Chronic

Renal Failure
Prepared by:
ALUMBRO, Anna Rose L. SN
COLANO, Afra B. SN
GIMPAYAN, Jerica May F. SN
TUDAYAN, Ivana Kim G. SN
VALERIO, Stephanie Z. SN
(S.Y. 2015-2016)

Learning Objectives:
At the end of this case conference,
the students/ learners would be
able to:
Describe the anatomy and physiology of
the renal systems.
Discuss the types of Renal Failure and its
difference.
Define the Chronic Renal Failure
Explain the stages of Chronic Kidney
Disease (CKD)
Identify the clients at risk and causes for
development of CRF.

Learning Objectives:

Describe the pathophysiology of CRF

Identify the signs and symptoms or
clinical manifestations of End-Stage
Renal Disease
Discuss the diagnostic findings of CRF.
Compare and contrast the treatment
options or the medical managements
Identify the prioritized and common
Nursing Diagnosis

I. Anatomy and Physiology

Kidney/s
located @ upper abdominal cavity on either
side of the vertebral column, behind the
peritoneum (retroperitoneal)
upper portions of the kidneys rest on the
lower surface of the diaphragm and
enclosed and protected by the lower rib
cage
left kidney is slightly higher than the right
one.

I. Anatomy and Physiology

Kidney/s
embedded in adipose tissue that acts as a
cushion and covered by a fibrous
connective tissue membrane called the

renal fascia (helps hold the kidneys in

place)
each has an indentation called the hilus
on its medial side (renal and the renal vein
and ureter emerge)

A. Internal Structure of the

Kidney
outer tissue layer is called the renal
cortex; it is made of renal
corpuscles and convoluted tubules
inner tissue layer is the renal
medulla, w/c made of loops of Henle
and collecting tubules. Renal
medulla consists of wedge shaped
pieces called renal pyramids (apex
or papilla)

A. Internal Structure of the

Kidney
renal pelvis; this is not a layer of
tissues, but rather a cavity formed by the
expansion of the ureter within the kidney
at the hilus. Funnel-shaped extensions of
the renal pelvis, called calyces, (enclose
the papillae of the renal pyramids.

B.

The Nephron
structural and functional unit of the
kidney.
Each kidney contains approximately
1 million nephrons
Each nephron has two major
portions: a renal corpuscle and a

renal tubule

B.

The Nephron

a.Types of Nephron
Cortical Nephron
80-85 % of the total number of
nephrons located in the outermost
part of the cortex

Juxtamedullary nephrons
15-20% located deeper in the
cortex

b.Parts of Nephrons
Renal Corpuscle
consists of a glomerulus surrounded by
a Bowmans capsule

glomerulus is a capillary network that

arises from an afferent arteriole and
empties into an efferent arteriole
efferent arterioles diameter is smaller
than the afferent arteriole, w/c helps
maintain a fairly high blood pressure in
the glomerulus

b.Parts of Nephrons
Renal Corpuscle

Bowmans capsule; it encloses the

glomerulus. The inner layer of
Bowmans capsule is made of
podocytes; means foot/feet
cells, that are on the surface of
the glomerular capillaries w/c
creates pores, slits between
adjacent feet, which make this

b.Parts of Nephrons
Renal Tubule
consists of the following parts: proximal
convoluted tubule (in the renal cortex), loop
of Henle (or loop of the nephron, in the
renal medulla), and distal convoluted tubule
(in the renal cortex).
distal convoluted tubules from several
nephrons empty into a collecting tubule.
Several collecting tubules then unite to form
a papillary duct that empties urine into a

b.Parts of Nephrons
Renal Tubule
All parts of the renal tubule are surrounded
by peritubular capillaries, which arise from
the efferent arteriole. The peritubular
capillaries will receive the materials
reabsorbed by the renal tubules.

Flow of the Urine

C.Blood Vessels of the Kidney

pathway of blood flow through
the kidney is an essential part of
the process of urine formation

II.Renal Failure
refers to temporary or permanent damage
to the kidneys that result in loss of normal
kidney function which cannot remove the
bodys metabolic wastes (Brunner &
Suddarth, 2010).
two different types of renal failure--acute
and chronic.
Acute renal failure has an abrupt onset and
is potentially reversible.
Chronic renal failure progresses slowly over
at least three months and can lead to
permanent renal failure.

