Dr. Rai Muhammad Asghar
Department of Paediatrics BBH
Rawalpindi Medical College
Chronic Renal Failure
Chronic Kidney Disease
Chronic Renal Failure
Chronic Kidney Disease
Defined as either renal injury (proteinuria)
and / or a glomerular filtration...
Etiology:
Under 5 yr (most commonly Congenital
abnormalities)
* Renal Hypoplasia
* Renal Dysplasia
* Obstructive Uropathy
...
Etiology
After 5 yrs (Acquired and inherited disorders)
* Glomerulonephritis
* Nephronophthisis
* Alport Syndrome
Througho...
Pathogenesis
Hyperfiltration Injury
* Final common pathway of glomerular
destruction
* Hypertrophy of remaining nephrons
*...
Pathogenesis (Continued)
Proteinuria:
* Exerts a direct toxic effect
* Infiltration of monocytes / macrophages
* Enhancing...
Stages of CKD
Stage

Description

GFR

1

Kidney damage with normal or ↑ GFR

> 90

2

Kidney damage with mild ↓ GFR 60-89...
Pathophysiology of Chronic Kidney
disease
Accumulation of nitrogenous waste products
Decrease in glomerular filtration rat...
Hyperkalemia
Decrease in GFR
Metabolic acidosis
Excessive potassium intake
Hyporeninemic hypoaldosteronism
Renal Osteodyst...
Anemia
Decreased erythropoietin production
Iron deficiency, Vitamin B12 deficiency
Decreased erythrocyte survival
Bleeding...
Gastrointestinal symptoms (feeding
intolerance abdominal pain)
Gastroesophageal reflux
Decreased gastrointestinal motility...
Clinical Manifestation
Depends upon underlying renal disease
* Lethargy, Anorexia, Vomiting
* Growth failure / short statu...
Physical Examination
* Pallor & sallow appearance
* Short stature
* Bony abnormality of renal osteodystrophy
* Edema
* Hyp...
Laboratory Findings
* Elevated BUN and creatinin
* ↓ GFR
* Hyperkalemia
* Hyponatremia
* Acidosis
* Hypocalcemia
* Hyperph...
GFR
GFR (ml/min /1.73m2) = k x height (cm)
S. Creatinin (mg/dl)
k= 0.33 LBW < 1 yr
0.45 term AGA < 1yr
0.55 children & ado...
Treatment
Aims
* Replacing absent / diminished renal
function
* Slowing progression of renal
dysfunction
Fluid & Electrolyte Management
* Most patients maintain normal sodium &
water balance
* Polyuric with urinary sodium loss:...
Acidosis
Sodium bicarbonate tab.( 650mg =8 mEq base)
Bacitra ((1mEq sodium citrate / ml)
Maintain serum bicarbonate > 22 m...
Nutrition
* Progressive restriction of various dietary components
* Dietary restriction of phosphorus, potassium and sodiu...
Growth
* Short stature is long term sequela
* Growth hormone resistant state
(GH ↑, IGF ↓)
* Abnormality of IGF binding pr...
Renal Osteodystrophy
* Spectrum of bone disorders in CKD
* High turnover bone disease
* Secondary hyperparathyroidism
* Os...
Pathophysiology (Renal Osteodystrophy )
* When GFR decline to 50% of normal
* Decline in 1α hydroxylase
* Decreased produc...
Clinical Manifestations of Renal
Osteodydtrophy
* Muscle weakness, Bone pain
Fractures with minor trauma
Rickitic changes,...
Treatment of Renal Osteodystrophy
* Low phosphorus diet
* Phosphate binders
* Calcium carbonate & calcium acetate
* Sevela...
Anemia
* Inadequate erythropoitin production
* Iron deficiency
* Folic acid , Vitamin B12 deficiency
* Decreased erythrocy...
Hypertension
* Salt-restriction
* Diuretic therapy
* Hydrochlorothiazide 2 mg/kg/24hrs
* Furosemide 1-2 mg/kg/dose
* ACE i...
Immunizations
* Immunization according to the schedule
* Avoid live vaccine if on immunosuppressive drugs
* Give live vacc...
Adjustment in drug dose
adjust doses as per GFR
Strategy to slow the progression
* Optimal control of hypertension
* Maintain serum phosphorus (Ca x Ph=<55)
* Prompt trea...
Chronic renal failure
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Transcript of "Chronic renal failure "

