This document discusses renal failure, including anatomy, functions of the kidneys, classifications of renal failure as acute or chronic, causes, symptoms, and management of both acute and chronic renal failure. It addresses diagnostic evaluation and treatment of acute renal failure, including life-threatening conditions like hyperkalemia. Chronic renal failure and end-stage renal disease are discussed along with causes, symptoms, and treatment options like hemodialysis and peritoneal dialysis. Complications and considerations for emergency medical services are also summarized.

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