Chronic Renal Failure (CRF) Risk factors Causes Stage CRF Treatment

Chronic Renal Failure (CRF) OR CRD/CKD

ChronicChronic Hepatitis Classification viral hepatitis Clinical features and Treatment. Read more ... » renalDiabetic Nephropathy and Renal complications of DM (Diabetes Mellitus). Read more ... » diseaseFILARIASIS Lymphatic Systems Disease Causes Diagnosis Signs and Symptoms with Treatment. Read more ... » is a destruction of neph­rons of the kidneys due to several causesFILARIASIS Lymphatic Systems Disease Causes Diagnosis Signs and Symptoms with Treatment. Read more ... ». The damage to renal structure and function is irr ­versib This results in uremia which leads to dysfunction of several organs.

Chronic kidneyDiabetic Nephropathy and Renal complications of DM (Diabetes Mellitus). Read more ... » disease (CKD) is defined as kidney damage or glomerular filtration rate (GFR) <60 mL/min/1.73 m²for >3 months.

The destruction of kidney is a chronic process of more than 3 months.

Stages of Chronic Renal Disease/Chronic Kid­ney Disease (CKD)

• Stage 1
  • Kidney damage with normal or in­creased GFR – 90 ml/min/1.73 m²
• Stage 2
  • Kidney damage with decreased GFR­60-89
• Stage 3
  •  Moderately decreased GFR 30-59
• Stage 4
  • Sftverely decreased GFR 15-29
• Stage 5
  • Renal failure GFR < 15

Risk factors for CRD/CKD

• Family history of renal disease
•  HypertensionThyroid Goiter. Read more ... »
• Diabetes
• Autoimmune disease
• Old age
• History of acuteFILARIASIS Lymphatic Systems Disease Causes Diagnosis Signs and Symptoms with Treatment. Read more ... » renal failure
• Smoking
• Low income/education
• Ethnic minority status
• Evidence of kidney damage
• Proteinuria, abnormal urinary sediment, urinary tract structural abnormalities.
• A typical cause of chronic renal disease (CRD) is dia­betic nephropathyDiabetic Nephropathy and Renal complications of DM (Diabetes Mellitus). Read more ... ».
• The first feature of CRD is usually albuminuria. Albumin-specific dipstick measurement of albumin to creatinine ratio in the first morning urine spot sample if more than 17 mg albumin per gram of serum crea­tinine in adult males and more than 25 mg albumin per gram of creatinine in adult females signifies CRD.

History of CRF

• Oliguria, nocturia, polyuria, change in urinary frequency
• HematuriaDIAGNOSIS and Investigations OF SECONDARY HYPERTENSION. Read more ... »
• Bone disease
• FatigueFatigue diagnosis medicine and treatment. Read more ... », depressionVisada Depression Ayurveda and Modern. Read more ... », weakness
• Pruritus, tremor
• Metallic taste in mouth, uremia
• Anorexia, nauseaNausea and Vomiting. Read more ... », vomitingNausea and Vomiting. Read more ... »
• ObesityThyroid Goiter. Read more ... »
• Dyspnea
• Hypertension
• Poorly controlled diabetes with retinopathyOphthalmologic Complications of DM (Diabetes Mellitus). Read more ... », neuropathy
• Hyperlipidemia
• ClaudicationCYANOTIC CONGENITAL HEART DISEASE Coarctation of the Aorta with Clinical features. Read more ... »

Common causes of chronic renal disease and presentations

• Diabetic kidney —>
  • History of diabetes, proteinuria, retinopathy
• Hypertension —->
  • High blood pressureChronic Long-term Complications Of Diabetes Mellitus. Read more ... », Family history, Normal urinary findings
• Non-diabetic glomerular disease —– >
  • Nephritic, Nephrotic
• Cystic kidney disease —–>
  • Urinary tract symptomsFILARIASIS Lymphatic Systems Disease Causes Diagnosis Signs and Symptoms with Treatment. Read more ... », abnormal urinary sediments, abnormal imaging findings
• Tubulointerstitial disease —–>
  • UTI, Drugs, tubular syndromes, abnormal urine findings

Pregnancy Considerations in CRF

• Renal function in CKD may deteriorate during pregnancy.
• Creatinine >1.5 and hypertension are major risk factors for worsening renal function.
• Increased risk of premature labor, preeclampsia, and/or fetal loss

Physical ExaminationHow to take good medical history & examination. Read more ... » in Chronic Renal Failure (CRF)

