Chapter 65 Renal Failure
Chronic
PATHOPHYSIOLOGY
Chronic renal failure (CRF) is most frequently a result of chronic kidney disease (CKD). The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative has defined CKD as structural or functional abnormalities that persist for 3 months or longer. Pathologic abnormalities or other markers of kidney damage (abnormal blood or urine tests or imaging studies) are present, with either normal or decreased glomerular filtration rate (GFR). CKD also includes conditions in which the GFR is less than 60 mL/min/1.73 m2 for 3 months or longer. Irreversible deterioration of renal function may occur over months to years.
CKD is classified into five stages. During stage 1, kidney damage is present, with normal or increased glomerular filtration rate (GFR). The focus of stage 1 is on diagnosis, treatment of associated conditions, and slowing the disease process. Stages 2, 3, and 4 represent a progressive decline in GFR. The focus of these stages is on monitoring and treating complications. Preparation for kidney replacement therapy (dialysis) occurs during stage 4. Stage 5 represents renal failure, when the GFR falls below 15 mL/min/1.73 m2. During this stage, the loss of nephrons and renal function affects the kidney’s ability to maintain normal physiologic functioning.
CRF is associated with a variety of biochemical dysfunctions. Sodium and fluid imbalances result from the kidney’s inability to concentrate urine. Hyperkalemia results from decreased potassium secretion. Impaired resorption of bicarbonate and hydrogen ion retention lead to metabolic acidosis. Uremia occurs, with a build-up of blood urea, creatinine, and waste products. Encephalopathy and neuropathy have been associated with the accumulation of uremic toxins. Poor appetite, nausea, and vomiting lead to malnutrition. Anemia results from impaired red blood cell (RBC) production, decreased RBC life span, an increased tendency to bleed (due to impaired platelet function), and poor nutrition. Bone demineralization and impaired growth result from secretion of parathyroid hormone, elevation of plasma phosphate (decreasing serum calcium), acidosis (causing calcium and phosphorus release into the bloodstream), impaired intestinal calcium absorption, and poor nutrition (related to dietary restrictions and other factors). Renal osteodystrophy (altered bone growth) is related to dysfunctional interactions between parathyroid hormone, calcium, phosphorus, and Vitamin D. Growth failure has been associated with growth hormone imbalance and other nutritional and metabolic factors. Altered sexual development has been associated with a variety of biochemical processes.
Causes of CRF are associated with a variety of congenital and acquired factors including the following:
1. Glomerular disease (e.g., pyelonephritis, glomerulonephritis, glomerulouropathy)
2. Obstructive uropathies (e.g., vesicoureteral reflux)
3. Renal hypoplasia or dysplasia
4. Inherited renal disorders (e.g., polycystic kidney disease, congenital nephrotic syndrome, Alport syndrome)
5. Vascular neuropathies (e.g., hemolytic-uremic syndrome [HUS], renal thrombosis)
6. Kidney loss or damage (e.g., severe renal trauma, Wilms’ tumor)
INCIDENCE
1. The incidence of CRF in children has been increasing for many years. It is expected to rise in the future along with the increasing incidence of diabetes, hypertension, and obesity in the United States.
2. The exact incidence of CRF in children is difficult to quantify. It has been estimated at approximately 1:100,000. Incidence is highest in adolescents and males.
3. The most frequent causes (nearly 50%) of CRF in young children are related to congenital renal and urinary tract malformations (e.g., renal hypoplasia, renal dysplasia, obstructive uropathies, vesicoureteral reflux). Acute renal diseases such as glomerulonephritis, HUS, and pyelonephritis are the most frequent causes of acquired CRF in older children.
CLINICAL MANIFESTATIONS
Although the child’s symptoms will vary with different disease processes, the most common symptoms associated with CRF are the following:
1. Fluid and electrolyte imbalance, leading to the following:
2. Metabolic acidosis causing tachypnea and/or decreased serum bicarbonate
4. Anemia, resulting in the following:
5. Uremic neurologic effects (neuropathy and encephalopathy), leading to the following:
6. Renal osteodystrophy leading to the following:
7. Growth and development dysfunction leading to the following:
COMPLICATIONS
1. Cardiovascular: alteration in fluid and electrolytes, acid-base imbalance (metabolic acidosis), and anemia can lead to cardiac dysfunction, congestive heart failure, hypertension, left-ventricular hypertrophy, tachycardia, arrhythmias, cardiac arrest, and/or vascular volume depletion (with excessive fluid loss or removal). Fluid overload can lead to edema, oliguria, hypertension, and/or congestive heart failure. Conversely, polyuria, decreased fluid intake, and other factors causing vascular volume depletion can lead to dehydration, hypotension, and shock.
