CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF CHRONIC RENAL FAILURE Definition: It is a long term decline in kidney function. Acute on chronic renal failure—a patient with diagnosed or undiagnosed CRF with some remaining RF & subjected to acute insult ie infection ,dehydration , obstruction …etc , causing rapid deteroration of RF with s&s of uremia. CRITERIA FOR DIAGNOSIS: The major criterion is a slow inexorable rise in the serum BUN and creatinine. 1. Most diseases that cause CRF usually appear as ARF. A. A renal biopsy may be performed while the patient is examined at ARF. B. When a chronic process is suspected or the creatinine level ˃5 micgm/dl ; a biopsy is seldom helpful and show chronic GN/ diffuse scarring. 2.USS abdomen---- can examine renal size and estimate functional reserve --- small scarred or contracted kidney. 3. Three stages of CRF may be identified. I. Renal insufficiency---maliase ,nocturia ,anemia II. Frank renal failure---- progressive acidosis ,hypocalcemia ,hyperphosphatemia , worsening anemia III. Uremia or end stage renal disease
Transcript
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
CHRONIC RENAL FAILURE
Definition:
It is a long term decline in kidney function.
Acute on chronic renal failure—a patient with diagnosed or undiagnosed CRF with some remaining RF & subjected to acute insult ie infection ,dehydration , obstruction …etc , causing rapid deteroration of RF with s&s of uremia.
CRITERIA FOR DIAGNOSIS:
The major criterion is a slow inexorable rise in the serum BUN and creatinine.
1. Most diseases that cause CRF usually appear as ARF.
A. A renal biopsy may be performed while the patient is examined at ARF.
B. When a chronic process is suspected or the creatinine level ˃5 micgm/dl ; a biopsy is seldom helpful and show chronic GN/ diffuse scarring.
2. USS abdomen---- can examine renal size and estimate functional reserve --- small
scarred or contracted kidney.3. Three stages of CRF may be identified.
I. Renal insufficiency---maliase ,nocturia ,anemiaII. Frank renal failure---- progressive
acidosis ,hypocalcemia ,hyperphosphatemia , worsening anemiaIII. Uremia or end stage renal disease
GFR ˂ 5cc/min + severe symptoms + require dialysis
MAJOR CAUSES OF CRF:
I. GLOMERULAR DISEASE----60%1. Nephrotic causes:
GN- Glomerulonephritis—(( membranous ,membranoproliferative ,chronic non specific)) ,Focal glomerulosclerosis
2. Nephritic causes:
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
Post infectious GN , crescentric GN ,IgA nephropathy ,Good Pasteurs syndrome , proliferative GN , secondary GN (( PAN , SLE ,amyloidosis , diabetic glomerulosclerosis)).
II. CONGENITAL AND INHERITED DISEASES:Polycystic kidney diseaseMedullary cystic diseaseAlports syndromeCongenital hypoplasia
VI. OBSTRUCTIVE UROPATHY:CalculusRetroperitoneal fibrosisProstatic hypertrophyPelvic tumour
VII. CAUSE OF ARF:10-15% of cause of ARF advances to CRF & ESRD.
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
FACTORS THAT ACCELERATE END STAGE RENAL DISEASE:Any patient with rapidly rising creatinine & BUN ; when the patient previously had a slow defined rate of increase ; should be evaluated:1. Urinary tract obstruction:
Seen when obstruction was the orginal cause of CRF. Uremic pt may also have bladder neck dysfunction and obstructive urethral
edema after instrumentation. S & S are frequently absent.
2. Urinary tract infection:100% CRF pt will be infected at sometime & universally after instrumentation.
3. Volume depletion:Is a common problem in early renal insufficiency when the ability to conserve NA may be lost.NA loss----Diuretic ,Diarrhea ,Vomiting ,Fever , Exercise .
4. Hypokalemia:More common in CRFK-excreting ability is preserved until quite late in the course of CRF.Hyperkalemia----sign of far advanced uremia
COMPLICATION OF CRF
A. ANEMIA:Type – normoocytic normochromic ,microcytic hypochromicCauses :1. Decrease Erythropiotein production2. Faster turnover of RBC3. Uremic hemolytic effect4. Decrease RBC life span5. Toxic effect on bone marrow6. Blood loss during dialysis7. Bleeding tendency
Course ---usually early in the course of renal insufficiency w HCT 25-32% HCT should be done. Serum iron and transferin levels which reveal peripheral block to iron utilization . ferritin usually accumulate in CRF WITH LOW SERUM IRON .
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
B. PLATELET AND CLOTTING DISORDERS:1. CRF is often accompanied by:
I. Acquired von willebrands disordersII. Factor III & platelet dysfunction
2. These problems are generally observed in advanced uremia , BUN (( 100—150 mg/dl)) + creatinine (˂ 10mg /dl)
3. They are aggravated by aspirin and infection4. Antibiotics (cefamandole ,moxalactam) affecting VIT K dependent
factors should be avoided.5. Diagnosis by:
Platelet count , bleeding time ,prothrombin ,partial thromboplastin
C. Peripheral neuropathy:1. Occurs in advanced RF ,PARTIALLY REVERSIBLE BY DIALYSIS ,toxin related2. Diagnosis by careful examination of vibration sense , touch sense , postion sense.3. Nerve conduction studies confirm diagnosis.
