Renal Failure, Chronic

Renal Failure, Chronic

DRG Category:674
Mean LOS:7 days
Description:SURGICAL: Other Kidney and Urinary Tract Procedures With CC
DRG Category:683
Mean LOS:4.7 days
Description:MEDICAL: Renal Failure With CC

Chronic renal failure (CRF) refers to irreversible renal dysfunction as manifested by the inability of the kidneys to excrete sufficient fluid and waste products from the body to maintain health. CRF is fatal if it is not treated.

CRF is a progressive process; stages are defined by categorizing how much renal function remains. The first stage of renal deterioration is reduced renal reserve, which occurs when the patient has a glomerular filtration rate (GFR; the amount of filtrate formed by the kidneys each minute; normally 125 mL/minute) of 35% to 50% of normal. The second stage, renal insufficiency, occurs when the patient has a GFR that is 25% to 35% of normal. The patient with renal failure has a GFR of 20% to 25% of normal. The patient with the final stage of renal dysfunction, end-stage renal disease (ESRD), has a GFR of 15% to 20% of normal or less. When patients reach ESRD, treatment with dialysis is commonly initiated. Patients with CRF are generally treated on an outpatient basis unless the patient develops complications or an urgent problem that requires hospitalization.

All individuals with CRF experience similar physiological changes, regardless of the initial cause of the disease. The kidneys are unable to perform their normal functions of excretion of wastes, concentration of urine, regulation of blood pressure, regulation of acid-base balance, and production of erythropoietin (the hormone needed for red blood cell production and survival). Complications of CRF include uremia (accumulation of metabolic waste products in the blood and body tissues), anemia, peripheral neuropathy, sexual dysfunction, osteopenia (reduction of bone tissue), pathological fractures, fluid overload, congestive heart failure, hypertension, pericarditis, electrolyte imbalances (hypocalcemia, hyperkalemia, hyperphosphatemia), metabolic acidosis, esophagitis, and gastritis. One classification of renal failure from the National Kidney Foundation, based on GFR (the flow rate of filtered fluid through the kidney) is as follows:

  • Stage 1: Kidney damage with normal or increased GFR (> 90 mL/minute/1.73 m2)
  • Stage 2: Mild reduction in GFR (60 to 89 mL/minute/1.73 m2)
  • Stage 3: Moderate reduction in GFR (30 to 59 mL/minute/1.73 m2)
  • Stage 4: Severe reduction in GFR (15 to 29 mL/minute/1.73 m2)
  • Stage 5: Kidney failure (GFR less than 15 mL/minute/1.73 m2 or dialysis)

Causes

CRF may be caused by either kidney disease or diseases of other systems (Table 1).

Causes of Chronic Renal Failure
Table 1. Causes of Chronic Renal Failure
CATEGORYDISEASES
Congenital/hereditary disordersPolycystic kidney disease, renal tubular acidosis
Connective tissue disordersProgressive systemic sclerosis, systemic lupus erythematosus
Infections/inflammatory conditionsChronic pyelonephritis, glomerulonephritis, tuberculosis
Vascular diseaseHypertension, renal nephrosclerosis, renal artery stenosis
Metabolic/endocrine diseasesDiabetes mellitus, gout, amyloidosis, hyperparathyroidism
Obstructive diseasesRenal calculi
Nephrotoxic conditionsMedication therapy, drug overdose

Genetic considerations

Several heritable diseases can lead to renal failure, including the autosomal recessive condition Alport’s syndrome, which causes nephropathy that is often associated with sensorineural deafness and can be transmitted as X-linked recessive, autosomal recessive, and autosomal dominant forms. Mutations in atrial natriuretic peptide receptor-1 (NPR1) may also contribute to nephropathy and renal failure.

Gender, ethnic/racial, and life span considerations

Both men and women are at risk for CRF. Geriatric patients are more susceptible to some of the causes of acute renal failure (ARF) and may therefore experience CRF more frequently. CRF as a result of other diseases (diabetes mellitus or uncontrolled hypertension) is more common in the elderly simply because they have had the disease longer. CRF affects all races and ethnicities, and the prevalence in various populations depends on predisposing conditions such as diabetes and hypertension; therefore, a significantly higher prevalence exists in the African American and Native American populations than in Asian Americans and whites.

Global health considerations

The global incidence of CRF is increasing, with rates highest in the United States and Japan. Worldwide, chronic kidney disease is a critical public health problem that is acknowledged as a common condition associated with an increased risk of cardiovascular and renal disease. Generally, treatments for end-stage renal disease (ESRD) are very expensive; developing nations may not have the economic resources to treat renal failure patients. Very few patients with CRF survive in developing countries where treatment is not government sponsored.

