CHRONIC RENAL FAILURE PART I

CRF ● DEFINITIONS ● ETIOLOGY ● PATHOPHYSIOLOGY ● PATHOGENESIS

ETIOLOGY CONGENITAL:PCKD HYPOPLASIA ALPORTS ● VASCULAR: RENAL A.STENOSIS ● HT ● GLOMERULAR DISEASES ● INTERTITIAL DISEASES: Ch.PYELONEPHRITIS REFLUXNEPHROPATHY ANALGESIC NEPHROPATHY

ETIOLOGY ● SYSTEMIC DISEASES: SLE DM OTHERS ● MALIGNANCY: MULTIPLE MYELOMA ● OBSTRUCTIVE: RENAL STONES B/L CA CERVIX ● ETIOLOGY UNCERTAIN ● OTHERS

MOST COMMON DM HT CH.GLOMERULONEPHRITIS CH.PYELONEPHRITIS

CRF DIABETIC NON-DIABETIC

GENETIC CONSIDERATION ACE GENE DELETION GENES CODING RAS HUMAN CHROMO-10 RENAL FAILURE SUSCEPTABILITY GENE

PATHOPHYSIOLOGY OF CRF LONG TERM REDUCTION IN RENAL MASS INTRAGLOMERULAR CAPILLARY PRESSURE & FLOW ADAPTIVE HYPERFILTRATION HYPERTROPHY OF SURVIVING NEPHRONS SCLEROSIS OF VIABLE NEPHRONS ACEI NSAID -+ RAS ACTIVITY

EQUATION FOR ESTIMATION OF GFR ● ESTIMATED GFR= 1.86 X [Pcr] x [AGE] ● COCKCROFT – GAULT FORMULAE: ESTIMATED CR. CLEARANCE = [140 – AGE] X BW [KG] 72 X Pcr [Mg/dl]

RISK FACTORS WITH NORMALGFR Old age Autoimmune disease HT DM Family H/O Heritable renal disease Past episode of ARF Current evidence of kidney damage with normal or increased GFR

STAGEDESCRIPTIONGFR At increased risk90 ĉ risk factors 1N or GFR90 2MILD GFR MOD. GFR SEVERE GFR RENAL FAILURE< 15 STAGES OF CRF

PATHOPHYSIOLOGY OF UREMIC SYNDROME CONSEQUENT TO ACCUMULATION OF PROTEIN METABOLISM CONSEQUENT TO LOSS OF OTHER RENAL FUNCTIONS - FLUID & ELECTROLYTE BALANCE - HORMONAL ABNORMALITIES

CLINICAL MANIFESTATIONS

SODIUM & WATER HOMEOSTASIS UNDERLYING DISEASE PROCESS DISRUPT TUBULO GLOMERULAR BALANCE Na+ INTAKE Na+ RETENTION ECF VOLUME EXPANSION HYPERTENSION ACCELERATES NEPHRON INJURY

K HOMEOSTASIS ● HYPERKALEMIA -Decrease in GFR not always decrease K EXCRETION -EARLY HYPERKALEMIA DIABETIC NEPHROPATHY RENAL TUBULAR ACIDOSIS

HYPOKALEMIA ● DECREASED K+ INTAKE. ● DIURETIC INDUCED ● INCREASED GIT LOSS ● FANCONI’S SYNDROME ● RENAL TUBULAR ACIDOSIS.

METABOLIC ACIDOSIS ● DEFECTIVE AMMONIUM PRODUCTION ● HYPERKALEMIA WORSENS ACIDOSIS ● ACIDOSIS RARELY <7.35

DISORDER OF BONE METABOLISM ● HIGH BONE TURN OVER STATE ● LOW BONE TURN OVER STATE ● CALCIPHYLAXIS

CARDIO - VASCULAR ABNORMALITY ● HT WITH LVH ● MYOCARDIAL ISCHEMIA ● CCF ● PERICARDITIS ● DILATED CARDIOMYOPATHY