… … ACUTE RENAL FAILURE (ARF)… v ...…...ACUTE TUBULAR NECROSIS (ATN)........

● Sudden decline in GFR ● Results from either nephrotoxic or

● Subsequent retention of products in the ischemic injury that damages the renal
blood that are normally excreted by the tubular epithelium (early recovery)
kidneys ● In severe cases, extends to the basement
● Disrupts electrolyte balance, acid-base membrane (late recovery)
homeostasis, and fluid volume equilibrium ●
1. Ischemic Acute Tubular Necrosis
3 CATEGORIES OF ACUTE RENAL FAILURE - Inadequate perfusion (tubular endothelial
function impairment) → nonuniform patchy
areas of tubular cell damage and cast
formation
Epidemiology and Etiology
Causes
● Advanced Stage of Prerenal Injury
1. Massive hemorrhage
2. Severe volume loss
3. Severe dehydration
4. Severe, prolonged hypotension
5. Shock: cardiogenic, hypovolemic, septic
6. Sepsis
7. Anaphylaxis
-
2. Toxic (Nephrotoxic) Acute Tubular
Necrosis
- Damage by drugs and chemical agents →
uniform, widespread injury to the renal
endothelium
- Healing is more rapid (non-injury of the
basement membrane)
EPIDEMIOLOGY AND ETIOLOGY
Causes
● Endogenous Toxins
1. Rhabdomyolysis
2. Tumor Lysis Syndrome
● Exogenous Toxins
1. Radiocontrast dye
● Nephrotoxic Antimicrobials
1. Aminoglycosides: Gentamicin, Tobramycin
2. Cephalosporins: Cefazolin
3. Antifungals: Amphotericin B
4. Antivirals: Acyclovir
● Nephrotoxic Immunosuppressants
1. Cyclosporins: Tacrolimus
● Nephrotoxic Chemotherapeutics
1. 5-azacitidine
2. Cisplastatin
3. Methotrexate

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● Nephrotoxic Street Drugs ASSESSMENT AND DIAGNOSIS
1. Heroin
2. Amphetamines Laboratory Assessment
3. Phencyclidine (PCP) ● Once acute renal disease is suspected, the
● Nephrotoxic Analgesics presence or degree of renal dysfunction is
1. NSAIDS assessed using both urine and blood analysis
PATHOPHYSIOLOGY

PHASES OF ACUTE TUBULAR NECROSIS

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 ● BUN - creatinine ratio is calculated to
determine the cause of acute renal
dysfunction
SERUM CREATININE ↑
● Rises if kidneys are not working
● If the value doubles, reflects a decrease of
approximately 50% in the GFR
CREATININE CLEARANCE
● Normal creatinine clearance 120mL/min
● Value decreases with renal failure
FRACTIONAL EXCRETION OF SODIUM (FENa)
● Measured early in the ARF course to
differentiate between a prerenal and
intrarenal condition
RADIOLOGIC FINDINGS
● CT Scan of the abdomen: Evaluate
anatomic status of the kidney in the
critically ill
● Angiography: Associated with contrast
media and nephrotoxic renal failure
“AT RISK” DISEASE STATES AND ARF
● Many patients come into the CCU with
disease states that predispose them to
develop ARF
● Some individuals are unaware that they
already have kidney damage
UNDERLYING CHRONIC KIDNEY DISEASE
(CKD)
● Kidney function must be assessed in
critically ill patients at risk for fluid and
electrolyte imbalance

ACIDOSIS ↓
● pH below 7.5 is one of the trademarks of
ARF
● Accumulation of non-excreted waste
product
BLOOD UREA NITROGEN (BUN) ↑
● Not reliable indicator of kidney damage