  1. 1. Dr. Rai Muhammad Asghar Department of Paediatrics BBH Rawalpindi Medical College
  2. 2. Chronic Renal Failure Chronic Kidney Disease
  3. 3. Chronic Renal Failure Chronic Kidney Disease Defined as either renal injury (proteinuria) and / or a glomerular filtration rate <60 ml/min/1.73m2 for >3mo Prevalence: 18 per 1 million
  4. 4. Etiology: Under 5 yr (most commonly Congenital abnormalities) * Renal Hypoplasia * Renal Dysplasia * Obstructive Uropathy * Congenital Nephrotic Syndrome * Prune Belly Syndrome * Cortical Necrosis * FSGS * Polycystic Kidney * Renal Vein Thrombosis * Hemolytic Uremic Syndrome
  5. 5. Etiology After 5 yrs (Acquired and inherited disorders) * Glomerulonephritis * Nephronophthisis * Alport Syndrome Throughout Childhood years * Cystinosis * Hyperoxaluria * Polycystic Kidney Disease
  6. 6. Pathogenesis Hyperfiltration Injury * Final common pathway of glomerular destruction * Hypertrophy of remaining nephrons * Increase glomerular blood flow * ↑ glomerular filtration in surviving nephrons * Progressive damage to surviving nephrons (due to elevated hydrostatic pressure / toxic effect) * ↑ excretory burden on surviving nephrons * Sclerosis of nephrons
  7. 7. Pathogenesis (Continued) Proteinuria: * Exerts a direct toxic effect * Infiltration of monocytes / macrophages * Enhancing glomerular sclerosis Hypertension: * Exacerbate disease progression * Arteriolar nephrosclerosis * Hyperfiltartion injury Hyperphosphatemia : * Calcium phosphate deposition Hyperlipidemia: * Oxidant medicated injury
  8. 8. Stages of CKD Stage Description GFR 1 Kidney damage with normal or ↑ GFR > 90 2 Kidney damage with mild ↓ GFR 60-89 3 Moderate ↓ in GFR 30-59 4 Severe decrease in GFR 5-29 5 Kidney failure <15
  9. 9. Pathophysiology of Chronic Kidney disease Accumulation of nitrogenous waste products Decrease in glomerular filtration rate Acidosis Decrease ammonia synthesis. Impaired bicarbonate reabsorption Decrease net acid excretion Sodium Retention Excessive renin production, oliguria Sodium Wasting Solute diuresis, tubular damage
  10. 10. Hyperkalemia Decrease in GFR Metabolic acidosis Excessive potassium intake Hyporeninemic hypoaldosteronism Renal Osteodystrophy Impaired renal production 1,25Dihydroxycholecalciferol Hyperphosphatemia Hypocalcemia Secondary hyperparathyroidism Growth Retardation Inadequate caloric intake Renal osteodystrophy, Metabolic acidosis Anemia, Growth hormone resistance
  11. 11. Anemia Decreased erythropoietin production Iron deficiency, Vitamin B12 deficiency Decreased erythrocyte survival Bleeding tendency Defective platelet function Infection Defective granulocyte functions Indwelling dialysis catheters Neurologic symptoms (fatigue, poor concentration Headache, drowsiness, memory loss, seizures, peripheral neuropathy) Uremic factors, Aluminum toxicity hypertension
  12. 12. Gastrointestinal symptoms (feeding intolerance abdominal pain) Gastroesophageal reflux Decreased gastrointestinal motility Hypertension Volume overload, Excessive renin production Hyperlipidemia Decreased plasma lipoprotein lipase activity Pericarditis / cardiomyopathy Uremic factors, Hypertension Fluid overload Glucose intolerance Tissue insulin resistance
  13. 13. Clinical Manifestation Depends upon underlying renal disease * Lethargy, Anorexia, Vomiting * Growth failure / short stature * Failure of thrive * Pallor * Edema * Hypertension * Hematuria * Proteinuria * Polyuria * UTI
  14. 14. Physical Examination * Pallor & sallow appearance * Short stature * Bony abnormality of renal osteodystrophy * Edema * Hypertension
  15. 15. Laboratory Findings * Elevated BUN and creatinin * ↓ GFR * Hyperkalemia * Hyponatremia * Acidosis * Hypocalcemia * Hyperphosphatemia * Elevated uric acid * Hypoproteinemia (if proteinuria) * Normocytic, normochromic anemia * Elevated serum cholesterol and triglyceride * Hematuria & Proteinuria(glomerulonephritis)
