The urinary system consists of the kidneys, ureters, urinary bladder and urethra. The kidneys filter waste from the blood to produce urine, which then passes through the ureters into the bladder. The bladder stores urine until urination, when it passes through the urethra. Together this system eliminates waste from the body and regulates fluid and electrolyte balance. Chronic kidney disease results in the gradual loss of kidney function over time due to damage and scarring of the kidneys. It has multiple causes and stages of severity, eventually progressing to kidney failure if untreated.

2. • The urinary system consists of the kidneys, ureters, urinary bladder and
urethra.
• The kidneys filter the blood to remove wastes and produce urine.
• The ureters, urinary bladder and urethra together form the urinary tract,
which acts as a plumbing system to drain urine from the kidneys, store it,
and then release it during urination.
• Besides filtering and eliminating wastes from the body, the urinary system
also maintains the homeostasis of water, ions, pH, blood pressure, calcium
and red blood cells.
• The kidneys have extensive blood supply via the renal arteries which leave
the kidneys via the renal vein.

3. • The kidneys are a pair of bean-shaped organs found along the posterior
wall of the abdominal cavity.
• The left kidney is located slightly higher than the right kidney because
the right side of the liver is much larger than the left side.
• The kidneys filter metabolic wastes, excess ions, and chemicals from
the blood to form urine.

4. • The ureters are a pair of tubes that carry urine from the kidneys to the
urinary bladder.
• The ureters are about 10 to 12 inches long and run on the left and
right sides of the body parallel to the vertebral column.
• Gravity and peristalsis of smooth muscle tissue in the walls of the
ureters move urine toward the urinary bladder.
• The ends of the ureters extend slightly into the urinary bladder and
are sealed at the point of entry to the bladder by the ureterovesical
valves.
• These valves prevent urine from flowing back towards the kidneys.

5. • The urinary bladder is a sac-like hollow organ used for the storage of
urine.
• The urinary bladder is located along the body’s midline at the inferior
end of the pelvis.
• Urine entering the urinary bladder from the ureters slowly fills the
hollow space of the bladder and stretches its elastic walls.
• The walls of the bladder allow it to stretch to hold anywhere from 600 to
800 millilitres of urine.

6. • The urethra is the tube through which urine passes from the bladder to the exterior of
the body.
• The female urethra is around 2 inches long and ends inferior to the clitoris and superior
to the vaginal opening.
• In males, the urethra is around 8 to 10 inches long and ends at the tip of the penis. The
urethra is also an organ of the male reproductive system as it carries sperm out of the
body through the penis.
• The flow of urine through the urethra is controlled by the internal and external urethral
sphincter muscles. The internal urethral sphincter is made of smooth muscle and opens
involuntarily when the bladder reaches a certain set level of distention. The opening of
the internal sphincter results in the sensation to have needed to urinate.
• The external urethral sphincter is made of skeletal muscle and may be opened to allow
urine to pass through the urethra or may be held closed to delay urination.

7. • Removal of waste product from the body (mainly urea and uric acid).
• Regulation of electrolyte balance (e.g. sodium, potassium and
calcium).
• Regulation of acid-base homeostasis
• Controlling blood volume and maintaining blood pressure.
• Production of Hormones. (e.g. Erythropoietin, Calcitriol, Renin).

11. • Renal failure is a serious medical condition affecting the kidneys.
• When a person suffers from renal failure, their kidneys are not
functioning properly or no longer work at all.
• Renal failure can be a progressive disease or a temporary one depending
on the cause and available treatment options.
• In renal failure the kidneys undergo cellular death and are unable to filter
wastes, produce urine and maintain fluid balances. This dysfunction
causes a build up of toxins in the body which can affect the blood, brain
and heart, as well as other complications.
• Renal failure is very serious and even deadly if left untreated.

12. Diseases of the kidneys are divided into 4 major groups
1.Glomerular diseases: These are most often immunologically-mediated
and may be acute or chronic.
2.Tubular diseases: These are more likely to be caused by toxic or
infectious agents and are often acute.
3.Interstitial diseases: These are likewise commonly due to toxic or
infectious agents
4.Vascular diseases: These include changes in the nephron as a
consequence of increased intra-glomerular pressure such as in hypertension
or impaired blood flow.

13. • Acute renal failure occurs suddenly and is usually initiated by
underlying causes, for example dehydration, infection, serious injury to
the kidney or the chronic use of over the counter pain medications like
Tylenol (Acetaminophen) or Advil (Ibuprofen).
• Chronic renal failure is more serious than acute renal failure because
symptoms may not appear until the kidneys are extremely damaged.
Chronic renal failure can be caused by other long term diseases, such as
diabetes and high blood pressure. Chronic renal failure can worsen over
time, especially when the problem has gone undiagnosed and treatment is
delayed.