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RISK OF ACUTE RENAL FAILURE
● Classification to determine the risk of
developing ARF in critically ill patients
(proposed by nephrologists)
● If ARF is superimposed on a kidney that is
already compromised, it is recommended
that the term chronic be added to the
RIFLE criteria to denote an
“acute-on-chronic” renal failure etiology
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OLDER AGE AND ARF
● Risk factor for development of CKD
● 11% of individuals >65 years old without
HTN or DM have stage 3 or worse CKD
● In the presence of HTN and DM → risk of
developing CKD ↑
HEART FAILURE AND ARF
● 54-63% of critically ill patients with ARF
have HF
RESPIRATORY FAILURE AND ARF
● 54-88% of critically ill patients with ARF
have RF
● Prolonged mechanical ventilation is
associated with an increased incidence of
ARF and dialysis
● (Positive pressure ventilation → ↓ RBF,
GFR, UO)
SEPSIS AND ARF
● Sepsis and septic shock → hemodynamic
instability and ↓ renal perfusion
● Mechanism is presumed to be prerenal
TRAUMA AND ARF
● Crush injuries have an elevated risk of
kidney failure (release of creatinine and
myoglobin from damaged muscle cells)
● Creatinine kinase (CK), a marker of
systemic muscle damage, will rise with
rhabdomyolysis
CONTRAST - INDUCED NEPHROTOXIC
INJURY AND ARF
● Rise in SCr of > 0.5 mg/dL or a 25% rise
from the patient’s baseline within 48 to 72
hours of contrast medium exposure
● Patients at risk: baseline SCr >1.5 mg/dL,
DM, HF, or volume depletion
HEMODYNAMIC MONITORING AND FLUID
BALANCE
● Important for the analysis of fluid volume
status in the critically ill patient with ARF
● Includes surveillance of:
1. Central venous pressure (CVP)
2. Pulmonary artery occlusion pressure
(PAOP)
3. Cardiac output (CO)
4. Cardiac index (CI)
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Daily Weight
● Powerful indicator of fluid gains or losses
over 24 hours
● 1-kg weight gain over 24H represents 1L
of additional fluid retention
Physical Assessment
● Used to assess fluid balance
● Signs suggestive of ECF depletion: thirst,
decreased skin turgor, and lethargy
● Signs that imply intravascular fluid volume
overload: pulmonary congestion,
increasing HF, and rising BP
Electrolyte Balance
Potassium
● Hyperkalemia
➢ Potassium supplements are
stopped
➢ IV diuretics can be administered (in
patients producing urine)
➢ IV administration of insulin and
glucose
➢ Na polystyrene sulfonate resin
(Karyexalate) that binds K in the
bowel and eliminates in the feces
➢ Dialysis
Sodium
● Dilutional hyponatremia: corrected by fluid
restriction
● Hypernatremia during dialysis: change
amount of Na in the dialysate bath
Calcium
● Hypocalcemia: administration of Ca
supplements, vitamin D preparations, and
synthetic calcitriol
Phosphorus
● Hyperphosphatemia: medications that
bind dietary phosphorus in the Gl tract are
administered
● Dietary-phosphorus binding drugs:
➢ 1st generation - aluminum salts -
abandoned due to aluminum
toxicity
➢ 2nd generation - calcium salts -
problem with 1 serum Ca and
extraosseous calcification
AFABLE, AGUILAR, AGUIRRE, ANASARIAS, ANG
➢ 3rd generation - sevelamer and
lanthanum carbonate - commonly
used nowadays
Medical Management
● Treatment goals is focused on:
➢ Prevention
➢ Compensation for the deterioration
of renal function
➢ Regeneration of the remaining
kidney functional capacity
Prevention
● The only truly effective remedy
● Patient's risk for development of ARF
must be assessed
Fluid Resuscitation
● Fluid replacement is the only treatment
shown to prevent renal tubular injury
● Objectives are to replace fluid/electrolyte
losses and prevent ongoing loss
● IV fluid is initiated when oral fluid intake is
inadvisable
● Maintenance fluids are calculated based
on:
➢ BSA (average of 1500 ml/m /24
hours)
➢ Baseline metabolism
➢ Environmental temperature
➢ Humidity
● Rate of replacement depends on:
➢ Cardiopulmonary reserve
➢ Adequacy of renal function
➢ Urine output
➢ Fluid balance
➢ Ongoing loss
➢ Type of fluid replaced
● Crystalloids and colloids are IV fluids used
for volume management in critically ill
patients
➢ Crystalloids: balanced salt solutions that
are used both for maintenance infusion
and replacement therapy
➢ Colloids: contains oncotically active
particles that are used to expand
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 intravascular volume to achieve and
maintain hemodynamic stability
Diuretics
● Stimulate urinary output in the fluid
overloaded patient with functioning
kidneys
● Care in avoiding creation of secondary
electrolyte abnormalities
Dopamine
● Stimulates renal blood flow
● Effective in increasing urine output in the
short term
Fenoldopan
● Dopamine-1 receptor agonist
● Similar in structure to dopamine and
dobutamine
● Lowers BP and prevent contrast-induced
nephrotoxicity
Acetylcysteine
● Frequently prescribed for patients with
mildly elevated SC before a radiology
study using contrast dye
Dietary-Phosphorus Binders
● Taken at the time of the meal
● If taken 2 hours after, it will not decrease
Fluid Restriction the phosphorus level

