Research Paper on Acute Renal Failure

Introduction

Acute renal failure (ARF) is a condition that occurs when the kidneys are not capable of filtering waste products from the blood (Smeltzer, Bare, Brunner, & Suddarth, 1992). ARF, also known as acute kidney injury (AKI), can also be described as a syndrome characterized by severe, rapid decline in renal functioning leading to the inability of the patient to keep fluid, acid-base balance, and electrolyte balance (Tait, James, Williams, & Barton, 2015). The medical definition of AKI is based on urine output, the level of creatinine, and the severity of reduction in urine output and elevated creatinine level when checked against the patient's baseline level when the condition started (Tait et al. 2015). Based on this criteria, AKI is categorized into three stages (stage 1, stage 2, and stage 3). Stage 1 AKI is characterized by an increase of serum creatinine level by 1.5 to 1.9 times compared to the baseline. On the other hand, stage 2 AKI is characterized by an increase of serum creatinine level by 2.0 to 2.9 times compared to the baseline. Lastly, marked by the rise of serum creatinine level by more than 3 times compared to the baseline (Tait et al. 2015).

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Classification of AKI into the three stages is also based on the urine output. Stage 1 AKI is manifested by urine output of <0.5 ml/kg/hr in every six hours while stage 2 AKI is manifested through urine output of <0.5 ml/kg/hr during 2 6-hour blocks. Lastly, stage 3 AKI is revealed through urine output of <0.3 ml/kg/hr in more than 24 hours. The inability of the kidney to efficiently filter wastes leads to accumulation of wastes to a dangerous level leading to imbalanced. The diagnosis of acute renal failure is based on the clinical identification of elevated levels of blood urea nitrogen (BUN) and creatinine. The BUN-creatinine ratio is essential in the differential diagnosis of acute renal failure. In the present paper, the pathophysiology, manifestations of acute renal failure, laboratory and diagnostic tests for acute renal failure, related patient education will be discussed.

Pathophysiology of AKI

A normal kidney is comprised of about 1 million nephrons, which are essential in overall glomerular filtration rate (GFR). In case of kidney injury (regardless of the cause), the kidney is capable of maintaining GRF, even if the number of nephrons progressively destroyed following injury. This is because the remaining nephrons show glomerular hyperfiltration and compensatory hypertrophy, hence allowing for continuous filtration of plasma solutes. However, when the GFR reduced to 50%, there is increased in the levels of creatinine and urea and creatinine. A decrease of GFR by 50% is linked to 50% decline of the filtration and excretion of creatinine, hence resulting in a two-fold increase in the level of creatinine in the plasma (Huether & McCance, 2013).

After kidney injury, compensatory hypertrophy and hyperfiltration of the remaining nephrons have been linked to progressive renal dysfunction. Hypertrophy and hyperfiltration refer to the enlargement of the residual nephrons and increased capability of filtration following kidney injury. These two compensatory mechanisms cause progressive renal dysfunction because the increased load on each of the functioning glomerulus stimulates mechanisms which damage the nephrons (Woodward & Oliveira, 2016). Specifically, these mechanisms lead to elevated glomerular capillary pressure which damages the capillaries, resulting in glomerulosclerosis (Hales, 2007). Progressive kidney injury has also been linked to high blood pressure, hyperphosphatemia, Hyperlipidemia, Proteinuria, reduced perfusion, and nephrotoxins.

Acute renal failure is manifested in several ways. First, it is revealed by elevated BUN and serum creatinine. In chronic renal failure, BNU-creatinine ratio of 10 to 15 is normally seen (Humes, 2001). ARF is also manifested through oliguria. Oliguria is a condition characterized by a urine output of less than 400 mL per day in adults, less than 0.5 mL/kg/h in children, and less than 1 mL/kg/h in infants. Oliguria is one of the clinical hallmarks of ARF and is the most important criteria for diagnosing ARF. Oliguria is acute at the onset of ARF and is, therefore, one of the earliest indications of improper renal functioning.

Another symptom associated with ARF is fluid overload. Fluid overload is a complication linked to an impairment of water and sodium excretion. Additionally, patients with oliguric ARF are at a higher risk for fluid imbalance because of extensive systematic inflammation, low colloid osmotic pressure and elevated capillary leak. These conditions are also associated with a high fluid overload which is linked to pulmonary oedema and heart failure (Rimmele & Kellum, 2010).

ARF is also manifested through hypertension. Due to the progression of ARF, the blood pressure rises as a result of the accumulation of salt and water (Humes, 2001). High blood pressure has also been linked to accelerated progression of ARF and can lead to atherosclerosis (Humes, 2001). Lastly, the presence of ARF is shown through electrolyte abnormalities. Some of the electrolyte problems associated with ARF include bicarbonate deficiency, hypocalcemia, hyperphosphatemia, and hyperkalemia, and hypervolemia (Chambers, 1987).

