Dr S Chakradhar 1. CHRONIC RENAL FAILURE Chronic renal failure (CRF) refers to an irreversible...

Dr S ChakradharDr S Chakradhar 11

CHRONIC RENAL FAILURECHRONIC RENAL FAILURE

Chronic renal failure (CRF) refers to an irreversible Chronic renal failure (CRF) refers to an irreversible deterioration in renal function which classically deterioration in renal function which classically develops over a period of years . develops over a period of years .

Initially, it is manifest only as a biochemical Initially, it is manifest only as a biochemical abnormality. abnormality.

Eventually, loss of the excretory, metabolic and Eventually, loss of the excretory, metabolic and endocrine functions of the kidney leads to - the endocrine functions of the kidney leads to - the development of the uraemia. development of the uraemia.

When death is likely without renal replacement When death is likely without renal replacement therapy, it is called end-stage renal failure (ESRF). therapy, it is called end-stage renal failure (ESRF).

22Dr S Chakradhar Dr S Chakradhar

Stages of CRFStages of CRF

It is divided into 4 stages from normal renal function to uraemia It is divided into 4 stages from normal renal function to uraemia

Diminished renal reserveDiminished renal reserve GFR is about 50% of normal GFR is about 50% of normal Asymptomatic. No azotemia Asymptomatic. No azotemia

Renal insufficiencRenal insufficiency y GFR is 20 – 50% of normal. GFR is 20 – 50% of normal. There is azotaemia, anemia, HTN, polyuria, nocturia There is azotaemia, anemia, HTN, polyuria, nocturia

Renal failure Renal failure GFR is less than 20% of normal GFR is less than 20% of normal There is uraemia , hypokalaemia & metabolic acidosis There is uraemia , hypokalaemia & metabolic acidosis

ESRDESRD GFR less than 5%GFR less than 5%

33Dr S Chakradhar Dr S Chakradhar

Classification: Classification:

On the basis of calculated GFR:On the basis of calculated GFR: Mild CRF = 20-50 ml/minMild CRF = 20-50 ml/min Moderate CRF = 10-20 ml/minModerate CRF = 10-20 ml/min Severe CRF = less than 10 ml/minSevere CRF = less than 10 ml/min ESRD = less than 5 ml/minESRD = less than 5 ml/min

CAUSESCAUSES

1.1. Pre-renal:Pre-renal: Hypertensive Nephropathy (Hypertensive Nephrosclerosis)Hypertensive Nephropathy (Hypertensive Nephrosclerosis) Renal artery stenosisRenal artery stenosis

55Dr S ChakradharDr S Chakradhar

2.Renal2.Renal

Glomerular:Glomerular:

Primary GN:Primary GN:

1.Focal segmental Glomerulosclerosis1.Focal segmental Glomerulosclerosis

2.Membranoproliferative GN2.Membranoproliferative GN

3.IgA Nephropathy3.IgA Nephropathy

4.Membranous GN4.Membranous GN

5.Post-infectious GN5.Post-infectious GN

Secondary Glomerular disease:Secondary Glomerular disease:

1.Diabetes nephropathy1.Diabetes nephropathy

2.Amyloidosis2.Amyloidosis

3.Heroin Nephropathy3.Heroin Nephropathy

4.Collagen vascular disease: SLE, PAN4.Collagen vascular disease: SLE, PAN


TubulointerstitialTubulointerstitial Analgesic nephropathyAnalgesic nephropathy Nephrotoxins: Heavy metalsNephrotoxins: Heavy metals Multiple myelomaMultiple myeloma Reflux nephropathyReflux nephropathy Chronic pyelonephritisChronic pyelonephritis TuberculosisTuberculosis

Hereditary:Hereditary: Polycystic kidney diseasePolycystic kidney disease


Post –Renal:Post –Renal: Renal stonesRenal stones Urethral TBUrethral TB Prostatic ObstructionProstatic Obstruction Congenital defectsCongenital defects


Common Causes :Common Causes : Diabetic nephropathyDiabetic nephropathy HypertensionHypertension Chronic glomerulonephritisChronic glomerulonephritis Chronic pyelonephritis Chronic pyelonephritis Obstructive uropathyObstructive uropathy Congenital (polycystic kidney disease), Renal Congenital (polycystic kidney disease), Renal

vascular disease, analgesic nephropathy.vascular disease, analgesic nephropathy.




