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Budoor Al Shehhi Aisha Al Shamsi Raya Al Mazrouei Amna Bedwawi Manal Al Mazrouei

Chronic Renal Failure. Budoor Al Shehhi Aisha Al Shamsi Raya Al Mazrouei Amna Bedwawi Manal Al Mazrouei. Plan. Case presentation Pathophysiology of Chronic Renal Failure Treatment of Chronic Renal Failure. Past medical History:. < 150 mg/ day. Incidental Proteinuria.

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Budoor Al Shehhi Aisha Al Shamsi Raya Al Mazrouei Amna Bedwawi Manal Al Mazrouei

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  1. Chronic Renal Failure Budoor Al Shehhi Aisha Al Shamsi Raya Al Mazrouei Amna Bedwawi Manal Al Mazrouei

  2. Plan.. Case presentation Pathophysiology of Chronic Renal Failure Treatment of Chronic Renal Failure

  3. Past medical History: < 150 mg/ day • Incidental Proteinuria • Completely asymptomatic • 120/ 80 • BP of 156 / 98 mmHg • The physical examination is otherwise normal

  4. Laboratory results: Urinalysis: • Clear amber • Specific gravity 1.020 • 1.025 – 1.030 • +2 proteinuria • Trace blood • WBC 2-4 per HPF • 0– 4 per HPF • RBC 4-6 per HPF • 0 – 3 per HPF • No casts

  5. Blood tests: • Hgb. 12.0 gm% • 13.5-17.5 gm% • BUN 26mg% • 8-25 mg% • Creatinine 1.5mg% • 0.6-1.5 mg % Normal electrolytes : • 8.5-10.5 mg/dl • Calcium 9.2 mg% • 3.6-5.3gm/dl • Albumin 3.9 mg% 24 hour urine collection: • < 0.15 gm • 3.1 gm protein • 90-140mls/min • Creatinin clearance 60 mls/min

  6. Imaging studies: • Chest X-ray • Normal Ultrasound of the kidneys (Right 11.9 cm, Left 12.4 cm) • No hydronephrosis

  7. Present Medical History • Patient history: • Easy fatiguability • Anorexia • Mild pruritis • Shortness of breath on moderate exertion

  8. Present Medical History • Physical examination: • Pallor • Diffuse scratch marks over his arms, trunk and back • BP 186/108 mmHg • Elevated JVP • GII/VI systolic murmur along the left sternal border, bilateral basal rales on auscultation of the chest, normal abdominal exam and 1+ ankle edema..

  9. Investigations obtained at this present visit: Urinalysis: • clear amber • specific gravity 1.017 • 1.025-1.030 • +1 proteinuria • Trace blood • WBC 2-4/ HPF • 0-4/HPF • RBC 4-6/ HPF • 0-3/HPF • granular casts 2-4 / HPF • 0-2/LPF

  10. Blood tests: • Hgb. 9.1 gm% • 13.5-17.5 gm/dl • BUN 96mg% • 8-25 mg/dl • Creatinine 7.2 mg% • 0.6-1.5 mg/dl • Na+ 136 • 135-146 • 3.5-5mmol/L • K+ 4.8 • Cl- 107 • 95- 106mmol/ L • HCO3- 16.4 • 22-30mmol/L • Calcium 7.1 mg% • 8.5-10.5 mg/dl • Alk P 310 U/ ml • 2.5-11.5 U/ml • 3.6-5.3g/dl • Albumin 3.4 mg%

  11. 24 hour urine collection: • < 0.15g/24 hours • 2.1 gm protein • 82-140ml/min • Creatinine Clearance 19 ml/min CXR: • Cardiomegaly • Mild pulmonary congestion

  12. Aetiology of chronic kidney failure: • 1- Congenital & inherited diseases: • Polycystic kidney disease • Alport’s syndrome • Congenital hyopplasia • 2- Glomerular diseases: • Primary: Glomerulonephritides including focal glomerulosclerosis • Secondary: SLE, Vasculitis, amyloidosis • 3- Vascular disease: • Arteriosclerosis • Systemic sclerosis with renal involvement • Microscopic polyarteritis • Main and medium- sized vessel vasculitis

  13. 4- Tubulointerstitial disease: • Tubulointerstitial nephritis (idiopathic, drugs, immune mediated). • Reflux nephropathy • TB • Schistosomiasis • 5- Urinary Tract Obstruction: • Calculous disease • Prostatic disease • Pelvic tumors • 6- Diabetes mellitus • 7- Hypertension

  14. Pathogenesis & Clinical manifestations Due to impaired functions of the kidney

  15. - breathlessness- fatigue- generalized swelling- metallic taste- vomiting & nausea - weight loss In general Chronic renal failure symptoms includes: - seizures- mental slowness and - confusion- leg cramps- itching- pale skin color- poor appetite

  16. Metabolic changes: -Hyperkalemia. -Metabolic acidosis. -Na+ & water retention. -Haematological changes(normochromic normocytic anaemia -Mineral & bone changes.

