Renal Failure

Jessica S., Abbie S., Erin A., Abriana K

Introduction

Your kidneys filter waste and excess fluids from your blood and then excrete it in your urine. Renal failure is a significant loss of kidney function requiring dialysis. End stage renal failure is a renal function of less than 10 percent requiring dialysis or a transplant. When kidney failure reaches an advanced stage dangerous levels of fluid and waste build up in the body, leading to further complications.

Pathophysiology

  • Nephron destruction eventually causes irreversible kidney damage.
  • Disease may progress through stages based on the glomerular filtration rate (GFR).
  • Stage 1 GFR is greater than 90 mL/minute/1.73 m²; stage 5 GFR is less than 15 mL/minute/1.73 m².

Clinical Manifestations

  • Decreased urine output
  • Hypotension or hypertension
  • Altered level of consciousness
  • Peripheral edema
  • Cardiac arrhythmias
  • Bibasilar crackles
  • Pleural friction rub
  • Gum ulceration and bleeding
  • Uremic fetor
  • Abdominal pain on palpation
  • Poor skin turgor
  • Pale, yellowish-bronze skin color
  • Thin, brittle fingernails and dry, brittle hair

Risk Factors

  • Chronic infections such as chronic pyelonephritis
  • Collagen diseases such as systemic lupus erythematosus and scleroderma
  • Endocrine disease, such as diabetes
  • Nephrotoxic agents
  • Obstructive processes such as calculi
  • Vascular diseases
  • Hypertension
  • Renal artery stenosis

Diagnostics

Laboratory

  • Results of blood urea nitrogen level test are elevated, creatinine level (serum), sodium, potassium, phosphate, and ammonia levels are elevated.
  • Arterial blood gas analysis shows decreased arterial pH and bicarbonate levels.
  • Hematocrit and hemoglobin levels are low; red blood cell (RBC) survival time decreases.
  • Serum albumin level may be decreased.
  • Mild thrombocytopenia and platelet defects appear.
  • Aldosterone secretion is increased.
  • Hyperglycemia and hypertriglyceridemia occur.
  • High-density lipoprotein levels are decreased.
  • Urinalysis reveals proteinuria, glycosuria, and urinary RBCs, leukocytes, casts, and crystals.

Imaging

  • Kidney-ureter-bladder radiography, excretory urography, nephrotomography, renal scanning, and renal arteriography show reduced kidney size.
  • Ultrasonography may reveal small kidneys or structural abnormalities.
  • Renal scanning may identify renal artery stenosis.
  • Computed tomography scanning (kidney) identifies renal masses or cysts.

Diagnostic Procedures

  • Renal biopsy allows histologic identification of the underlying pathology.
  • Electroencephalography shows changes suggesting metabolic encephalopathy.
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Treatments

General

  • Hemodialysis or peritoneal dialysis
  • Control of hypertension
  • Venous thromboembolism (VTE) prophylaxis if hospitalized
  • Rest when needed
  • Creation of access for dialysis
  • Possible kidney transplant

Diet Changes

  • Low-protein (with peritoneal dialysis, high-protein), high-calorie, low-sodium, low-phosphorus, low-potassium diet
  • Sodium and fluid restrictions
  • Protein restriction for stage 5 disease based on serum protein and albumin levels

Medications

  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers to control hypertension and progression of proteinuria
  • Antidiabetic agents to control glucose levels
  • Phosphate binders, such as calcium carbonate (Caltrate) or calcium acetate (PhosLo), for hyperphosphatemia
  • Oral calcium carbonate and calcitriol (Rocaltrol) for hypocalcemia
  • Erythropoietin alfa (Epogen), darbepoetin alfa (Aranesp), or iron salts such as ferrous sulfate (Feosol) for anemia
  • Statins for hyperlipidemia
  • Loop diuretics for fluid volume overload unless patient has reached stage 5 chronic renal disease
  • Calcimimetic agents such as cinacalcet (Sensipar) to reduce parathyroid hormone levels
  • Calcium supplements or calcitriol (Rocaltrol) for hypocalcemia
  • Sevelamer (Renagel) to help reduce phosphate levels (doesn't induce hypercalcemia)
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Citations

  • Huether, S., & McCance, K. (2012). Understanding pathophysiology (5th ed.). St. Louis, Mo.: Mosby/Elsevier.