1. Renal Failure
Wendy DeMartino, MD
PGY-2

2. Objectives
 Anatomy
 Function
 Acute Renal Failure (ARF)
 Causes
 Symptoms
 Management
 Chronic Renal Failure (CRF)
 Causes
 Symptoms
 Dialysis

3. Anatomy
 2 Kidneys
 2 Ureters
 Bladder
 Urethra

5. Kidney Function
 Detoxify blood
 Increase calcium absorption
 calcitriol
 Stimulate RBC production
 erythropoietin
 Regulate blood pressure and
electrolyte balance
 renin

8. Classifications
 Acute versus chronic
 Pre-renal, renal, post-renal
 Anuric, oliguric, polyuric

9. Acute Versus Chronic
 Acute
 sudden onset
 rapid reduction in urine output
 Usually reversible
 Tubular cell death and regeneration
 Chronic
 Progressive
 Not reversible
 Nephron loss
 75% of function can be lost before its
noticeable

10. Acute Renal Failure
 Pre-renal = 55%
 Renal parenchymal (intrinsic)= 40%
 Post-renal = 5-15%

12. Causes of ARF
 Pre-renal =
 vomiting, diarrhea, poor fluid intake, fever, use of
diuretics, and heart failure
 cardiac failure, liver dysfunction, or septic shock
 Intrinsic
 Interstitial nephritis, acute glomerulonephritis, tubular
necrosis, ischemia, toxins
 Post-renal =
 prostatic hypertrophy, cancer of the prostate or
cervix, or retroperitoneal disorders
 neurogenic bladder
 bilateral renal calculi, papillary necrosis, coagulated
blood, bladder carcinoma, and fungus

13. Symptoms of ARF
 Decrease urine output (70%)
 Edema, esp. lower extremity
 Mental changes
 Heart failure
 Nausea, vomiting
 Pruritus
 Anemia
 Tachypenic
 Cool, pale, moist skin

14. Diagnosis of Renal Failure

15. Acute Renal Failure
Management
 Make/think about the diagnosis
 Treat life threatening conditions
 Identify the cause if possible
 Hypovolemia
 Toxic agents (drugs, myoglobin)
 Obstruction
 Treat reversible elements
 Hydrate
 Remove drug
 Relieve obstruction

16. ARF: Life Threatening
Conditions
 Hyperkalemia
 Volume overload
 Vascular access

17. Hyperkalemia Symptoms
 Weakness
 Lethargy
 Muscle cramps
 Paresthesias
 Hypoactive DTRs
 Dysrhythmias

18. Hyperkalemia & EKG
 K > 5.5 -6
 Tall, peaked T’s
 Wide QRS
 Prolong PR
 Diminished P
 Prolonged QT
 QRS-T merge –
sine wave

22. Hyperkalemia Treatment
 Calcium gluconate (carbonate)
 Sodium Bicarbonate
 Insulin/glucose
 Kayexalate
 Lasix
 Albuterol
 Hemodialysis

23. Chronic Renal Failure
 150–200 cases per million people =
new cases each year
 Chronic renal failure and ESRD
affect more than 2 out of 1,000
people in the U.S
 Mortality = 20%

24. Chronic Renal Failure
Causes
 Diabetic Nephropathy
 Hypertension
 Glomerulonephritis
 HIV nephropathy
 Reflux nephropathy in children
 Polycystic kidney disease
 Kidney infections & obstructions

25. CRF Symptoms
 Malaise
 Weakness
 Fatigue
 Neuropathy
 CHF
 Anorexia
 Nausea
 Vomiting
 Seizure
 Constipation
 Peptic ulceration
 Diverticulosis
 Anemia
 Pruritus
 Jaundice
 Abnormal
hemostasis

26. Acute Problems in CRF
 Relating to underlying disease
 Relating to ESRD
 Dialysis related problems

27. Problems Related to ESRD
 Metabolic – K/Ca
 Volume overload
 Anemia, platelet disorder, GI bleed
 HTN, pericarditis
 Peripheral neuropathy, dialysis
dementia
 Abnormal immune function

28. Dialysis
 ½ of patients with CRF eventually
require dialysis
 Diffuse harmful waste out of body
 Control BP
 Keep safe level of chemicals in body
 2 types
 Hemodialysis
 Peritoneal dialysis

29. Hemodialysis
 3-4 times a week
 Takes 2-4 hours
 Machine filters
blood and
returns it to
body

30. Types of Access
 Temporary site
 AV fistula
 Surgeon constructs by combining an artery
and a vein
 3 to 6 months to mature
 AV graft
 Man-made tube inserted by a surgeon to
connect artery and vein
 2 to 6 weeks to mature

31. Temporary Catheter

32. AV Fistula & Graft

33. What This Means For You
 No BP on same arm as fistula
 Protect arm from injury
 Control obvious hemorrhage
 Bleeding will be arterial
 Maintain direct pressure
 No IV on same arm as fistula
 A thrill will be felt – this is normal

34. Access Problems
 AV graft thrombosis
 AV fistula or graft bleeding
 AV graft infection
 Steal Phenomenon
 Early post-op
 Ischemic distally
 Apply small amount of pressure to
reverse symptoms

35. Peritoneal Dialysis
 Abdominal lining filters blood
 3 types
 Continuous ambulatory
 Continuous cyclical
 Intermittent

36. EMS Considerations
 Make sure the dressing remains
intact
 Do not push or pull on the catheter
 Do not disconnect any of the
catheters
 Always transport the patient and
bags/catheters as one piece
 Never inject anything into catheter

37. Dialysis Related Problems
 Lightheaded –give fluids
 Hypotension
 Dysrhythmias
 Disequilibration Syndrome
 At end of early sessions
 Confusion, tremor, seizure
 Due to decrease concentration of blood
versus brain leading to cerebral edema