  17. Hyperkalemia

  18. Hyperkalemia: • -manifested when GFR<20-25ml/mint. • -due to decreased renal ability of K+ excretion. • -Observed with sudden loads of K+ from endo. Or exo. sources: • k+ diet • Drugs (ACI, NSAIDS, K+ sparing diuretics. • Type IV RTA. • Haemolysis, infection & truma. • acidemia & lack of insulin.

  19. Hyperkalaemia: • -Normal range of K+ (3.7-5.2 mmole/L). • -Normally asymptomatic. • - In severe cases: >7mmol/L. • tingling around tips & fingers. • loss of tendon jerk. • abdominal distention. • arrythmia • ECG changes: - Tall T-wave, PR interval & QRS complexes are lengthened.

  20. Metabolic Acidosis Causes: -Inability to produce enough NH3 in prox.tubules. -In advanced cases, accumulation of PO4,SO4 & other organic anions cause the small anion gap.

  21. Clinical Features: • Hyperventilation. • Respiratory distress. • Fatigue. • Reduced cardiac output. • Confusion & drowsy.

  22. Increase in ECV: -When GFR<10-15ml/min. -failure to excrete Na+ & water. -At higher GFR, may be due to increase ingestion of Na+ & water. Leads to… -Hypertention. -Oedema. -Ascites. -CV & pulmonary oedema.

  23. Cont., • Hematologic abnormalities: • RBC count • WBC function • Clotting and bleeding

  24. RBC count: • Normochromic, normocytic anemia ---mainly due to low production of erythropoietin>>> low erythropoiesis. • Additional causes: • Toxic uremic effect on bone marrow • Bone marrow fibrosis due to increased PTH • Reduced RBC survival>>> hemolysis • Blood loss due to capillary fragility and poor platelet function • Increased GI blood loss due to dialysis and use of heparin • Decreased dietary intake and absorption of iron

  25. WBC funtion • Suppression of leukocytes >>> increased susceptibility to infection.

  26. Clotting & Bleeding • Platelet aggregation, platelet factor III & prothrombin >>>> prolonged bleeding time & increased tendency of bleeding.

  27. Secondary hyperparathyroidism • Causes: • Hyperphosphatemia: • Suppresses hydroxylation of 25-OH vit.D to 1,25 diOH vit.D • Hypocalcemia: develops because of : • Decreased intestinal calcium absorption • Calcium binding to high plasma levels of phosphate • Decreased renal production of 1,25 diOH vit.D:

  28. Effects on Bone: Renal Osteodystrophy • High-bone turnover: Osteitis fibrosa: • - Due to hyperparathyroidism • Osteomalacia: • Due to aluminium deposition • Defective mineralization due to decreased active vitamin D • Adynamic bone disease: • -Predominant bone lesion in chronic peritoneal dialysis • Cysts at the ends of long bones: • -Due to dialysis related amyloidosis from beta2-microglubulin accumulation in chronic dialysis (8-10 yrs)

  29. Other manifestations of uremia in ESRD • Pericarditis >>> cardiac temponade • Encephalopathy >>> coma & death • Peripheral Neuropathy • GI symptoms: anorexia, nausea, vomiting, diarrhea • Skin manifestations: Pallor, Dryness, Pruritus, Ecchymosis • Easy fatiguability, failure to thrive • Malnutrition • Erectile dysfunction, decreased libido, amenorrhea.

  30. Management Chronic kidney failure can not be cured but there are four goals of therapy: Slow the progression of disease. Treat underlying causes and contributing factors. Treat complications of disease. Replace lost kidney functions.

  31. The previous goals can be achieved by the following: - Blood glucose and blood pressure control (ACEI) - Diet: low protein diet (controversial) - Treatment of hyperlipidemia. - Avoidance of nephrotoxins such as: - IV radiocontrast. - NSAIDs - Aminoglycosides.

  32. - Treating the complications: • Fluid retention by diuretics • Anemia by injections of a recombinant human hormone, erythropoietin • Low calcium by calcium supplements • Hyperphosphatemia with dietary phosphate binders and dietary phosphate restriction. • Hyperpathayroidism with calcitriol or vitamin D analoges. • Metabolic acidosis with oral alkali supplements. - Treating the uremic manifestations by the following: 1- Hemodialysis: takes 3-4 hours and usually performed about 3 times a week.

  33. 2- Peritoneal dialysis: - It is done by putting 2 Liters of dialysis fluid into the abdominal cavity through a catheter. - The fluid will balance out electrolytes and toxic waste products and it needs to be exchanged 4 times a day. 3- Kidney transplant: can be from living related donors, living unrelated donors or cadavers.

  34. Complications of Haemodialysis: 1- Vascular problems ( CHF) 2- Metabolic complications (Hyperparathyroidism) 3- Neuromuscular (neuropathy) 4- Hematologic (Anemia) 5- GI (bleeding) 6- Genitourinary ( Sexual dysfunction) Complications of peritoneal dialysis: 1- Infections (Peritonitis) 2- New onset diabetes (Hyperglycemia) 3- Hypervolemia (Hypertension, pulmonary edema) 4- Obesity 5- Hypokalemia Complications of renal transplantation: 1- Infections 2- Malignancies 3- Cardiovascular diseases

  35. Thank You

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