1. Dr S Chakradhar 1

2. CHRONIC RENAL FAILURE Chronic renal failure (CRF) refers to an irreversible deterioration in renal function which classically develops over a period of years. Initially, it is manifest only as a biochemical abnormality. Initially, it is manifest only as a biochemical abnormality. Eventually, loss of the excretory, metabolic and endocrine functions of the kidney leads to - the development of the uraemia. Eventually, loss of the excretory, metabolic and endocrine functions of the kidney leads to - the development of the uraemia. When death is likely without renal replacement therapy, it is called end-stage renal failure (ESRF). When death is likely without renal replacement therapy, it is called end-stage renal failure (ESRF). 2 Dr S Chakradhar

3. Stages of CRF It is divided into 4 stages from normal renal function to uraemia Diminished renal reserve GFR is about 50% of normal GFR is about 50% of normal Asymptomatic. No azotemia Asymptomatic. No azotemia Renal insufficiency GFR is 20 – 50% of normal. GFR is 20 – 50% of normal. There is azotaemia, anemia, HTN, polyuria, nocturia There is azotaemia, anemia, HTN, polyuria, nocturia Renal failure GFR is less than 20% of normal GFR is less than 20% of normal There is uraemia, hypokalaemia & metabolic acidosis There is uraemia, hypokalaemia & metabolic acidosisESRD GFR less than 5% GFR less than 5% 3 Dr S Chakradhar

4. Classification: On the basis of calculated GFR: Mild CRF = 20-50 ml/min Mild CRF = 20-50 ml/min Moderate CRF = 10-20 ml/min Moderate CRF = 10-20 ml/min Severe CRF = less than 10 ml/min Severe CRF = less than 10 ml/min ESRD = less than 5 ml/min ESRD = less than 5 ml/min

5. CAUSES 1. Pre-renal: Hypertensive Nephropathy (Hypertensive Nephrosclerosis) Hypertensive Nephropathy (Hypertensive Nephrosclerosis) Renal artery stenosis Renal artery stenosis 5 Dr S Chakradhar

6. 2.RenalGlomerular: Primary GN: 1.Focal segmental Glomerulosclerosis 2.Membranoproliferative GN 3.IgA Nephropathy 4.Membranous GN 5.Post-infectious GN Secondary Glomerular disease: 1.Diabetes nephropathy 2.Amyloidosis 3.Heroin Nephropathy 4.Collagen vascular disease: SLE, PAN 6 Dr S Chakradhar

7. Tubulointerstitial Analgesic nephropathy Analgesic nephropathy Nephrotoxins: Heavy metals Nephrotoxins: Heavy metals Multiple myeloma Multiple myeloma Reflux nephropathy Reflux nephropathy Chronic pyelonephritis Chronic pyelonephritis Tuberculosis TuberculosisHereditary: Polycystic kidney disease Polycystic kidney disease 7 Dr S Chakradhar

8. Post –Renal: Renal stones Renal stones Urethral TB Urethral TB Prostatic Obstruction Prostatic Obstruction Congenital defects Congenital defects 8 Dr S Chakradhar

9. Common Causes : Diabetic nephropathy Diabetic nephropathy Hypertension Hypertension Chronic glomerulonephritis Chronic glomerulonephritis Chronic pyelonephritis Chronic pyelonephritis Obstructive uropathy Obstructive uropathy Congenital (polycystic kidney disease), Renal vascular disease, analgesic nephropathy. Congenital (polycystic kidney disease), Renal vascular disease, analgesic nephropathy. 9 Dr S Chakradhar

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11. Dr S Chakradhar 11

12. Pathogenesis: Exact mechanism of clinical syndrome of uraemia is not known. Exact mechanism of clinical syndrome of uraemia is not known. It is most likely caused by accumulation in body fluids of a number of substances (phosphate, parathyroid hormone, urea, creatinine) It is most likely caused by accumulation in body fluids of a number of substances (phosphate, parathyroid hormone, urea, creatinine) Renal failure does not occur until GFR is reduced below 50% of normal. Renal failure does not occur until GFR is reduced below 50% of normal. 12 Dr S Chakradhar

13. Acute on chronic renal failure Renal failure worsens at times when there is any form of stress (hypovolemia, hypervolemia, radiocontrast administration, nephrotoxic drugs, infections, urinary tract obstruction, uncontrolled hypertension.) Renal failure worsens at times when there is any form of stress (hypovolemia, hypervolemia, radiocontrast administration, nephrotoxic drugs, infections, urinary tract obstruction, uncontrolled hypertension.) In these conditions, even though patient was asymptomatic or less symptomatic previously, there is sudden deterioration of remaining renal function. In these conditions, even though patient was asymptomatic or less symptomatic previously, there is sudden deterioration of remaining renal function. 13 Dr S Chakradhar

14. Anemia Erythropoietin deficiency, decreased erythropoiesis due to marrow suppression, blood loss, decreased red-cell survival, reduced intake and absorption of iron. Erythropoietin deficiency, decreased erythropoiesis due to marrow suppression, blood loss, decreased red-cell survival, reduced intake and absorption of iron. Mostly normocytic normochromic Mostly normocytic normochromicT/T: Inj. Recombinant Erythropoietin. Inj. Recombinant Erythropoietin. 14 Dr S Chakradhar

