Definition of Kidney Failure
Acute Renal Failure (ARF)
Acute Renal Failure (ARF) is a condition where the glomerular filtration rate (GFR) is decrease spontaneously and kidney function ability in maintaining balance water excretion. It called clinical syndrome that is caused by metabolic damage or kidney pathology, this condition is signed by kidney function decrease and it occurs fast and azotemia.
Chronic Renal Failure (CRF)
Chronic renal failure is a condition where kidney function can not work well in maintaining fluid and electrolyte balance, glomerular filtration rate is decrease progressively and irreversible, the kidney is fail to maintain body fluid and electrolyte balance, and this condition will appear as uremia.
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Etiology of Kidney Failure
Acute Renal Failure (ARF)
Three categories of Acute Renal Failure (ARF) are pre-renal, intra-renal, and the last is post-renal. These etiologies will explain in detail.
Pre-renal
Pre-renal is an etiology of Acute Renal Failure (ARF) that is caused by kidney hypoperfussion and glomerulus filtration rate (GFR) decrease. General clinical condition about this hypoperfussion may caused by blood or plasm loss; bleeding and massive burn wound, extracellular fluid loss; vomit and diarrhea, capillary capacity increase; sepsis, ganglion blockage and anaphylaxis reaction, cardiac output failure; congestive heart failure, dysrhythmia, lung emboli, and heart infarct.
Intra-renal
Intra-renal etiology is glomerulus structure or distal tubules damage. The condition such as burn and edema which caused by trauma, infection, or necrotic agent can make acute tubules necrosis (ATN) and kidney stop working. Bad transfusion reaction can cause intra-renal failure, hemoglobin will be released by hemolysis mechanism through glomerulus membrane and it will be concentrated in distal tubules, and it will be hemoglobin factor production. The main factor is non steroid anti inflammation consumption, especially in elderly.
Post-renal
This etiology is an etiology of Acute Renal Failure (ARF) caused by obstruction in distal tubules, distal tubules pressure will decrease, and glomerulus filtration rate (GFR) is increase.
Chronic Renal Failure (CRF)
The causes of chronic renal failure (CRF) is so many, but in general it can divided into two groups:
Systemic Disease; diabetes mellitus, glomerulonephritis, pyelonephritis, uncontrolled hypertension, urinary tract obstruction, vascular disturbances, infection, medication or toxic agent, and hereditary lesion such as kidney polycystic. Environment and Toxic Agent are the second one.
Pathophysiology
Acute Renal Failure (ARF)
To know more about pathophysiology of kidney makes you understand well, click here. Some conditions such as like hypovolemia, hypotension, cardiac output decrease or congestive heart failure, kidney obstruction or bladder obstruction that is caused by tumor, blood coagulation, artery and vein obstruction. If those condition is treated before permanent damage, BUN level, oliguria, and other sign and symptoms of acute renal failure (ACF) can be handled. There is four clinical steps of acute renal failure:
First Stadium
First stadium is first respond of kidney toward many condition, and the result of this respond is signed by oliguria.
Second Stadium
Second stadium or oliguria stadium is signed by 75% tissue damage, this tissue is a tissue that produce urine. BUN level will increase. BUN level increase is different in diet. In this stadium, creatinine serum level starts increase above normal level. Azotemia is usually mild except the patient is infected, heart failure, or dehydration. In this stadium also has nocturia symptoms, nucturia is caused by thickening failure. The symptoms appear as a respond toward stress and diet changes spontaneously. The patient usually does not pay attention on this symptoms. Persistent peeing at night time until 700 ml urine production, or the patient woke up to pee frequently at night. In normal condition, the ration between peeing at night and day is 3 : 1 or 4 : 1. Nocturia sometimes is as a respond of anxiety or water consumption. Polyuria in kidney failure is more sever in tubules damage, polyuria might be mild and rarely more than 3 liters a day. Anemia may appear in kidney failure with kidney function between 5 to 25%. Kidney function is clearly decrease and it may have anemia symptoms and the blood pressure will increase and the result is the patient activities disturbed.
