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CRONIC RENAL FAILURE

CRONIC RENAL FAILURE. It is a progressive ,irreversible loss of renal function developed over a period of years manifested initially as only biochemical abnormalities ((AZOTEMIA)) and eventually development of the clinical signs and symptoms of chronic renal failure ((URAEMIA)). Etiology.

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CRONIC RENAL FAILURE

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  1. CRONIC RENAL FAILURE

  2. It is a progressive ,irreversible loss of renal function developed over a period of years manifested initially as only biochemical abnormalities ((AZOTEMIA))and eventually development of the clinical signs and symptoms of chronic renal failure ((URAEMIA))

  3. Etiology 1. Hypertension 2. DM 3. GN.

  4. 4. Cystic kidney diseases eg. PKD 5. Interstitial renal diseases 6. Congenital 7. Systemic inflammatory diseases eg. SLE 8. Unknown

  5. Clinical presentations: 1. Asymptomatic and discovered during routine examination to have raised blood urea and serum creatinine 2. Nocturia often an early symptom 3. Often accompanied by hypertension, protienuria, anemia, tiredness, fatigue and anorexia.

  6. 4. Cardiovascular manifestations: hypertension, peripheral oedema, arrhythmia, pericarditis and pericardial effusion 5. GIT symptoms: may be too early in form of nausea, vomiting, hiccoughs &GI bleeding 6. Hematological; fatigue, anemia, bleeding tendency.

  7. 7. Neurological complications : muscular twitching, confusion, drowsiness, fit, restless leg and comma. 8. dermatological: pruritus, earthy color. 9. acute exacerbations (acute on chronic) presented with metabolic acidosis and Kussmaul respiration. 10. features of the underlying cause.

  8. Investigations 1. CBP : anemia (N.N., hypochromic microcytic or macrocytic) 2. ↑B,urea , ↑S. cr. ,↑ K , ↑ phosphate, ↓ ca, ↓bicarbonate 3. Blood sugar and lipid profile 4. hepatitis and HIV serology for dialysis or transplantation

  9. 5.X- ray of the bones may shows features of secondary hyperparathyroidism ( ostitis fibrosa cystica) 6. abdominal Ultrasonography will show small size kidneys or any evidence of obstructive uropathy 7. Chest X- ray ……Heart size , pulmonary edema

  10. 8.ECG……..arrhythmia, pericarditis, IHD, Hyperkalemia 9.Tissue typing if transplantation is considered 10. Specific investigations to identify the underlying cause eg. ANA for SLE

  11. Management A. Treatment of the underlying cause if possible eg. GN B. Look for reversible factors which are making renal function worse - hypertension : antihypertensive drugs with BP goal of 130\85 mmHg

  12. - Obstructive uropathy….Relieve the obstruction - urinary tract infection ..Vigorous treatment - Nephrotoxic medication should be avoided eg. Tetracycline, Nalidixic acid, aspirin, sulphonylurea, spirinolactone and acetazolamide.

  13. C. Retarding the progression of CRF: When serum createnin >3.5 mg\dL. , progressive deterioration in renal function irrespective of its etiology and the rate of deterioration is very variable between patients but it is constant for an individual patient and changes in the slop may be achieved by:

  14. 1. Blood pressure control. 2. Moderate protein restriction to 60 gm\day should be accompanied by adequate intake of calories. 3. specific treatment of the underlying cause eg. Immunosuppressive therapy for GN.

  15. 1. regulation of fluid and electrolytes; D. Limiting the adverse effect of CRF:

  16. - Solute and fluid intake must be restricted as renal failure advanced but those with salt wasting disease may require a high sodium and water intake eg. Cystic kidney diseases and tubulointerstitial diseases while those with glomerular disease require restriction of sodium and water intake to avoid volume overload.

  17. - Diuretics may be necessary if the patient is unable to restrict the sodium intake adequately - correction of acidosis with sodium bicarbonate supplement or in form of calcium carbonate which also used to bind dietary phosphate. - Limitation of potassium intake

  18. - In patient who are unable to maintain their volume status by diet and diuretics or if they are persistently hyperkalaemic or severely acidotic, dialysis therapy is indicated.

