WHEN the KIDNEYS FAIL
Management and Implications of Renal Failure
Kidneys are fist-sized, bean-shaped organs, which are located at th lowest part of the rib cage and the sides of the spine (National Kidney Foundation, Inc. 2003). Their major function is to remove waste products and excess fluids from the body in the form of urine. The production of urine consists of excretion and re-absorption, necessary to maintain a stable chemical balance. The kidneys also regulate the salt, potassium and acid content of the body. They produce many hormones, which affect other important organ functions. One of these hormones, for example, stimulates the production of red blood cells. Others help regulate blood pressure and the processing of calcium. The kidneys likewise eliminate chemicals, balance body fluids and produce a form of Vitamin D, which makes the bone strong and healthy. Damage to the kidneys or reduced kidney functions can constitute chronic kidney disease or CKD. Protein in the urine for three months or more, for example, signals kidney damage. A glomerular filtration rate of lower than 60 for three months or more signals CKD. Diabetes and high blood pressure are the two main causes of CKD. These may be inherited or congenital. Untreated CKD may lead to kidney or renal failure. The condition may need to be treated with dialysis or Kidney transplantation (National Kidney Foundation, Inc.).
Chronic renal failure consists of a progressive loss of kidney function from disease or another cause (Cannon 2004). It eventually leads to end-stage renal disease. Diabetics have the highest risk of developing chronic renal failure or CRF. Statistics reveal that approximately 3 million Americans will suffer from CRF by 2008. At present, CRF accounts for 50,000 annual deaths in the U.S. CRF is quite expensive to treat because of the costs of dialysis. Early diagnosis, aggressive management and treatment can retain kidney function and prevent or the progression of CRF to the end-stage (Cannon).
Psychosocial and Physiological Changes – a study of 147 long-term renal failure patients, who were on dialysis, identified depression as the strongest predictor of death (Anderson 2005), it also significantly correlated with two-year mortality. Findings revealed that 70% of the patients experienced depression, high anxiety, self-depreciation, introversion and hypochondriasis. Mental, neurological, hormonal functions are interwoven and unified systems. Their unity encompasses biofeedback and voluntary controls. It impacts thought and beliefs, past and present stress, placebo, social relationships and patient response to medication, strongly prompting the use of a holistic approach (Anderson).
Physiological changes or conditions resulting from kidney failure include anemia, osteodystrophy, itching or pruritus, sleep disorders and amyloidosis (National Kidney and Urologic Diseases Information Clearinghouse Center 2000). Diseased kidneys do not produce enough the hormone erythropoietin or EPO. This hormone stimulates the bone marrow to produce red blood cells. Hence, the bon marrow produces fewer of these. Renal osteodystrophy makes the bone thin and weak or deformed. Growing children with kidney failure exhibit this change visibly. Patients undergoing peritoneal dialysis complain of skin itchiness. The condition is worse during or right after treatment because of uremic toxins, which the procedure does not sufficiently remove. They also suffer from sleep apnea, which disturbs sleep and can lead to so-called “day-night reversal.” They are unable to sleep because of uncomfortable or “restless” legs. Dialysis-related amyloidosis is common among patients undergoing dialysis for more than 5 years. This happens when th proteins in the blood deposit on their joints and tendons cause pain, stiffness and fluid (NKUIDCC).
Hemodialysis is one of the two treatment options of a patient who enters the end stage (Cannon 2004). The other is kidney transplant. Dialysis performs the function of the kidneys but does not cure the disease or prevent possible complications. It may even cause those complications and even reduce one’s quality of life. Hemodialysis sends the blood through a dialyzer and goes back to the body after eliminating toxins and excess fluid. It is usually done thrice a week, each time for 3 to 5 hours or more. Common negative reactions are fluid and electrolyte imbalances, hypotension, light-headedness, leg cramps, nausea and vomiting. The other type is peritoneal dialysis, which uses the peritoneum to filter the blood without removing it from the body. It uses dialysate, which is later drained through a peritoneal catheter. Peritonitis is the most common complication (Cannon). A study of 336 hemodialysis and 185 peritoneal dialysis patients undergoing both types found that peritoneal dialysis was a preference 1.5 times more (Wellbery 2004). The quality of care, freedom of choice and cost are major reasons for their choice. Physicians, however, prefer hemodialysis because of reimbursement trends (Wellbery).
