KIDNEY

FAILURE
Disusun oleh :
1. Febrianti safitri
2. Resca N S
3. Saiful R R
4. Devi Fitriana
 Kidney Failure Definition
Chronic kidney failure is a disorder of kidney function in which the ability of the kidneys to
maintain metabolism and fluid and electrolyte balance is disturbed due to a decrease in the ability
of kidney function to work normally. This decline in kidney function is chronic, progressive, and
quite advanced, and is persistent and irritative
According to the World Health Organization (WHO), in Indonesia there will be an increase
in patients with kidney disease between 1995-2025 by 41.4% ((IRR), 2013). In 2011 there were
15,353 patients undergoing hemodialysis and in 2012 there were 4,268 people. Thus, the total
number became 19,621 patients who had just undergone hemodialysis until 2012 in 244
hemodialysis units in Indonesia.
 Fluid Needs in Patients with Kidney Failure
Normal fluid loss consists of insensible and insensible losses. Insensible losses are losses that
are not realized consciously, such as loss of water through respiration, normal feces or sweating.
Sweating is a negligible volume in dogs and cats. There is variation in respiratory loss in dogs,
who may lose a lot of fluid from panting, but average 22 ml/kg/day. The main sensible fluid loss
in normal patients is urine output. Reasonable additional losses include volume lost due to
vomiting, diarrhea, body cavity drainage, burns, etc.
In healthy animals, this loss is replaced by drinking and fluids contained in the diet. In sick
animals, who may not voluntarily consume food or water, or who may be restricted in their
consumption due to vomiting, fluid therapy is required to replace this loss. With kidney disease.
 Fluid therapy for inpatients
Many drugs have been evaluated for efficacy in treating AKI, and some of them
are helpful in certain settings. However the most effective therapy for AKI is
careful management of fluid balance, which involves careful assessment of
hydration, a fluid treatment plan tailored to the specific patient, repeated and
frequent reassessment of fluid and electrolyte balance, with appropriate
changes in the treatment plan in response. with the rapidly changing clinical
situation of patients with renal failure.
 Assess hydration
The key feature for a proper fluid plan is accurate determination of hydration status. Extravascular
fluid compartment deficits (interstitial and intracellular) lead to dehydration. A severe deficit can
decrease the intravascular compartment, leading to poor perfusion. Dehydration of less than about
5% is difficult to detect clinically. A deficit of 5 to 6% causes sticky mucous membranes. Six to
eight percent dehydration causes dry mucous membranes and decreased skin elasticity. With 8-
10% dehydration, the eyes may be sunken, and more than 12% dehydrated, the cornea is dry,
mentally dull, and perfusion is impaired. Overhydration may manifest as moist mucous
membranes, increased skin elasticity (severe or gelatinous), chills, nausea, vomiting, restlessness,
serous nasal discharge, chemosis, tachypnea, cough, dyspnea, rales and pulmonary edema, pleural
effusion, ascites, diarrhea. , or subcutaneous edema (especially the hock joint and intermandibular
space). Uremic patients often have xerostomia, leading to dry mucous membranes regardless of
hydration status. Hypoalbuminemia or vasculitis may lead to accumulation of interstitial fluid
despite an intravascular volume deficit. Thinness or old age reduces skin elasticity.
Accurately recorded weight before illness is an invaluable aid to assessing hydration. Body
weight should be measured several times a day on the same scale. Sick animals can lose up to
0.5-1% of body weight per day due to anorexia; changes in excess of this amount are due to
changes in fluid status. An increase in blood pressure may indicate an increase in fluids;
conversely, a drop in blood pressure may indicate fluid loss. Because of the high percentage of
patients with hypertension (80% of dogs with severe acute uremia and 20-30% of dogs and cats
with CKD), trends rather than absolute values ​are more useful in assessing changes in hydration
status. Similarly, changes in trends for PCV and total solids may reflect changes in volume, in
the absence of bleeding or blood transfusion. Measurement of central venous pressure (CVP) via
a centrally placed intravenous catheter can provide information about intravascular filling.