15. • Definition
• Epidemiology
• Classification and Causes
• Pathophysiology
• Phases of ARF
• Sign and Symptoms
• Complications
• Diagnosis
• Prevention
• Management & Treatment

16. • Acute renal failure (ARF) is a syndrome characterized by rapid onset
of renal dysfunction, chiefly oliguria or anuria, and sudden increase
in metabolic waste-products (ureaand creatinine) in the blood with
consequent development of uremia.
OR
• Acute renal failure or Acute kidney failure (AKF) occurs when
kidneys suddenly become unable to filter waste products from blood.
When kidneys lose their filtering ability, it results in accumulation of
nitrogenous wastes and fluid and electrolyte imbalance.
• Acute renal failure is also called acute kidney injury (AKI). It develops
rapidly over a few hours or a few days.

17. • Acute renal failure almost always occurs in connection with another
medical condition or events.
• Conditions that can increase risk of acute renal failure include:
• Being hospitalized, especially for a serious condition that requires
intensive care
• Advanced age
• Blockages in the blood vessels in arms or legs (peripheral artery
disease)
• Diabetes
• High blood pressure
• Heart failure
• Kidney diseases
• Liver diseases.

18. • Acute kidney injury is common among hospitalized patients particularly
in critically ill people who need intensive care.
• It affects some 3-7% of patients admitted to the hospital and
approximately 25-30% of patients in the intensive care unit.

19.  Pre-renal ARF (Functional):
• Which is caused by a sudden serious drop in blood flow to the kidneys.
 Intrinsic or intra renal ARF (Structural)
• Which is the result of damage to structure with in the kidneys.
 Post-renal ARF (Obstruction)
• Which is caused by a blockage that prevents urine from flowing out of the
kidneys.

21.  PRE-RENAL ARF
• Circulatory volume depletion (Hypovolemia):
• Excessive diuresis, haemorrhage, GI losses (dehydration), Fluid shifting
(ascites, peritonitis), burns.
• Impair cardiac efficiency:
• Cardiomyopathy cardiogenic shock, MI, heart failure,
dysrhythmias
• Vasodilation:
• Sepsis, anaphylaxis, medications that cause vasodilation.

22. INTRINSIC OR INTRA RENAL ARF
Prolonged renal ischemia resulting from:
• Pigment nephropathy (associated with the breakdown of blood cells
containing pigments that in turn occlude kidney structures)
• Myoglobinuria (trauma, crush injuries, burns). Myoglobin (a protein
released from muscle when injury occurs) and hemoglobin are liberated,
causing renal toxicity, ischemia, or both.
• Hemoglobinuria (transfusion reaction, hemolytic anemia). Hemoglobin is
released through hemolysis, filters through the glomeruli, and becomes
concentrated in the kidney tubules to such a degree that precipitation of
hemoglobin occurs.
• Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin,
tobramycin), Heavy metals (lead, mercury), Solvents and chemicals
(ethylene glycol, carbon tetrachloride, arsenic), NSAIDs & ACE inhibitors

23. Rhabdomyolysis, which results in accumulation of myoglobin in the
glomeruli secondary to damage to skeletal muscle, Nephrotoxicity
secondary to herbal remedies
Infectious processes such as:
Acute pyelonephritis: Common bacterial infection of renal pelvis and
kidney
Acute glomerulonephritis: Inflammation and damage of glomeruli
leading to haematuria, proteinuria, and azotemia

24.  POST-RENAL ARF:
• Urinary tract obstruction, including:
• Calculi (stones)
• Tumours
• Benign prostatic hyperplasia
• Strictures
• Blood clots
• Neurogenic bladder
• Bladder cancer
• Bladder outlet obstruction,
• Urethral obstruction

25. Ischemia or
toxicinfection
Pre-renal factors: decrease in
effective circulation of blood
Decrease in GFR If ischemia prolongs:
Intra renal ARF
Impaired Nephron functioning
: Acute Tubular Necrosis
(ATN)
Activates Renin
Angiotensin Aldosterone
system
Constriction of
peripheral arteries and
renal afferent
arterioles
Decrease GFR,
tubular dysfunction.
Oliguria

26. Onset or Initiation phase:
This period begins with the precipitating events and ends when oliguria
develops. This phase can last from hours to days.
Oliguric Phase:
This phase usually lasts between 1-8 weeks and is characterized by further
damage to the renal tubular wall and membranes. Urine output is < 400 ml
per day. In this phase, serum concentration of urea, creatinine, uric acid,
potassium, magnesium. Dialysis may be required.

