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
Acute Renal FailureManagement 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
Chronic Kidney DiseaseChronic kidney disease (CKD)encompasses a spectrum ofdifferent pathophysiologicprocesses associated withabnormal kidney function and aprogressive decline in glomerularfiltration rate (GFR).
Recommended Equations for Estimation ofGlomerular Filtration Rate (GFR) Using SerumCreatinine Concentration (PCr), Age, Sex, Race, andBody Weight1. Equation from the Modification of Diet in RenalDisease study*Estimated GFR (mL/min per 1.73 m2) = 1.86 x(PCr)–1.154 x (age)–0. 203Multiply by 0.742 for womenMultiply by 1.21 for African Americans2. Cockcroft-Gault equationEstimated creatinine clearance (mL/min)= (140–age) x body weight (kg) 72 x PCr (mg/dL)Multiply by 0.85 for women
Leading Categories ofEtiologies of CKD Diabetic glomerular disease Glomerulonephritis Hypertensive nephropathy Primary glomerulopathy with hypertension Vascular and ischemic renal disease Autosomal dominant polycystic kidney disease Other cystic and tubulointerstitial nephropathy
Causes of Anemia in CKD Relative deficiency of erythropoietin Diminished red blood cell survival Bleeding diathesis Iron deficiency Hyperparathyroidism/bone marrow fibrosis "Chronic inflammation" Folate or vitamin B12 deficiency Hemoglobinopathy Comorbid conditions: hypo/hyperthyroidism, pregnancy, HIV-associated disease, autoimmune disease, immunosuppressive drugs
Problems Related to ESRD Metabolic – K/Ca Volume overload Anemia, platelet disorder, GI bleed HTN, pericarditis Peripheral neuropathy, dialysis dementia Abnormal immune function
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
Hemodialysis 3-4 times a week Takes 2-4 hours Machine filters blood and returns it to body
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
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
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
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
Patient EducationSocial, psychological, and physical preparation for the transition to renalreplacement therapy and the choice of the optimal initial modality are bestaccomplished with a gradual approach involving a multidisciplinary team.Along with conservative measures discussed in the sections above, it isimportant to prepare patients with an intensive educational program,explaining the likelihood and timing of initiation of renal replacement therapyand the various forms of therapy available. The more knowledgeable thatpatients are about hemodialysis (both in-center and home-based), peritonealdialysis, and kidney transplantation, the easier and more appropriate will betheir decisions. Patients who are provided with educational programs aremore likely to choose home-based dialysis therapy. This approach is ofsocietal benefit because home-based therapy is less expensive and isassociated with improved quality of life. The educational programs should becommenced no later than stage 4 CKD so that the patient has sufficient timeand cognitive function to learn the important concepts, to make informedchoices, and implement preparatory measures for renal replacementtherapy.