Volume-deficient animals will have a CVP of less than 0 cm H20. A CVP of more than 10 cm
H20 is consistent with volume overload or right-sided congestive heart failure. However, pleural
effusion incorrectly increases CVP. Since each parameter is affected by aspects other than
hydration status, these factors must be considered in aggregate.
 Route of fluid administration
In most hospitalized patients, the intravenous route is the most appropriate route of
administration. In some situations, such as very small patients, including newborn
puppies or kittens, IV catheterization may be difficult. Intraosseous fluid administration
may be used in that setting. In dehydrated patients, fluids administered into the
peritoneal cavity are readily absorbed, but this method is not reliable for increasing
diuresis or in oliguric patients. Fluids administered subcutaneously may not be absorbed
rapidly or completely, and it is not possible to give large volumes via this route, making
subcutaneous fluids unsuitable for the hospital setting.
 Liquid type

A balanced polyionic solution (ie, Ringer's lactate solution [LRS], Plasmalyte-148, Normosol-R)
is an appropriate choice for initial volume resuscitation fluids and replacement of dehydration deficits.
Physiological (0.9%) NaCl does not contain potassium and is a suitable choice for hyperkalemic
patients.
After rehydration, maintenance fluids with lower sodium concentrations are more appropriate (ie,
0.45% NaCl with 2.5% dextrose, LRS strength with 2.5% dextrose). Dextrose 5% in water (D5W) is
rarely suitable as a single fluid choice, but can be combined with LRS or 0.9% saline to make a sodium
strength solution or (25 ml LRS + 25 ml D5W = 50 ml LRS strength + 2.5% dextrose).
Colloid solutions (ie, hydroxyethyl starch, 6% dextran) may be appropriate if hypoalbuminemia is
present. The recommended dose is 20 ml/kg/day, and can be used to replace the nonsensical portion
when using the "in-and-out" method (see below). Higher doses may be associated with coagulopathy.
An alternative to synthetic colloids is human albumin, but this product carries a risk of anaphylaxis.
 Treatment of patients with acute uremic crisis from protein-losing nephropathy with severe hypoalbuminemia
involves additional considerations. The increase in intravascular volume and hydrostatic pressure from crystalloid
infusion is not counteracted by the colloid oncotic pressure in the plasma, increasing peripheral interstitial edema.
Even with the use of colloid solutions, aggressive diuresis with crystalloids may not be possible without causing
peripheral edema.
Red blood cell transfusions may be indicated if there are symptoms of anemia. Red blood cell survival is shorter
in a uremic environment, blood sampling can cause great losses, and erythropoietin production is generally
suppressed. Acute gastrointestinal bleeding may cause anemia, and if bleeding is rapid, hypotension and
hypovolemia may develop and require rapid infusion of crystalloid or colloid solutions. Intensive diuresis can lead to
heart failure to exclude disease in anemic cats. On the other hand, rapid blood transfusions can lead to congestive
heart failure. In patients with impaired cardiovascular function or incipient volume overload, transfusions may need
to be given later than usual.
The fluid option that is sometimes overlooked is water that is given enterally. Because vomiting is a
common problem with uremia, enteral feedings or water are often contraindicated, and many uremic
patients refuse to consume water voluntarily. However, water supplied through a feeding tube must be
included in the water calculation.
Ultimately, fluid choice should be guided by monitoring the patient's fluid and electrolyte
balance. The main determining factor in proper fluid selection is sodium concentration, because the
rate of free water loss relative to sodium loss varies widely in patients with AKI. The guiding
principle in treating sodium disorders is to reverse them at the same rate at which they develop
because a rapid increase or decrease in sodium concentration can lead to CNS dysfunction.