● Prevent circulatory overload and

development of interstitial edema
● 1L fluid/24 hours (urine output is 500 ml or
Nutrition
less); insensible losses: 500 - 700 ml/day
Fluid Removal
● Hemodialysis or hemofiltration are the
treatment of choice
● Electrolyte restriction (sodium, potassium,
and phosphorus)
● Limit protein intake (control azotemia)
● Limit fluids
● Carbohydrates are encouraged (provide
energy for metabolism and healing)

Nursing Management
Pharmacologic Management
● Goals:
1. Eliminate any nephrotoxic
medications
2. If drugs are eliminated through the
kidneys, it is important to decrease
the frequency of administration or
to decrease the dose and to
monitor the serum concentration
by measuring serum drug levels
● Aimed at evaluation of kidney function
level, infection risk, fluid imbalance,
electrolyte disturbance, anemia, readiness
to learn, and need for education
NURSING DIAGNOSES: ACUTE RENAL
FAILURE
● Excess Fluid Volume related to renal
dysfunction
● Ineffective Renal Tissue Perfusion related
to decreased renal blood flow

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 ● Anxiety related to biologic, psychologic, Preventing Anemia
&/or social integrity ● Anemia is an expected side effect of renal
● Decreased Cardiac Output related to failure that occurs because the kidney no
decrease in preload longer produces the hormone
● Risk for Infection risk factors: erythropoietin —> bone marrow is not
protein-calorie malnutrition, invasive stimulated to produce RBCs
monitoring devices PATIENT EDUCATION
● Disturbed Body Image related to
functional dependence on life-sustaining ● It is vital to provide accurate and
technology uncomplicated information to the patient
● Ineffective Coping related to situational and family about ARF, including its
crisis and personal vulnerability prognosis, treatment and possible
● Disturbed Sleep Pattern related to complications
fragmented sleep ● Explain pathophysiology.
● Deficient Knowledge: Fluid Restriction, - ARF is a sudden, severe
Reportable Symptoms, and Medications impairment of renal function,
related to lack of previous exposure to causing an acute buildup of toxins
information in the blood.
● Explain etiology.
Risk factors for ARF
- Prerenal, intrarenal, postrenal
•Elderly persons (decreased GFR) ● Identify predisposing factors.
•Dehydrated patients (hypoperfusion → ischemic ● Explain diet and fluid restrictions.
ATN) ● Demonstrate how to check BP, PR, RR,
•Patients with increased SCr before and weight.
hospitalization ● Discuss good hygiene and how to avoid
infections.
•Patients undergoing radiology procedure ● Emphasize need for exercise and rest.
involving contrast dye ● Describe medications and adverse effects.
Infectious Complications ● Explain the need for ongoing follow-up
with healthcare professional.
● Explain purpose of dialysis and
•­ WBC importance of regular treatments.
•Redness at a wound or IV site
COLLABORATIVE MANAGEMENT
● Management of the patient with ARF is
•­ temperature complex and requires the expertise of
•Indwelling catheter different healthcare clinicians
•Pulmonary hygiene (especially in ventilated 1. Assess risk of renal failure.
patients) - Assess baseline renal function on
all patients at risk for development
Fluid Balance of ARF.
● Urine output is measured on an hourly 2. Protect the kidneys.
basis - If patient has preexisting renal
● Hemodynamic values (HR, BP, CVP, dysfunction, avoid nephrotoxic
PAOP, CO, and CI) and daily weight drugs, limit exposure to radiologic
measurements are correlated with input contrast dye, and prevent both
and output hypotension and hypovolemia.
3. Monitor urine output.
Electrolyte Imbalance
- Intervene for low urine output
● Hyperkalemia and hypocalcemia (cardiac before patient is oliguric or anuric
dysrhythmias), hyponatremia (fluid for several hours.
overload), hyperphosphatemia (pruritus), 4. Supply nutrition.
and acid-base imbalances all occur during - Oral, enteral, or parenteral nutrition
ARF is needed to combat catabolism in
● Clinical manifestations must be prevented critically ill patients with renal
and their associated side effects controlled dysfunction.

