By Brent Lee Lechner, D.O. MAJ, MC, USA

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Presentation transcript:

By Brent Lee Lechner, D.O. MAJ, MC, USA Chronic Renal Failure By Brent Lee Lechner, D.O. MAJ, MC, USA

Outline Case Presentation Labs and rads Electrolyte Abnormality Discussion Fix ‘em Trivia Questions: Name that Tune

Name that tune Disease: Obesity and metabolic disease Artist: Jimmy Buffet Fans: Parrot Heads

Case History Meet: Jake “Stonewall” Jackson 5 year old white male PMHx: infrequent voiding and bedwetting Recent move West Virginia Weight Check at Pediatrician

Case History Mother states: Term delivery No hospitalizations “ this child has been much smaller than my other children” “he has not grown in 1 and ½ years” Term delivery No hospitalizations Does not eat well Morning nausea and vomiting

Case History He has had usual fevers and colds Mom also states: “he pees only one or two times per day” “has always wet the bed” Never had his blood pressure taken No prenatal care No NICU stay

Case History PMHx: PSHx: IMM: UTD Allergy: NKDA FHx: Bedwetting (primary) Poor Growth PSHx: None IMM: UTD Allergy: NKDA Cats FHx: GF: Coal Miner’s Lung Bladder cancer GM: high Cholestrol Lung Dz: Smoker 4 healthy siblings No dialysis, ESRD, or Renal Stones

Physical Examination Vitals. T: 99. 1. BP: 120/82. P: 102. R: 28 Physical Examination Vitals T: 99.1 BP: 120/82 P: 102 R: 28 PO2: 99% (WGT and HGT: Below the 5th%) WGT: 12 kg HGT: 92 cm Head: NC, 0 Lesions Eyes: PERRLA, EOMI, Normal Fundo B Ears: B Clear TM Nose: Non-swollen turbinates Throat: Non- red, 0 exudate Neck: Supple, 0 LA, 0 mass Skin: 0 rash, 0 spots Chest: Slight Tachycardia, S1, S2, II/VI flow murmur Lungs: B CTA without wheezing Abdomen: ND/NT, Thin, Soft, BS(+), 0 HSM Extremities: 0 c/c: FROM Bilateral Ankles 1+/4 Edema Pulses: 2+/2 all extremities

Name That Tune Physical Exam Finding: Artist: Johnny Cash Ambiguous Genitalia Artist: Johnny Cash Nickname: “The Man in Black”

What laboratory test would be helpful ? Urinanalysis Chem10 CBC/d Arterial Blood Gas

Laboratory Studies Urinanalysis pH: 6.5 S.G.: 1.005 Ketones (-) Glucose (-) Blood (-) Protein (trace) LE (-) Nitrites(-)

Laboratory Tests Renal Panel Na: 129 mEq/L Ca: 7.6 mg/dl K: 5.3 mEq/L PO4: 8.2 mg/dl Cl: 102 mEq/L Mg: 1.8 mEq/L HCO3: 15 mEq/L BUN: 67 mg/dl Creatinine: 1.8 mg/dl

Laboratory Tests CBC WBC: 6,700/ml HBG: 8.3 g/dl HCT: 24.1 % PLTS: 439,000/ml MCV: 65 mm3 Normal Differential and No blasts seen

Laboratory Tests Arterial Blood Gas pH: 7.29 pCO2: 35 mm Hg pO2: 95 mm Hg HCO3: 16 mEq/L

Name That Tune Diagnosis: Depression or adjustment disorder Lost your lady Lacking Melatonin Artist: Bill Withers

What Radiological Studies do you want ? Renal Ultrasound

Radiology Renal Ultrasound Incomplete Voiding Pattern Left Kidney: 4.6 cm Right Kidney: 4.2 cm Bilaterally thinning of cortex Slightly Trabeculated Bladder Bilateral Dilated Ureters

What is the definition of Chronic Kidney Failure ? GFR less than 60 ml/min/1.73 m2 Estimated GFR calculated by the Schwartz Formula: Schwartz Formula = (k)(HGT[cm])/Stable Serum Creatinine (k) = 0.33 in Premies (k) = 0.45 in Term Infants-1 year old (k) = 0.55 in Children (1 year old and greater, female adolescents) (k) = 0.65 in Adolescent males Estimated GFR = 24 hour creatinine clearance

Signs and symptoms of CRF Hypertension Growth Failure Fatigue Pallor Edema

Epidemiology

Name That Tune Diagnosis: Narcissistic Pussy Cat Dolls Beauty obsession Burning Pussy Cat Dolls

Laboratory Tests Renal Panel Na: 129 mEq/L Ca: 7.6 mg/dl K: 5.3 mEq/L PO4: 8.2 mg/dl Cl: 102 mEq/L Mg: 1.8 mEq/L HCO3: 15 mEq/L BUN: 67 mg/dl Creatinine: 1.8 mg/dl

Why is K+ high? Potassium Rx: Renal Failure leads to acidosis due to inability to excrete NH4+(distal RTA). Increased acidosis leads to K+ flux out of cells into the serum Decreased GFR leads to less filtering of K+ Rx: Limit K+ intake (avoidance of spirolactone) Sodium Citrate to control acidosis Use of non-K+ sparing diuretics Watch use of ACE-Inhibitors

