Acute renal failure (ARF) refers to the abrupt loss of kidney function.

Over a period of hours to a few days, the Glomerular filtration Rate (GFR) falls, accompanied by concomitant rise in serum creatinine and urea nitrogen. A healthy adult eating a normal diet needs a minimum daily urine output of approximately 400 ml to excrete the bodys waste products through the kidneys. An amount lower than this indicates a decreased GFR. ARF affects approximately 1% of patients on admission to the hospital, 2% to 5% during the hospital stay, 4% to 15% after cardiopulmonary bypass surgery and 10% of cases acute renal failure occurs in isolation (i.e. single organ failure). Pathophysiology

Sudden decrease in kidney function, which may or may not be associated with a decrease in urine output and results in a buildup of toxic wastes, such as urea and creatinine in the blood Stages Initiation period initial insult and oliguria. Oliguric period Urine output less than 400 mL/day. Uremic symptoms first appear and hyperkalemia may develop. Diuresis period gradual increase in urine output signaling beginning of glomerular filtration recovery.

Recovery period improving renal function that may take 3 months to 12 months. Causes

Prerenal Hypovolemia

Heart failure Hemorrhage Excessive diarrhea Vomiting Diuresis

Intrarenal Acute tubular necrosis Postrenal Kidney stones

Tumor Spinal cord injury Benign Prostatic Hypertrophy

Manifestations

Critical illness and lethargy with persistent nausea, vomiting, and diarrhea. Skin and mucous membranes are dry. Central nervous system manifestations: drowsiness, headache, muscle twitching, seizures.

Urine output scanty to normal; urine may be bloody with low specific gravity. Steady rise in blood urea nitrogen (BUN) may occur depending on degree of catabolism; serum creatinine values increase with disease progression. Hyperkalemia may lead to dysrhythmias and cardiac arrest. Progressive acidosis, increase in serum phosphate concentrations, and low serum calcium levels may be noted.

Anemia from blood loss due to uremic GI lesions, reduced red blood cell lifespan, and reduced erythropoietin production. Complications

The following are the complications of acute renal failure Volume overload. Due to non-functional excretion system.

Pulmonary edema. Due to fluid overload. Electrolyte imbalance. Since excess electrolytes are not excreted.

Metabolic acidosis due to dramatic decrease of kidneys excretory function. Assessment Methods Urine output measurements

fluid intake and output Diagnostic Procedures Urine tests Urinalysis: Analysis of the urine affords enormous insight into the function of the kidneys. Twentyfourhour urine tests: This test requires you to collect all of your urine for 24 consecutive hours. The urine may be analyzed for protein and waste products (urea nitrogen and creatinine). The presence of protein in the urine indicates kidney damage. The amount of creatinine and urea excreted in the urine can be used to calculate the level of kidney function and the glomerular filtration rate (GFR). Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function. As kidney disease progresses, GFR falls. The normal GFR is about 100140 mL/min in men and 85115 mL/min in women. It decreases in most people with age. The GFR may be calculated from the amount of waste products in the 24hour urine or by using special markers administered intravenously. Patients are divided into five stages of chronic kidney disease based on their GFR. Urine Specific Gravity This is a measure of how concentrated a urine sample is. A concentrated urine sample would have a specific gravity over 1.030 or 1.040 Blood tests Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum creatinine are the most commonly used blood tests to screen for, and monitor renal disease. Creatinine is a breakdown product of normal muscle breakdown.

Urea is the waste product of breakdown of protein. The level of these substances rises in the blood as kidney function worsens.

Electrolyte levels and acidbase balance: Kidney dysfunction causes imbalances in electrolytes, especially potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a particular concern.

The acidbase balance of the blood is usually disrupted as well.

Decreased production of the active form of vitamin D can cause low levels of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes its levels in the blood to rise. Blood cell counts: Because kidney disease disrupts blood cell production and shortens the survival of red cells, the red blood cell count and hemoglobin may be low (anemia). Some patients may also have iron deficiency due to blood loss in their gastrointestinal system. Other nutritional deficiencies may also impair the production of red cells. Other tests Ultrasound: Ultrasound is often used in the diagnosis of kidney disease. An ultrasound is a noninvasive type of test. In general, kidneys are shrunken in size in chronic kidney disease, although they may be normal or even large in size in cases caused by adult polycystic kidney disease, diabetic nephropathy, and amyloidosis. Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in cases in which the cause of the kidney disease is unclear. Usually, a biopsy can be collected with local anesthesia only by introducing a needle through the skin into the kidney. Gerontologic Considerations

Half of all patients who develop acute renal failure during hospitalization are older than 60 years. The etiology of ARF in older clients include prerenal causes, such as dehydration, intrarenal causes such as nephrotoxic agents, and complications of major surgery. Thirst suppression, enforced bed rest, lack of access to water and confusion all contribute to elder patients failure to consume adequate fluids. All medications need to be monitored for potential side effects that could result in damage to the kidney either through reduced circulation or nephrotoxicity. Outpatient procedures that require fasting or a bowel preparation may cause dehydration and therefore require careful monitoring.

Care Settings Clients with acute renal failure are treated in inpatient medical or surgical care unit. Nursing Priorities 1. Reestablish or maintain fluid and electrolyte balance. 2. Prevent complications. 3. Provide emotional support for client and significant other (SO). 4. Provide information about disease process, prognosis, and treatment needs. Nursing Diagnosis

Excess fluid Volume related to compromised regulatory mechanism. Risk for Decreased Cardiac Output (RF may include: fluid overload, fluid shifts, fluid deficit). Risk for Imbalanced Nutrition: Less than Body Requirements Risk for Infection Deficient Knowledge