27.  Diuretic Phase:
• In the diuresis period, the third phase, the patient experiences gradually
increasing urine output, which signals that glomerular filtration has
started to recover.
• Urine out put starts to increase gradually up to 1-2 L.
• Laboratory values stop rising and eventually decrease.
• Although the volume of urinary output may reach normal or elevated
levels, renal function may still be markedly abnormal. Because uremic
symptoms may still be present, the need for expert medical and nursing
management continues.
 Recovery Period Phase:
• The recovery phase can last from 3-12 months. During this phase edema
decreases, the renal tubules begin to function adequately and fluid and
electrolytes return to normal.

28. PRE-RENAL ARF Little or no proteinuria, BUN / Creatinine, urine
output, Na conc.
Urine specific gravity
INTRINSIC
OR INTRA
RENAL ARF:
Urine output often decreased. Weight gain, swelling esp.
of the legs and feet, anemia, platelets dysfunction, definite
proteinuria, high Na concentration, Increased BUN,
Creatinine.
POST-RENAL ARF: Urine output often decreased, often anuria. Na
concentration varies, usually decreased. Little or no
proteinuria, symptoms of obstructions.

29. • Fluid and electrolytes imbalance, e.g. hyperkalaemia, hyperphosphatemia,
hypocalcaemia
• Little or no urine output,
• Haematuria
• Low specific gravity of urine
• Anaemia (due to reduced erythropoietin production)
• Thirst and a dry mouth, GI disturbance,
• Secondary infection,
• Bladder distension
• Uraemia

30. Potential complications of acute renal failure include:
• Fluid build-up: Acute renal failure may lead to a build-up of fluid in
chest, which can cause shortness of breath.
• Chest pain: If the lining that covers heart becomes inflamed, it may
lead to chest pain.
• Muscle weakness: When body’s fluids and electrolytes are out of
balance, muscle weakness can result. Elevated levels of potassium in
blood are particularly dangerous.
• Permanent kidney damage: Occasionally, Acute renal failure causes
permanent loss of kidney function, or end-stage renal disease.
• Death: Acute renal failure can lead to loss of kidney function and,
ultimately death. The risk of death is highest in people who had
kidney problems before acute kidney failure.

31. • History (diseases, drugs).
• Physical examination.
• Blood tests generally include CBC, BUN, creatinine,
electrolytes.
• Urine analysis
• Renal ultrasound shows changes in renal anatomy.
• Evaluating for urethral obstruction ( CT Scan).
• Renal arteriography or venography (vascular causes).
• Biopsy: In certain situations, a kidney biopsy may
recommend to remove a small sample of kidney tissue for lab
testing.

32. • Provide adequate hydration to patients at risk for dehydration
• Prevent and treat shock promptly with blood and fluid replacement.
• Monitor central venous and arterial pressures and hourly urine output of critically ill
patients to detect the onset of renal failure as early as possible. Treat hypotension
promptly.
• Continually assess renal function (urine output, laboratory values) when appropriate.
• Take precautions to ensure that the appropriate blood is administered to the correct
patient in order to avoid severe transfusion reactions, which can precipitate renal
failure.
• Prevent and treat infections promptly. Infections can produce progressive renal
damage.
• Give meticulous care to patients with indwelling catheters to prevent infections from
ascending in the urinary tract. Remove catheters as soon as possible.
• To prevent toxic drug effects, closely monitor dosage, duration of use, and blood
levels of all medication or excreted by the kidneys.

33. • Improve renal perfusion
IV fluids
Blood transfusion (if cause is blood loss)
• Adequate dietary intake, high carbohydrate and low protein diet
• Fluid and electrolytes balance
• Monitoring for dyspnoea, tachycardia and expanded neck veins to detect
fluid excess.
• Auscultation of lungs for crackles
• ECG monitoring
• Dialysis/ Continuous Renal Replacement Therapy

34. • Medications
• Renal dose of Dopamine
• Glucocorticoid (inflammatory stages)
• Diuretics such as Mannitol, furosemide in case of oedema
• Albumin if the cause of ARF is hypovolemia due to albumin loss.
• [Kayexalate]) (Sodium polystyrene sulphonate) orally to decrease
hyperkalaemia.
• Kidney transplant

36. • Definition
• Stages
• Causes
• Pathophysiology
• Clinical Manifestations
• Diagnosis
• Management & Treatment

37. • Chronic Kidney disease (CKD), also called chronic renal failure, is the irreversible
loss of renal function due to replacement of functional nephrons with fibrous scar
tissue. Kidneys filter wastes and excess fluids from blood, which are then excreted
in urine.
• When chronic renal failure reaches an advanced stage, dangerous levels of fluid,
electrolytes and wastes can build up in body. In early stage of chronic renal failure,
become clinically apparent as renal insufficiency, evidenced by azotemia and
possibly polyuria and nocturia resulting from impaired tubular transport and
concentration of urine.
• Chronic renal failure may not become apparent until kidney function is
significantly impaired. Chronic renal failure can progress to end-stage kidney
failure, which is fatal without artificial filtering (dialysis) or a kidney transplant.
• Chronic renal failure represents progressive and irreversible destruction of kidney
structures, leading to the accumulation of metabolic products, drugs and poisons,
and disorders of water, electrolyte, acid-base balance, and renal endocrine
functions.