Pathogenesis:Pathogenesis: Exact mechanism of clinical syndrome of uraemia Exact mechanism of clinical syndrome of uraemia

is not known.is not known. It is most likely caused by accumulation in body It is most likely caused by accumulation in body

fluids of a number of substances (phosphate, fluids of a number of substances (phosphate, parathyroid hormone, urea, creatinine)parathyroid hormone, urea, creatinine)

Renal failure does not occur until GFR is reduced Renal failure does not occur until GFR is reduced below 50% of normal.below 50% of normal.


Acute on chronic renal failureAcute on chronic renal failure

Renal failure worsens at times when there is any Renal failure worsens at times when there is any

form of stress (hypovolemia, hypervolemia, form of stress (hypovolemia, hypervolemia,

radiocontrast administration, nephrotoxic drugs, radiocontrast administration, nephrotoxic drugs,

infections, urinary tract obstruction, uncontrolled infections, urinary tract obstruction, uncontrolled

hypertension.)hypertension.)

In these conditions, even though patient was In these conditions, even though patient was

asymptomatic or less symptomatic previously, there asymptomatic or less symptomatic previously, there

is sudden deterioration of remaining renal function. is sudden deterioration of remaining renal function.


AnemiaAnemia

Erythropoietin deficiency, decreased erythropoiesis due to Erythropoietin deficiency, decreased erythropoiesis due to marrow suppression, blood loss, decreased red-cell survival, marrow suppression, blood loss, decreased red-cell survival, reduced intake and absorption of iron.reduced intake and absorption of iron.

Mostly normocytic normochromic Mostly normocytic normochromic T/T:T/T: Inj. Recombinant Erythropoietin.Inj. Recombinant Erythropoietin.


Renal osteodystrophyRenal osteodystrophy

It is skeletal manifestation of chronic renal failure. It is skeletal manifestation of chronic renal failure. Low level of calcium and increased phosphate in the blood Low level of calcium and increased phosphate in the blood

→ → increased parathyroid hormone increased parathyroid hormone →increased osteoclastic →increased osteoclastic activity →resorption of bone →cystic appearance in activity →resorption of bone →cystic appearance in radiograph.radiograph.

Osteomalacia & Osteitis fibrosa (hyperthyroid bone disease) Osteomalacia & Osteitis fibrosa (hyperthyroid bone disease) Osteoporosis and osteosclerosis.Osteoporosis and osteosclerosis.


Neuro-mascular abnormalityNeuro-mascular abnormality Myopathy – Muscle cramps, rest-less leg syndrome Myopathy – Muscle cramps, rest-less leg syndrome (Probably due to poor nutrition, hyperthyroidism, Vit (Probably due to poor nutrition, hyperthyroidism, Vit

D deficiency & disorders of electrolyte)D deficiency & disorders of electrolyte) Neuropathy - Paresthesia (sensory), foot drop Neuropathy - Paresthesia (sensory), foot drop

(motor) (motor) (due to demyelination of medullated nerves) (due to demyelination of medullated nerves)


Endocrine disturbancesEndocrine disturbances InsulinInsulin

Post receptor defectPost receptor defect Reduced tubular metabolismReduced tubular metabolism

Sex hormonesSex hormones Decreased level of estrogen and testosteroneDecreased level of estrogen and testosterone

HyperprolatinemiaHyperprolatinemia

Cardiovascular diseaseCardiovascular disease HypertensionHypertension Accelerated atherosclerosisAccelerated atherosclerosis Pericarditis, pericardial effusionsPericarditis, pericardial effusions


Acidosis :Acidosis :Impaired secretion of hydrogen, Loss of Impaired secretion of hydrogen, Loss of

bicarbonate.bicarbonate. InfectionInfection BleedingBleeding Gastrointestinal disordersGastrointestinal disorders

Anorexia, nausea, vomiting, increased Anorexia, nausea, vomiting, increased incidence of peptic ulcer disease incidence of peptic ulcer disease




