17 Renal Failure S Ghamdi

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17 Renal Failure S Ghamdi

  1. 1. R enal F ailure : acute, chronic &ESRD Saeed M.G. Al-Ghamdi, FRCPS,FACP Faculty of Medicine King Abdulaziz University Hospital
  2. 2. RF : Items for Discussion <ul><li>Definitions of ARF, CRF & ESRD </li></ul><ul><li>Classification & causes of RF </li></ul><ul><li>Statistics </li></ul><ul><li>Presentations </li></ul><ul><li>Investigations </li></ul><ul><li>Treatment </li></ul>
  3. 3. ARF : Definition <ul><li>Abrupt decline of Glomerular filtration rate which is potentially reversible </li></ul>
  4. 4. ARF: Statistics <ul><li>Prevalence: </li></ul><ul><ul><li>In 5% of medical-surgical ward admission </li></ul></ul><ul><ul><li>In 25% of non-emergent surgery </li></ul></ul><ul><ul><li>In 15% of ICU admission </li></ul></ul><ul><li>Mortality: </li></ul><ul><ul><li>Oliguric ARF: 50-80% </li></ul></ul><ul><ul><li>Non-Oliguric ARF: 15-40% </li></ul></ul><ul><ul><li>Risk of death: 6.2 folds </li></ul></ul>
  5. 5. ARF: Classification & Causes <ul><li>Pre-renal ARF : 40-80% </li></ul><ul><li>Renal ARF: 20-30% </li></ul><ul><li>Post-renal ARF : 2-10% </li></ul>
  6. 6. Pre-renal Causes: <ul><li>1) Extra-renal fluid loss: </li></ul><ul><ul><li>Vomiting </li></ul></ul><ul><ul><li>Continuous un-replaced NG suctioning </li></ul></ul><ul><ul><li>Continuous un-replaced drainage </li></ul></ul><ul><ul><li>Diarrhea , intestinal fistula </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Intestinal obstruction </li></ul></ul><ul><ul><li>Excessive Sweating & heat stroke ,burns </li></ul></ul>
  7. 7. Pre-renal Causes: <ul><li>2) Renal fluid loss </li></ul><ul><ul><li>Osmotic Diuretics: hyperglycemia, mannitol </li></ul></ul><ul><ul><li>Loop and thiazide diuretics </li></ul></ul><ul><ul><li>Un-replaced post-obstructive diurecis </li></ul></ul><ul><li>3) Change in renal hemodynamics </li></ul><ul><ul><li>ACEI in bilateral Renal Artery Stenosis </li></ul></ul><ul><ul><li>NSAIDS in patient with dehydration or CHF </li></ul></ul>
  8. 8. Pre-renal Causes <ul><li>4) Cardiac causes </li></ul><ul><li>Due to renal hypo-perfusion </li></ul><ul><ul><li>In severe systolic heart failure (EF <15%) </li></ul></ul><ul><ul><li>Severe valvular heart disease </li></ul></ul><ul><ul><li>Arrhythmias: Complete Heart Block </li></ul></ul><ul><ul><li>Cardiac temponade </li></ul></ul><ul><ul><li>Right Ventricular Infarction </li></ul></ul><ul><ul><li>Severe core pulmonale </li></ul></ul>
  9. 9. ARF: Pre-renal Causes <ul><li>5) Peripheral vasodilatation: </li></ul><ul><ul><li>Anti-hypertensive drugs </li></ul></ul><ul><li>6) Hepato-Renal Syndrome </li></ul><ul><li>Due to renal vaso-constrictors & third spacing </li></ul><ul><ul><li>In advanced irreversible liver disease </li></ul></ul><ul><ul><li>Other causes of ARF should be ruled out </li></ul></ul><ul><ul><li>Very low urine sodium (<10) </li></ul></ul>
  10. 10. Renal Causes of ARF <ul><li>1) acute tubular necrosis (ATN) </li></ul><ul><ul><li>Septic syndrome (with & without hypotension) </li></ul></ul><ul><ul><li>Significant bleeding leading to prolonged hypotension </li></ul></ul><ul><ul><li>Severe dehydration leading to prolonged hypotension </li></ul></ul><ul><ul><li>Cardiogenic shock </li></ul></ul><ul><ul><li>Severe PET & ET </li></ul></ul>