15. Renal osteodystrophy It is skeletal manifestation of chronic renal failure. Low level of calcium and increased phosphate in the blood → increased parathyroid hormone → increased osteoclastic activity → resorption of bone → cystic appearance in radiograph. Low level of calcium and increased phosphate in the blood → increased parathyroid hormone → increased osteoclastic activity → resorption of bone → cystic appearance in radiograph. Osteomalacia & Osteitis fibrosa (hyperthyroid bone disease) Osteomalacia & Osteitis fibrosa (hyperthyroid bone disease) Osteoporosis and osteosclerosis. Osteoporosis and osteosclerosis. 15 Dr S Chakradhar

16. Neuro-mascular abnormality Myopathy – Muscle cramps, rest-less leg syndrome Myopathy – Muscle cramps, rest-less leg syndrome (Probably due to poor nutrition, hyperthyroidism, Vit D deficiency & disorders of electrolyte) Neuropathy - Paresthesia (sensory), foot drop (motor) Neuropathy - Paresthesia (sensory), foot drop (motor) (due to demyelination of medullated nerves) 16 Dr S Chakradhar

17. Endocrine disturbances Insulin Insulin Post receptor defect Post receptor defect Reduced tubular metabolism Reduced tubular metabolism Sex hormones Sex hormones Decreased level of estrogen and testosterone Decreased level of estrogen and testosterone Hyperprolatinemia Hyperprolatinemia Cardiovascular disease Hypertension Hypertension Accelerated atherosclerosis Accelerated atherosclerosis Pericarditis, pericardial effusions Pericarditis, pericardial effusions 17 Dr S Chakradhar

18. Acidosis : Acidosis : Impaired secretion of hydrogen, Loss of bicarbonate. Impaired secretion of hydrogen, Loss of bicarbonate. Infection Infection Bleeding Bleeding Gastrointestinal disorders Gastrointestinal disorders Anorexia, nausea, vomiting, increased incidence of peptic ulcer disease Anorexia, nausea, vomiting, increased incidence of peptic ulcer disease 18 Dr S Chakradhar

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20. Dr S Chakradhar 20

21. Clinical feature: Patient may be Asymptomatic until GFR is 15 ml/ min (70 per cent of the Nephrons are dead) Patient may be Asymptomatic until GFR is 15 ml/ min (70 per cent of the Nephrons are dead) Symptoms of Uremia – Anorexia, Nausea, vomiting, malaise, pruritus Symptoms of Uremia – Anorexia, Nausea, vomiting, malaise, pruritus Features of complications: Anemia, bone pain Features of complications: Anemia, bone pain Generalized Myopathy- muscle cramps, Generalized Myopathy- muscle cramps, Hypertension Hypertension Breathlessness- Deep Respiration due to acidosis Breathlessness- Deep Respiration due to acidosis Urinary symptoms: May present with anuria / oliguria, Nocturia / polyuria Urinary symptoms: May present with anuria / oliguria, Nocturia / polyuria Infection- U.T.I is common Infection- U.T.I is common 21 Dr S Chakradhar

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23. Investigations: T.C,D.C, ESR,Hb T.C,D.C, ESR,Hb Urine R/E and C/S Urine R/E and C/S Blood urea and Creatinine Blood urea and Creatinine Creatinine Clearance rate Creatinine Clearance rate Blood sodium and potassium Blood sodium and potassium Urine analysis: Proteinuria, hematuria, broad waxy cast Urine analysis: Proteinuria, hematuria, broad waxy cast X-ray KUB region X-ray KUB region USG USG Renal biopsy Renal biopsy 23 Dr S Chakradhar

24. Features suggesting CRF: 1. Evidence of Osteodystrophy on bone film. 2. Peripheral neuropathy 3. Small kidneys 4. Prolong uremic symptoms (long history) 5. Previous record of eleveted urea, creatinine. 6. Previous history of dialysis/renal biopsy 7. BUN, creatinine—Stable in CRF while in ARF raises 20-40mg/day, and Creatinine 2-4mg/day 8. Broad waxy cast in urine microscopy 24 Dr S Chakradhar

25. Management: 1. Dietary modifications 2. Treatment of complications 3. Dialysis 4. Renal transplantation 25 Dr S Chakradhar

26. Treatment Symptomatic - restriction of protein Symptomatic - restriction of protein Sodium restriction if edema, CCF and hypertension Sodium restriction if edema, CCF and hypertension Restriction of potassium Restriction of potassium Patients with CRF should be kept volume expanded,should take 2- 3l/day to excrete waste products as effectively as possible Patients with CRF should be kept volume expanded,should take 2- 3l/day to excrete waste products as effectively as possible Hypertension - antihypertensive Hypertension - antihypertensive Calcium supplementation Calcium supplementation Anaemia— Anaemia— 26 Dr S Chakradhar

27. Replacement of Renal function 1. Hemodialysis 2. Peritoneal dialysis Renal transplant- definite treatment Renal transplant- definite treatment End stage Renal Disease This is the terminal stage of uremia. End stage Renal Disease This is the terminal stage of uremia. 27 Dr S Chakradhar

28. Indications of Dialysis in CRF: 1. Uremic symptoms such as pericarditis, encephalopathy, seizures or coagulopathy 2. Fluid overload unresponsive to diuresis 3. Refractory hyperkalemia 4. Severe metabolic acidosis 5. Serum creatinine about 10mg/dl, and urea 200mg/dl 28 Dr S Chakradhar

29. Complications: Hypertension Hypertension Anemia Anemia Systemic Acidosis Systemic Acidosis Metabolic Bone Disease Metabolic Bone Disease Congestive Cardiac Failure and Pericarditis Congestive Cardiac Failure and Pericarditis Coagulopathy Coagulopathy Susceptible to Infection Susceptible to Infection Encephalopathy Encephalopathy Neuropathy Neuropathy 29 Dr S Chakradhar

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