Chronic Renal Failure

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Chronic Renal Failure

• David Dayya, D.O.
• St. Barnabas Hospital
• Dept. of Family Medicine

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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

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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

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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

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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

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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

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Pulmonary System

• Immunodysfunction
• Risk of Pneumonias
• Pleural effusions, CHF, Pleuritis

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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

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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

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Hematopoetic System

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

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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

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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

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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

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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

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Complications

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

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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
  

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Questions?