Chronic Renal Failure for General Practice

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Chronic Renal Failure for General Practice

• Robin Jeffrey
• Bradford Hospitals

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Progressive and irreversible deterioration in
glomerular /- tubular function measured over
months and years
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Pyramid of chronic renal disease
600/M
gt5000/M
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Measurement of renal function

• Glomerular function
• Inulin clearance, radio-isotopic clearance
• Creatinine clearance, Cockcroft-Gault
• Serum creatinine, serum urea

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• Tubular function
• Serum K, PO4, urate,
• Acid-base balance
• Endocrine function
• Haemoglobin
• Serum calcium, PO4, PTH

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GFR
time
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Cockcroft-Gault formula

• Calculated Crcl
• (140-age) x weight x 1.2
• serum creatinine

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example

• 70 year old woman
• Weight 45kg
• Crcl 25ml.min
• Serum creatinine 132umol/l

• 25 year old male
• Weight 85kg
• Crcl 25ml/min
• Serum creatinine 469umol/l

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Urea as a marker of renal function

• Elevated by
• Dehydration
• Increased dietary protein inc. gut bleed
• Catabolic states inc. infection and steroids

• Reduced by
• Overhydration
• Starvation
• Liver disease
• pregnancy

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GFR
x
x
x
time
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Who gets renal disease

• Elderly
• Males
• Ethnic minorities

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Progression of CRF

• Continuation of primary disease process
• Factors associated with acute reversible
  deterioration
• Background irreversible progression

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dehydration and reduced renal perfusion
obstruction
Acute insult
toxins
hypercalcaemia
infection
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Background progression

• Adaptive hyperfiltration hypothesis
• Hypertension
• Proteinuria
• Tubulo-interstitial nephritis
• Hyperlipidaemia
• Cytokines
• Genetic factors

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Glomerular maladaptation
Increased intraglomerular pressure
Glomerular hypertrophy
Maintain GFR
Glomerulosclerosis
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GFR
time
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Clinical factors associated with accelerated
progression

• Hypertension
• Heavy proteinuria
• Type of renal disease
• Genetic markers
• ? Ethnic relationship
• Smokers

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Management of chronic renal failure

• Reversal of underlying disease
• Avoid/treat acute insults
• Slow progression of nephropathy
• Minimise complications
• Prepare physically and mentally for renal
  replacement therapy

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GFR
time
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Slow disease progression

• Control of blood pressure
• Reduce proteinuria
• The special role of ACE inhibitors
• Low protein diet

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Lewis slide from uptodate
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Anaemia
Left Ventricular Hypertrophy

Acidosis
METABOLIC COMPLICATIONS
Renal osteodystrophy
Accelerated Atherosclerosis
Hyperkalaemia
Catabolism
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Management of complications

• Erythropoietin
• Sodium bicarbonate
• Calcium-based phosphate binders
• Vitamin D supplementation
• Statins
• Anti-hypertensives

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Psychological and physical preparation for RRT

• Education about different forms of dialysis and
  transplantation
• Support and counselling of patient and family
• Surgical creation of dialysis access
• Discussion about potential living donor

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CHRONIC RENAL FAILURE
LIVING DONOR
PRE-DIALYSIS
ESRF
CADAVERIC
RENAL TRANSPLANT
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Late referral to specialist care is associated
with

• Inferior biochemical control
• Malnourishment
• Poorer quality of life
• Longer hospitalisation
• Increased early morbidity and mortality

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Initiation of dialysis

• Ethics conservative care of CRF
• Ideally smooth and programmed
• Emergency in 50
• Absolute and relative indications

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