Medicine 5th year, 3rd, 4th & 5th lectures (Dr. Kawa Husain)

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The lecture has been given on Dec. 5th, 9th & 11th, 2010 by Dr. Kawa Husain.
  • 2. CHRONIC RENAL FAILURE<br />Chronic renal failure (CRF) refers to an irreversible deterioration in renal function which classically develops over a period of years . <br />
  • 3. Initially, CRF manifest only as a biochemical abnormality. <br />Eventually, loss of the excretory, metabolic and endocrine functions of the kidney leads to the development of the clinical symptoms and signs of renal failure, which are referred to as uraemia. <br />End stage renal disease (ESRD):renal failure which need renal replacement therapy.<br />When death is likely without renal replacement therapy, it is called end-stage renal failure (ESRF).<br />
  • 4. Aetiology of CRF<br />CRF may be caused by any condition which destroys the normal structure and function of the kidney.<br />
  • 5. Common causes of Chronic Renal Failure<br />Diabetes Mellitus <br />Hypertension <br />Glomerulonephritis<br />Chronic pylonephritis/reflux 10%<br />Polycystic kidney disease <br />Interstitial nephritis <br />Obstruction <br />Unknown <br />
  • 6. Diabetes (most common cause)<br /> Hypertension<br /> Chronic Glomerulonephritis<br />Polycystic Kidney Disease<br />
  • 7. Pathogenesis of CRF<br />Disturbances in water, electrolyte and acid-base balance contribute to the clinical picture in patients with CRF, but the exact pathogenesis of the clinical syndrome of uraemia is unknown. <br />Many substances present in abnormal concentration in the plasma have been suspected as being 'uraemic toxins', and uraemia is probably caused by the accumulation of various intermediary products of metabolism.<br />
  • 8. Clinical Features of CRF<br />
  • 9. Major manifestations of Uremic Syndrome<br />The Uremic Syndrome:<br />Gastrointestinal<br /> -Anorexia , Nausea , Vomiting , Disturbance of taste , Gastritis Peptic ulcer , GI bleeding.<br />Cardiovascular <br /> - Cardiomegally , arrhythmias , pericarditis , accelerated atherosclerosis.<br />Pulmonary <br /> -Pneumonitis , pleuritis, pleural effusion , non-cardiogenic pulmonary oedema.<br />Haematologic<br /> - Anaemia , bleeding disorders , leukocyte dysfunction.<br />
  • 10. Skin<br /> -Pruritus , yellow pigmentation , earthy colour face.<br />Musculoskeletal <br /> -Muscle weakness , gout & pseudogout , renal osteodystrophy .<br />Endocrine / Metabolic<br /> -Hyperparathyroidism , amenorrhea , impotence , hyperlipidemia increased insulin resistance.<br />Acid base / Electrolytes<br /> -Acidosis , hyperkalemia , fluid overload , hypocalcemia , hyperphosphatemia , hypermagnesemia.<br />Nervous system <br /> -Central : irritability , insomnia , lethargy , seizures , coma.<br /> -Peripheral : glove-and stocking sensory loss , restless leg , foot drop or wrist drop.<br />
  • 11. Clinical assessment<br />Renal failure may present as a raised blood urea and creatinine found during routine examination, often accompanied by hypertension, proteinuriaoranaemia. <br />When renal function deteriorates slowly, patients may remain asymptomatic until GFR falls below 20 - 30 ml/minute( normal range 80 – 120 mL/ min ). <br />Nocturia, due to the loss of concentrating ability and increased osmotic load per nephron, is often an early symptom. <br />Thereafter, due to the widespread effects of renal failure, symptoms and signs may develop that are related to almost every body system . <br />
  • 12. Patients may present with complains which are not obviously renal in origin, such as tiredness or breathlessness. <br />There may be unusually deep respiration related to metabolic acidosis (Kussmaul's respiration). <br />Later, hiccoughs, pruritus, anorexia and nausea. <br /> vomiting, muscular twitching, fits, drowsiness and coma ensue.<br />
  • 13. Specific manifestations of Uremia<br />
  • 14. Specific manifestations of Uremia<br />Gastrointestinal manifestations <br />Are common at low GFRs, including: <br />anorexia followed by nausea, and vomiting is commonly seen.<br />There is a higher incidence of peptic ulcer disease in uraemic patients.<br />
  • 15. Anaemia<br />Anaemia is common in CRF; it usually correlates with the severity of renal failure and contributes to many of the non-specific symptoms of CRF. <br />Several mechanisms are implicated(causes of anaemiainCRF):<br /> 1- Relative deficiency of erythropoietin <br /> 2- Diminished erythropoiesis due to toxic effects of uraemia on marrow precursor cells <br /> 3- Reduced red cell survival <br /> 4- Increased blood loss due to capillary fragility and poor platelet function <br /> 5- Reduced dietary intake and absorption of iron and other haematinics. <br />