Third Stadium
Third stadium where the symptoms is clear and the patient can not do some activities daily living as usual. The symptoms are nausea, vomit, loss of appetite, seizure, and even coma. The last stadium will appear about 90% from nephron destruction. The GFR level is about 10% higher than normal condition, it may be 5 to 10 ml per minutes. In this condition, creatinine serum and BUN level will increase. In last kidney stadium, the patient will have sever symptoms because the kidney can not maintain homeostatic balance between fluid and electrolyte in the body. The patient usually have oliguria less than 500 ml per day because of glomerulus failure although disease process is started by kidney tubules attack. Biochemical changes and symptoms called uremia syndrome influenced every systems in the body. In last stadium, the patient will die except the patient has kidney transplantation treatment or dialysis.
Clinical Manifestation
Acute Renal Failure (ARF)
Urine output is low with or without blood, BUN and creatinine level are increase, anemia, hyperkalemia, acidosis metabolic, edema, anorexia, nausea, vomit, skin turgor is bad and irritation on the skin.
Chronic Renal Failure (CRF)
Respiration disturbance, edema, hypertension, anorexia, nausea, vomit, gastric ulcer, stomatitis, proteinuria, hematuria, lethargy, apathies, anemia, bleeding, bad skin turgor, skin irritation, renal dystrophy, hyperkalemia, and metabolic acidosis.
Diagnosis Tests
- Urine: volume, color, sediment, urine mass, protein and creatinine
- Blood: BUN or creatinine, red blood cells, natrium serum, kalium, magnesium phosphate, protein, and osmolality serum.
- Radiology: kidney size, the location ureter or bladder, check the obstruction.
- Pyelography retrograde: to show kidney pelvic and ureter abnormality
- Arteriogram: to check the kidney blood supply and a mass around the kidney.
- Sistouretrogram: to show the bladder size, ureter reflux, and retention.
- Ultrasonography: to check the kidney and bladder size, mass, cyst, and upper urinary tract obstruction.
- Biopsy: perhaps it need to do with endoscopy to make sure tissue cells for histology diagnosis.
- Endoscopy: it need to do to find kidney pelvic; kidney stone, hematuria, or tumor.
- ECG: the heart may show abnormality in electrolyte, acid-base balance, arrhythmia, ventricle hypertrophy, or pericarditis signs.
Treatment
Acute Renal Failure (ARF)
Hyperkalemia
The fluid and electrolyte balance is a main problem in Acute Renal Failure (ARF); hyperkalemia is really threaten life, so it need to minimize kalium level in the blood. The patients need to monitor their kalium level through electrolyte test (kalium > 5.5 mEq/L; International Standard (IS) : 5.5 mmol/L), ECG change (Tall T sign in the ECG is a sign for hyperkalemia), and clinical status of the patients. Kalium level can be minimized by resin ion replace (natrium pohstruren sulfonate / kayexalatel) with oral or enema ways. Sorbitol is always prescribed together with kayexalate to induce diarrhea type (fluid loss in gastrointestinal). If enema retention is prescribed (colon is the main place in kalium substitution), rectal catheter can be prescribed to minimize the retention. Patients with high kalium level need dialysis, peritoneal dialysis or hemofiltration immediately. Glucose, insulin, or calcium gluconate intra vein can be done as an emergency procedure for hyperkalemia. Natrium bicarbonate can be prescribed for pH plasm so that kalium will move into cells and the result is kalium level decrease. All of extra renal kalium production need to minimize.
Fluid Balance
Fluid balance needs to be in normal balance, it based on body weight, central vein measurement, urine concentration and serum, fluid loss, blood pressure, and clinical status of the patients. Oral input and output from urine, gastric drainage, wound drainage, and perspiration must be counted and used as a basic fluid therapy. Fluid loss from skin (sweat) and respiration that are from normal metabolism process need to think about, and it can contribute fluid therapy. The patients need to measure their body weight and they can be predicted decrease their body weight about 0.2 to 0.5 kilogram everyday if the nitrogen balance is negative (colon input that is received less than needed). If the patients losses their body weight or have hypertension, it is like a sign for fluid retention. Excessive body fluid can be detected through clinical manifestation such as like dyspnea, tachycardia, and neck vein distention. Lung auscultation will have a wet crackles signs. It is because of pulmonary edema. The excessive fluid can make this condition, so the aware of parenteral input (infusion or water consumption) need to do to prevent excessive body fluid. Edema in whole body need to assess presacreal and pretibial area everyday.