 Volume and level

Some patients may experience hypovolemic shock, which is manifested as mental dullness, hypotension
(systolic blood pressure <80 mmHg), poor peripheral perfusion (cold extremities, pale/grey mucous
membranes with slow capillary refill time), hypothermia, or hypothermia. tachycardia. . Immediate
correction of shock is required to prevent further and irreversible organ damage. The standard dose of
crystalloid is 60-90 ml/kg for dogs and 45-60 ml/kg for cats, which is given over 5 to 15 minutes. If
hemodynamic parameters are not sufficiently improved with the first dose, a second dose should be
given. Resuscitation efforts are continued until the patient is hemodynamically healthy. If the patient
remains hypotensive and there is concern about volume overload, monitoring of central venous pressure
may be helpful.
For patients with dehydration, the dehydration deficit is calculated as body weight (in kg) x
estimated % dehydration = fluid deficit in L. Since dehydration of less than 5% cannot be detected
clinically, a 5% dehydration deficit is considered in patients who appear normally hydrated. If a fluid
bolus is used for resuscitation, that volume is subtracted from the dehydration deficit.
The rate of replacement of the dehydration deficit depends on the clinical situation. In patients with
AKI, who are suspected of being dehydrated for a short period of time, rapid replacement is prudent.
This returns renal perfusion to normal levels and can help prevent further damage to the kidneys. In
situations where urine output may be reduced, rapid replacement of the dehydration deficit allows
the clinician to quickly determine whether oliguria is an appropriate response to volume depletion or
is a pathological change from renal failure. In that setting, it is recommended to replace the deficit
in 2-4 hours. If there is a potential compromise of cardiac diastolic function, rapid fluid boluses may
precipitate congestive heart failure, and a more gradual rate of rehydration (ie, over 12-24 hours)
may be prudent. In patients with chronic dehydration, a more gradual replacement of the fluid
deficit is acceptable to minimize the risk of heart problems or rapid electrolyte changes, and 24
hours is the commonly chosen time frame. In patients who are severely dehydrated and chronically
debilitated, it may take up to 48 hours to rehydrate.
The concept of maintenance fluid rate is based on the average fluid loss from insensible (respiration) and sensible
(urinary output) sources. The most frequently quoted value is 66 ml/kg/day. Ignoring normal individual variation,
the assumption with this value is that urine output is normal and there is no other source of fluid loss, which is
rare in patients with renal failure. However, it makes a reasonable starting point for calculating fluid delivery
volumes. If accurate measurements of urine output and persistent losses are available, fluid therapy can be
adjusted accordingly (see "in-and-out" methods below). If this parameter is not measured accurately, the estimated
loss should be included in the rate of fluid administration. In practical terms, after initial fluid resuscitation if
needed for shock,
Because uremic toxins are retained in renal failure, administration of fluid volumes that exceed "maintenance"
may increase the excretion of some uremic toxins in animals with the ability to increase urine output in response
to fluid challenge. Volume varies based on clinical situation and physician preference, but generally ranges from
2.5-6% of body weight per day, in addition to maintenance fluid levels. In practical terms, twice the maintenance
fluid rate is equivalent to the maintenance rate plus a 6% "push" for diuresis (60 ml/kg/day = 6% of body weight).
If urine output is highly variable from normal, either oliguria (<0.5 ml/kg/hour) or polyuria (>2 ml/kg/hour), a fluid plan
based on this assumption may not be adequate. Animals with renal failure may have urine output in the "normal" range
(0.5-2.0 ml/kg/hr), but if their kidneys are unable to change urine volume to excrete the fluid load, the patient has
"relative oliguria". The nitty-gritty method of administering fluids is appropriate in this situation. It should only be used
after rehydration is complete and is not appropriate if the patient is still dehydrated.
There are three components of volume calculation in the “Ins-and-Outs” method, consisting of 1) insensible loss (loss of
fluids through respiration and normal feces) = 22 ml/kg/day, 2) replacement of urine volume calculated by actual
measurements ( see below for measurement techniques), and 3) ongoing losses (ie, vomiting, diarrhea, body cavity
drainage) that are generally expected.