CHRONIC RENAL FAILURE R.Manoj Kumar

Definition CRF refers to an irreversible deterioation in renal function which classically develops over a period of years. CRF corresponds to CKD stages 3-5

CAUSES of CRF Congenital and Inherited- Polycystic Kidney Disease, Alport’s syndrome Renal artery stenosis Hypertension Glomerular diseases- IgA Nephropathy most common Interstitial diseases Systemic Inflammatory diseases- SLE, Vasculitis Diabetes Mellitus Unknown causes

PATHOGENESIS Disturbances in water, electrolyte and Acid-Base balance contribute to the clinical picture in Patient with CRF;But the exact Pathogenesis of the clinical syndrome of Uremia is unknown. Many substances present in Abnormal concentrations in the Plasma have been suspected as being Uremic toxins and uremia is probably caused by the accumulation of various intermediate products of metabolism like Nitrogenous excretory products such as Guanido compounds,Urates,Hippurates,products of nucleic acid metabolism,polyamines,Myoinositol,Phenols and Indoles.

CLINICAL FEATURES Fluid & Electrolyte disturbance – Volume expansion Hyponatremia Hyperkalemia Hyperphosphatemia Endocrine-metabolic disturbance – Sec hyperparathyroidism Adynamic Bone Carbohydrate resistance Hyperuricemia Decreased HDL levels PEM Impaired growth Amenorrhea

Neuromuscular disturbances- Fatigue Sleep disorders Headache Lethargy Muscular irritability Myoclonus Seizures Coma Myopathy

CVS & Pulmonary disturbances- Arterial Htn CHF Pulmonary edema Pericarditis Cardiomyopathy Uremic Lung Atherosclerosis Hypotension Arrhythmias Vascular calcifications

Skin disturbances- GIT- Pallor Hyperpigmentation Pruritus Ecchymoses Uremic frost GIT- Anorexia Nausea & vomiting Gastroenteritis GI bleeding Idiopathic ascites Peritonitis

Hematologic & Immunologic disturbance- Anemia Lymphocytopenia Bleeding diathesis Inc susp to infection Leucopenia Thrombocytopenia

INVESTIGATIONS Hematology- Full blood count Hematinics Biochemistry Urea,electrolytes,creatinine Calcium,phosphate,albumin Parathyroid hormone Lipids, Glucose

Hepatitis and HIV serology Imaging- Renal Ultrasound Chest X-ray Microbiology- Hepatitis and HIV serology Imaging- Renal Ultrasound Chest X-ray Renal artery imaging E.C.G Immunology- Grouping Tissue typing CMV,EBV,VZV

If diagnosis is not Known. Consider Immunoglobulin and Protein electrophoresis Urinary BenceJones proteins Compliment Rheumatoid factor ANCA Anti-GBM Cryoglobulins

TREATMENT

Renal replacement therapy

Problems with Haemodialysis Hypotension during Dialysis Cardiac Arrhythmias Hemorrhage Air Embolism Dialyser Hypersensitivity Emergencies between treatments- Pulmonary edema Systemic sepsis

Problems with Peritoneal dialysis Peritonitis Catheter exit site infection Ultra filtration failure Peritoneal membrane failure

Management after Transplantation Immunosuppressive therapy- Prednisolone,ciclosporine and Azathioprine Rejection is treated by short course of very high dose corticosteroids and more potent therapies such as anti-lymphocyte antibodies or plasma exchange Immunosuppression leads to Increased incidence of infection such as CMV & Pneumocystis

PROGNOSIS Cadaver donors- 96% patient survival 92% graft survival at 1 year 84% patient survival 76% graft survival at 5 years Living donors- 92% patient survival 86% graft survival at 5 years Renal transplantation offers the best hope of complete rehabilitation and is the most cost effective treatment for end stage CRF

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