D. Aluminium toxicity dementia:1. It is degenerative disorder due to aluminium deposition in the CNS2. May occur prior to dialysis in patient with advanced uremia if they are
consuming aluminium containing antacids for months –years.
3. Manifesting by suttering dysphagia that progress to aphasia, seizures, disorientation. Hem dialysis aggravates this.
4. It is difficult to get s.aluminium.Be aware for: ---Ca supplement
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
Look for the onsetPatient response to vit D metabolitesAluminium supplements
Clinical diagnosis -- history and finding.
E. Metabolites complications:1. Uremia patients develop peripheral insensitivity to insulin causing
glucose intolerance and hyperinsulinism.2. Hyperlipidemic stat---( increase VLDL)--- is characterized of uremia due
to inhibition of lipoprotein lipase and hyperinsulinism .3. Decrease dose of insulin in diabetic because of decrease renal clearance
F. Vascular complication:
1.HTN:Difficult to control unless dialysis initiated HTN in CRF is due to
2.Pericardial disease:.ECHO may assist in the diagnosis of all pericardial disease..Pericardial disease common B/C haemodialysis and intermittent anticoagulant.
A. AUTE PARICARDITIS:.Common complication of uremia.Respond to dialysis.Symptoms--- fever + pleuritic chest pain. A TWO OR THREE component friction rub is present in all patients.
B. CARDIAC TEMPONADE:I. May cause significant fall in BP during dialysis.
II. Distant heart soundsMonophysiologically elevated neck veinsPulsus paradoxus (( ˃ 15---20 mmhg )) 70%--80% of pt
III. Right heart catheterization :Equalization of diastolic pressure in all chambers.
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
C. CHRONIC CONSTRICTIVE PERICARDITIS: NECK VEINS –elevated , kussmauls sign , inspiratory increase There may be a pericardial knock caused by ventricular
constriction at the end of diastole. Pulsus paradoxus is rarely present.
3.Atherosclerosis:Results from :
Glucose intolerance Poorly controlled HTN Hyperlipedemia High prevelance of smoking
G. INFECTION:1.Uremia inhibit phagocytic ability and causes T cell deficiency predisposing to bacterial and viral infection
2.fever is often suppressed in uremiaThe most frequent serious side infections :
Staphylococcal septicemiaStaphylococcal abscess in urinary tract (( perinephric))OsteomyelitisEndocarditisHepatitis BHerpes zoster
H. RENAL OSTEODYSTROPHY:Patient with hypocalcemia and hyperphosphatemia , hand radiographs should be obtained to screen for the onset of osteodystrophy.Radioimmunoassay for N. terminal (( PTH)) may be obtained to demonstrate 2ry hyperarathyrodism.Degree and type of disease require above biopsy with special stains .
WHAT IS THE RECOMMENDED DIAGNOSTIC APPROACH?
Factors that accelerate CRF :1. Urinary tract obstruction:
USS abdomen & pelvis is indicated if BUN & creatinine have suddenly increased.2. Urinary tract infection:
Microscopic examination of urine for WBC , RBC and bacteria is imperative.
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
AS RF PROGRESS ; URINANALYSIS LESS HELPFUL.3. Volume depletion:
Postural change in blood pressure and pulse may suggest volume depletion.It is non specific finding in diabetic pt B/C of autonomic neuropathy.
NOTE:IN A PATIENT WITH HTN OR DM OR RISK FOR RF, IF THE PATIENT PRESENT WITH MULTISYSTEM SYMPTOMS , C.RENAL FAILURE SHOULD BE EXCLUDED.
In CRF , THE FOLLOWING ARE MANDATORY FOR DX:1. SYSTEMIC SYMPTOMS OF CHRONIC DURATION2. ANEMIA3. HYPERKALEMIA4. HYPOCALCEMIA5. HYPERPHOSPHATEMIA6. USS ABDOMEN - SMALL SHRINKED SCARRED KIDNEYS EXCEPT PCKD
Emergency investigations:Blood glucoseRenal function tests and electrolytesLiver function testFull blood countUss abdomen and pelvis24 hour collection of urine for creatinine clearanceLipid profileCoagulation screenUrine microscopy and cultureBlood cultureChest x ray
CHRONIC RENAL FAILURE BY DR MAGDI AWAD SASI 2014 part 3 RF
Calcium and phosphateECG Serology
The major complications:1. Hypertensive crises:
Fluid over load Diseases—TTP/HUS , glomerulonephritis
2. Metabolic emergencies:Severe uremia Hyperkalemia Severe acidosis Hyponatremia hHypocalcemia Hyperphosphatemia.