  11. 11. Renal Causes of ARF (Cont..) <ul><li>2 ) Toxic and pigment-induced ATN </li></ul><ul><ul><li>Aminoglycoside nephrotoxicity </li></ul></ul><ul><ul><li>Amphotericin-induced nephrotoxicity </li></ul></ul><ul><ul><li>Contrast-nephropathy </li></ul></ul><ul><ul><li>Hemoglobinuria (severe intravascular hemolysis) </li></ul></ul><ul><ul><li>Myoglobinuria (Rhabdomyolysis) </li></ul></ul>
  12. 12. Renal Causes of ARF (Cont..) <ul><li>3) Glomerular diseases and systemic vasculitis </li></ul><ul><ul><li>Rapidly progressive Glomerulonephritis (RPGN) </li></ul></ul><ul><ul><ul><li>Immune-complex nephritis: (post-infectious GN, lupus nephritis, HSP, ..Etc.) </li></ul></ul></ul><ul><ul><ul><li>Anti-GBM disease </li></ul></ul></ul><ul><ul><ul><li>Pauci-immune nephritis: Wegener's Granulomatosis </li></ul></ul></ul>
  13. 13. Renal Causes of ARF (Cont..) <ul><li>4) acute interstitial nephritis </li></ul><ul><ul><li>Drug-induced (NSAIDS, beta lactam antibiotics,rifampicin, furosemide, allopurinol ..Etc.) </li></ul></ul><ul><ul><li>Auto-immune (SLE, Sjogren syndrome, HES ) </li></ul></ul><ul><ul><li>Infection-related (Legionella, salmonella ,..Etc.) </li></ul></ul><ul><ul><li>Sarcoidosis </li></ul></ul><ul><ul><li>Idiopathic </li></ul></ul>
  14. 14. Renal Causes of ARF (Cont..) <ul><li>5) Acute Pyelonephritis </li></ul><ul><ul><li>In transplant kidney </li></ul></ul><ul><ul><li>In single functioning kidney </li></ul></ul><ul><li>6) Acute Allograft Rejection </li></ul><ul><li>7) Lymphomatous Infiltration of the kidneys </li></ul><ul><ul><li>In HIV+ve Patients </li></ul></ul><ul><ul><li>PTLD </li></ul></ul>
  15. 15. ARF: Renal Causes <ul><li>8) renal vasular & Ischemic disorders </li></ul><ul><ul><li>Vasculitis </li></ul></ul><ul><ul><li>Scleroderma renal crisis </li></ul></ul><ul><ul><li>Malignant HTN </li></ul></ul><ul><ul><li>TTP, HUS, DIC </li></ul></ul><ul><ul><li>Renal artery thrombosis </li></ul></ul><ul><ul><li>Renal vein thrombosis </li></ul></ul><ul><ul><li>Cholesterol Athero-embolic disease </li></ul></ul>
  16. 16. ARF: Renal Causes (contin..) <ul><li>9) acute cortical necrosis (ACN) </li></ul><ul><ul><li>In association with hypotension and DIC </li></ul></ul><ul><ul><ul><li>Abruptio placenta, placenta previa </li></ul></ul></ul><ul><ul><ul><li>IUFD </li></ul></ul></ul><ul><ul><li>Presentation: </li></ul></ul><ul><ul><ul><li>Loin pain </li></ul></ul></ul><ul><ul><ul><li>Anuria </li></ul></ul></ul><ul><ul><ul><li>Gross hematuria </li></ul></ul></ul><ul><ul><ul><li>Cortical calcification (after healing) </li></ul></ul></ul>
  17. 17. Renal Causes of ARF (Cont..) <ul><li>10) acute papillary necrosis </li></ul><ul><ul><li>Acute Pyelonephritis in diabetic </li></ul></ul><ul><ul><li>Sickle cell disease </li></ul></ul><ul><ul><li>Phenacetin-induced nephropathy </li></ul></ul><ul><li>Pesentation: </li></ul><ul><ul><li>Loin pain </li></ul></ul><ul><ul><li>Oligo-anuria </li></ul></ul><ul><ul><li>Passage of tissues (papillae) </li></ul></ul>
  18. 18. ARF : Presentation (Cont..) <ul><li>Features suggest renal causes of ARF </li></ul><ul><ul><li>History of arthritis and or arthralgia </li></ul></ul><ul><ul><li>Recent drug exposure </li></ul></ul><ul><ul><li>Recent surgery and or intervention </li></ul></ul><ul><ul><li>Recent URTI or tonsillitis </li></ul></ul><ul><ul><li>Peri-orbital and facial edema </li></ul></ul><ul><ul><li>HTN and absence of signs of hypovolemia </li></ul></ul><ul><ul><li>Vasculitis or livedo reticularis </li></ul></ul>