38. Stage 1:
GFR >90 ml/min despite kidney damage. Kidney damage with
normal or increased GFR.
Stage 2:
Mild reduction (GFR 60-89 ml/min).
GFR of 60 may represent 50% loss in function.
Stage 3:
Moderate reduction (GFR 30-59 ml/min)
Stage 4:
Severe reduction (GFR 15-29 ml/min)
Stage 5:
Kidney Failure (GFR <15 ml/min)
End-stage renal disease.

39. Reduced Renal Reserve:
40% - 75% loss of nephron function. Patient is Asymptomatic.
Renal insufficiency:
75% - 90% loss of nephron function (25% of normal renal function) mildly
elevated creatinine and BUN, impaired urine concentrating ability, anemia, Dehydration.
Renal failure.
At this stage, about 90% of functional renal tissue has been destroyed. GFR is
approximately 10% of normal. Tubular cells are essentially nonfunctional. As a
result, the regulation of sodium and water is lost resulting in oedema, metabolic acidosis,
hypocalcaemia, and signs and symptoms of uraemia.
End-state renal failure: (ESRD)
The final stage of chronic renal failure, less than 10% of nephron function
remaining. All of the normal regulatory, excretory, and hormonal functions of
the kidney are severely impaired. Elevated creatinine and blood urea nitrogen levels as
well as electrolyte imbalances.

40.  CKD and CRF can result from a number of causes including.
• Diabetes Mellitus.
• Hypertension
• ARF
• Systemic lupus erythematosus
• Chronic Glomerulonephritis
• Polycystic Kidneys
• Nephrotoxins

41. Deterioration and
destruction of
nephrons
Progressive loss of
renal function
Decrease GFR and
clearances ability
reduced
Increase
BUN and
Creatinine
Remaining
functional nephrons
hypertrophy
Kidney lose their ability to
concentrate the urine and
reabsorb electrolytes
(Diluted urine)
Further damage
to kidney and
GFR decrease
Uremia
or
death occur

42. • Neurologic
• Neuromuscular
• Cardiovascular
• Respiratory
• Gastrointestinal
• Hematologic
• Skin
• Bone diseases
• Sexual dysfunction

44. Blood tests:
Kidney function tests look for the level of waste products, such as creatinine
and urea in blood. Higher levels of creatinine indicate a lower glomerular
filtration rate and as a result a decreased capability of the kidneys to excrete
waste products.
Urine tests:
Testing of a urine sample shows that the kidney is allowing the loss of
protein or red blood cells into the urine. It may reveal abnormalities that
point to chronic kidney failure and help to identify the cause of chronic renal
failure.

45. • Calcium and phosphorus binders.
• Calcium carbonate and calcium acetate
• Antihypertensive and Cardiovascular Agents.
• Anti-seizure Agents.
• Erythropoietin.
• Iron supplements

46. • Conservative treatment.
• Dialysis.
• Haemodialysis
• Peritoneal
• Transplantation.

47. • Removes waste, salt and extra water to prevent them from building up in
the body.
• Keeps a safe level of certain chemicals in the blood, such as potassium,
sodium and bicarbonate.
• Helps to control blood pressure.
 HAEMODIALYSIS:
• A procedure in which a machine filters harmful waste and excess salt and
fluid from patient’s blood.
• A needle is inserted into the arm through a special access point.
• The arterial blood is then directed through the needle to a machine called a
dialyzer (Artificial kidney) which filters the blood.
• The filtered blood returns to the patient’s Venous blood through another
needle.

49. • Technical problems.
• Hypotension or hypertension.
• Febrile reaction.
• Arrhythmias.
• Haemolysis.
• Haemorrhage.

50. • Peritoneal dialysis is another procedure that removes wastes, chemicals,
and extra water from body.
• It does not use an artificial membrane, but rather uses the lining of the
patient's abdominal cavity, known as the peritoneum, as a dialysis
membrane.
• Access: Peritoneal dialysis requires intraperitoneal catheter.

52. • A kidney transplant involves surgically placing a healthy kidney
from a donor into body. Transplanted patient may need to take
medications for the rest of life to keep body from rejecting the new
organ.
• Complication: Rejection