  • 16. Plasma erythropoietin is usually within the normal range and thus inappropriately low for the degree of anaemia. <br />In patients with polycystic kidneys, anaemia is often less severe or absent, while in some interstitial disorders it appears disproportionately severe for the degree of renal failure. This is probably because of the effects of these disorders on the interstitial fibroblasts that secrete erythropoietin<br />
  • 17. Acidosis<br />Declining renal function is associated with metabolic acidosis , which is often asymptomatic. There may be unusually deep respiration related to metabolic acidosis (Kussmaul's respiration).<br />Effects of metabolic acidosis :<br />Sustained acidosis results in protons being buffered in bone in place of calcium, thus aggravating metabolic bone disease. <br />Acidosis may also contribute to reduced renal function and increased tissue catabolism. <br />
  • 18. Cardiovascular disease and lipids <br />CRF is an independent risk factor for occlusive cardiovascular disease. <br />Hypertensiondevelops in approximately 80% of patients with CRF. <br /> In part, this is caused by sodium retention. <br /> Chronically diseased kidneys also tend to hypersecreterenin, leading to high circulating concentrations of renin, angiotensin II and aldosterone. <br /> This is exaggerated if there is renal under-perfusion related to renal vascular disease. <br /> Hypertension must be controlled, as it causes further vascular and glomerular damage and worsening of renal failure<br />Atherosclerosisis common and may be accelerated by hypertension. <br />
  • 19. Pericarditisis common in untreated or inadequately treated ESRF. <br /> It may lead to pericardial tamponade and, later, constrictive pericarditis. <br />Hypercholesterolaemia<br /> is almost universal in patients with significant proteinuria, and increased triglyceride levels are also common in patients with CRF. <br /> It has been suggested that as well as influencing the development of vascular disease, this may accelerate the progression of chronic renal disease.<br />
  • 20. Renal osteodystrophy<br />This metabolic bone disease which accompanies CRF consists of a mixture of osteomalacia,hyperparathyroid bone disease (osteitisfibrosa), osteoporosis and osteosclerosis. <br />Osteomalacia<br />Results from diminished activity of the renal 1α-hydroxylase enzyme, with failure to convert cholecalciferol to its active metabolite, 1,25-dihydroxycholecalciferol. <br />A deficiency of the latter leads to diminished intestinal absorption of calcium, hypocalcaemia and reduction in the calcification of osteoid in bone. <br />
  • 21. Osteitisfibrosaresults from this secondary hyperparathyroidism .<br />The parathyroid glands are stimulated by the low plasma calcium, and also by hyperphosphataemia.<br /> In some patients tertiary or autonomous hyperparathyroidism with hypercalcaemia develops. <br />Osteoporosis occurs in many patients , possibly related to malnutrition.<br />Osteosclerosisis seen mainly in the sacral area, at the base of the skull and in the vertebrae; the cause of this unusual reaction is not known.<br />
  • 22. Myopathy<br />Generalisedmyopathyis due to a combination of poor nutrition, hyperparathyroidism, vitamin D deficiency and disorders of electrolyte metabolism. <br />Muscle cramps are common, and quinine sulphate may be helpful. <br />The 'restless leg syndrome', in which the patient's legs are jumpy during the night, may be troublesome and is often improved by clonazepam<br />
  • 23. Neuropathy<br />Neuropathy results from demyelination of medullatedfibres, with the longer fibres being involved at an earlier stage. <br />Sensory neuropathy may cause paraesthesiae. Amitriptyline and gabapentin may provide some symptom relief. <br />Motor neuropathy may present as foot drop.<br />Uraemic autonomic neuropathy may cause delayed gastric empty-ing, diarrhoea and postural hypotension. <br />Clinical manifestations of neuropathy appear late in the course of CRF but may improve or even resolve once dialysis is established.<br />
