Acute renal failure (ARF) is defined as a rapid decline in kidney function over hours or days. It can be caused by decreased blood flow to the kidneys, damage or toxicity to the kidney cells. Symptoms include decreased urine output, fatigue, nausea and fluid retention. Treatment involves treating the underlying cause, fluid management, and potentially dialysis. Chronic renal failure (CRF) is the gradual, permanent loss of kidney function over months or years due to conditions like diabetes or hypertension. It leads to a buildup of waste products and imbalances in electrolytes. Management includes dietary modifications, medication, and long-term dialysis or transplant.

1. Dr. Angelo Smith M.D
WHPL

5. NORMALARF CRF

7. Inability of kidney to maintain
homeostasis leading to a buildup
of nitrogenous wastes
Different to renal insufficiency
where kidney function is
deranged but can still support
life

8.  Occurs over hours/days
 Lab definition
 Increase in baseline creatinine of more than 50%
 Decrease in creatinine clearance of more than
50%
 Deterioration in renal function requiring dialysis
▪ Anuria – no urine output or less than 100mls/24 hours
▪ Oliguria - <500mls urine output/24 hours or <20mls/hour
▪ Polyuria - >2.5L/24 hours

9. Persons at Risks
 Major surgery
 Major trauma
 Receiving nephrotoxic medications
 Elderly

11.  Pre renal
(functional)
 Renal-intrinsic
(structural)
 Post renal
(obstruction)

17. Pathophysiology of ischemic and toxic ARF

18. Stages
 Onset – 1-3 days with ^ BUN and creatinine and
possible decreased UOP
 Oliguric – UOP < 400/d, ^BUN, Crest, Phos, K, may
last up to 14 d
 Diuretic – UOP ^ to as much as 4000 mL/d but no
waste products, at end of this stage may begin to see
improvement
 Recovery – things go back to normal or may remain
insufficient and become chronic

19. Subjective symptoms
Nausea
Loss of appetite
Headache
Lethargy
Tingling in extremities

20.  vomiting
 disorientation,
 edema,
 ^K+
 decrease Na
 ^ BUN and
creatinine
 Acidosis
 uremic breath
 CHF and pulmonary
edema
 hypertension caused
by hypovolemia,
anorexia
 sudden drop in UOP
 convulsions, coma
 changes in bowels

21.  Increased UOP
 Gradual decline in BUN and creatinine
 Hypokalemia
 Hyponaturmia
 Tachycardia
 Improved LOC

22.  Rising creatinine and urea
 Rising potassium
 Decreasing Hb
 Acidosis
 Hyponatraemia
 Hypocalcaemia

23.  Urinary sediment
 Urinary indices
 Urine volume
 Urine electrolytes
 Radiologic studies

27.  Immediate treatment of pulmonary edema and
hyperkalaemia
 Remove offending cause or treat offending cause
 Dialysis as needed to control hyperkalaemia,
pulmonary edema, metabolic acidosis, and uremic
symptoms
 Adjustment of drug regimen
 Usually restriction of water, Na, and K intake, but
provision of adequate protein
 Possibly phosphate binders and Na polystyrene
sulfonate

28.  Medical treatment
 Fluid and dietary restrictions
 Maintain E-lytes
 D/C or change cause
 May need dialysis to jump start renal function
 May need to stimulate production of urine with IV
fluids, Dopomine, diuretics, etc.

29.  Medical treatment
 Hemodialysis
▪ Subclavian approach
▪ Femoral approach
 Peritoneal dialysis
 Continous renal replacement therapy (CRRT)
▪ Can be done continuously
▪ Does not require dialysate

31. Involves progressive, irreversible loss of
kidney function
Defined as either presence of
 Kidney damage
▪ Pathological abnormalities
 Glomerular filtration rate (GFR)
▪ <60 ml/min for 3 months or longer

34. Glomerulonephritis – the most
common cause in the past
Diabetes mellitus
Hypertension
Tubulointerstitial nephritis
 are now the leading causes of CRF

36.  Subjective symptoms are relatively same as acute
 Renal
 Hyponaturmia
 Dry mouth
 Poor skin turgor
 Confusion, salt overload, accumulation of K with
muscle weakness
 Fluid overload and metabolic acidosis
 Proteinuria, glycosuria
 Urine = RBC’s, WBC’s, and casts

37. Cardiovascular
 Hypertension
 Arrythmias
 Pericardial
effusion
 CHF
 Peripheral edema
 Neurological
 Burning, pain, and itching,
parestnesia
 Motor nerve dysfunction
 Muscle cramping
 Shortened memory span
 Apathy
 Drowsy, confused,
seizures, coma, EEG
changes

39. GI
 Stomatitis
 Ulcers
 Pancreatitis
 Uremic fetor
 Vomiting
 consitpation
 Respiratory
 ^ chance of infection
 Pulmonary edema
 Pleural friction rub
and effusion
 Dyspnea
 Kussmaul’s
respirations from
acidosis