Assessment

History

The patient may report a history of ARF (see Renal Failure, Acute, p. 961), although usually the patient does not become symptomatic until he or she has a GFR less than 35% of normal. The patient likely complains of oliguria and weight gain. Ask the patient about the color of the urine, whether it is clear or cloudy, and whether it is frothy. The patient may also complain of a metallic taste in the mouth, anorexia, and stomatitis. Elicit a gastrointestinal (GI) history with particular attention to nausea, vomiting, hematemesis, diarrhea, and constipation.

Elicit the patient’s description of any central nervous system (CNS) symptoms. Blurred vision is common. Patients may have impaired decisionmaking and judgment, irritability, decreased alertness, insomnia, increased extremity weakness, and signs of increasing peripheral neuropathy (decreased sensation in the extremities, hands, and feet; pain; and burning sensations).

Patients often report changes in other body systems as well. Some have idiopathic bone and joint pain in the absence of a diagnosis of arthritis. Others suffer from loss of muscle mass and nocturnal leg cramping. Men may be impotent or notice gynecomastia, and women may mention amenorrhea (absence of menses). Both may have decreased libido.

Physical examination

CRF affects all body systems. Patients with CRF have significant cardiovascular involvement. Hypertension is usually noted in the patient with CRF and may indeed be its cause. Patients often have rapid, irregular heart rates; distended jugular veins; and if pericarditis is present, a pericardial friction rub and distant heart sounds. Respiratory symptoms include hyperventilation, Kussmaul breathing, dyspnea, orthopnea, and pulmonary congestion. Rales may signify fluid overload. Frothy sputum combined with shortness of breath may indicate some degree of pulmonary edema.

The renal effects of CRF are pronounced. You may smell a urine-like odor on the breath and notice a yellow-gray cast to the skin. If the patient is producing any urine at all, it may be dilute, with casts or crystals present. The skin is fragile and dry, and there may be uremic frost on the skin or open areas owing to severe scratching (pruritus) by the patient. The patient may have bruising; petechiae; brittle nails; dry, brittle hair; gum ulcerations; or bleeding. If the patient has been followed for CRF, there may already be access sites created in preparation for dialysis. Assess the sites for patency (an arteriovenous fistula should have a palpable thrill and audible bruit) and signs of infection.

When you assess the CNS, you may find that the patient has difficulty with ambulation because of altered motor function, gait abnormalities, bone and joint pain, and peripheral neuropathy. The patient’s mental status may range from mild behavioral changes to profound loss of consciousness and seizures. Electrolyte imbalances may result in signs of hypocalcemia (see Hypocalcemia, p. 568), muscle cramps, and twitching.

Psychosocial

Patients with CRF present complex and difficult challenges to caregivers. Many have personality and cognitive changes. Apathy, irritability, and fatigue are common and interfere with interpersonal relationships. Sexual dysfunction is common. A careful assessment of the patient’s capabilities, home situation, available support systems, financial resources, and coping abilities is important before any nursing interventions can be planned.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Blood urea nitrogen5–20 mg/dLElevatedKidneys cannot excrete wastes
Serum creatinine0.5–1.1 mg/dL> 3 mg/dLKidneys cannot excrete wastes
Creatine clearanceFemales: 85–125 mL/min; males: 95–135 mL/min< 95% decreaseAcute damage to the kidney limits ability to clear creatinine

Other Tests: Urinalysis; complete blood count; erythrocyte sedimentation rate; hemodynamic monitoring; renal ultrasound; radionuclide scanning; magnetic resonance angiography; renal biopsy; serum levels of sodium, potassium, magnesium, and phosphorus; arterial blood gases

Primary nursing diagnosis

Diagnosis

Fluid volume excess related to compromised regulatory mechanisms

Outcomes

Fluid balance; Hydration; Circulation status; Cardiac pump effectiveness

Interventions

Fluid monitoring; Fluid/electrolyte management; Intravenous therapy; Circulatory care; Medication management; Hemodialysis therapy; Vital signs monitoring

Planning and implementation

Collaborative

Patients who have progressed to ESRD require either dialysis or renal transplantation. The three basic types of dialysis are peritoneal dialysis, hemodialysis, and continuous hemofiltration. Peritoneal dialysis uses the peritoneum as the semipermeable membrane. Access is achieved with the surgical placement of a catheter into the peritoneal cavity. Approximately 2 L of sterile dialysate is infused into the cavity and left for a variable period of time (usually 4 to 8 hours). At the end of the cycle, the dialysate is removed and discarded. A fresh amount of sterile dialysate is infused, and the cycle is continued.

Hemodialysis uses a surgically inserted vascular access, such as a shunt, or vascular access into an arterialized vein that was created by an arteriovenous fistula. In emergencies, vascular access through a large artery may be used. The blood is removed through one end of the vascular access and is passed through a machine (dialyzer). The dialyzer contains areas for the dialysate and the blood, separated by a semipermeable membrane. The fluid and waste products move quickly through the membrane because the pressure on the blood side is higher than that on the dialysate side. The blood is returned to a venous access site.