• Complete physical plus ophthalmicOphthalmologic Complications of DM (Diabetes Mellitus). Read more ... » exam; assess volume status (e.g., blood pressure with orthostatics; edema; jugular venous distention; weight)
• Skin: Sallow complexion, uremic “frost”
• Ammonialike odor (uremic fetor)
• Cardiovascular: Assess for mumurs, bruits, pericarditisCOMPLICATIONS OF Acute Myocardial Infarction (AMI) AND TREATMENT -2. Read more ... »
•  At GFR (Glomerular Filtration Rate) less than 60 ml/ min all organ systems are affected.
• There is anaemia, loss of energy, decreasing appe­tite, abnormal calcium and phosphorus metabolismGlycogen Storage Diseases von Gierke disease, Andersen's disease, McArdle's disease. Read more ... », metabolic bone disease, sodiumRenin and Hypertension Low renin and High Renin essential hypertension with Treatment. Read more ... », water, potassium and acid-base disturbances.
• At GFR < 15 ml/min the patient is not able to lead a regular life and may be in a uremic state needing’ urgent renal replacement therapy (dialysis etc.)

Genetics of CRF –

• There may be a monogenic inheritance,
• autosomal dominance or
• polymorphism of ACE (Angiotensin Con­verting Enzyme) genes.

Cockcroft-Gault Equation for creatinine clear­ance

• . Creatinine clearanceSome Important Values-Ideal Body Values. Read more ... » ml/min in men = (140-age) X body weight in Kg. / 72 x Pcr mg/dl
• Creatinine clearance ml!min in women (140-age) X body weight in Kg. X 0.85  /  72 x Pcr mg/dl

UREMIA IN CRF

• Azotemia is retention of nitrogenous waste products due to renal insufficiency.
• Uremia is progressive renal insufficiency with multi­organ involvement.
• In uremia there is anorexia, malaise, vomiting, head­ache.
• In uremia there is toxicity due to urea, urates, hippurates, polyamines, phenols, benzoates and in­doles.
• As a result there is :
• Anaemia Malnutrition
• Impaired metabolism of carbohydrates, fats and proteins
• Loss of energy Metabolic’ bone disease
• Increased levels of :
  • PTH – parathyroid hormoneAnterior Pituitary Hormones and Disorders. Read more ... »
  • InsulinDiabetes mellitus Types,Causes,Symptoms and Diagnosis. Read more ... » ,
  • Glucagon
  • Luteinizing hormone
  • Prolactin
• Decreased levels of :
  • EPO – erythropoietin
  • 1,25, dihydroxycholecalciferol
• Electrolyte abnormalities

Fluid, Electrolyte and Acid Base Disturbance Sodium and water

• There is increase of sodium and water in the body.
• There is sodium retention.
• There is extracellular fluid volume expansion (ECFV).
• Therefore, there is hyper­tension.
• There is weight gain.
• There is volume deple­tion only if there is vomiting, diarrhea, sweating, fe­ver or diuretic administration.

Treatment

•  Diuretics – loop diuretics, metolazone ‘Q/ Restricted salt intake
• Dialysis
• For volume depletion – normal saline infusion

Potassium

• There may be hypokalemia due to excretion of potas­sium in GITToxoplasma Infection Transmission Clinical Manifestations Diagnosis Treatment. Read more ... ».
• - There may be hyperkalemia due to constipation, pro­tein catabolism, hemolysis, haemorrhage, RBC trans­fusion, metabolic acidosis.
• Drugs which may cause hyperkalemia are ACE inhibi­tors, ARBs, potassium sparing diuretics, Beta blockersMANAGEMENT of Acute Myocardial Infarction (AMI) -1. Read more ... » and NSAIDs.
• hyperkalemia is more common in CRD than hypokale­mia.

Metabolic acidosis in CRF

• ~There is metabolic acidosis because of reduced abil­ity to produce ammonia.
• Hyperkalemia in CRD decreases ammonium excre­tion. This results in metabolic acidosis.
• In diabetics there is hyperkalemia, metabolic acido­sis-renal tubular acidosisTubular Diseases of the Kidney Types Clinical Features Diagnosis with Treatment. Read more ... », hyporenin hypoaldostero­nism.
• Treatment of hyperkalemia improves acidosis.

Treatment of Hyperkalemia and Acidosis

• Potassium binding resins
• Restriction of potassium salts
• Loop diuretics
• For acidosis NAHC0₃ may be given if pH <7.35 .