Dietary Changes – Many patients also prefer peritoneal dialysis to hemodialysis because the latter restricts the diet (NKUDICC 2000). Peritoneal dialysis removes body wastes slowly but it always does. In hemodialysis, on the other hand, wastes can build up for two or three days between treatments. In addition, a patient on hemodialysis must observe a restrictive diet. Some clinics help plan the meals of patients undergoing peritoneal dialysis. Their dietitians can give advice on how to prepare more satisfying meals (NKUDICC).
Management and Implications – Managing acute renal failure begins with determining the cause (Agrawal and Swartz 2000). It includes a thorough history and physical examination, blood tests, urine studies and a renal ultrasound examination. Renal failure warrants supportive therapy to maintain fluid and electrolyte balances, reduce the production of nitrogenous wastes, and to sustain nutrition. Death is most frequently the result of an infection or cardio-respiratory complications. Acute renal failure happens to 5% of hospitalized patients, of whom 0.5% require dialysis. In the last decade, the survival rate has not improved because most patients are now older and have already developed enhancing health conditions. Of the causes of death, infection accounts for 75%. The second most common are cardio-respiratory complications. Their GFR goes down for days and weeks, reducing the excretion of nitrogenous wastes. Fluid and electrolyte balances can no longer be maintained. Most patients suffering from acute renal failure show no symptoms. It is diagnosed only by high levels of blood urea nitrogen or BUN and serum creatinine. Authorities define the condition as an acute increase of the serum creatinine level from baseline. Cephaloxporins and trimethoprim-sulfamethoxazole may also cause acute renal failure by simply inhibiting the tibular secretion of creatinine without damaging the kidneys. The BUN can also increase if a patient receives costicosteroids or if they have increased catabolism or gastrointestinal bleeding (Agrawal and Swartz).
Diagnostic Strategy and Differential – the standard approach is to first eliminate pre-renal and post-renal causes and then examine the potential renal etiologies (Agrawal and Swartz 2000). BUN and serum electrolyte, creatinine, calcium, phosphorus and albumin levels, and a complete blood with differential are all taken. The patient should also undergo the dipstick test, microscopy, sodium and creatinine levels and urine osmolality determination tests (Agrawal and Swartz).
Initial treatment should first correct fluid and electrolyte balances and uremia while the cause of acute renal failure is being determined (Agrawal and Swartz 2000). The patient is resuscitated with saline. Often, however, the problem of volume overload occurs. The first treatment to volume overload is furosemide administered intravenously every six hours at between 20 and 100 mg dose. It can be doubled and repeated. The final resort is ultrafiltration through dialysis. Main electrolyte problems may be hyperkalemia and acidosis. Treatment should be aggressive, depending on the degree of hyperkalamia. Calcium, intravenously administered, can reverse the cardio-protective and temporarily contains the neuromuscular effects of hyperkalemia (Agrawal and Swartz).
Acute renal failure can also render a patient’s nutrition deficient (Agrawal and Swartz 2000). His total caloric intake should be between 30 and 45 kcal per kg per day. Most of the intake should cosist of carbohydrates and fats. If he is not on dialysis, his protein intake should be controlled at 0.6 g per kg per day. If he is on dialysis, his protein intake should be 1 to 1.5 g pr kg per day. Lastly, the physician should review all the patient’s medications. The dosages should be adjusted according to the GFR, and the serum levels of medication. Records show that 20-60% of patients will need short-term dialysis, especially when the patient’s BUN goes over 100 mg per dL and the serum creatinine level goes beyond the 5-10 mg per dL Indications for dialysis include acidosis or electrolyte disturbances. These disturbances do not respond to pharmacologic therapy, fluid overload, which does not respond to diuretics, and uremia. A patient who has progressive acute renal failure should see a nephrologist (Agrawal and Swartz).
Agrawal. M. And Swartz, R. (2000). Acute renal failure. 9 pages. American Family Physicians: American Academy of Family Physicians
Anderson, R.A. (2005). Renal failure: mortality and depression. 2 pages. Townsend Letter for Doctors and Patients: The Townsend Letter Group
Cannon, J.D. (2004). Recognizing chronic renal failure – the sooner, the better. 5 pages. Nursing: Springhouse Corporation
National Kidney and Urologic Diseases Information Clearinghouse Center. (2000). Treatment methods for kidney failure: peritoneal dialysis. 10 pages. National Institute of Diabetic and Digestive and Kidney Diseases: Gale Group
Wellbery, C. (2004). Patients prefer peritoneal dialysis to hemodialysis. 2 pages. American Family Physician: American Academy of Family Physicians
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