1. Chronic Renal Failure for General Practice
Robin Jeffrey
Bradford Hospitals

2. Progressive and irreversible deterioration in glomerular +/- tubular function measured over months and years

3. Pyramid of chronic renal disease

4. Measurement of renal function
Glomerular function
Inulin clearance, radio-isotopic clearance
Creatinine clearance, Cockcroft-Gault
Serum creatinine, serum urea

5. Tubular function Endocrine function Serum K, PO4, urate,
Acid-base balance
Endocrine function
Haemoglobin
Serum calcium, PO4, PTH

6. GFR
time

7. Cockcroft-Gault formula
Calculated Crcl
= (140-age) x weight x 1.2
serum creatinine

8. example 70 year old woman 25 year old male Weight 45kg Weight 85kg
Crcl 25ml.min
Serum creatinine 132umol/l
25 year old male
Weight 85kg
Crcl 25ml/min
Serum creatinine 469umol/l

9. Urea as a marker of renal function
Elevated by
Dehydration
Increased dietary protein inc. gut bleed
Catabolic states inc. infection and steroids
Reduced by
Overhydration
Starvation
Liver disease
pregnancy

11. GFR x x x
time

19. Who gets renal disease
Elderly
Males
Ethnic minorities

21. Progression of CRF Continuation of primary disease process
Factors associated with acute reversible deterioration
Background irreversible progression

22. Acute insult dehydration and reduced renal perfusion obstruction
toxins
infection
hypercalcaemia

23. Background progression
Adaptive hyperfiltration hypothesis
Hypertension
Proteinuria
Tubulo-interstitial nephritis
Hyperlipidaemia
Cytokines
Genetic factors

24. Glomerular maladaptation
Increased intraglomerular pressure
Glomerular hypertrophy
Maintain GFR
Glomerulosclerosis

25. GFR
time

26. Clinical factors associated with accelerated progression
Hypertension
Heavy proteinuria
Type of renal disease
Genetic markers
? Ethnic relationship
Smokers

27. Management of chronic renal failure
Reversal of underlying disease
Avoid/treat acute insults
Slow progression of nephropathy
Minimise complications
Prepare physically and mentally for renal replacement therapy

28. GFR
time

30. Slow disease progression
Control of blood pressure
Reduce proteinuria
The special role of ACE inhibitors
Low protein diet

31. Lewis slide from uptodate

33. Anaemia
Left Ventricular
Hypertrophy
Acidosis
METABOLIC
COMPLICATIONS
Renal osteodystrophy
Accelerated
Atherosclerosis
Hyperkalaemia
Catabolism

38. Management of complications
Erythropoietin
Sodium bicarbonate
Calcium-based phosphate binders
Vitamin D supplementation
Statins
Anti-hypertensives

39. Psychological and physical preparation for RRT
Education about different forms of dialysis and transplantation
Support and counselling of patient and family
Surgical creation of dialysis access
Discussion about potential living donor

40. CHRONIC
RENAL FAILURE
PRE-DIALYSIS
LIVING
DONOR
ESRF
CADAVERIC
RENAL
TRANSPLANT

43. Late referral to specialist care is associated with:
Inferior biochemical control
Malnourishment
Poorer quality of life
Longer hospitalisation
Increased early morbidity and mortality

45. Initiation of dialysis
Ethics – ‘conservative care of CRF’
Ideally smooth and programmed
Emergency in 50%
Absolute and relative indications