  19. 2.Correction of anemia; Anemia is common in those with CRF and it may be result from: a. Relative deficiency of erythropoietin b. Bon marrow depression c. reduced intake and absorption of iron d. ↓ red cell survival e. ↑ blood loss ( bleeding, dialysis, sampling) f. loss of foliate in dialysis

  20. So correction of anemia usually achieved by: a. Recombinant human erythropoietin b. folate supplement c. Iron supplement should be used to keep serum ferritin >100ug.\L. d. Androgen may be used in resistant cases e. blood transfusion in refractory anemia.

  21. 3. Bleeding: it is mostly due to impaired platelet function and adequate dialysis partially correct bleeding tendency. 4. Infection should be recognized and treated promptly

  22. 5. Cardiovascular diseases and lipid: - hypertension develops in about 80% of patients with CRF and it must be controlled as it cause farther vascular and glomerular damage and worsening of renal failure. - Hyperlipidemia commonly seen and anti Hyperlipidemia (statine group) achieve substantial reduction of lipid in chronic renal diseases.

  23. 6. Renal osteodystrophy : it consist of mixture of osteomalacia, hyperparathyroid bone disease (ostitis fibrosa cystica ), osteoporosis and osteosclerosis.

  24. Treatment: a. dietary restriction of food with high phosphate content (milk , cheese ,egg ) b. use of phosphate binding drugs eg. Calcium carbonate. c. 1α – hydroxylated vitamin D. d. In severe bone disease with autonomous parathyroid function , parathyroidectomy may be necessary

  25. 7. Myopathy: a. muscle cramps are common and quinine sulphate may be helpful b. restless leg syndrome often improved by clonazepam.

  26. 8.other adverse effects a. neuropathy: usually appear late and may improve or even resolve once dialysis is established b. amenorrhea treated by dopamine agonists

  27. c. GIT symptoms treated symptomatically and there is higher incidence of peptic ulcer diseases so H2 –receptor antagonists or proton pump inhibitors are commonly used d. depression is common and psychological support should be provided for both the patients and their families

  28. 1. Haemodialysis: E. RENAL REPLACEMENT THERAPY:

  29. - In which there's diffusion of solutes between plasma and dialysate across a synthetic semi-permeable membrane fallowing a concentration gradient. -movement of solutes may be bidirectional and continuo as long as the concentration gradient remain.

  30. - Fluid is removed by applying negative pressure to the dialysate side (( ultrafiltration)). - Vascular access is required and arteriovenous fistula should be formed.

  31. Haemodialysis usually carried out of 3-4 hours, three times per week but usually start with 1 hour and increase the time gradually to prevent • (( disequilibrium Syndrome )). • - It is preferred in patients with obesity, hernia, COPD, back pain, abdominal wall scars and Hypoalbuminemia. • - Anticoagulant are usually required.

  32. 2. Haemofiltration: - It involve the movement of large volumes of fluid across extremely porous membranes - It is effective therapy to critically ill or who is haemodynamically unstable patients.

  33. 3.Peritoneal dialysis; - Uses the peritoneum as a semi permeable dialysis membrane. - Solute move down a concentration gradient and water down an osmotic gradient achieved by using an osmolar compound ((typically glucose)) in the dialysis fluid.

  34. - It is preferred in young children and elderly patient with cardiovascular instability. - Peritonitis is the most common complication

  35. 4.Renal transplantation: - It offer the best chance of long term survival in patient with ESRD. - All patients should be considered for transplantation unless there's contraindication for it. -

  36. In the transplant operation, the donor vessels are anastomosed to the recipient iliac artery and vein and the donor ureter to the bladder.

  37. Contraindications; 1. Malignancy 2. Severe ischemic heart disease 3. Active vasculitis or anti GBM disease 4. Age less than 1 year or more than 75 years. 5. Significant comorbidity

  38. * Complications The most common complication is graft rejection which is of 3 types: 1.Hyperacute rejection: it occurs within min-hours of transplantation (( incompatibility )). 2. Acute rejection: it occurs 2-8 weeks after transplantation. 3. Chronic rejection: it is more indolent and poorly responsive to antirejection therapy.

  39. - Immunosuppressive therapy is required to prevent rejection using; - Cyclosporine or tacrolimus - azathioprime - predenselon - sepsis is an important complication.

  40. GOOD LUCK

  41. GOOD BYE

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