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 5. Provide renal replacement.
- If patient has lost renal function
during acute illness, replace kidney
function with intermittent
hemodialysis or CRRT as
indicated.
RENAL REPLACEMENT THERAPY – DIALYSIS
● Available for the treatment of ARF
Includes:
1. intermittent hemodialysis (IHD)
2. continuous renal replacement therapy
(CRRT)
3. peritoneal dialysis (PD)
HEMODIALYSIS (IHD)
● Separates and removes from the blood
the excess electrolytes, fluids, and toxins
by use of a hemodialyzer
● Efficient in removing solutes, but it does
not remove all metabolites
● Intermittent, each treatment takes 3 to 4
hours, 3x/week (daily in ARF)
Indications and Contraindications for
Hemodialysis
Indications:
● BUN > 90 mg/dL
● Serum creatinine 9 mg/dL
● Hyperkalemia
● Drug toxicity
● Intravascular and extravascular fluid
overload
● Metabolic acidosis
● Symptoms of uremia (pericarditis, GI
bleeding)
● Changes in mentation
● Contraindications to other forms of dialysis
Contraindications:
● Hemodynamic instability
● Inability to be anticoagulated
● Lack of access to circulation
HEMODIALYZER (Artificial Kidney)
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Ultrafiltration
● A positive hydrostatic pressure is applied
to the blood and a negative hydrostatic
pressure is applied to the dialysate bath
(transmembrane pressure) à pull and
squeeze the excess fluid from the blood
Anticoagulation
● Either heparin or sodium citrate is added
to the system just before the blood enters
the dialyzer
● Anticoagulates the blood within the
dialysis tubing
Vascular Access
● Access to the bloodstream
● Can either be a:
1. Temporary acute access
2. Permanent vascular access
Temporary Acute Access
•Subclavian and femoral veins are catheterized
when short-term access is required
•Done when vascular access is nonfunctional in a
patient requiring urgent HD
•Venous only
Permanent Vascular Access
● Common denominator is a connection to
the arterial circulation and a return conduit
to the venous circulation
● Can be a/an:
1. Arteriovenous fistula
2. Arteriovenous graft
3. Tunneled catheters
Arteriovenous Fistula
● Connects an artery to a vein
● Vein stretches over time
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 ● Best way to access to the bloodstream for
HD

Arteriovenous Fistula
● A tube, usually made of plastic, that connects
an artery to a vein
● 2nd best way to gain access to the bloodstream
for HD

Tunneled Catheters
● A catheter is inserted into a vein in the neck or
chest to provide vascular access for HD
● The tip rests in the heart
● Intended to be temporary, but for some
patients it is the only choice and becomes a
permanent access

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 diversion needs to achieve optimal benefit of
Medical Management treatment.
● Involves the decision to place a vascular
CONTINUOUS RENAL REPLACEMENT
access device and then to choose the most
THERAPY (CRRT)
appropriate type and location for each
patient
● Patients in the critical care setting only ● Newer mode of dialysis
requires temporary vascular access ● Advantage of being a continuous therapy,
(catheter) lasting 12 hours to several days, where the
● Exact quantity of fluid &/or solute removal venous blood is circulated through a highly
to be achieved via HD is determined porous hemofilter (continuous removal of
individually per patient fluid from the plasma)
● Highly advantageous for use in patients with
multisystem problems
Nursing Management
● Draw blood samples & review blood
chemistries before treatment.
● Record baseline V/S: Wt, T°, PR, RR, and BP.
● Explain HD procedure & its purpose.
● Check equipment & solutions.
● Use sterile technique to initiate HD & for
needle insertions and catheter connections.
● Use gloves, eye shield, and clothing to prevent
direct contact with blood.
● Initiate HD.
● Anchor connections & tubing securely.
● Check system monitors to ensure patient
safety.
● Monitor BP, PR, RR, T° & patient response
during dialysis.
● Administer heparin.
● Monitor clotting times and adjust heparin
administration appropriately.
● Adjust filtration pressures to remove an
appropriate amount of fluid.
● Institute appropriate hypotensive protocol.
● Discontinue HD.
● Compare post-HD V/S & blood chemistries
with pre-HD values.
● Avoid taking BP or doing IV punctures in arm
with fistula.
● Provide catheter or fistula care.
● Work collaboratively with patient to adjust
diet regulations, fluid limitations, &
medications to regulate fluid and electrolyte
shifts between treatment.
● Teach patient to self-monitor SSx that indicate
need for medical treatment.
● Work collaboratively with patient to relieve Methods used in critical care units:
discomfort from side effects of the disease 1. Slow Continuous Ultrafiltration (SCUF)
and treatment. 2. Continuous Venovenous Hemofiltration
● Work collaboratively with patient to adjust (CVVH)
length of dialysis, diet regulations, & pain and