III. Chronic Renal Failure

Termed as an End-Stage Renal
Disease (ESRD).
A progressive and irreversible
deterioration in renal function in
which the bodys ability to maintain
metabolic and fluid and electrolyte
balance fails, resulting in uremia or
azotemia.
Usually end result of gradual tissue
destruction

III. Chronic Renal Failure

incidence of ESRD has increased by
almost 8% per year from the past 5
years.
In the US, more than 280,000 patients
with CRF (65%) are receiving
hemodialysis, more than 120,000
(28%) have functioning renal
transplants, and more than 24,000
(7%) are receiving peritoneal dialysis

IV.

Stages of Chronic Kidney

Disease

Stages are based on the GFR.

Normal GFR: 90 - 125 mL/min/1.73
(According to National Kidney Foundation)

m2

V. Risk Factors and Causes of

CRF/ ESRD
Chronic kidney disease (CKD)
Injury or trauma to the kidneys
Major blood loss
Diabetes Mellitus
Hypertension
Chronic Glomerulonephritis
Pyelonephritis
Obstruction of the Urinary tract
Hereditary Lesion (Polycystic Kidney
Disease)
Vascular Disorders

VI. Pathophysiology of CKD and

CRF/ESRD

VII. SIGNS/SYMPTOMS/ Clinical

Manifestations
1.Neurologic

Weakness and fatigue

Confusion
Inability to concentrate
Disorientation
Tremors
Seizures
Asterixis
Restlessness of legs
Burning of soles of feet
Behavior changes

2. Integumentary

VII. SIGNS/SYMPTOMS/ Clinical

Manifestations
3. Cardiovascular

Hypertension
Pitting edema (feet, hand, sacrum)
Periorbital edema
Pericardial friction rub
Engorged neck vein
Hyperkalemia
Hyperlipidemia

4. Pulmonary
Crackles
Depress cough reflex

VII. SIGNS/SYMPTOMS/ Clinical

Manifestations
5. Gastrointestinal
Ammonia odor of breath ( uremic
fetor)
Metallic taste
Mouth ulceration and bleeding
Nausea and vomiting
Constipation and diarrhea

6. Hematologic
Anemia
Thrombocytopenia

VII. SIGNS/SYMPTOMS/ Clinical

Manifestations
7. Reproductive
Amenorrhea
Testicular atrophy
Infertility
Decrease libido

VIII.

Diagnostic Findings

A.Laboratory Assessment

Glomerular Filtration Rate

glomerular filtration (d/t
nonfunctioning glomeruli)
creatinine clearance value
serum creatinine and BUN
levels

VIII.

Diagnostic Findings

A.Laboratory Assessment
Sodium and Water
retention/excretion (altered urine
output)
Acidosis
Metabolic acidosis
Decreased acid secretion
Anemia
inadequate erythropoietin production

VIII.

Diagnostic Findings

A.Laboratory Assessment
Calcium and Phosphorus Imbalance
Activation of Vit. D
Hypocalcemia
PTH
Hyperphosphatemia

B.

Radiographic Assessment

renal osteodystrophy
kidneys are atrophic and may
be 8 to 9 cm or smaller

IX. Medical Management

The goal of management is to maintain
kidney function and homeostasis for as
long as possible

A.Pharmacological Therapy
Calcium and Phosphorus Binders
Hyperphosphatemia and
hypocalcemia are treated with
medications that bind dietary
phosphorus in the GI tract
Calcium Carbonate or Calcium
Acetate

IX. Medical Management

A.Pharmacological Therapy
Antihypertensive and
Cardiovascular Agents
Hypertension is managed by
intravascular volume control and a
variety of antihypertensive agents.
Digoxin or Dobutamine

IX. Medical Management

A.Pharmacological Therapy
Antiseizure Agents
Neurologic abnormalities might occur
IV Diazepam (Valium) or Phenytoin (Dilantin)

Erythropoietin
Treatment for Anemia
Epogen

IX. Medical Management

B. Nutritional Therapy
.Dietary Intervention is necessary with
deterioration of renal function and includes:
Careful regulation of protein
intake
Fluid intakes to balance fluid
losses
Sodium intake to balance sodium
losses
And some restriction of potassium
Adequate caloric intake

IX. Medical Management

C. Dialysis
. used to remove fluid and uremic waste
products from the body when the
kidneys are unable to do so
. Indicated also to treat patients with
edema that does not respond to other
treatment, hepatic coma,
hyperkalemia, hypercalcemia,
hypertension, and uremia.

