Chronic Renal failure

1. Presented by:
Meenakshi Vyas
M.Sc.(MSN) 1st year
CHRONIC RENAL FAILURE

2. Chronic Renal Failure
Introduction:
• Also known as chronic kidney disease (CKD)/chronic kidney failure/End stage
renal disease (ESRD).
• Kidneys are the vital organ of the excretory system.
• Kidneys filter water and excess fluid from the blood and then removed in
urine.
• Advanced chronic kidney disease can cause dangerous levels of fluids,
electrolytes and wastes to build up in the body.
• Chronic renal failure 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 uraemia or azotaemia (retention of urea
and other nitrogenous wastes in the blood).

3. Definition:
Chronic kidney disease is defined as:
- Structural or functional abnormalities of the kidneys
for more than 3 months, as manifested by kidney
damage, with or without decreased GFR.
- GFR < 60ml/min/1.73m2 with or without kidney
damage

4. STAGES OF CHRONIC KIDNEY DISEASE

5. ETIOLOGY AND RISK FACTORS OF CRF:
-CRF may result from an episode of acute renal failure or it may develop insidiously
over many years.
 Systemic disease such as Diabetes mellitus , Hypertension
 Kidney diseases/infections like Chronic glomerulonephritis/ Pyelonephritis/ Polycystic
kidney disease
 Any injury to kidney- mechanical or functional
 Certain medications like NSAIDS
 Obstruction in urinary tract
 Hereditary lesions
 Vascular disorder
 Toxic agents like fuels, solvents, lead etc
 Auto-immune diseases like SLE

6. PATHOPHYSIOLOGY
Primary kidney
disease,
damage from
other disease,
urine outflow
obstruction
Decreased
GFR
Hypertrophy
of remaining
nephrons
Inability to
concentrate
urine
Further loss of
nephron function
Loss of excretory renal
function and non
excretory renal function
Polyurea
Hyponatremia
Decreased
renal
blood flow

7. Loss of excretory renal functions
•Metabolic acidosis
Failure of excretion
of Hydrogen ions
•Hyperphosphatemia → decreased Calcium
absorption→Hypocalcemia
Decreased phosphate
excretion
•HYPERKALEMIA
Decreased potassium
Excretion
•Hyponatremia ,water Retention causing
Hypertension, heart failure, oedema
Decreased Na+
reabsorption in tubule
•Uremia causing Increased BUN, creatinine, uric acid,
proteinura, , pericarditis, pruritis, CNS changes,
bleeding tendencies
Decreased excretion of
Nitrogenous waste

8. Loss of non-excretory renal functions
• Decreased libido
• Infertility
• Delaye woundhealing
• Infection
• Advanced atherosclerosis
• Erratic blood glucose level
• Anemia, pallor
• Decreased calcium absorption:-
osteodystrophy and hypocalcemia
Disturbances in
reproduction
Immune disturbances
ed production of
lipids
Impairedinsulinaction
No production of
erythropoietin
Failure to convert
inactive forms of
calcium

9. CLINICAL MANIFESTATION OF
CHRONIC RENAL FAILURE
Neurologic: -Weakness& fatigue, confusion, inability to concentrate,
disorientation, tremors, seizures, asterixis, restlessness of legs, burning of soles
of feet, behavioural changes.
Cardiovascular:
Hypertension, pitting oedema, periorbital oedema, pericarditis, hyperkalaemia,
hyperlipidaemia.
Pulmonary: -Crackles, depressed cough reflex, pleuritic pain, shortness of
breath, tachypnoea, uremic lung.

10. …………….contd.
Gastrointestinal: - Ammonia order to breath, metallic taste, mouth ulceration and
bleeding, anorexia, nausea and vomiting, hiccups, constipation or diarrhoea,
bleeding from GI tract.
Reproductive: -Amenorrhea, Testicular atrophy, infertility, decreased libido.
Musculoskeletal :
 Osteoporosis
 Osteosclerosis
 Osteomalacia
 Osteitis fibrosa
 Muscle cramps

11.  Integumentary changes:-
Skin-very dry because of atrophy of sweat gland.
Pruritis-excoriated skin.
Skin color-urochrome pigments.
Muehrcke’s line
uremic frost

12.  HEMATOLOGIC CHANGES
• Anemia, fatigue, weakness as kidneys are to produce erythropoietin.
• Haemolysis, clotting abnormalities.
• Bleeding tendencies as accumulation of uremic interfere with platelet
adhesiveness.
 IMMUNOLOGIC CHANGES
• More susceptible to infection
• Delayed wound healing.

13. Diagnostic test for Chronic renal failure
•History and Physical examination
•Blood tests: Sodium, Potassium, pH, bicarbonates , phosphorous , calcium
•Kidney function tests - for the level of waste products, such as creatinine and
urea, BUN
•Urine tests
•Imaging tests: USG,KUB X-ray, Renal CT /MRI
•Retrograde pyelogram
•Renal biopsy-Removing a sample of kidney tissue for testing.