Bone disease and Disorders of Calcium and Phos­phate

• High bone turnover and high PTH levels result in sec­ondary hyperparathyroidism and osteitis fibrosa.
• Low bone turnover and low PTH level result in osteo­malacia.
• Decreased GFR causes decreased excretion of phos­phate and retention of phosphates.
• This causes increased PTH and lowering of calcium, decrease of calcitriol resulting in hypocalcemia and bone diseases, osteomalacia, vitamin D deficiency, metabolic acidosis.
• This causes bone pains, fractures, incapacity, diffi­culty in walking and movements.
• Calciphylaxis is metastatic calcification of soft tissue and blood vessels.

Treatment

• Calcitriol
• Avoid aluminium compounds Calcium acetate
• Calcium carbonate and Sodium phosphate binding agents.

Cardiovascular abnormalities in CRF

• Ischemic heartAcute Myocardial Infarction CLINICAL PRESENTATION. Read more ... » disease
• Hypertension
• Left ventricular hypertrophy
• Congestive heart failureHeart Failure Causes Symptoms NYHA classification with Heart Failure Treatment. Read more ... » Pulmonary edemaPulmonary Edema Causes Diagnosis with Treatment. Read more ... »
• Uremic pericarditis and cardiacAcute Myocardial Infarction CLINICAL PRESENTATION. Read more ... » tamponade, hem­orrhagic pericardial effusion
• DyslipidemiasDyslipidemias Causes Risk Factors Epidemiology Etiology. Read more ... »
• Hyperhomocysteinemia.

Treatment

• For hypertension:
  • ACE I and ARB’s if serum crea­tinine less than three
  • Nifedipine, hydralazine, diltiazem, minoxidil.
• For dyslipidemias :
  • Statins, gemfibrozil
• For hyperhomocystinemia -
  • Vitamins, folate supplementation
• Control of diabetes:
  • Metformin is not used Insulin levels are increased in CRD
• For Pericarditis :
  • Dialysis, pericardiectomy, as­piration of fluid.

Hematological abnormalities Anaemia due to :

• · Insufficient EPa (Erythropoietin)
• · Iron and folate deficiency
• · Hyperparathyroidism
• · Chronic inf~ction
• · Hemoglobinopathies
• · Coagulation abnormalities
• · Increased bleeding time
• · Increased platelet aggregation
• · Thromboembolic complications.

Treatment

• EPa (Erythropoietin) is given 50-150 units /kg/ week subcutaneous
• Side-effect of EPa – Hypertension, malignan­cies
• Iron supplementation Vitamin B_I2, folate Anticoag u lant prophylaxis.

Neuromuscular abnormalities in CRF

• Central and Peripheral neuropathy Memory impairment
• Insomnia
• · Asterixis
• · Irritability
• · Muscle twitching
• · Seizures
• · Restless legs syndromeMetabolic,Insulin Resistance Syndrome X Causes Symptoms. Read more ... »
• · Coma

Gastrointestinal abnormalities in CRF

• · Uremic fetor or odour or breath
• · Gastritis
• · Peptic disease
• · Abdominal pain, nausea, vomiting
• · Pancreatitis
• · Anorexia
• · Hiccups.

Endocrine and Metabolic disturbances

• · Impaired glucoseGlycogen Storage Diseases von Gierke disease, Andersen's disease, McArdle's disease. Read more ... » metabolism
• · Plasma insulin levels are elevated
• · Amenorrhoea
• · Growth retardation.

Dermatologic abnormalities

• · Itching – Uremic pruritus
• · Pallor – Skin necrosis

Management Treatment of CRD

• · Control hypertension – ideal blood pressure 125/ 75
• · Control diabetes – preprandial glucose 90 – 130 mg/dl and HBA_1C level <7.2%
• · Treat infections
• · Avoid nephrotoxic drugs
• · Estimation of plasma creatinine, GFR
• · Management of electrolyte imbalance
• · Management of acid-base disturbance
• · Ultrasound for kidney size, renal masses
• · Treat obstructive uropathy
• · Voiding cystourethrography and management
• · Renal biopsy and specific management
• · Management of bleeding
• · If kidney size <8.5 cm irreversibility of disease
• · Protein restriction to 0.6 g/kg/day
• · Dialysis
• · Kidney transplantation.

Indications for Dialysis in CRF

• Pericarditis
• Neuropathy due to uremia
• Encephalopathy
• Muscle irritability
• Anorexia, nausea, vomiting Fluid electrolyte abnormalities Severe volume overload Non-responsive hyperkalemia Progressive metabolic acidosis Asterixis
• Serum creatnine >8 mg/dl.

Indications for Kidney transplantation in CRF

• Irreversible ESRD (End Stage Renal Disease) Good antigenic match with donor
• First degree relative donor
• Primary transplantation.