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Chronic Renal Failure

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A loss or decrease in renal function measured as a loss or decrease in GFR ... Renal Ricketts '/ Osteomalacia. Osteitis Fibrosa Cystica. Osteoporosis ... – PowerPoint PPT presentation

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Title: Chronic Renal Failure


1
Chronic Renal Failure
  • David Dayya, D.O.
  • St. Barnabas Hospital
  • Dept. of Family Medicine

2
Epidemiology
  • Diabetes Mellitus 30
  • Hypertension 25
  • Glomerulonephritis 15
  • Others i.e. Nsaids 8-10
  • African Americans and Hispanics gt Caucasions
  • Approximately 250,000 Dialysis and renal
    transplant patients in the U.S.
  • Estimated Cost 5-10 billion

3
Definitions
  • A loss or decrease in renal function measured as
    a loss or decrease in GFR
  • An increase in nitrogenous waste ( BUN, CR)
    Azotemia
  • Renal Insufficiency ? Renal Failure
  • Acute vs. Chronic ? Reversible vs. progressive
    irreversible loss of renal function

4
GFR determination
  • Ideally agent neither absorbed or secreted
  • Creatinine vs. Inulin (GFR estimation)
  • 24 Hour Urine Analysis, Limitations in coll.
  • CrCl (Ucr/Pcr) X (Uvol/day)
  • Cockgroft Gault Equation
  • CrCl (140-age) X Wt.(kg)/ (72 X Pcr)
  • Pcr 0.6 1.3mg/dl
  • Ucr ? mg/dl
  • Uvol 0.5cc/kg/hr
  • GFR 100-120ml/min
  • ESRD lt10ml/min

5
Uremia
  • Syndrome occurs when Cr. Approximately 8-10
  • An excess of urea and nitrogenous waste in the
    blood that results in a complex of symptoms due
    to severe persisting renal failure that can be
    relieved by dialysis
  • Metabolic Acidosis
  • Hyperphosphatemia
  • Hyperuricemia
  • Hypermagnesemia
  • No response to aldosterone
  • Catabolic state

6
Endocrine System
  • PTH increases
  • Active form of Vitamin D decreases
  • GNRH decreases hence decreased FSH, LH
  • Ammenorhea, Infertility, Oligospermia, Impotence
  • Renal cells involved in gluconeogenesis and in
    Insulin metabolism

7
Pulmonary System
  • Immunodysfunction
  • Risk of Pneumonias
  • Pleural effusions, CHF, Pleuritis

8
Cardiovascular System
  • Increased incidence of CAD
  • Accelerated atherosclerosis secondary to
    increased free radical production mediated via
    heavy metal catalysis which results in oxidative
    reactions causing an increase in oxidized LDL the
    central mediator in atherogenesis.
  • CHF sec. to hypervolemia and cardiomyopathy
  • Edema
  • Pericardial Tamponade and Pericarditis

9
Skeletal System
  • Renal Osteodystrophy
  • PTH, Vitamin D
  • Alpha-hydroxylase mediated catalyzation of
    reaction forming active Vitamin D 1,25-Dihydroxy
    cholecalciferol
  • PTH effect on Kidneys PO4 excretion and Ca
    reabsorption
  • Renal Ricketts / Osteomalacia
  • Osteitis Fibrosa Cystica
  • Osteoporosis
  • Aluminum deposition in growth plates

10
Hematopoetic System
  • Erythropoetin Anemia
  • WBC function Immunosuppression
  • Platelet function Coagulopathy
  • K, Mg, Na
  • Anion Gap Metabolic Acidosis
  • Hypoosmolarity secondary to Total body
    sodium

11
Nervous System
  • Neurotoxicity of middle molecules
  • Proteins/polypeptides
  • Asterixis present short neural pathways affected
    first followed by longer neural pathways
  • Autonomic Nervous System dysfunction leading to
    labile blood pressure, orthostasis
  • Gastroparesis
  • Dementia, Delerium, Seizures, Coma, Death
  • Aluminum role in CNS disturbance

12
Integumentary System
  • Pruritis
  • PTH related leading to neuronal stimulation
  • Yellow skin discoloration secondary to Urochrome
    deposition
  • Bronze skin discoloration secondary to
    hemochromatosis
  • Dermal deposition of CaPO4 i.e. metastatic
    calcifications

13
Management
  • Restrict dietary protein to control uremia
    improves nausea, vomiting, malaise, and
    encephalopathy
  • Calories to control catabolic breakdown products
  • Limit high phosphate containing products
  • Increase Fiber
  • Consult Nutritionist
  • Phosphate Binders Ca X PO4 gt70
  • Diuretics D.O.C. for HTN and volume overload

14
MGT. continued
  • K-Binding Resins, Calcium Gluconate, Insulin,
    Dextrose, Bicarbonate
  • Calcium/Vitamin D, Rocaltrol (0.25-1mcg po qd)
    supplementation
  • Avoid heavy metal containing products
  • Control coagulopathy, Transfuse,
    Epogen(50-100U/kg SC/IV 3X/week)
  • Pneumovax, Influenza vaccines
  • Fertility referral i.e. invitro fertilization,
    artificial insemination, fertility drugs
  • Dialysis
  • Transplantation

15
Complications
  • Fluid Overload, HTN
  • Pericardial Tamponade
  • Hyperkalemia
  • Hypermagnesemia
  • Metabolic Acidosis
  • Neurotoxicity (asterixis)

16
ARF VS. CRF
  • History Normal Incr. BUN/CR
  • Kidney Size Normal Decreased
  • Bone Films R.O. Absent R.O. Present
  • H/H Normal Anemia Present

17
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