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 3. Continuous Venovenous Hemodialysis CRRT Terminology
(CVVHD) ● Diffusion: movement of solutes along a
4. Continuous Venovenous Hemodiafiltration concentration gradient from “high” concentration to
(CVVHDF) a “low” concentration across a semipermeable
membrane
● Convection: occurs when a pressure gradient is set
up so that the water is pushed or pumped across the
dialysis filter and carries the solutes from the
bloodstream with it
● Absorption: filter attracts solute, and molecules
attach (absorb) to the dialysis filter
● Ultrafiltrate volume: fluid that is removed each hour
● Replacement fluid: increase the volume of fluid
passing through the hemofilter and improve
convection solute (pre- or post-filter dilution)
● Anticoagulation: prevent hemofilter from becoming
obstructed with clots by giving unfractionated
heparin and sodium citrate

Type of method to be used depends on:

● Clinical assessment
● Metabolic status
● Severity of uremia
● Availability of treatment modality in the
institution

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AFABLE, AGUILAR, AGUIRRE, ANASARIAS, ANG 12
Medical Management

• Intermittent HD or CRRT is usually begun before

the BUN level exceeds 90 mg/dL or the creatinine
exceeds 9 mg/dL
• Patient’s SCr, BUN, and fluid volume status are
the deciding factors
• CRRT is more effective in the early stages of ARF

Nursing Management

• CRRT system is set up by a dialysis staff but is run

on a 24-hour basis by the critical care nurses Catheter Placement
with training
Most catheter have four segments:
CCU nurses: 1. External – outside the abdomen
monitors fluid intake and 2. Tunnel – passes through subcutaneous tissue
output and muscle
3. Cuff – stabilization at the peritoneal
prevents and detects
membrane
potential complications
4. Internal – numerous holes for fast delivery
trends electrolyte laboratory
and drainage of dialysate
values
supervises safe operation of
the CRRT equipment
provides patient and family
education about the patient’s
condition inclusive of CRRT

PERITONEAL DIALYSIS

• Involves introduction of sterile dialyzing fluid

through an implanted catheter into the
abdominal cavity.

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INFECTION

● Most significant risk is development of

peritonitis secondary to catheter
contamination and infection
• Reason a PD patient would be admitted to the
hospital
• Critical care nurse must be acutely aware of the
signs and symptoms of systemic infection: Medical Management
1. Rise in WBC count • PD is used for long-term end-stage kidney
2. increased temperature failure (never used as a first-time acute
3. malaise care intervention)

Clinicians remain vigilant for signs of localized catheter Nursing Management

or abdominal infection:
■ catheter site redness 1. Explain the selected PD procedure and
■ site swelling purpose.
■ cloudy dialysis effluent following the 2. Warm the dialysis fluid before installation.
dwell time 3. Assess patency of catheter, noting difficulty in
■ abdominal tenderness or pain (75%) inflow/outflow.

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 4. Maintain record of inflow/outflow volumes &
individual cumulative fluid balance.
5. Have the patient empty the bladder before
peritoneal catheter insertion.
6. Avoid excess mechanical stress on PD
catheters.
7. Monitor BP, PR, RR, T° & patient response
during dialysis.
8. Ensure aseptic handling of peritoneal catheter
& connections.
9. Draw blood samples & review blood
chemistries.
10. Obtain cell count cultures of peritoneal
effluent, if indicated.
11. Record baseline V/S: Wt, T°, PR, RR, & BP
12. Measure and record daily weight & abdominal
girth.
13. Anchor connections & tubing securely.
14. Check equipment & solutions.
15. Administer dialysis exchanges.
16. Monitor for signs of infection and respiratory
distress.
17. Monitor for bowel perforation or fluid leaks.
18. Work collaboratively with patient to adjust
length of dialysis, diet regulations, & pain and
diversion needs to achieve optimal benefit of
the treatment.
19. Teach patient to monitor self for SSx that
indicate need for medical treatment.
20. Teach procedure to patient requiring home
dialysis.

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