Paediatric Renal Failure

Acute and Chronic

2020 Block
The Kidney
 Key renal functions
• Excretion of urea, creatinine (urine production).
• Electrolyte balance(Na+, K+, Ca2+, PO4-2, Mg2+).
• Acid-base balance(HCO3-, H+).
• Maintenance of extracellular fluid volume hence
blood pressure.
• Synthesis of erythropoietin for RBC production
• Vitamin D metabolism for bone production
 Acute Renal Failure
• Is the loss of the kidneys’ ability to maintain water
and electrolyte homeostasis.
• Sudden interruption of kidney function resulting
from obstruction, reduced circulation, or disease of
the renal tissue.
• Results in retention of toxins, fluids, and end
products of metabolism.
• Usually reversible with medical treatment.
• May progress to end stage renal disease, uremic
syndrome, and death without treatment.
 Acute Renal Failure
• Persons at Risks

– Major surgery

– Major trauma

– Receiving Nephrotoxic medications

 Acute Renal Failure
• CAUSES
– PRERENAL
• There is reduced renal perfusion with renal ischemia.
• This is due to Hypovolemia, shock, blood loss, embolism,
pooling of fluid due to ascites or burns, cardiovascular disorders,
sepsis(common cause in children).

– INTRARENAL
• renal cellular damage
• Causes include; Nephrotoxic agents(neomycin for eye
infection), infections, ischemia and blockages, polycystic kidney
disease
 Acute Renal Failure
– POSTRENAL

• There is obstruction to urinary outflow.

• Causes include; Stones, blood clots, BPH, urethral edema
from invasive procedures
 Acute Renal Failure
Pathophysiology
Either prerenal, intrarenal or post renal has three entities in
renal pathology.
• The glomerular injury leads to decreased surface area
and permeability. This increases proximal tubular
reabsorption resulting to decreased GFR and oliguria
• Vasoconstriction that progress to decreased intrarenal
blood flow and later decreased GFR and oliguria.
• Tubular injury with sloughing of cells cast formed and
obstruction occurs. This increase intraluminal pressure. later
decreased GFR and oliguria.
 Acute Renal Failure
• Stages
- There is decreased glomerular filtration rate.
– Onset – 1-3 days with increased 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
 Acute Renal Failure - signs

– Oliguric phase –
• vomiting • CHF and pulmonary
• disorientation, edema
• edema, • hypertension caused by
• Increased K hypovolemia, anorexia
• decrease Na+ • convulsions, coma
• Increased BUN and • changes in bowels
creatinine
• Acidosis
• uremic breath
 Acute Renal Failure - signs
– Diuretic phase
• Gradual decline in BUN and creatinine
• Hypokalemia
• Tachycardia
• Improved LOC
Acute Renal Failure - Symptoms
SPECIFIC
– Oliguria
– Anuria( not common)
NON SPECIFIC
– Nausea
– Loss of appetite
– Headache
– Lethargy
– Tingling in extremities
 Acute Renal Failure
Diagnostic tests
• Urinalysis;
acidic urine,
specific gravity; prerenal=high
intrinsic=low,
post renal=normal
protein; -ve
 Acute Renal Failure
• Serum chemistry;
– BUN, creatinine, sodium, potassium. pH, bicarbonate.
Haemoglobing and Hematocrit

• Urine studies
• US of kidneys
• ABD and renal CT/MRI
 Acute Renal Failure
Medical treatment
• It depends the cause of renal failure.
• The goal is to minimize or prevent permanent renal failure.
Pre-renal
If cause is shock/dehydration, resuscitate with iv fluids 20ml/kg
of n/s.
1. If due to ischemic, fluid replacement with ringer’s solution
essential. Give 20ml/kg over 5 – 10 minutes. Make sure renal
perfusion and blood pressure is stabilized.
• With blood loss albumin is given.
• If no oliguria improvement, intrinsic renal damage suspected.
 Medical treatment