14. MEDICAL MANAGEMENT
OF CHRONIC RENAL
FAILURE

15. MEDICAL MANAGEMENT OF CRF
•Hyperkalaemia
•Pericarditis
•Hypertension
•Anaemia
PREVENT
COMPLICATIONS

16. PHARMACOLOGICAL MANAGEMENT
Administration of:-
Anti-hypertensives
Erythropoietin
Iron Supplements
Phosphate binding agents
calcium supplements
Anti-coagulants
Potassium binders

17. NUTRITIONAL MANAGEMENT:-
• Restricted fluid intake, sodium and potassium intake.
• Low protein diet (0.6- 0.8 g/kg /day)
• High chloric diet to prevent muscle wasting.
• Vitamin and Calcium supplements must be ensured.
No Yes

18. OTHER THERAPY: DIALYSIS:
Indications:
1. Acidaemia from metabolic acidosis, situations in
which correction with sodium bicarbonate is impractical
or may result in fluid overload
2. Severe hyperkalemia, especially when combined with AKI
3. Intoxication, that is, acute poisoning with a dialyzable substance. These substances
can be represented by the mnemonic
SMILE: salicylic acid, Magnesium-containing laxatives, isopropanol, lithium,, and ethylene glycol
4. Overload of fluid not expected to respond to treatment with diuretics
5. Uraemia complications, such as pericarditis, encephalopathy, or gastrointestinal
bleeding

19. Principle of Dialysis:
 Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid
across a semi-permeable membrane.
 Diffusion describes a property of substances in water. Substances in water tend to move
from an area of high concentration to an area of low concentration.
 Blood flows by one side of a semi-permeable membrane, and a dialysate, or special
dialysis fluid, flows by the opposite side. A semipermeable membrane is a thin layer of
material that contains holes of various sizes, or pores. Smaller solutes and fluid pass
through the membrane, but the membrane blocks the passage of larger substances (for
example, red blood cells, large proteins).
 This replicates the filtering process that takes place in the kidneys, when the blood enters
the kidneys and the larger substances are separated from the smaller ones in the
glomerulus.

20. Types of Dialysis:
• Haemodialysis
• Peritoneal dialysis
• Haemofiltration
• Hemodiafiltration
• Intestinal dialysis

21. SURGICAL MANAGEMENT

22. .
NURSING MANAGEMENT:
Nursing management Assessment:
1. Complete history taking:
Past & present history regarding illness, any medication, diet,
wt. changes, patterns of urination etc.
2. Assess pt. for the multiple effects of CRF on all body systems.
3. Assess the pt.’s understanding of CRF, the diagnostic tests,& the
treatment regimens.
4. Assess the pt.’s need for dialysis.
5. Assess the significant other’s understanding of the treatment regimen.

23. Nursing diagnosis.
1. Fluid volume excess related to decrease urine output.
2. Imbalanced nutrition: less than body requirements related to nausea and
vomitting.
3. Constipation related to inadequate dietary intake.
4. Activity intolerance related to fatigue, anemia, retention of waste products,
dialysis.
5. Risk for impaired skin integrity.
6. Risk for infection.
7. Risk for injury.
8. Risk for compromised family and ineffective individual coping.
9. Risk for ineffective family & individual therapeutic regimen management.
10. Disturbed self- esteem related to dependency, role, change in body image,
& change in sexual function.

24. 1)Excess fluid volume related to decreased urine output, dietary excesses and
retention of sodium and water
Goal: -maintenance of ideal weight without excess fluid.
INTERVENTION; -
 Assess fluid status
i. Daily Weight
ii. Intake and Output balance
iii. Skin turgor & presence of oedema
iv. Distention of neck veins
v. Blood pressure, pulse rate and rhythm
vi. Respiratory rate and efforts
 Limit fluid intake to prescribed volume and restrict salt intake.
 Explain to patient and family rationale for restriction.
 Assist patient to cope with the discomforts resulting from fluid restriction.

25. b)Imbalance nutrition less than body requirement related to nausea,
vomiting
Goal:-Maintain the adequate nutritional intake
 Assess the nutritional status of the patient,
 Provide intake of high biologic value protein foods: eggs, dietary product,
meat.
 Encourage the high calorie, low protein, low sodium, and low potassium
snacks between the meals.
 Weight the patient daily.

26. c)Knowledge deficit related to condition and treatment
Goal: -Increase the knowledge about the condition and treatment
Intervention
 Assess the understanding of cause of renal failure, consequences of renal
failure and the treatment.
 Provide the explanation of renal function and consequences of renal failure
at patient’s level of understanding.
 Assist the patient to identify ways to incorporate changes related to illness
and its treatment into lifestyle.
 Answer each question of the patient.
 Clarify all doubts of the patient.

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