40. Endocrine
 Stunted growth in children
 Amenorrhea
 Male impotence
 ^ aldosterone secretion
 Impaired glucose levels
R/T impaired CHO
metabolism
 Thyroid and parathyroid
abnormalities
Hemopoietic
 Anemia
 Decrease in RBC survival
time
 Blood loss from dialysis
and GI bleed
 Platelet deficits
 Bleeding and clotting
disorders – purpura and
hemorrhage from body
orifices , ecchymoses

41. Skeletal
 Muscle and bone pain
 Bone demineralization
 Pathological fractures
 Blood vessel
calcifications in
myocardium, joints,
eyes, and brain
Skin
 Yellow-bronze skin
with pallor
 Puritus
 Purpura
 Uremic frost
 Thin, brittle nails
 Dry, brittle hair, and
may have color
changes and alopecia

43. • is clinical syndrome that results from profound loss
of renal function
• cause(s) of it remains unknown
• rerers generally to the constellation of signs and
symptoms associated with CRF, regardless of
cause
• presentations and severity of signs and symptoms
of uremia vary and depend on
• the magnitude of reduction in functioning renal
mass
• rapidity with which renal function is lost

44.  the most likely candidates as toxins in uremia are
the by–products of protein and amino acid
metabolism
 Urea – represents some 80% of the total nitrogen
excreted into the urine
 Guanidino compunds: guanidine, creatinine, creatin,
guanidin-succinic acid)
 Urates and other end products of nucleic acid
metabolism
 Aliphatic amines
 Peptides
 Derivates of the aromatic amino acids: tryptophan,
tyrosine, and phenylalanine

45. Metabolic acidosis of CRF is not due to
overproduction of endogenous acids
but is largely a reflection of the
reduction in renal mass, which limits
the amount of NH3 (and therefore
HCO3
-
) that can be generated

47. BUN – indicator of glomerular filtration rate and
is affected by the breakdown of protein. Normal is
10-20mg/dL. When reaches 70 = dialysis
 Serum creatinine – waste product of skeletal
muscle breakdown and is a better indicator of
kidney function. Normal is 0.5-1.5 mg/dL. When
reaches 10 x normal, it is time for dialysis
 Creatinine clearance is best determent of kidney
function. Must be a 12-24 hour urine collection.
Normal is > 100 ml/min

48. K+ -
 The kidneys are means which K+ is excreted.
Normal is 3.5-5.0 ,mEq/L. maintains muscle
contraction and is essential for cardiac function.
 Both elevated and decreased can cause problems
with cardiac rhythm
 Hyperkalemia is treated with IV glucose and Na
Bicarb which pushes K+ back into the cell.

49. Ca
 With disease in the kidney, the enzyme for
utilization of Vit D is absent
 Ca absorption depends upon Vit D
 Body moves Ca out of the bone to compensate
and with that Ca comes phosphate bound to it.
 Normal Ca level is 4.5-5.5 mEq/L
 Hypocalcemia = tetany
▪ Treat with calcium with Vit D and phosphate
▪ Avoid antacids with magnesium

50. Metabolic acidosis
Fluid imbalance
Insulin resistance
Anemia
Immunological problems

51.  Medical treatment
 IV glucose and insulin
 Na bicarb, Ca, Vit D, phosphate binders
 Fluid restriction, diuretics
 Iron supplements, blood, erythropoietin
 High carbs, low protein
 Dialysis - After all other methods have failed

52. Hemodialysis
 Vascular access
▪ Temporary – subclavian or femoral
▪ Permanent – shunt, in arm
▪ Care post insertion
 Can be done rapidly
 Takes about 4 hours
 Done 3 x a week

53.  Peritoneal dialysis
 Semipermeable
membrane
 Catheter inserted
through abdominal wall
into peritoneal cavity
 Cost less
 Fewer restrictions
 Can be done at home
 Risk of peritonitis
 3 phases – inflow, dwell
and outflow
 Automated peritoneal
dialysis
 Done at home at night
 Maybe 6-7 times /week
 CAPD
 Continuous ambulatory
peritoneal dialysis
 Done as outpatient
 Usually 4 X/d

54. Transplant
 Must find donor
 Waiting period long
 Good survival rate – 1 year 95-97%
 Must take immunosuppressant’s for life
 Decreased resistance to infections.
 Rejection
▪ Watch for fever, elevated B/P, and pain over
site of new kidney

55. • Potassium restriction
– 2 to 4 g
– High-potassium foods should be avoided
• Oranges
• Bananas
• Tomatoes
• Green vegetables
• Phosphate restriction
– 1000 mg/day
– Foods high in phosphate
• Dairy products
– Most foods high in phosphate are also high in
calcium