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

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

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

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

5. 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

6. 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

7. 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

8. Physical Examination Vitals. T: 99. 1. BP: 120/82. P: 102. R: 28
Physical Examination Vitals T: 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

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

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

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

12. 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: mg/dl
Creatinine: 1.8 mg/dl

13. 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

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

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

16. What Radiological Studies do you want ?
Renal Ultrasound

17. 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

18. 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

19. Signs and symptoms of CRF
Hypertension
Growth Failure
Fatigue
Pallor
Edema

20. Epidemiology

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

22. 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: mg/dl
Creatinine: 1.8 mg/dl

23. 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

24. 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: mg/dl
Creatinine: 1.8 mg/dl

25. 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

26. 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

27. 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: mg/dl
Creatinine: 1.8 mg/dl

28. 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

29. 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: mg/dl
Creatinine: 1.8 mg/dl

30. 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

31. 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: mg/dl
Creatinine: 1.8 mg/dl

32. 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.

33. 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: mg/dl
Creatinine: 1.8 mg/dl

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

35. 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

36. 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

37. 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%

38. 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

39. 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

40. 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

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