Acute Renal Failure - Coursework Example

Running Head: RENAL FAILURE ACUTE RENAL FAILURE School Submitted Acute Renal Failure Acute renal failure or ARF for short is the “rapid loss of glomerular filtration and tubular function, leading to abnormal water, electrolyte and solute balance [which] occurs over hours to days” (Allen, 2003, p.39). The length of onset constitutes one of the key differences between acute renal failure and chronic kidney disease (CKD) – with the former ( i. e., ARF) characterized by a quick onset from hours to a few days, while the latter (i. e., CKD) develops slowly over months or years. ARF usually occurs as one of the elements of a multi-system disorder like those of septic shock or severe trauma (Allen, 2003; Mathers, 2007). The causes of acute renal failure may, however, be classified into three groups: prerenal, intrarenal (also renal or intrinsic) and postrenal. Prerenal causes which lead to ARF are an outcome of factors outside of the kidneys which tend to diminish the blood supply in the kidney and results to decreased perfusion and filtration in the glomerulus. On the other hand, intrarenal causes are those conditions which result to direct damage to the renal tissue called the parenchyma, and as a consequence causes impairment of the functions of the kidney. Meanwhile postrenal causes pertain to mechanical obstructions in the urinary tract which impede the outflow of urine. When the flow of urine is obstructed, it refluxes into the renal pelvis. This actions causes impairment of the nephritic functions (Mathers, 2007). The various conditions which lead to prerenal, intrarenal and postrenal causes of ARF are graphically presented in Figure 1 next page. These conditions are color coded to signify grouping, such that same colored conditions belong to one category of possible triggers to the prerenal, intrarenal or postrenal causes of ARF. Figure 1. Causes of acute renal failure Signs and Symptoms of Acute Renal Failure Acute renal failure is said to be fully established when pulmonary edema and ischemia are observed. Among the conditions commonly associated with ARF are oliguria and anuria. Oliguria is defined as the production of less than 400 ml of urine in one day, while anuria is urine production of less than 100 ml in a day. Doctors would, however, prefer to find non-oliguric symptoms in patients with acute renal failure because experience with non-oliguric symptoms has shown a tendency to recover more easily and sustain fewer complications. It is, therefore, common for non-oliguric patients with ARF to be given better prognosis than those who are oliguric. (Allen, 2003; Mathers, 2007). Other than the aforementioned signs and symptoms, other warning signs to look out for are anorexia, coma, confusion, constipation or diarrhea, convulsions, drowsiness, dry mucous membranes, gastro-intestinal bleeding, headache, hematemesis, irritability, nausea, pallor, peripheral neuropathy, pruritus, purpura, skin dryness, stomatitis, uremic breath, uremic frost (rarely) and vomiting. Some symptoms like hypotension are manifested early. On the other hand, the following symptoms become apparent at a later time period: altered clotting mechanisms, anemia, arrhythmias, heart failure hypertension, and symptoms of fluid overload. Pulmonary edeme and Kussmauls’s respiration have also been evident from patients with ARF (Weaver and Jenkins, 2002). Physical Assessment Pain in the front upper left portion of the abdomen, particularly around the lower portion of the lung cage, medically termed as the referred abdominal pain, is a manifestation of the possibility of kidney stones. Nally (2002) maintained that further physical assessment is necessary to confirm renal problem associated with the referred abdominal pain. Fever is usually present in ARF patients. Volume status is examined by checking for the presence of orthostatic hypotension, edema, jugular venous distention, crackles and S3 gallop. The skin also provides indicators of ARF, particularly with the occurrence of diffuse rashes, livedo reticularis and atheroemboli. Kush, Kavanaugh and Stein (2004) defined livedo reticularis as a “painless, cyanotic mottling of the skin in a fishnet [or lace-like] pattern” (p. 232). The condition usually affects the extremities or the trunk, and is associated with diseases other than ARF. There are also cases when the presence of livedo reticulitis is not related to other medical conditions. Atheroemboli, on the other hand, manifests as a symptom of kidney failure in the form of blue toes, or a lacy blue discoloration of the skin of the feet and legs (Sadjadi, 2007) The bladder area in the abdomen is also checked for suprapubic fullness. Once the fullness is confirmed, the bladder is catheterized to evaluate the residual volume of postvoid, as well as to relieve bladder obstruction. Diagnosis and Medication Acute renal failure is diagnosed by observing progressive elevations in the concentrations of plasma urea or blood urea nitrogen (BUN), creatinine