Continuous hemofiltration uses vascular access in the same manner as hemodialysis. The patient’s heparinized blood goes from an arterial access, through the hemofilter (the semipermeable membrane), and back to the patient through venous access. No dialysate is used. The hemofilter uses the patient’s own blood pressure as the source of pressure. One disadvantage is that frequently too much fluid is filtered, resulting in the need for intravenous fluid replacement. Other procedures, such as venovenous dialysis, are also used in some institutions. Glycemic control, control of blood pressure, dietary protein restrictions, smoking cessation, calcium supplementation, management of anemia, and control of hyperlipidemia are all components of collaborative management.

Surgical interventions for the patient with CRF consist of creating peritoneal or vascular access for dialysis or renal transplantation. The transplanted kidney may come from a living donor or a cadaver. One-year survival rates are currently 80% to 95%. The new organ is placed in the iliac fossa. The original kidneys are not generally removed unless there is an indication, such as infection, for removing them. The greatest postoperative problem is transplant rejection. The diet for the CRF patient is generally restricted in fluids, protein, sodium, and potassium. It is usually high in calories, particularly carbohydrates. The fluid restriction is generally the amount of the previous day’s urine plus 500 to 600 mL. The patient with CRF is frequently taking many medications. A significant concern is that the patient’s altered renal function also alters the action and the excretion of medications; toxicity, therefore, is always considered a possibility, and dosages are altered accordingly.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
AntihypertensivesVaries by drugAngiotensin-converting enzyme (ACE) inhibitors; beta-adrenergic antagonistsTreat the underlying hypertension
DiureticsVaries by drugLoop and thiazide diureticsControl fluid overload early in the disease if the patient is not anuric (total absence of urinary output)
Sodium bicarbonate352–650 mEq/L PO tidAlkalinizing agentSupplements sodium bicarbonate when serum level falls below 18–20 mEq/L
Sodium polystyrene sulfonate (Kayexalate)Orally or by enema: 15 g/60 mL in 20–100 mL sorbitol to facilitate passage of resin through the intestinal tractCation exchange resin; 0.5–1 mEq/L of potassium is removed with each enema, but an equivalent amount of sodium is retainedExchanges sodium for potassium in the GI tract, leading to the elimination of potassium

Other Drugs: Hypocalcemia and hyperphosphatemia may be treated with lanthanum carbonate; sevelamer; and sucroferric oxyhydroxide or phosphorus-lowering agents such as calcium acetate, calcium carbonate, calcitriol, or doxercalciferol. If long-term effects of aluminum hydroxide are a concern, an oral calcium (with vitamin D) preparation may be given. Recombinant erythropoietin (Epogen) may be given for the treatment of anemia. If the patient undergoes renal transplantations, immunosuppressives such as azathioprine (Imuran) or cyclosporine (Sandimmune) are prescribed. Corticosteroids may also be given at this time to decrease antibody formation.

Independent

To help the patient deal with fluid restrictions, use creative strategies to increase the patient’s comfort and compliance. Use ice chips, frozen lemon swabs, hard candy, and diversionary activities. Give medications with meals or with minimal fluids to maximize the amount of fluid that is available for patient use. Skin care is important because of the effects of uremia. Uremia results in itching and dryness of the skin. If the patient experiences pruritus, help the patient clip the fingernails short and keep the nail tips smooth. Teach the patient to use skin emollients liberally, to avoid harsh soaps, and to bathe only when necessary. You may need to speak to the physician to request an as-needed dose of an oral antihistamine such as diphenhydramine (Benadryl). If the patient is hospitalized, frequent turning and range-of-motion exercises assist in preventing skin breakdown. If the patient is taking medications that cause frequent stools, teach the patient to clean the perineum and buttocks frequently to maintain skin integrity.

The patient needs to plan the week’s activities to incorporate the level of fatigue, the dialysis routine, and any desired activities. The patient may also find that cognitive activities are more easily accomplished on certain days in relationship to dialysis treatments. Reassure the patient that this is not unusual but is caused by the shift of fluid and waste products. Counseling relative to role function, family processes, and changes in body image is important. Sexuality counseling may be required. Reassure the patient that adaptation to a chronic illness with an uncertain future is not easy for either the patient or the significant others. Participate when asked in discussions related to feasibility of home dialysis, placement on the transplant list, and decisions related to acceptance or refusal of dialysis treatment. Encourage decisions that increase feelings of control for the patient.

