL decr <20mEq/L, ^ urine specific gravity

Prerenal ARF

Parenchymal damage AEB, ^BUN, ^ creatinine, variable output often decr, urine NaCL incr >40mEq/L, low normal 1.010 spec. grav.

Intrarenal ARF

Obstruction AEB ^BUN, ^Creatinine, decr or sudden anuria, NaCL decr <20mEq/L, variable urine spec. grav.

Postrenal ARF

Excessive bleeding
Fainting/feeling lightheaded
Hematoma
Infx
UTI
Pregnancy
Water deficit

All will alter GFR

Types of drugs that increase urine Sodium

Antibiotics
Diuretics
Prostaglandins

Drugs that decrease urine sodium

Corticosteriods =cause NaCL retention
NSAIDS

Why do RF patients present tired/confused?

proteins + toxins build up in brain

What are CNS s's/sx's of RF?

Drowsiness
Headache
Muslcle twitiching d/t e- imbalance
Seizures

N/V, diarrhea, ill and lethargic are s's that

They are GOING DOWNHILL
need to be treated FAST

What is the first thing to assess in ARF?

Decreased urine output
DARK URINE

What is next to assses in ARF?

LOC changes
Fatigue/Lethary
N/V, diarrhea

What is a late sx of ARF?

skin turgor

After Skin turgor check

HF
Edema
Pruritis

After pruritis check

Odor of breath
Resp. status
Anemia

After Anemia check

Tachypnia
Cool, pale skin
Abd pain

Finally check

metallic taste in mouth
seizures/coma

What seems like a common sx but may be a late sx

back pain

Why do people develop Hyperkalemia in ARF?

declining GFR = can't excrete K+
protein catabolism = release of K+ into body fluids

Whats the big deal with hyperkalemia?

dysrhythmias and cardiac arrest

ARF managment includes

tx life threatening cond = K+, fluid crisis
ID cause=hypovolemia, toxicity, obstruction
Tx reversible = hydrate, remove drug, relieve obstruction

JK; Mgmt includes

maintain fluid balance
avoid fluid excess
dialysis

How do we determine maintenance of fluid volume?

Body weight
CVP
Serum/Urine conc.
output
BP
clin status of pt

True or false
Parenteral and oral intake, output including insensible loss are calculated and used as basis for fluid replacement

TRUE

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