Nutrition
Protein diet is minimized until 1 g/kg while oliguria phase to decrease protein metabolism and prevent toxic accumulation. Calorie need is influenced by high carbohydrate diet because carbohydrate has an effect toward protein (high carbohydrate diet, protein will not use for energy but protein can be used for growth and tissue repair). Food and drinks that consist of kalium and phosphate (banana, orange, and coffee) is minimized. Kalium input must be limited about 2 gram per day.
Intra Vein Fluid and Diuretic
Adequate blood supply to kidney can be maintained through intra vein fluid and medication. Mannitol furosemide or extracrinic acid can be prescribed to start diuresis and prevent kidney failure. If Acute Renal Failure (ARF) is caused by hypovolemia hypoproteinemia, albumin infusion can be helpful. Shock and infection can be handled, if they are there.
Acidosis Correction and Phosphate Level
If the acidosis is severe occurred, artery gas must be monitored, ventilation procedure must be done if there is respiration problem. Patients need bicarbonate therapy or dialysis. Serum phosphate in patients can be controlled with phosphate binder agent (aluminium hydroxide), this agent prevents high level of phosphate serum by decrease the phosphate absorption in gastrointestinal system.
Continuous Monitor
During oliguria phase of Acute Renal Failure (ARF) from 10 to 20 days and followed diuretic phase where urine output is increase as a sign of kidney recovery. Evaluate the blood chemical and it can monitor the natrium level in the blood. Kalium and fluid that is needed during assessment toward high hydration or low hydration. During the diuretic phase, patients is given high protein diet, high calorie and do some activity step by step.
Dialysis
Dialysis can be done for complication prevention, such as like hyperkalemia, pericarditis, and seizure.
Chronic Renal Failure (CRF)
The purpose of chronic renal failure treatment is to maintain the homeostatic and prevent the complication by collaborative approach; hyperkalemia caused by excretion decrease, acidosis metabolic, catabolism and excessive diet. Pericarditis, pericardium effusion, heart temponade caused by waste product retention, and inadequate dialysis. Hypertension caused by fluid and natrium retention and angiotensin-aldosterone system malfunction. Anemia caused by erythropoietin decrease, red blood cells damage, gastrointestinal bleeding caused by toxin agent irritation and blood loss during hemodialysis. Bone disease and metastatic calfication caused by phosphate retention, low level of calcium, abnormal vitamin D metabolism. Complication can be prevented or handled by antihypertension, erythropoietin, Fe supplement, calcium supplement and phosphate binder agent. It need to do dialysis.
Diet Intervention
In kidney failure, the diet must be monitored include protein diet regulation, fluid input and output, natrium consumption, and kalium limitation. The basic data is about rest and activity of the patients, the patient may be fatigue or too weak to do some activity.
Circulation
Are there hypotension, pale, tissue edema, urinary pattern change, dysuria, abdomen retention. Fluid and food; body weight increase caused by edema, loss of body weight, nausea, vomit, and anorexia, epigastric pain. Neurosensory; headache, muscle cram, and seizure. Respiration; dyspnea, tachypnea, frequency and deep breath changes, ammonia smell, productive cough. Skin; ptikie, pruritus, and dry irritation skin.
The intervention for this condition are assessing the edema because the edema is identified as excessive fluid intake and it need to minimized so that the body weight can be maintained in ideal body weight. Controlling the fluid intake in 24 hours a day because it can be a sign for kidney function, fluid need, and fluid balance in the patients body. Measure the patient's body weight every day to help in maintaining the patients body fluid balance everyday. If the body weight is more than 0,5 kg per day, it show fluid balance change. An information about patients' condition can be helpful and the family can limit the fluid intake. Uncooperative patients with excessive body weight with fluid intake need dialysis. Then the drugs medication has important role in kidney failure, for instance antidiuretic, antidiuretic can expand the tubular from any debris, decrease hyperkalemia and increase adequate urine volume. The drugs that usually used is Furosemide. We have to know the treatment progress toward lab test, the result of kidney function lab can be a guidance for next medication.