  16. 16. GFR GFR (ml/min /1.73m2) = k x height (cm) S. Creatinin (mg/dl) k= 0.33 LBW < 1 yr 0.45 term AGA < 1yr 0.55 children & adolescent female 0.70 adolescent male
  17. 17. Treatment Aims * Replacing absent / diminished renal function * Slowing progression of renal dysfunction
  18. 18. Fluid & Electrolyte Management * Most patients maintain normal sodium & water balance * Polyuric with urinary sodium loss: give high volume, low caloric density feeding with sodium supplements * High BP, edema or heart failure: require sodium restriction & diuretic therapy * Fluid restriction is rarely necessary untill ESRD * Hyperkalemia: restriction of dietary K+ intake oral alkalinizing agent kayexalate
  19. 19. Acidosis Sodium bicarbonate tab.( 650mg =8 mEq base) Bacitra ((1mEq sodium citrate / ml) Maintain serum bicarbonate > 22 mEq/L
  20. 20. Nutrition * Progressive restriction of various dietary components * Dietary restriction of phosphorus, potassium and sodium * RDA of caloric intake for age * Protein intake 2.5g/kg/day * High biologic value protein (egg, milk, meat, fish, fowl) * Supplement carbohydrate (polycose), fat (MCT) and protein (pro-Mod) * Nasogastric, gastrostomy, or gastrojunal tube feeding * Continuous overnight infusions * Water soluble vitamins, routinely supplied * Zinc and iron only if deficiency * Supplement with fat soluble vitamins – usually not required
  21. 21. Growth * Short stature is long term sequela * Growth hormone resistant state (GH ↑, IGF ↓) * Abnormality of IGF binding protein * Recombinant human GH (0.05mg/kg/24hrs) * Continue until 50th percentile for MPH or achieves a final adult height or undergoes renal transplantation
  22. 22. Renal Osteodystrophy * Spectrum of bone disorders in CKD * High turnover bone disease * Secondary hyperparathyroidism * Osteitis fibrosa cystica
  23. 23. Pathophysiology (Renal Osteodystrophy ) * When GFR decline to 50% of normal * Decline in 1α hydroxylase * Decreased production of activated Vit. D * ↓ intestinal absorption of calcium * Hypocalcaemia * Secondary hyperparathyroidism(to correct hypocalcemia) * Increased bone resorption * When GFR declines to 25% of normal * Hyperphosphatemia – further promotes hypocalcemia and increased PTH
  24. 24. Clinical Manifestations of Renal Osteodydtrophy * Muscle weakness, Bone pain Fractures with minor trauma Rickitic changes, varus or valgus deformity * Ca ↓ Ph ↑, alkaline phosphate ↑, PTH normal * Subperiosteal resorption of bone with widening of metaphysis
  25. 25. Treatment of Renal Osteodystrophy * Low phosphorus diet * Phosphate binders * Calcium carbonate & calcium acetate * Sevelamer (Renagel) non calcium binder * Avoid aluminum based binder * Vitamin D therapy * Maintain calcium / phosphorus product (Ca x PO4) at < 55
  26. 26. Anemia * Inadequate erythropoitin production * Iron deficiency * Folic acid , Vitamin B12 deficiency * Decreased erythrocyte survival * Erythropoitin if Hb < 10g/dl * Dose 50-150 mg/kg/dose S/C 1-3 times/wk * Keep Hb between 12-13 g/dl * Darbopoeitin alfa (longer acting) * Dose 0.45μg/kg/wk
  27. 27. Hypertension * Salt-restriction * Diuretic therapy * Hydrochlorothiazide 2 mg/kg/24hrs * Furosemide 1-2 mg/kg/dose * ACE inhibitors - angiotensin II blockers for proteinuric renal disease (Enalapril, lisiopril, losartin) * Calcium channel blockers (Amlodipin) * B-Blockers (propranolol, atenolol)
  28. 28. Immunizations * Immunization according to the schedule * Avoid live vaccine if on immunosuppressive drugs * Give live vaccine before renal transplantation * Yearly influenza vaccine * Suboptimal response
  29. 29. Adjustment in drug dose adjust doses as per GFR
  30. 30. Strategy to slow the progression * Optimal control of hypertension * Maintain serum phosphorus (Ca x Ph=<55) * Prompt treatment of infections and episodes of dehydration * Correction of anemia * Control of hyperlipidemia * Avoidance of smoking * Prevention of obesity * Avoid use of NSAID * Dietary protein restriction helpful but not recommended in children
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