Acute Renal Failure Case Study

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Acute renal failure is the sudden interruption of kidney function due to obstruction, reduced circulation, or renal parenchymal disease. It’s usually reversible with medical treatment; otherwise, it may progress to end-stage renal disease, uremic syndrome and death.

Causes of Acute Renal Failure

The causes of acute renal failure are classified as prerenal, intrinsic (parenchymal or intrarenal), and post renal.

Prerenal failure:

• Diminished blood flow to the kidneys, possibly resulting from hypovolemia shock, severe anaphylaxis, embolism, blood loss, sepsis, pooling of fluid in ascited
• Burns
• Cardiovascular disorders, such as heart failure, arrhythmias, and tamponade.

Intrinsic Renal Failure

Intrinsic renal failure results from damage to the kidneys themselves, usually due to

• acute tubular necrosis, but possibly due to acute posstreptococcal glomerulonephritis,
• systemic lupus erythematosus,
• periarteritis nodosa,
• vasculitis,
• sickle-cell disease,
• bilateral renal vein thrombosis,
• nephrotoxins,
• chronic misuse of nonsteroidal anti-inflammatory drugs,
• radiopaque contrast agents,
• ischemia,
• renal myeloma,
• acute pyelonephritis, and
• exposure to heavy metals, such as lead or mercury.

Postrenal Failure

Postrenal failure results from bilateral obstruction of urinary outflow. Its multiple causes include:

• kidney stones, blood clots, and papillae from papillary necrosis, tumors, benign prostatic hyperplasia, strictures, and urethral edema from catheterization.

Incidences of Acute Renal Failure

In the United States, the annual incidence of acute renal failure is 100 cases for every million people. It’s diagnosed in 1% of hospital admissions. Hospital-acquired acute renal failure occurs in 4% of all admitted patients and 20% of patients who are admitted to critical care units.

Each year an estimated 120 Filipinos per million population (PMP) develop kidney failure. This means that about 10,000 Filipinos need to replace their kidney function each year.

The leading cause of kidney failure in the Philippines is diabetes (41%), according to the Philippine Renal Disease Registry Annual Report in 2008, followed by an inflammation of the kidneys (24%) and high blood pressure (22%). Patients were predominantly male (57%) with a mean age of 53 years.

Complications of Acute Renal Failure

The following are the complications of acute renal failure

• Volume overload. Due to non-functional excretion system.
• Pulmonary edema. Due to fluid overload.
• Electrolyte imbalance. Since excess electrolytes are not excreted.
• Metabolic acidosis due to dramatic decrease of kidney’s excretory function.

Signs and Symptoms

Acute renal failure is a critical illness. Its early signs are oliguria, azotemia and rarely, anuria. Electrolyte imbalance, metabolic acidosis, and other severe effects follow, as the patient becomes increasingly uremic and renal dysfunction disrupts other body systems:

• GI: Anorexia, nausea, vomitting, diarrhea or constipation, irritability, confusion, peripheral neuropathy, seizures, coma
• CNS: headache, drowsiness, irritability, confusion, peripheral neuropathy, seizures, coma
• CUTANEOUS: dryness, pruritus, pallor, purpura and rarely, uremic frost
• CARDIOVASCULAR: early in the disease, hypotension; later, hypertension, arrhythmias, fluid overload, heart failure, systemic edema, anemia, altered clotting mechanisms
• RESPIRATORY: pulmonary edema, Kussmaul’s respirations.
• Fever and chills indicate infection, a common complication

Diagnosing Acute Renal Failure

History. The patient’s history may include a disorder that can cause renal failure.

Blood Exam. Blood test results indicating intrinsic acute renal failure include elevated blood urea nitrogen, serum creatinine, potassium levels and low blood pH, bicarbonate, hematocrit, and hemoglobin level.

Urinalysis. Urine specimens show casts, cellular debris, and decreased specific gravity and, in glomerular diseases, proteinuria, and urine osmolality close to serum osmolality. Urine sodium level is less than 20 mEq/L if oliguria is due to decreased perfusion; more than 40 mEq/L if due to an intrinsic problem.

Other Studies. Other studies include renal ultrasonography, kidney-ureter-bladder X-rays, cautious use of excretory urography, renal scan and nephrotomography.

Nursing Care Plans for Acute Renal Failure

View Renal Failure Nursing Care Plans

Treatment of Acute Renal Failure

Treatment Goal

The goal of treatment is to correct or eliminate any reversible causes of kidney failure, such as obstructive uropathy, volume depletion, or the use of kidney-toxic medications.

Supportive measures include a diet high in calories and low in protein, sodium and potassium, with supplemental vitamins and restricted fluids. Meticulous electrolyte monitoring is essential to detect hyperkalemia. If hyperkalemia occurs, acute therapy may include dialysis, I.V. administration of hypertonic glucose, insulin infusion, and sodium bicarbonate, and administration of a potassium exchange resin (orally by enema) to remove potassium from the body.

If measures fail to control uremic symptoms, hemodialysis or peritoneal dialysis may be necessary. Continuous arteriovenovenous hemodiafiltration are alternative hemodialysis techniques for the treatment of acute renal failure. They’re generally reserved for when intermittent dialysis fails to control hypervolemia or uremia, or for patients for whom peritoneal dialysis isn’t possible.