2. Electrolyte imbalances: hyperkalemia can lead to cardiac rhythm disturbances and myocardial dysfunction. Hypernatremia can lead to thirst, stupor, tachycardia, increased deep tendon reflexes, and/or decreased level of consciousness. Hypercalcemia and/or hyperphosphatemia can lead to muscle cramps, tetany, paresthesias, irritability, depression, and/or psychosis.
3. Respiratory: fluid overload can lead to pulmonary edema, increased work of breathing, and respiratory failure. Shortness of breath and exercise intolerance related to anemia can exacerbate respiratory compromise.
4. Neurologic: altered level of consciousness, increased ICP, seizures, and coma can result from the build-up of toxins, fluid and electrolyte imbalance, and other metabolic factors.
5. Hematologic: bleeding and/or anemia—bruising, mouth sores, gastrointestinal bleeding, oozing from puncture sites, and other bleeding can occur related to hematologic dysfunction and/or prolonged bleeding time.
6. Infection: increased susceptibility, decreased ability to fight infection, and invasion of opportunistic organisms is related to invasive lines and procedures, skin breakdown, poor nutrition, and the need to administer antibiotics with caution (related to the kidneys’ limited ability to metabolize and excrete).
7. Alteration in growth and bone: altered growth patterns, short stature, osseous deformities, dental defects, and mouth sores are related to poor nutrition, osteodystrophy, and/or other factors affecting bone growth and formation.
8. Psychosocial: living with a chronic disease, repeated hospitalizations, dealing with frequent and painful medical interventions, altered growth patterns, chronic stress, and other factors can lead to developmental delays, altered body image, behavioral issues, altered family functioning, anxiety, depression, and/or other psychosocial issues.
LABORATORY AND DIAGNOSTIC TESTS
1. Blood chemistry panel—provides information about common CRF-related alterations including blood urea nitrogen (BUN), creatinine, electrolytes (potassium, sodium, calcium, magnesium, and phosphorus), acid-base status (bicarbonate), glucose and protein (albumen, total protein)
2. Complete blood count (CBC)—provides information related to alterations of the hematocrit, hemoglobin, and white blood cell (WBC) count associated with renal disease
3. Serum uric acid—increased; related to decrease renal excretion
4. Serum blood gas results (arterial, capillary or venous) provide data related to oxygenation and acid-base status
5. Cultures—should be obtained with signs of infection (i.e., fever; high or low WBC count; localized redness, odor, swelling and/or white or yellow drainage; cloudy urine, etc.)
6. Urine tests—provide information related to alterations in excretion of electrolytes, urine osmolality, and urine specific gravity and presence of hematuria and/or proteinuria associated with renal disease
7. Electrocardiogram (ECG)—to assess for ECG changes and/or arrhythmias
8. Chest and abdominal x-ray studies—to assess for fluid retention and kidney presence and size
9. Ultrasonography—to determine kidney size, urinary tract obstruction, tumors, cysts
10. Renal Doppler blood flow—to assess for renal vascular disease
11. Radiographic imaging: computed tomography (CT) scan, magnetic resonance imaging (MRI), intravenous pylography, radionuclide studies, renal arteriogram—to examine for renal obstruction, blood flow, kidney structures, renal function
MEDICAL MANAGEMENT
A primary goal is to stabilize the fluid volume and balance by limiting fluids, which is an important and ongoing aspect of CRF management. This is achieved through closely monitoring intake and output, monitoring weight gain patterns, administering fluid therapy to maintain adequate circulation and avoid volume overload, and removing excess fluids when needed. Maintaining electrolyte and glucose balances is critical. This is achieved by closely monitoring electrolytes, limiting potassium and sodium intake, and promptly correcting imbalances. If hyperkalemia is present, resin binding agents (Kayexalate), glucose and insulin, calcium gluconate, sodium bicarbonate, and/or dialysis may be needed. Calcium supplements, vitamin D, and phosphate binders may be helpful in maintaining calcium and phosphate balance. Glucose is administered when needed for hypoglycemia.