If the patient undergoes a renal transplantation, provide preoperative and postoperative care as for any patient with abdominal surgery. Monitoring of fluids is more important for these patients than for other surgical patients because a decrease in output may be an early sign of rejection. Other signs include weight gain, edema, fever, pain over the site, hypertension, and increased white blood cell count. Emotional support is important for the patient and family, both preoperatively and postoperatively, because both positive and negative outcomes produce emotional turmoil. Teaching about immunosuppressive drugs is essential before discharge.

Evidence-Based Practice and Health Policy

Koch, M., Haastert, B., Kohnle, M., Rump, L.C., Kelm, M., Trapp, R., & Aker, S. (2012). Peritoneal dialysis relieves clinical symptoms and is well tolerated in patients with refractory heart failure and chronic kidney disease. European Journal of Heart Failure, 14(5), 530–539.

  • In a study among 118 patients with CRF, treatment with peritoneal dialysis was associated with significant decreases in patient weight and serum urea and an increase in hemoglobin (p < 0.05).
  • In this sample, the survival rate was 77% at 3 months and 55% at 1 year. The overall mortality rate was 62.7% over a mean follow-up period of 1.11 years (range, 0.01 to 5.74 years). More than 70% of the mortality incidence was attributable to infectious and cardiovascular complications.
  • Prior to enrolling in the study, the majority of patients (74.4%) had been hospitalized during the previous year, mainly due to cardiac decompensation. Approximately 64% of patients were being treated with beta-blockers.

Documentation guidelines

  • Physical findings: Urinary output (if any) and description of urine, fluid balance, vital signs, findings related to complications of CRF, presence of pain or pruritus, mental status, GI status, skin integrity
  • Condition of peritoneal or vascular access sites
  • Nutrition: Response to dietary or fluid restrictions, tolerance to food, maintenance of body weight
  • Complications: Cardiovascular, integumentary, infection
  • Activity tolerance: Level of fatigue, ability to perform activities of daily living, mobility

Discharge and home healthcare guidelines

CRF and ESRD are disorders that affect the patient’s total lifestyle and the whole family. Patient teaching is essential and should be understood by the patient and significant others. Note that you may need to work collaboratively with social services to arrange for the patient’s dialysis treatments. Issues such as the location for outpatient dialysis and follow-up, home health referrals, and the purchasing of home equipment are important. All teaching should be reinforced at intervals during the patient’s lifetime.

care of peritoneal catheter for dialysis.
The access site is a sterile area that requires a sterile dressing except when the site is being accessed. Teach the patient or significant others the dressing technique recommended by your institution. In addition, the patient needs to learn the signs of an infected access site, such as swelling, redness, drainage, and odor. In addition, teach the patient to avoid restrictive clothing around the waist and to avoid external abdominal pressure.

care of external arteriovenous dialysis access (shunt).
A shunt can be surgically inserted on any limb, but the dominant arm is usually avoided. The access site is considered sterile and is covered with a sterile dressing at all times. Teach the patient to cover the access site between dialysis treatments with a dressing and further support, such as a nonelastic tensor bandage. Because one end of the shunt is inserted directly into an artery, care must be taken to ensure that the shunt does not accidentally come apart, which would lead to immediate hemorrhage. Teach the patient to carry a clamp to use if the shunt becomes disconnected. Teach the patient to feel for the “thrill” of blood moving through the shunt when it is touched (except during dialysis). The presence of darker blood within the shunt may indicate clotting; if this condition occurs, the patient needs to notify the dialysis staff or physician immediately. Any pressure on that limb—such as blood pressure readings, sleeping with the affected limb under the body, carrying boxes or groceries with that arm, or tight clothing—is contraindicated. Tell the patient not to use creams or lotions on the access site and to protect the site during bathing.

care of the arteriovenous fistula.
The increased pressure in the arterialized vein creates a large and sometimes unsightly vessel but also creates an access site with enough pressure to complete hemodialysis. Teach the patient to palpate a thrill over the anastomosis or graft site every day. Postoperatively, the patient may be asked to do strengthening exercises (grasping ball) to increase the size of the arterialized vein. After hemodialysis, the nursing staff applies pressure for a lengthy period of time to ensure clotting of the patient’s blood. If the patient notices excessive bleeding after a dialysis treatment, she or he must notify the dialysis unit. Teach the patient that the site does not need to be protected during bathing. Tell the patient to remind all healthcare personnel that the involved arm should not be used for blood pressure measurements and phlebotomy.

posttransplantation teaching.
Discharge teaching for the patient with a renal transplant includes information about medications and the signs of rejection. The immunosuppressive drugs place the patient at greater risk for infection and skin cancer. Teach the patient to avoid large groups of people in the first 3 to 4 months and strong sunlight for the duration of the transplant. Although most forms of daily activity are restricted only by how the patient is feeling, contact sports and heavy lifting are contraindicated because of the placement of the transplant. Teach the patient to report signs of infection, rejection, and skin changes immediately to the physician. Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions.

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