Clinical feature:Clinical feature: Patient may be Asymptomatic until GFR is 15 ml/ min (70 per Patient may be Asymptomatic until GFR is 15 ml/ min (70 per

cent of the Nephrons are dead)cent of the Nephrons are dead) Symptoms of Uremia – Anorexia, Nausea, vomiting, malaise, Symptoms of Uremia – Anorexia, Nausea, vomiting, malaise,

prurituspruritus Features of complications: Anemia, bone painFeatures of complications: Anemia, bone pain Generalized Myopathy- muscle cramps, Generalized Myopathy- muscle cramps, HypertensionHypertension Breathlessness- Deep Respiration due to acidosisBreathlessness- Deep Respiration due to acidosis Urinary symptoms: May present with anuria / oliguria, Nocturia Urinary symptoms: May present with anuria / oliguria, Nocturia

/ polyuria/ polyuria Infection- U.T.I is commonInfection- U.T.I is common



Investigations:Investigations: T.C,D.C, ESR ,HbT.C,D.C, ESR ,Hb Urine R/E and C/S Urine R/E and C/S Blood urea and CreatinineBlood urea and Creatinine Creatinine Clearance rateCreatinine Clearance rate Blood sodium and potassiumBlood sodium and potassium Urine analysis: Proteinuria, hematuria, broad waxy cast Urine analysis: Proteinuria, hematuria, broad waxy cast X-ray KUB regionX-ray KUB region USGUSG Renal biopsyRenal biopsy


Features suggesting CRF:Features suggesting CRF:

1.1. Evidence of Osteodystrophy on bone film.Evidence of Osteodystrophy on bone film.

2.2. Peripheral neuropathyPeripheral neuropathy

3.3. Small kidneysSmall kidneys

4.4. Prolong uremic symptoms (long history)Prolong uremic symptoms (long history)

5.5. Previous record of eleveted urea, creatinine.Previous record of eleveted urea, creatinine.

6.6. Previous history of dialysis/renal biopsyPrevious history of dialysis/renal biopsy

7.7. BUN, creatinine—Stable in CRF while in ARF raises 20-BUN, creatinine—Stable in CRF while in ARF raises 20-40mg/day, and Creatinine 2-4mg/day40mg/day, and Creatinine 2-4mg/day

8.8. Broad waxy cast in urine microscopyBroad waxy cast in urine microscopy


Management:Management:

1.1. Dietary modificationsDietary modifications

2.2. Treatment of complicationsTreatment of complications

3.3. DialysisDialysis

4.4. Renal transplantationRenal transplantation


TreatmentTreatment Symptomatic - restriction of proteinSymptomatic - restriction of protein Sodium restriction if edema, CCF and hypertensionSodium restriction if edema, CCF and hypertension Restriction of potassiumRestriction of potassium Patients with CRF should be kept volume expanded ,should Patients with CRF should be kept volume expanded ,should

take 2-3l/day to excrete waste products as effectively as take 2-3l/day to excrete waste products as effectively as possiblepossible

Hypertension - antihypertensiveHypertension - antihypertensive Calcium supplementationCalcium supplementation Anaemia—Anaemia—


Replacement of Renal functionReplacement of Renal function

1.1. HemodialysisHemodialysis

2.2. Peritoneal dialysisPeritoneal dialysis Renal transplant- definite treatmentRenal transplant- definite treatment

End stage Renal Disease This is the terminal stage of End stage Renal Disease This is the terminal stage of uremia.uremia.


Indications of Dialysis in CRF:Indications of Dialysis in CRF:

1.1. Uremic symptoms such as pericarditis, encephalopathy, Uremic symptoms such as pericarditis, encephalopathy, seizures or coagulopathyseizures or coagulopathy

2.2. Fluid overload unresponsive to diuresisFluid overload unresponsive to diuresis

3.3. Refractory hyperkalemiaRefractory hyperkalemia

4.4. Severe metabolic acidosisSevere metabolic acidosis

5.5. Serum creatinine about 10mg/dl, and urea 200mg/dlSerum creatinine about 10mg/dl, and urea 200mg/dl


Complications:Complications: HypertensionHypertension AnemiaAnemia Systemic AcidosisSystemic Acidosis Metabolic Bone DiseaseMetabolic Bone Disease Congestive Cardiac Failure and PericarditisCongestive Cardiac Failure and Pericarditis CoagulopathyCoagulopathy Susceptible to InfectionSusceptible to Infection EncephalopathyEncephalopathy NeuropathyNeuropathy




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Dr S Chakradhar 1. CHRONIC RENAL FAILURE Chronic renal failure (CRF) refers to an irreversible...

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