Give 2mg/kg Furosemide challenge to invoke

diuresis if there is fluid overload, low urine out
put and like in pulmonary edema. Dialysis done
if no improvement to diuretic
Post-renal
• Surgery is done to collect physical obstruction.
renal stones may resolve spontaneously.
Intrinsic- renal
• Careful fluid and electrolyte balance. Strict fluid
balance chart and wt.
 Medical treatment
• Nutritional support aiming on provision of
calories with no fluid increase, low proteins,
salt, k. avoid banana, tomatoes, citrus
fruits/juices, chocolate.
• Continue breast feeding
• NGT if child very sick for feeding.
• Hypertension is treated by drugs.
• No blood transfusion and Nephrotoxic drugs.
 Medical treatment
• Treat Hyperkalaemia which could cause fatal arrhythmias.
Common drugs are; calcium gluconate i.v., nebulised
salbutamol, dextrose/insulin, bicarbonate infusion.
• Medical treatment
– Hemodialysis
• Subclavian approach
• Femoral approach
• Peritoneal dialysis- Catheter inserted through abdominal wall into
peritoneal cavity
– continuous ambulatory Peritoneal dialysis
• Automated Peritoneal dialysis
•
 Acute Renal Failure
Nursing management
Nursing assessment
• Complete history and physical examination should be done
to identify disease progress and possible renal failure cause.
• Physiological assessment include; vital signs, LOC,
neurological to identify electrolyte imbalance(k, Na, Ca.), wt,
urinalysis, urine culture, blood chemistry, urine
characteristics e.g. cloudy indicates infection, tea colour
indicates hematuria
• Psychosocial assessment includes; feeling of anger, guilty,
anxiety, or fear associated with child’s illness
 Acute Renal Failure
Nursing diagnoses
1) Ineffective renal tissue perfusion related to Hypovolemia,
sepsis and drug toxicity.
2) Excessive fluid volume related to renal dysfunction and Na
retention.
3) Imbalanced nutrition: less than body requirements related
to low food intake sec. anorexia, nausea and vomiting.
4) Risk for infection related to immunosuppresion.
5) compromised family coping related to hospitalization and
uncertainty of child’s disease prognosis.
 Acute Renal Failure
Nursing implementation
• Aim is to prevent complications, maintain fluid balance,
administer drugs, meet nutritional needs, prevent infection
and monitor LOC and support parents emotionally.
Prevention of complications
• Give all medications as prescribed(compliance).
• Careful monitoring of vital signs, intake and output, serum
electrolytes an LOC.
 Acute Renal Failure

Maintain fluid balance

– Monitor input and output daily
– Measure BP 8 hourly.
– Weigh child daily
– Monitor serum Na and K
All above actions aim to maintain fluids and Na and K
balanced and decrease wt by 1% daily.
– In oliguric phase reduce fluids.
– If febric increase fluids by 12% each 1% this is to
replace fluids since the kidneys fail to conserve Na and
water.
 Nursing interventions
Administer medications
• Kidneys are major organs for drug excretion.
• But are impaired.
• Drug doses are reduced
• Interval increased
• Drug levels monitored for toxicity.
 Nursing interventions
Meet nutritional needs
• Provide dietary instructions for foods that reduce
excretory demands on kidney and provide sufficient
calories and protein for growth.
• To provide an appropriate diet that can reduce kidney
demands.
• Limit electrolytes as prescribed to prevent mineral
excess.
• Encourage intake of food high in carbohydrates and
calcium. Calories for growth, calcium for bone
mineralization.
 Nursing interventions
Prevent infection
• Altered nutrition, compromised immunity and invasive
procedure make the child susceptible to procedures.
• Hand washing, sterile techniques.
• urine culture, vital signs and lung sounds give clues to
infections.
Provide emotional support
Threat due to disease process affects the parents and child.
Parents feel guilt. Encourage the parents to verbalize their
concerns. Explain to parents the disease process and
management. Involve them in the management
 Nursing interventions
Home care teaching
• Make parents understand the importance of
adhering prescribed medications.
• Make them understand signs of progressive
renal failure.
• Counsel diet on diet according to severity of
the disease.
• Advice on follow up visits adherence.
 Acute Renal Failure
COMPLICATIONS
• Hyperkalaemia
• Hypertension
• Anaemia
• Seizures
• Cardiac failure with pulmonary edema
 Chronic Renal Failure
• Results form gradual, progressive loss of renal
function( over three months).

• Occasionally results from rapid progression of acute

renal failure.

