Chronic Renal failure

 Chronic Renal failure 

Chronic renal failure is defined as gradual , progressive and irreversible impairment of renal function leading to accumulation of metabolic waste product in the body .

According to National kidney foundation ( NKS-USA) CRF is defined as either kidney damage or GFR < 60 ml per minute for 3 or more months.

Causes :

1. Chronic Glomerulonephritis 

2. Diabetes mellitus

3. Hypertension- systemic

4. Chronic pyelonephritis 

5. Systemic lupus erythromatosus ( SLE)

6. Polycystic kidney disease 

7. Analgesic Nephropathy

8. Multiple myeloma 

9. Obstructive uropathy

10. Amyloidosis

C/F

Common:

- Lethargy

- Anorexia

- Vague general malaise 

- Weight loss

- Blunting of intellectual feature .

The profound metabolic disorder affect all systems.

GI :

* Anorexia

* Nausea,vomiting 

* Diarrhea-uraemic colitis

* Hiccups 

* Increased incidence of peptic ulcer 

Skin : 

- pruritus , excoriation 

- Bruising 

- Pigmentation 

- Pallor

- Brown arc in the nail

- Uraemic frost

Hematological :

- Anaemia

- Bruising 

- Prolonged bleeding 

- Lymphocytopenia 

- Epistaxis

Respiratory :

- Increased respiratory rate and depth of respiration.

- Uraemic breathing

- Increased incidence of chest infection 

- Pleural effusion 

Cardiovascular system:

* Hypertension and its consequences 

* Heart failure 

* Chest pain - uraemia pericarditis 

* Peripheral vascular diseases 

* Pericardial effusion > pulse paradoxus 

Endocrine:

* Secondary amenorrhea 

* Infertility

* Loss of libido 

Renal :

- Nocturia

- Polyuria , Hematuria 

- Salt and water retention 

- Edema

Renal osteodystrophy 

* Osteomalacia , osteoporosis, osteosclerosis

* Muscle weakness 

* Bone marrow 

* Hyperparathyroidism

* Muscle weakness ( proximal myopathy)

Neurological 

* Hypertensive encephalopathy 

* Peripheral neuropathy 

* Mental impairment 

* Muscle twitching 

* Tremor or convulsion

* Paralysis ( CVA)

* Autonomic Neuropathy 

Eye : 

- Conjunctivitis 

- Decreased visual acuity

Stage of CRF

Mild : 

- Nephron loss 51-60%

- Serum creatinine 2.3-5mg%

- Creatinine clearance 30-50ml/min

Moderate 

- Nephron loss 61-70%

- Serum creatinine. 3.5-6.6mg%

- Creatinine clearance. 20-30 ml/ min

Severe 

- Nephron loss 61- 70 %

- Serum creatinine 6.6-10 mg%

- Creatinine clearance. 5-20ml/ min 

End stage kidney disease 

- Nephron loss. > 90%

- Serum creatinine > 10 mg%

- Creatinine clearance < 5 ml/ min

Complications 

1. Uraemia gastritis 

2. Hypertension 

3. Anaemia 

4. Systemic acidosis 

5. Metabolic bone disease 

6. Congestive / cardiac tamponade 

7. Pericarditis/ Cardiac tamponade

8. Susceptible to infection 

9. Neuropathy 

- sensory neuropathy: paraesthesia

- Motor neuropathy: Foot drop

- Uraemic autonomic neuropathy 

* Delayed gastric emptying 

* Diarrhoea

* Postural hypotension 

Investigations 

Aim :

- To determine the cause of CRF

- To differentiate from ARF

- To detect life threatening metabolic disturbances 

- To detect complications of CRF

- To detect the precipitating factor in acute on chronic CRF

- To assess the need of hemodialysis

- To monitor the response to treatment 

a . Urine for R/M/E and culture and sensitivity 

b. 24 hr . Urinary protein estimation. eg Glomerulonephritis

c. Haematological 

* TC, DC , ESR ,HB % = infection ( increased total count) , Anaemia ( Decreased Hb%)

* Blood sugar 

* Serum urea , creatinine 

* Serum electrolytes Na+k+,

* Serum ca++ and phosphate level .

* Serum uric acid

- Creatinine clearance rate : staging of CRF

- Blood culture and sensitivity: Infection 

- HBsAg, HIV for dialysis purposes because they need separate machine .

- Alkaline phosphatase raised in renal osteodystrophy 

- Serum pH level

- ECG , ECHO : Hypertension and Hyperkalaemia 

- Nerve conduction study: peripheral neuropathy 

- Renal Biopsy RPGN : otherwise not done in CRF

- Test for connective tissue disease. ANA , ds DNA,

Treatment 

* Diet : protein 0.5 Gmail / kg/day (moderate). 20 gram /day ( severe)

      Adequate carbohydrates (250gm) + fat (60gm) to provide adequate calorie ( at least 2000 kcal / day ).

* Fluid: if GFR < 5 ml per min or evidence of fluid accumulation 

* Electrolytes : 

- No sodium restriction in the absence of edema, Cardiac Failure or hypertension and stage of kidneys.

- Restrictions of potassium- Avoid high k+ diet ( banana, tomato , coffee, chocolate etc)

* Control of hypertension 

       Adequate control of blood pressure is important in order to delay the progress of CRF.

Choice of drug in CRF hypertension 

i. Calcium channel blockers 

ii . ACE inhibitors 

iii . Methyldopa 

iV. Prazosin 

* Decrease phosphate absorption from GI tract:

       Aluminum hydroxide gel 300-600 mg

       Calcium carbonate 500 mg BD

* Treatment of Anaemia with blood transfusion or erythropoietin.

* For Renal osteodystrophy give 1€ hydroxylated vit . D with calcium 

* Avoid nephrotoxic drugs such as : tetracycline 

                   - Aminoglyscosides

                   - 1 st and 2nd generation of cephalosporin 

* Muscle twitching/ Convulsions: Diazepam/ phenytoin/ sodium valproate .

* Nausea / vomiting: metochlorpramide/Domperidone 

Replacement therapy 

- peritoneal dialysis 

- Haemodialysis

- Renal transplantation.

Indications of dialysis in CRF

Clinical:

* severe pruritus

* Persistent nausea / Vomiting 

* Impairment of mental functions

* Uraemic pericarditis

* Peripheral neuropathy 

* Uncontrolled hypertension 

* Fluid overload not responding to diuretics .

Biochemical 

Blood urea > 40 mmol / l

Serum creatinine. > 1000umol/ l

Serum k+. > 6.5 mmol / l

Serum HCO 3. > 12 new / l

Creatinine clearance rate. < 5 ml/ min

Reversible factor in CRF

a. Hypertension 

b. Reduced renal perfusion 

c. Urinary tract infection 

d. Other infections: increased catabolism and urea production 

e. Nephrotoxic medications.

Some important question 

1.How long can you live with renal failure?

 Ans :People with kidney failure may survive days to weeks without dialysis, depending on the amount of kidney function they have, how severe their symptoms are, and their overall medical condition.

2.What causes chronic renal failure?

 Ans :The two main causes of chronic kidney disease are diabetes and high blood pressure, which are responsible for up to two-thirds of the cases. Diabetes happens when your blood sugar is too high, causing damage to many organs in your body, including the kidneys and heart, as well as blood vessels, nerves and eyes.

3. What happens when your kidneys start shutting down?

 Ans :Acute kidney failure occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance.

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