and potassium, low pH value, and decreased levels of bicarbonate, hemoglobin (Hb) and hematocrit (HCT), from blood tests. Physical and laboratory examination of urine samples make up standard diagnostic procedures for detection of acute renal failure. Patients with acute renal failure exhibit casts and cellular debris in their urine. Urine samples also register lower specific gravity. In special cases, such as in kidney impairment related to glomerular diseases, presence of protenuria is detected and urine osmolality is found close to serum osmolality. Urine sodium level also provides a significant diagnostic indicator of ARF, since at less than 20 mEq/L, oliguria is an outcome of decreased perfusion while at greater than 40 mEq/L, oliguria is said to be brought about by intrinsic problems. The last section of this paper discusses the laboratory examinations usually administered in ARF cases. The use of modern equipment and procedures also facilitate diagnosis of ARF. These include computed tomography scan, magnetic resonance imaging, plain films of the abdomen, kidneys, ureters and bladders, renal scan, retrograde pyelography, and ultrasonography of the kidneys (Weaver & Jenkins, 2002). The main targets of ARF treatment are two-fold: to revive effective functioning of the kidney and, as much as possible, maintenance of a stable internal environment “despite transient renal failure” (Weaver & Jenkins, 2002, p. 628). Supplementary initiatives may be introduced in the patient’s diet in terms of high calories, low protein sodium and potassium, restricted fluids and additional vitamins. A thorough monitoring of electrolytes is in order for ARF patients in order to identify the onset of hyperkalemia, or abnormally increased level of potassium concentration in the blood because of defective renal excretion (Weaver & Jenkins, 2002; “Glossary”, 2008). Once hyperkalemia is detected, the treatment scheme includes intravenous administration of sodium bicarbonate, hypertonic glucose and insulin infusions. Another option may be polystyrene sulfonate either given to the patient orally or administered by enema to flush away excess potassium Once the above-mentioned therapy falls short of controlling the uremic symptoms, the patient’s condition may be considered acute and will necessitate hemodialysis or peritoneal dialysis (Weaver & Jenkins, 2002). Laboratory Examinations and Imaging Weaver and Jenkins (2002) and Park (2007) elucidated on the following laboratory examinations performed as part of routine test for acute renal failure: Creatinine clearance. This laboratory examination gages the ability of the kidney to clear the blood of creatinine. It also approximates the rate of glomerular filtration. Creatinine clearance tends to decrease with the functionality of the kidneys, and is normally lowered as a person ages. The normal values of creatinine clearance are 97 to 137 ml/min for males and 88 to 128 ml/min for females (Silberberg, 2007). BUN and serum creatinine. These laboratory examination evaluates the advancement and management of ARF. Both increase as the function of the kidneys are decreased. According to Habel (2002), the reference values for serum creatinine are 0.8 - 1.4 mg/dl mass for adult males; 0.6 - 1.1 mg/dl for adult females; and 0.2 - 1.0 mg/dl for children. Habel (2002) stressed that 10 mg/dl is a panic value for creatinine in non-dialysis patients. On the other hand, the normal value for BUN is 7 - 20 mg/dl (Mushnick, 2007a). Blood electrolyte tests. In the laboratory assessment for the confirmation of ARF, the standard blood electrolyte tests performed are calcium, phosphate (or phosphorus), potassium and sodium. The normal range for calcium is 2.2 to 2.6 mmol/L (Mahon & Hattersley, 2002), while the normal range for potassium is 3.7 to 5.2 mEq/L (Mushnick, 2007b). The normal range for phosphate (phosphorus) is 2.4 - 4.1 mg/dl (Holt, 2008), whereas the normal range for sodium is 135-145 mEq/L (Juhn, Eltz & Stacy, 2007). Complete Blood Count (CBC). Results of the CBC present significant data about blood platelets, red blood cells and white blood cells, which may be utilized to evaluate conditions such as diseases or infections which caused the renal failure. Cutler (2006) provided the following normal values for the various elements of a complete blood count: RBC for male, 4.7 to 6.1 million cells/mcL; RBC for female, 4.2 to 5.4 million cells/mcL; WBC: 4,500 to 10,000 cells/mcL; hematocrit for male, 40.7 to 50.3 %; hematocrit for female, 36.1 to 44.3 %; hemoglobin for male, 13.8 to 17.2 gm/dL; hemoglobin for female, 12.1 to 15.1 gm/dL; MCV, 80 to 95 femtoliter; MCH, 27 to 31 pg/cell; and MCHC, 32 to 36 gm/dL. The values for RBC, hematocrit and hemoglobin tend to vary with altitude. Urinalysis. Results of the urinalysis offer clues about kidney damage based on the presence of sediment in the urine. In analyzing the urine, practitioners are interested in: (1) urine eosinophils, a type of WBC, the presence of which is an indication of an allergic