Chronic Renal Failure for General Practice

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 600/M >5000/M

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

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

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

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

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 LIVING DONOR PRE-DIALYSIS 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