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Acute Renal Failure Nursing Guide

Content reviewed by Ann Dietrich, MD, FAAP, FACEP.

Acute Renal Failure etiology and epidemiology 

Acute renal failure (ARF), also known as acute kidney injury (AKI), is a sudden onset condition where the kidneys fail to filter waste products from the blood effectively, leading to the accumulation of toxins and disruption in fluid and electrolyte balance. ARF can develop within hours or days and is associated with significant morbidity.  

It occurs in approximately 7.5% of all hospitalized patients and is especially prevalent in the geriatric population, affecting 20% to 40% of patients admitted to intensive care units in Europe and the United States. 

Causes of ARF 

ARF can be precipitated by a variety of factors, including: 

  • Drug overdose 
  • Heart failure 
  • Hypercalcemia 
  • Myocardial infarction 
  • Pulmonary embolism 
  • Septic or anaphylactic shock 
  • Severe ascites 
  • Use of radiocontrast agents 

Medications associated with ARF include: 

  • Amphotericin B 
  • Anesthetics 
  • Norepinephrine 
  • NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) 

Hypovolemia, often due to: 

  • Burns 
  • Excessive gastrointestinal or renal losses 
  • Hemorrhagic blood loss 

Complications of ARF 

ARF can lead to several complications, such as: 

  • Intrarenal failure: 
    • Acute Tubular Necrosis (most common) 
    • Coagulopathies 
    • Glomerulopathies 
    • Malignant Hypertension 
    • Nephrotoxins 
    • Renal Artery or Vein Obstruction 
  • Postrenal failure: 
    • Obstruction in the ureter, bladder neck, or urethra due to: 
    • Benign Prostatic Hypertrophy (BPH) 
    • Clots 
    • Fibrosis 
    • Neurogenic Bladder 
    • Stone Disease 
    • Strictures 
    • Tumors 
    • Improperly placed urinary catheter 
    • Prostate, colon, or cervical cancer 

Prognostic risk factors 

  • Advanced age 
  • Multiorgan failure 
  • Hypotension 
  • Need for pressor support 
  • Multiple blood transfusions 
  • Emergent surgery 

Diagnosis 

Diagnostic evaluation for ARF typically includes: 

  • Arterial Blood Gas (ABG) Levels 
  • Blood Urea Nitrogen (BUN) and Serum Creatinine Levels 
  • Complete Blood Count (CBC) 
  • Peripheral Blood Smear 
  • Serological Tests (for hepatitis and autoantibodies) 
  • Serum Electrolytes, especially potassium 
  • Urinalysis 
  • Urine Electrolytes/Osmolality 
  • Urine sediment testing 
  • Doppler scan 
  • Kidney/Urinary Bladder Ultrasound 
  • Kidney, Ureter, and Bladder (KUB) X-ray 
  • Nuclear scan 
  • Angiogram (to diagnose renal artery stenosis) 
  • Electrocardiogram (ECG) 
  • Renal Biopsy 

ARF Management 

Management of ARF focuses on preventing further renal damage and supporting recovery. Key strategies include: 

  • Volume and electrolyte correction 
  • Identification and treatment of underlying causes 
  • Renal replacement therapies: 
    • Hemodialysis 
    • Peritoneal Dialysis 
    • Continuous Renal Replacement Therapy (CRRT) 
  • Fluid restriction: To the volume of urine output plus 500 mL/day. 
  • Dietary modifications: 
    • High calorie 
    • Low protein 
    • Low sodium 
    • Low potassium 

Medications: 

  • Diuretics: 
    • Furosemide (Lasix®): 20 to 40 mg PO daily for adults; pediatric dosing not established. 
  • Calcium Channel Blockers: 
    • Nifedipine (Adalat®, Procardia®): 10 to 30 mg PO tid for adults; pediatric dose is 0.25 to 0.5 mg/kg PO tid/qid prn. 
  • Vasodilators: 
    • Dopamine (Intropin®): 1 to 5 mcg/kg/minute IV for adults and pediatric patients. 
  • Toxicity Antidotes: 
    • Acetylcysteine (N-acetylcysteine®) for those at risk of radiocontrast toxicity: 1,200 mg before imaging and continued for 48 hours after the procedure. 

ARF nursing care plan

Assessment 

Perform a thorough assessment focusing on the following: 

  • General symptoms: 
    • Altered mental status or coma 
    • Dry mucous membranes 
    • Edema 
    • Oliguria or anuria 
    • Tachycardia 
    • Hypotension or hypertension 
    • Jaundice (if liver disease is present) 
  • Specific symptoms: 
    • Back pain 
    • Uremic odor to breath 
    • Hand tremors 
    • Ecchymosis, petechiae, or purpura 

ARF nursing diagnoses 

  • Activity intolerance 
  • Alteration in nutrition, less than body requirements 
  • Altered thought processes 
  • Fluid volume excess 
  • Ineffective tissue perfusion (Renal) 
  • Risk for infection 
  • Potential for injury 
  • Deficient knowledge 

Interventions 

  • Medication administration: Provide prescribed medications and IV fluids. 
  • Diet and fluid education: Instruct on dietary restrictions and fluid limitations. 
  • Emotional support: Encourage patients to express feelings and provide support. 
  • Electrolyte monitoring: Regularly assess for imbalances, particularly hyperkalemia. 
  • Edema and skin care: Monitor for edema and take measures to prevent skin breakdown. 
  • Monitor complications: Watch for signs of fluid overload and other complications. 
  • Vital signs and daily weights: Record daily weights and monitor vital signs to assess fluid balance. 

Expected outcomes 

  • Improved activity tolerance: Ability to perform daily activities without undue fatigue. 
  • Nutritional adequacy: Adequate caloric intake through appropriate dietary choices. 
  • Mental clarity: Restoration of normal mental status. 
  • Fluid balance: Maintenance of proper fluid balance and adequate urine output. 
  • Infection prevention: Absence of infection and further kidney damage. 

Individual/caregiver education 

  • Disease and treatment information: Provide detailed explanations about ARF, the diagnosis, and the treatment plan. 
  • Medication compliance: Stress the importance of adhering to the prescribed medication schedule. 
  • Dietary and fluid restrictions: Educate on the necessity of dietary modifications and fluid restrictions. 
  • Monitoring and reporting: Instruct on how to monitor for signs of volume overload and the importance of reporting any significant weight changes or edema. 
  • Long-term care: Emphasize the need for close follow-up with a nephrologist and the importance of avoiding nephrotoxic medications. 

ICD-10 Code for Acute Renal Failure 

  • N17.9 – Acute kidney failure, unspecified 

FAQs

Additional Information

Content Release Date 

3/31/2022

Content Expiration

12/31/2027

References 

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