IX. Medical Management

C. Dialysis
Methods of therapy includes:

.Hemodialysis
Most common method of dialysis. It used for
patient who are acutely ill and require shortterm dialysis (days to weeks) and for patients
with ESRD who require long term or
permanent therapy. A dialyzer (also referred
to as an artificial kidney)serves as a synthetic
semipermeable membrane , replacing the
renal glomeruli and tubules as the filter for
the impaired kidneys

IX. Medical Management

C. Dialysis
Methods of therapy includes:

.CRRT (Continuous Renal Replacement

therapies)
Indicated for patients with acute or chronic
renal failure who are too clinically unstable
for traditional hemodialysis, for patients with
fluid overload secondary to oliguria, renal
failure, and for patients whose kidney cannot
handle their acutely high metabolic or
nutritional needs

IX. Medical Management

C. Dialysis
Methods of therapy includes:

.Peritoneal Dialysis
Goal is to remove toxic substances and
metabolic wastes and to re-establish
normal fluid and electrolyte balance.
The treatment of choice for patient
with renal failure who are unable or
unwilling to undergo hemodialysis or
renal transplant.

IX. Medical Management

D. Renal/ Kidney Transplant
Kidney transplantation has become the
treatment of choice for most patients
with ESRD.
Patients choose kidney transplantation
for various reasons: desire to avoid
dialysis or to improve their sense of
well-being and the wish to lead a more
normal life.

IX. Medical Management

D. Renal/ Kidney Transplant
Criteria for Candidate in Kidney
Transplantation
Free of medical problems that might
increase the risk from the procedure
2 to 7 years old
Advanced and uncorrectable cardiac
disease are excluded
Metastatic Cancer (-)

IX. Medical Management

A.Renal/ Kidney Transplant
Criteria for Candidate in Kidney
Transplantation
Chronic Infection (-)
Severe Psychosocial problems (chemical
dependency) (-)
Long-standing pulmonary diseaserespiratory infections (-)
GIT problems (Peptic Ulcer, Diverticulosis)made worse by the large doses of steroid
used after transplantation (-)

IX. Medical Management

D. Renal/ Kidney Transplant

Donors
Usually 18 years old above and are
seldom older than 65 years of age
Absence of systemic Disease and
infection
No history of cancer
No hypertension or renal disease
Adequate renal function as
determined by diagnostic studies

X.

Nursing Diagnosis for CRF/

End-Stage Renal Disease

Excess fluid volume related to

decreased urine output, dietary
excessive and retention of sodium and
water.
Imbalance nutrition; less than body
requirements related to anorexia,
nausea, vomiting, dietary restrictions
and altered oral mucous membranes.

X.

Nursing Diagnosis for CRF/

End-Stage Renal Disease

Risk for infection related to inadequate

primary defenses (broken skin),
chronic disease and malnutrition.
Risk for injury related to internal
biochemical risk factor associated with
renal failure (increased susceptible to
bleeding, falls and fractures)
Deficient knowledge regarding
condition and treatment

X.

Nursing Diagnosis for CRF/

End-Stage Renal Disease

Activity intolerance related to

fatigue, anemia, retention of
waste products, and dialysis
procedure
Risk for situational low selfesteem related to dependency,
role changes, change in body
image and change in sexual
function

Reference:
Scanlon, V. and Sacnders, T. (2011). Essentials of Anatomy and
Physiology (7th Edition)
LaCharity, Linda A. Interventions for Clients with Acute and Chronic
Renal Failure
Smeltzer, Bare, Hinkle, Cheever, (2008). Brunner & Suddarths
Textbook of Medical-Surgical Nursing (11th Edition)
Ignatavicus & Workman (2006) Medical Surgical Nursing: Critical
Thinking for Collaborative Care (5th Edition)
Pathophysiology an Incredibly Easy (Pocket Guide)
Doenges, Moorhouse & Murr, (2010). Nursing Care Plans: Guidelines
for Individualizing Client Care Across the Life Span (9th Edition)
http://www.hopkinsmedicine.org/
http://www.kidneyfund.org/
http://www.netwellness.org/

THANK
YOU