Nutrition Intervention
The observation of patients' diet can be helpful in identifying patients' status and diet effectivity. Patients' general condition, uremic status, and diet can influence the nutrition. The patients need to do oral hygiene before and after meal, because oral hygiene can decrease the mouth smell and uncomfortable feeling in the mouth because of microorganism. Not only those benefits, but the oral hygiene prevent stomatitis or mouth ulcer. The patients are only given less protein and fat diet, and high carbohydrate so that there is no protein accumulation lead to acid circumstances. The patients must limit the salt consumption because the salt or natrium can accumulate the fluid inside the body. Small portion can be helpful for patient because of nausea and vomit, and they can be prevented well. Drugs medication for patient with kidney failure related to nausea and vomit (usually caused by fetouremic or the patients' breath smell is like feton) is antiemetic. If the patients do not have a nausea feeling, the oral nutrition can be given well.
Activity
The patients' need in some activities must be assessed because it will give a guidance for next treatment intervention. Assessing the fatigue is to know about activity intolerance. Not only about those, but also about the patients' psychology or stress factors because the psychology factors about activities can contribute as well. Relax environment and activity schedule must be regulated. The patients will need help in self-care, so the nurses must help them.
Collaboration in blood laboratory examination, Imbalance calcium, magnesium, kalium, and natrium may interfere with neuromuscular function which is requiring energy use to increase hematocrit and hemoglobin which is showing one indication in erythropoietin disorders.
The patients maybe have an anxiety feeling so we need to assess client's level of anxiety for the degree anxiety. The patients usually don not know about their condition and give them accurate information of the disease so that patients can learn about the disease and treatment, in order to understand and accept the diagnosis and medical consequences. Help the patients to identify how understand various changes due to illness so that the patients can understand that life does not have to undergo significant changes as a result of the illness. Let patients and families express their feelings so that it will reducing the burden of thinking and it can reduce anxiety and can be cooperative with procedures and the nurses will be easier to carry out the next intervention. Manage visiting time which allows the presence of ancestry because it can reduce the level of anxiety by presenting family support.
Patient with chronic kidney failure have problem in breathing pattern, so the patients' breathing pattern is needed to assess because dyspnea, tachycardia, and irregular breathing and the sound of Rhonchi is an indication of respiratory disorders. Skin color, nails and mucous membranes are like an indicator, paleness and cyanosis is an indication of anemia associated with congestion and heart failure resulting in inadequate tissue perfusion. The best position of patient with breathing problem is semi-Fowler position, that position allows abdominal organs away from the diaphragm, so lung expansion will be maximal. Observing the vital signs (pulse, blood pressure, breathing frequency, and body temperature) because the impaired exchange of O2 is a result in changes of vital signs, especially blood pressure, breathing frequency, and pulse. The last thing that we can do is collaboration for supplemental oxygen administration, maximum oxygen is needed for the heart muscle or myocardium. Blood gas is needed to monitor because blood gas analysis is very important to know the disruption of gas exchange in the lungs.
Skin integrity damage
Skin integrity damage with edema and hoarding orokrom can be a big problem in all patient. The skin color, turgor, and vascular are needed to observe. It indicates poor circulation area / damage that can cause pressure ulcer or decubitus. The patients need to change the position as often as possible. This procedure is to reduce the pressure ulcer. Give skin care (hygiene) and providing lotion to minimizing dermal irritation and the risk of skin damage. Maintain dry linen and free of wrinkles because it will make dermal irritation and decrease the risk of skin damage. The patients use a moist compress and keep nails stay short, this procedure can eliminate the discomfort feeling and reduce the risk of injury (skin). The patient is not allowed wear tight clothing, it can make the skin irritation.
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