Discuss what is happening on a cellular level with the disease process. Be careful to realize that patients have co-morbidities and you may need to discuss the other diseases impact on the pathophysiology and care of the patient.
Renal Failure
Patient Profile:
J.M. is a 37-year-old woman transferred to a large medical center from a small rural hospital for further evaluation of lower abdominal pain, nausea, vomiting, and progressive deterioration of urinary output.
Subjective Data:
-Long history of ETOH Abuse with a drinking binge two days ago
-Arthritis with heavy use of ibuprofen
-HTN for three years, treated with hydrochlorothiazide and a calcium channel blocker
-Borderline NIDDM for three years, does not want to take medications and has been trying
to lose weight and “watch her sugar intake.”
Objective Data:
B/P: 160/110 K: 6.3 mEq/L Urinary output: <15ml/hr Na: 149 mEq/L Lethargic Hgb A1C: 9.2%
Creatinine: 9.6 mg/dL BUN: 121 mg/dL
- Address how the various factors in her past medical history could have contributed to her present renal problem.
- Is her acute renal failure likely to be prerenal, intrarenal, postrenal, or a combination? Why?
- Discuss each of the laboratory values and how they reflect the pathophysiology that occurs in renal failure. What is the significance of her Hgb A1C level?
- What are the specific priorities of treatment for J.M.?
- Explain the types of dialysis available, their indications, and their advantages/ disadvantages. What type of dialysis will most likely be used for J.M?
- After two weeks of intensive support and dialysis, J.M’s urinary output returns. Explain the diuretic phase of recovery in Acute Renal Failure, and what complications can occur.
- Do you think she needs intervention for her diabetes? What guidelines did you consult? How would you start in treating a patient with newly diagnosed Type 2 diabetes? Which medication(s) might you want to start first? What patient education issues would you emphasize in the initial period?
Full Answer Section
In both AKI and CKD, the damage to the kidneys can occur at the cellular level. The cells of the kidneys, called nephrons, are responsible for filtering waste products from the blood. When nephrons are damaged, they are less able to filter the blood, and waste products can build up in the body.
There are a number of different cellular mechanisms that can lead to renal failure. One common mechanism is apoptosis, or programmed cell death. Apoptosis can be triggered by a variety of factors, such as inflammation, oxidative stress, and ischemia (lack of blood flow). When nephrons undergo apoptosis, they die and are no longer able to filter the blood.
Another cellular mechanism that can lead to renal failure is necrosis, or cell death due to injury. Necrosis can be caused by a variety of factors, such as ischemia, exposure to toxins, and infections. When nephrons necrose, they release their contents into the surrounding tissue, which can lead to inflammation and further damage to the kidneys.
Impact of Co-Morbidities on Renal Failure
The co-morbidities that J.M. has can all have a significant impact on her renal function.
- ETOH abuse: Alcohol is a nephrotoxin, meaning that it can damage the kidneys. Alcohol can also lead to dehydration, which can further damage the kidneys.
- Arthritis with heavy use of ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can damage the kidneys, especially in people who are already at risk for renal failure.
- HTN for three years, treated with hydrochlorothiazide and a calcium channel blocker: Both hydrochlorothiazide and calcium channel blockers can damage the kidneys, especially in people who are already at risk for renal failure.
- Borderline NIDDM for three years, does not want to take medications and has been trying to lose weight and “watch her sugar intake.”: Diabetes is a major cause of CKD. High blood sugar levels can damage the nephrons over time.
Care of the Patient
The care of a patient with renal failure will depend on the severity of the condition and the underlying cause. In some cases, renal failure can be reversible, but in other cases, it is permanent.
The goals of treatment for renal failure are to:
- Remove waste products from the blood
- Maintain fluid and electrolyte balance
- Control blood pressure
- Treat the underlying cause of the renal failure
If J.M.'s renal failure is reversible, the treatment will focus on removing the underlying cause of the damage. For example, if her renal failure is caused by AKI, the treatment will focus on treating the underlying condition, such as shock or dehydration. If her renal failure is caused by CKD, the treatment will focus on managing the underlying disease, such as diabetes or high blood pressure.
If J.M.'s renal failure is permanent, the treatment will focus on managing the symptoms and preventing complications. This may involve dialysis, a procedure that filters the blood outside of the body. Dialysis can be a temporary or permanent treatment for renal failure.