Laboratory Tests Renal Panel Na: 129 mEq/L Ca: 7.6 mg/dl K: 5.3 mEq/L PO4: 8.2 mg/dl Cl: 102 mEq/L Mg: 1.8 mEq/L HCO3: 15 mEq/L BUN: 67 mg/dl Creatinine: 1.8 mg/dl

Why HCO3- is low? Acidosis Rx: Decreased GFR and decreased Ammonia synthesis occur in CRF Non-anion gap metabolic acidosis occurs Inability to make NH4+ for excretion (Distal RTA) Rx: Sodium Citrate

Too much water! Water Rx: Decreased GFR: less water filtered Interstitial scarring leads to inability to concentrate urine Water becomes function of Osmolar load Rx: Diuretics and Dialysis Sometimes, adequate volume

Laboratory Tests Renal Panel Na: 129 mEq/L Ca: 7.6 mg/dl K: 5.3 mEq/L PO4: 8.2 mg/dl Cl: 102 mEq/L Mg: 1.8 mEq/L HCO3: 15 mEq/L BUN: 67 mg/dl Creatinine: 1.8 mg/dl

What about Na+? Sodium Hypernatremia or Hyponatremia Rx: Based on etiology of CRF Interstitial Scarring or Obstructive Uropathy leads to sodium wasting Rx: If in sodium wasting state, then NaCl supplementation as well as Na Citrate If HTN or volume expansion state, then low Na Diet and possible diuretic Control HTN with Diuretic Proteinuria and HTN – Think ACE-Inhibitor

Laboratory Tests Renal Panel Na: 129 mEq/L Ca: 7.6 mg/dl K: 5.3 mEq/L PO4: 8.2 mg/dl Cl: 102 mEq/L Mg: 1.8 mEq/L HCO3: 15 mEq/L BUN: 67 mg/dl Creatinine: 1.8 mg/dl

Why is the Ca++ low? Calcium Rx: Decreased Renal Mass and Function (GFR <40 ml/min/1.73 m2) Decreased GI absorption of calcium because the kidneys inability to convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D Hypercalcuria increases in distal RTA and, thus, calcium loss occurs Rx: Supplementation with calcium in the form of calcium carbonate for phosphorus binding and buffering acidosis Vitamin D supplementation

Laboratory Tests Renal Panel Na: 129 mEq/L Ca: 7.6 mg/dl K: 5.3 mEq/L PO4: 8.2 mg/dl Cl: 102 mEq/L Mg: 1.8 mEq/L HCO3: 15 mEq/L BUN: 67 mg/dl Creatinine: 1.8 mg/dl

High PO42- ? Phosphorus Rx: Decreased GFR to excrete phosphorus Increased phosphorus released from bone to buffer acidosis Increased phosphorus and decreased calcium leads to secondary hyperparathyroidism Rx: Phosphate-binding agents: calcium-containing or sevelamer.

Laboratory Tests Renal Panel Na: 129 mEq/L Ca: 7.6 mg/dl K: 5.3 mEq/L PO4: 8.2 mg/dl Cl: 102 mEq/L Mg: 1.8 mEq/L HCO3: 15 mEq/L BUN: 67 mg/dl Creatinine: 1.8 mg/dl

Toxins Uremia BUN and creatinine elevation are direct result of decreased GFR. Metabolic toxin elevation are direct result of decreased GFR.

Who wants to do dialysis ? Rx: Dialysis Indications Volume Overload Hyperkalemia Severe Acidosis Rapid or acutely declining renal function (GFR<10-15 ml/min/1.73 m2) Toxin ingestion

Laboratory Tests CBC WBC: 6,700/ml HBG: 8.3 g/dl HCT: 24.1 % PLTS: 439,000/ml MCV: 65 mm3 Normal Differential and No blasts seen

Anemia Less Renal Mass (GFR < 50 ml/min/ 1.73m2) leads: Decreased erythropoietin production Decreased RBC survival Chronic Disease State Iron Deficiency Rx: Epogen SC Iron supplementation to keep Fe Sat% >20%

Growth Malnutrition Growth Hormone Resistance develops in CRF Metabolic acidosis increases protein breakdown rates (decreased albumin synthesis) IGF-1 GH axis is disturbed Amino acid excretion diminished Hypertriglyceridemia and hypercholesterolemia common Anoxeria is common RX: Consider G-tube Vitamin Supplementation No protein limitation Low Na Diet GH injections

Neurologic and Cognitive Function Severe impairment secondary to poor nutritional status Higher Rate of anxiety, school adjustment problems among dialysis patients Rx: Maintain Nutritional Status Seek Psychological Assistance

What medications are used in CRF? Bicitra (1 mEq/ml) soln PO EPOGEN (10,000 U/ml) SC Rocaltrol PO Kayaxelate soln PO/PR Calcium Carbonate PO Renagel PO Iron Tablets PO Growth Hormone SC

Name that Tune Diagnosis: Petite Mal Genre: Country Artist: Dwight Yoakum