  • 24. Endocrine Function<br /> A number of hormonal abnormalities may be present of which the most important are hyperprolactinaemia & hyperparathyroidism . <br />In both sexes there is loss of libido and sexual function, related at least in part to hyperprolactinaemia . <br /> In women amenorrhoea is common.<br />The half-life of insulin is prolongedin CRF due to reduced tubular metabolism of insulin; insulin requirements may therefore decline in diabetic patients in end-stage CRF. <br />However, there is also a post-receptor defect in insulin action, leading to relative insulin resistance. <br />This latter abnormality is improved by dialysis treatment. <br />
  • 25. Bleeding<br />There is an increased bleeding tendency in renal failure which manifests in patients with advanced disease as cutaneousecchymoses and mucosal bleeds.<br />Platelet function is impaired and bleeding time prolonged. <br />Adequate dialysis treatment partially corrects the bleeding tendency.<br />
  • 26. Infection<br />Cellular and humoral immunity are impaired, with increased susceptibility to infection.<br /> Infections are the second most common cause of death in dialysis patients, after cardiovascular disease; they must be recognised and treated promptly.<br />
  • 27. Acute or Chronic Renal failure?<br />History<br />Previous renal function test.<br />Small kidneys on u/s<br />Anaemia.<br />Bone changes.<br />
  • 28. Investigations and management of CRF<br />
  • 29. Investigations and management of CRF<br />There are several aspects to the management of CRF: <br />Identify the underlying renal disease. <br />Look for reversible factors which are making renal function worse . <br />Attempt to prevent further renal damage. <br />Attempt to limit the adverse effects of the loss of renal function. <br />Institute renal replacement therapy (dialysis or transplantation)<br />
  • 30. .At presentation the nature of the underlying disease should be determined, if possible, by<br /> history, examination, testing of biochemistry, immunology, radiology and biopsy .<br /> The degree of renal failure is assessed and complications are documented. <br />
  • 31. Investigations <br /> -Blood urea & serum creatinine: increased<br />- Serum electrolytes <br /> .serum calcium :decreased<br /> .serum potassium : increased ( risky )<br /> .serum uric acid : increased(but rarely cause gout ) <br /> .serum phosphate : increased<br />General urine examination: for: protein , RBC , features of UTI ( may need urine culture ) , cast ( waxy broad cast is characteristic for CRF)<br />Complete blood picture: usually there is anaemia. <br />PH of blood : metabolic acidosis.<br />Viral markers : HBsAg , Anti-HCV Ab & HIV test (if the patient need dialysis ) (vaccination against hepatitis B if no previous infection; isolation of dialysis machine if positive) .<br />
  • 32. ECG: look for<br /> -Features of hyperkalemia (hyperacute T- wave ,then prolongation of PR- interval & QRS ,then loss of P-wave , & if not managed may cause asystole )<br /> -Features of pericardial effusion( low voltage ECG ).<br /> -Features of IHD.<br />Echocardiography: look for any evidence of pericardial effusion<br /> or cardiomyopathy ( DCMP).<br />CXR: look for features of pulmonary oedema , pleural effusion , chest infection , enlarged cardiac shadow.<br />Abdominal Ultrasoud: look for the size & ecchogenecity of the kidneys & if there is ascitis.<br /> In CRF , usually bilateral small kidneys (except polycystic kidney disease , amyloidosis , hydronephrosis , diabetic nephropathy )<br />
  • 33. X- ray of bone : for evidence of renal osteodystrophy.<br />Renal biopsy : only indicated in CRF with normal size kidneys<br /> ( not indicated in CRF with small size kidneys ).<br />GFR<br />If diagnosis is not known further investigation needed as :<br />Immunoglobulins and protein electrophoresis <br />Urinary Bence Jones protein <br />Complement <br />ANA: and dsDNA if ANA is positive <br />Rheumatoid factor <br />ANCA: in all possible inflammatory renal disease <br />Anti-GBM: in all possible inflammatory renal disease <br />Cryoglobulins: if cryoglobulinaemia is clinically suspected <br />
  • 34. Patients often have bilateral small kidneys at presentation, and in such a situation renal biopsy is usually inadvisable because of the difficulty in making a histological diagnosis in severely damaged kidneys and the fact that treatment is unlikely to improve renal function significantly<br />
  • 35. Hyperkalemia & EKG<br />K > 5.5 -6<br />Tall, peaked T’s<br />Wide QRS<br />Prolong PR<br />Diminished P<br />Prolonged QT<br />QRS-T merge – sine wave<br />
  • 36.
  • 37. Chronic Kidney Disease Staging<br />
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