• Symptoms occur when 75% of function is lost but

considered chronic if 90-95% loss of function

• urinalysis is necessary D/T ;accumulation or uremic

toxins, which produce changes in major organs
 Chronic Renal Failure
• Subjective symptoms are relatively same as acute
• Signs
– Renal
• Proteinuria, glycosuria
• Urine = RBC’s, WBC’s, and casts
 Chronic Renal Failure
• Signs
– Cardiovascular – Neurological
• Hypertension • Burning, pain, and itching,
parestnesia
• Arrythmias
• Motor nerve dysfunction
• Pericardial effusion • Muscle cramping
• CHF • Shortened memory span
• Peripheral edema • Apathy
• Drowsy, confused, seizures,
coma, EEG changes
 Chronic Renal Failure
• Objective symptoms
– GI – Respiratory
• Stomatitis • ^ chance of infection
• Ulcers • Pulmonary edema
• Pancreatitis • Pleural friction rub and
• Uremic fetor effusion
• Vomiting • Dyspnea
• consitpation • Kussmaul’s respirations
from acidosis
 Chronic Renal Failure
• Objective symptoms
– Endocrine
• Stunted growth in children
• Amenorrhea
• Male impotence
• ^ aldosterone secretion
• GI bleed
Impaired glucose levels R/T
impaired CHO metabolism
• Thyroid and parathyroid
abnormalities
– Hemopoietic
• Anemia
• Decrease in RBC survival
time
• Blood loss from dialysis and
• Platelet deficits
• Bleeding and clotting
disorders – purpura and
hemorrhage from body
orifices , ecchymoses
 Chronic Renal Failure
• Objective symptoms
– Skeletal – Skin
• Muscle and bone pain • Yellow-bronze skin with
• Bone demineralization pallor
• Pathological fractures • Puritus
• Blood vessel calcifications • Purpura
in myocardium, joints, • Uremic frost
eyes, and brain • Thin, brittle nails
• Dry, brittle hair, and may
have color changes and
alopecia
 Chronic Renal Failure
• Lab findings
– 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
 Chronic Renal Failure
• 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
– Kayexalate is also used
 Chronic Renal Failure
• 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
 Chronic Renal Failure
• Other abnormal findings
– Metabolic acidosis
– Fluid imbalance
– Insulin resistance
– Anemia
– Immunological problems
 Chronic Renal Failure
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
 Chronic Renal Failure
MEDICAL TREATMENT…………….
• 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
 Chronic Renal Failure
MEDICAL TREATMENT……….
• Peritoneal dialysis
– Semi permeable 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
TYPES
• 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
 Chronic Renal Failure
MEDICAL TREATMENT…………………
• Transplant
– Must find donor
– Waiting period long
– Good survival rate – 1 year 95-97%
– Must take immunosuppressant’s for life
– Rejection
• Watch for fever, elevated B/P, and pain over site of
new kidney
 Chronic Renal Failure
Kidney Transplant
 Chronic Renal Failure
• Post op care
– ICU
– I/O
– B/P
– Weight changes
– Electrolytes
– May have fluid volume deficit
– High risk for infection
 Transplant Meds
• Patients have decreased resistance to infection
• Corticosteroids – anti-inflammarory
– Deltosone
– Medrol
– Solu-Medrol
• Cytotoxic – inhibit T and B lymphocytes
– Imuran
– Cytoxan
– Cellcept
• T-cell depressors - Cyclosporin
 Chronic Renal Failure
• Nursing diagnoses
very specific to Chronic Renal Failure
– delayed growth and development related to decreased
caloric intake and protein loss in dialysate.
– Impaired social interaction related to impaired immunity
and hemodialysis schedules during school hours.
– Activity intolerance related to anemia and fatigue.
– Ineffective therapeutic regimen management related to
complexity of care plan and economic difficulties
– Disturbed body image related to visible external
catheters for dialysis.
 Chronic Renal Failure
• Nursing care
– Frequent monitoring
– Hydration and output
– Cardiovascular function
– Respiratory status
– E-lytes
– Nutrition
– Mental status
– Emotional well being
– Ensure proper
medication regimen
– Skin care
– Bleeding problems
– Care of the shunt
– Education to client and
family