Supporting cardiovascular and respiratory function is important, particularly when complications are present. This is achieved by avoiding fluid overload while maintaining circulating volume, controlling hypertension (with antihypertensive medications and sodium restriction), and providing cardiovascular and respiratory support medications as needed (diuretics, inotropes, antiarrhythmic medications, oxygen). Other important aspects of CRF management include preventing and treating infections, nutritional support, management of anemia, and bleeding control. When CKD progresses to CRF, dialysis is often needed to prevent uremia. For children with severe CRF, renal transplantation may be an option.
NURSING ASSESSMENT
1. Assess for signs of fluid and electrolyte status.
2. Assess for signs of cardiovascular dysfunction (tachycardia, severe hypertension, delayed capillary refill, cool extremities, weak pulses, hypotension, cardiac arrhythmias).
3. Assess for signs of respiratory compromise (pulmonary edema, increased work of breathing and use of accessory muscles [retractions, nasal flaring, grunting], oxygen desaturation, respiratory acidosis).
4. Assess for signs of infection (fever, increased WBC count, positive cultures, shock).
5. Assess for signs of uremia.
6. Assess for signs of life-threatening complications: sepsis, shock, fluid overload, severe hypertension, heart failure, respiratory failure, severe electrolyte imbalance, severe acidosis, uncontrolled bleeding, coma, and seizures.
7. Assess for signs of malnutrition, growth retardation, and bone deformity.
8. Assess child’s comfort level, activity level, and developmental level.
9. Assess child’s coping response to long-term illness, alteration in development, treatment regimen, and possibility of renal transplant and/or death.
10. Assess family’s ability to cope with their child’s long-term needs and provide effective care.
NURSING DIAGNOSES
• Fluid volume, Risk for imbalanced (fluid volume excess, fluid volume deficient)
• Urinary elimination, Impaired
• Tissue perfusion, Ineffective
• Airway clearance, Ineffective
• Nutrition: less than body requirements, Risk for imbalanced
• Activity intolerance, Risk for
• Growth and development, Delayed
NURSING INTERVENTIONS
1. Monitor fluid-electrolyte and acid-base balance.
2. Support cardiovascular, pulmonary, and hematologic functioning.
3. Maintain skin integrity and prevent infection.
4. Promote growth and nutrition (work with dietitian).
5. Assess child’s comfort level, and implement pain control measures (see Appendix I).
6. Assess coping responses, and provide psychosocial support for the child and family (see Appendix F).
Discharge Planning and Home Care
Assess the child’s and family’s understanding and ability to comprehend teaching. Promote the child’s and parents’ self-efficacy, self-confidence, and skill mastery related to the long-term management of CKD and CRF. Provide the child and the parents with developmentally appropriate verbal and written instruction (using appropriate language and reading level), demonstration, practice, and return demonstration of skills as indicated. Topics should include the following:
1. Disease process (include expected clinical progress and signs of complications)
2. Medications (dose, route, schedule, side effects, complications)
3. Nutrition (dietary restrictions and supplements)
4. Skin care and bleeding precautions
5. Prevention of infection and wound and/or line care as indicated (dressing change, site assessment, flushing, emergency care as needed)
6. Home or outpatient dialysis (peritoneal or hemodialysis) as indicated
7. Child’s developmental needs—assist family to address the need for developmental support and activity despite the child’s fatigue, exercise intolerance, altered body image, potential mood alterations, disruption in home and school routines (e.g., doctor’s appointments, dialysis, frequent hospitalizations), and other factors affecting normal growth and development patterns (refer to Appendix B)
8. Multidisciplinary support services (e.g., case management, social services, psychology, clergy, support groups, school programs, outpatient therapy, home nursing, respite care)—assist families to manage the financial, emotional, physical, and spiritual burdens of having a child with a chronic and life-threatening medical condition (see Appendix G)
CLIENT OUTCOMES
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