reaction usually to a certain kind(s) of drugs, causing damage to the kidneys; (2) fractional excretion of sodium, which gages the efficiency of the kidney in processing sodium and facilitates diagnosis by distinguishing between prerenal and intrinsic ARF. Supporting laboratory examinations are imaging tests which assists in differentiating between acute and chronic kidney problem and assess the presence of blockage in the urinary tract. Common imaging tests for ARF include: Abdominal Ultrasound. An abdominal ultrasound scan in most postrenal ARF cases shows a dilated collecting system medically termed as hydronephrosis, which is triggered by very high pressure within the urinary tract (Fishman, Hoffman, Klausner & Thaler, 2004). Abdominal X-ray or spiral CT scan. A plain abdominal X-ray can reveal an infracted and calcified renal cortex, which is possible even when the renal medulla is undamaged (Armstrong & Bircher, 2002). A spiral CT scan of the urinary tract is an effective method of verifying kidney stones and obstruction in the urinary tract, and is comparable with intravenous pyelography (South-Paul, Matheny & Lewis, 2007). Computed tomography (CT) scan. The CT scan is a very valuable equipment for recognizing such complications as renal abscess or renal carcinoma (Schrier, 2007). For conditions in which ARF is caused by blockage specially those of postrenal origin, more extensive tests are required to locate the obstruction and ascertain what is causing such obstruction. Imaging procedures with the use of retrograde pylography, magnetic resonance imaging (MRI) and kidney scan or renal scintigraphy may present a much better alternative. REFERENCES Allen, A. (2003). The aetiology of acute renal failure. In P. Glynne, A. Allen, & C. D. Pusey (Eds.), Acute Renal Failure in Practice (pp. 39-45). London, UK: Imperial College Press. Armstrong, T. & Bircher, G. (2002). Acute renal failure. In N. Thomas (Ed.), Renal Nursing (2nd ed.) (pp. 103-122). New York: Elsevier Health Sciences. Cush, J. J., Kavanaugh, A. & Stein, C. M. (2004). Rheumatology: Diagnosis and Therapeutics (2nd ed.). Conshohocken, PA: Lippincott, Williams & Wilkins. p. 232. Cutler, C. (2006). CBC. Retrieved October 28, 2008 from Medline Plus: http://www.nlm.nih.gov/medlineplus/ency/article/003642.htm#Normal%20Values Fishman, M. C., Hoffman, A. R., Klausner, R. D. & Thaler, M. S. (2004). Medicine (5th ed.). Conshohocken, PA: Lippincott, Williams & Wilkins. Glossary. (2008). Retrieved October 26, 2008 from Cancerline UK: http://www.cancerlineuk.net/517210/?selectedPage=4&letter=H. Habel, M. (2002). Understanding Renal Functions Tests. Retrieved October 28, 2008 from http://www.rnceus.com/renal/renalcreat.html Holt, E. H. (2008). Serum Phosphorus. Retrieved October 28, 2008 from Medline Plus: http://www.nlm.nih.gov/medlineplus/ency/article/003478.htm Juhn, G., Eltz, D. R. & Stacy, K. A. (2007). Sodium – blood. Retrieved October 28, 2008 from Medline Plus: http://www.nlm.nih.gov/medlineplus/ency/article/003481.htm Mahon, A. & Hattersley, J. (2002). Investigations in renal failure. In N. Thomas (Ed.), Renal Nursing (2nd ed.) (pp. 143-170). New York: Elsevier Health Sciences. Mathers, T. R. (2007). Nursing management: acute renal failure and chronic kidney disease. In S. L. Lewis, M. M. Heitkemper, S. R. Dirksen, P. G. O’Brien & L. Bucher (Eds.), Medical-Surgical Nursing: Assessment and Management of Clinical Problems (pp. 1194-1207). St. Louis, MO: Mosby Inc. Mushnick, R. (2007a). BUN. Retrieved October 28, 2008 from Medline Plus: http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/003474.htm Mushnick, R. (2007b). Potassium Test. Retrieved October 28, 2008 from Medline Plus: http://www.nlm.nih.gov/medlineplus/ency/article/003484.htm Nally, J. V. (2002). Acute renal failure. Cleveland Clinical Journal of Medicine, 69(569). Retrieved October 26, 2008 from http://enotes.tripod.com/renalfailure.htm Parks, R. (2007). Acute Renal Failure – Exams and Tests. Retrieved October 26, 2008 from http://health.yahoo.com/other-other/acute-renal-failure-exams-and-tests/healthwise--aa115388.html Sadjadi, S. A. (2007). Atheroembolic Kidney Disease. Retrieved October 28, 2008 from http://www.merck.com/mmhe/sec11/ch145/ch145c.html Schrier, R. W. (2007). Diseases of the Kidney and Urinary Tract: Clinicopathologic Foundations of Medicine (Vol. 1) (2nd ed.). Conshohocken, PA: Lippincott, Williams & Wilkins. p. 232. Silberberg, C. (2007). Creatinine Clearance. Retrieved October 28, 2008 from Medline Plus: http://www.nlm.nih.gov/medlineplus/ency/article/003611.htm South-Paul, J. E., Matheny, S. C. & Lewis, E. L. (2007). Current Diagnosis and Treatment in Family Medicine (2nd ed.). New York: McGraw-Hill Professional. Swearingen, P. (2007). All-in-One Care Planning Resource (2nd ed.). St. Louis, MO: Mosby Inc. Weaver, S. H. & Jenkins, P. (2002). Renal and urologic care. In Springhouse (Ed.), Illustrated Manual of Nursing Practice (3rd ed.), (pp. 602-679). Conshohocken, PA: Lippincott, Williams & Wilkins. Read More