Laboratory and Diagnostic Tests for Acute Renal Failure

Renal Ultrasonography

Renal ultrasonography is used to identify obstruction of the urinary system. A kidney ultrasound is a non-invasive diagnostic-imaging test used in assessing the location of the kidney as well as its size and shape. Ultrasonography is also useful in the assessment of renal blood flow. This method uses a transducer, placed on the skin and that transmits ultrasound waves at a high frequency, thus capable of being heard. The ultrasound waves travel through the body, including all the body organs and structures. The ultrasound waves bounce off the organs like an echo and bounce back to the transducer. The reflected waves are processed by a transducer and transformed by a computer into images of the structures or organs being observed.

A kidney ultrasound is useful in detecting infection, fluid collection, obstructions, cysts, and abscesses in or around the kidney. A renal ultrasound is also conducted to aid in placing needles for drawing tissue sample from the kidneys, for draining of fluid from abscesses or cysts, or for placing a drainage tube. Moreover, renal ultrasound aids in determining renal blood flow, especially through the renal arteries and veins.

Nursing Interventions

There are specific nursing interventions that must be adhered to in ARF. The first nursing intervention is the maintenance of strict measurement of fluid intake and output. Measurement of patient's intake and output, followed by notification of the doctor if there is a deficit of between 5% and 10% is required. Second, nurses should be knowledgeable in drugs which can be toxic when the kidneys are not working at their optimum. Examples of these drugs include aspirin, NSAIDS, and Statins.

The nurses should also monitor the patients' lung sounds and oedema. This is important in ensuring proper monitoring of the fluid balance. Another intervention involves monitoring of potassium (K+) level. The normal range is between .5 - 5.0 mEq/L. It is critical to monitor potassium levels because of the important role potassium play in acid-base equilibrium. Moreover, the nurses should ensure strict adherence to dietary changes and salt restriction. This can be realized if nurses educate patients on the need to decrease sodium intake and regulate fluid intake. On the other hand, if the affected patient is on a potassium wasting diuretic, they should be taught on the appropriate quantity of potassium he or she should consume.

Lastly, it is critical for nurses to monitor the patients' BUN range. BUN normal range varies between 7-20 mg/dL. It is also crucial for nurses to assess the patients' creatinine level. The normal creatinine level ranges from 0.7-1.4 mg/dL. Both of this measure is useful in understanding the effectiveness of the treatment in AKI. The BUN assesses the quantity of urea in blood while creatinine is a byproduct of creatinine metabolism, and it is excreted by the kidneys.

Related Patient Education

Patient education in ARF involves educating the patient on the stage of kidney failure he or she is in, how he or she got the disease and ways of slowing down the progression of kidney disease. It is essential for the patient to know the stages of the kidney disease as well as the recommended treatment for the stage. The stages of kidney disease are five, ranging from nearly stage 1 (normal kidney function) to stage 5 (kidney failure), which requires dialysis or a kidney transplant. It is crucial for a patient to know to understand the stage of the kidney disease in order to take control of the disease as well as slow down the progression of the disease. A nurse needs to tell the patient that the stages of renal disease are not linked to the symptoms alone, but also to glomerular filtration rate (GFR). GFR reflects the efficiency of the kidneys in removing waste from the blood. Determination of GFR involves a simple blood test. Consequently, each kidney patient should undergo the test.

The patient should also be educated on ways of slowing down the progression of the kidney disease. Some of these ways include avoidance of smoking, increased physical exercise, and taking medications as drugs as prescribed by the physician. The patient should also be advised to reduce intake of foods containing a lot of proteins as well as foods that are high in fats, sodium, potassium, and phosphorous as they strain the kidneys. Moreover, nurses should advise the patients to understand the medications needed to control the disease. The patients should be advised to avoid herbal supplements as well as over-the-counter medicines because they can be harmful to their kidneys. They should also be encouraged to consult their physicians or pharmacists before taking any new drugs. Lastly, patient education should also target people of different ages and gender. For instance, women of childbearing age having ARF should be made aware of increased risk for decreased fertility in patients with ARF compared to their counterparts who do not have the disease. All these measures should be adhered to by the patients.

References

Chambers, J. K. (1987). Fluid and electrolyte problems in renal and urologic disorders. The Nursing Clinics of North America, 22(4), 815-826.

Hales, D. (2007). An Invitation to Health, Brief Edition. Cengage Learning.

Huether, S. E., & McCance, K. L. (2013). Understanding pathophysiology - E-Book. Elsevier Health Sciences.

Rimmele, T., & Kellum, J. A. (2010). Oliguria and fluid overload. In Fluid Overload (Vol. 164, pp. 39-45). Karger Publishers.

Smeltzer, S. C. O., Bare, B. G., Brunner, L. S., & Suddarth, D. S. (1992). Brunner and Suddarth's textbook of medical-surgical nursing. Lippincott.

Tait, D., James, J., Williams, C., & Barton, D. (2015). Acute and Critical Care in Adult Nursing. Learning Matters.

Woodward, S., & Oliveira, D. (2016). Eureka: Renal Medicine. JP Medical Ltd.