  19. 19. ARF: Post-renal Causes <ul><li>Intra-renal (tubular) obstruction : (medical) </li></ul><ul><ul><li>Acute uric acid nephropathy </li></ul></ul><ul><ul><li>Calcium oxalate Crystalluria: ethylene glycol poisoning or high dose vitamin C </li></ul></ul><ul><ul><li>Myeloma cast nephropathy </li></ul></ul><ul><ul><li>IV Methotrexate crystalluria </li></ul></ul><ul><ul><li>IV acylovir and oral Indinavir crystalluria </li></ul></ul><ul><ul><li>Sulfonamides crystalluria (sulfadiazine, SMZ) </li></ul></ul>
  20. 20. Post-renal Causes of ARF <ul><li>Extra- renal ( tubular ) obstruction (surgical) </li></ul><ul><ul><li>Ureteral/pelvic </li></ul></ul><ul><ul><ul><li>Intrinsic: tumor, stone, clot, papilla </li></ul></ul></ul><ul><ul><ul><li>Extrinsic: retroperitoneal and pelvic malignancies , fibrosis and ligation </li></ul></ul></ul><ul><ul><li>Bladder: stones, clots, tumor, neurogenic, BPH, Prostatic ca , post-operative </li></ul></ul><ul><ul><li>Uretheral: PUV , stone …etc </li></ul></ul>
  21. 21. ARF: Causes Vasculitis & thrombosis & CAED ACEI & NSAID in predisposed patients Acute GN Severe cardiac failure Surgical obstruction Interstitial nephritis Systemic vaso-dilatation Intra-tubular obstruction ATN Renal & extra-renal fluid loss Post-renal Renal Pre-Renal
  22. 22. Renal Artery Thrombosis <ul><li>In hyper-coagulable states </li></ul><ul><li>Presentation: </li></ul><ul><ul><li>Severe loin pain </li></ul></ul><ul><ul><li>Gross hematuria </li></ul></ul><ul><ul><li>Complete anuria if bilateral </li></ul></ul><ul><li>Diagnosis by Doppler, IVP & Angiogram </li></ul><ul><li>Treated by thrombolysis and or heparin </li></ul>
  23. 23. Renal Vein Thrombosis : S&S <ul><li>L oin pain </li></ul><ul><li>Macro and or Microhematuria </li></ul><ul><li>Proteinuria </li></ul><ul><li>ARF if bilateral or single kidney </li></ul><ul><li>Diagnosed by </li></ul><ul><ul><li>U/S Doppler </li></ul></ul><ul><ul><li>Spiral CT </li></ul></ul><ul><ul><li>Renal venography </li></ul></ul>
  24. 24. RVT : Predisposing Factors <ul><li>Severe dehydration in neonates </li></ul><ul><li>Severe nephrotic syndrome (S.Alb.<20 g) </li></ul><ul><li>Hypercoagulable states </li></ul><ul><ul><li>Protein S or C deficiency </li></ul></ul><ul><ul><li>Anti-Phospholipids antibody syndrome </li></ul></ul><ul><ul><li>Homocysteinuria </li></ul></ul><ul><ul><li>Malignancies </li></ul></ul>
  25. 25. Cholesterol Athero-embolic Disease <ul><li>Predisposing factors </li></ul><ul><ul><li>Follows intravascular intervention </li></ul></ul><ul><ul><li>May follow bellow renal vascular surgery </li></ul></ul><ul><ul><li>May occur after anti-coagulation </li></ul></ul><ul><ul><li>May occur spontaneously </li></ul></ul>
  26. 26. CAED : Presentation <ul><li>3-6 weeks after vascular instrumentation </li></ul><ul><ul><li>Progressive rise of S.Creatinine </li></ul></ul><ul><ul><li>Livedo Reticularis </li></ul></ul><ul><ul><li>Gangrenous toes and peripheral skin </li></ul></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><ul><li>Eosinophilia </li></ul></ul><ul><ul><li>Hypocomplementemia </li></ul></ul><ul><ul><li>Diagnosed by kidney biopsy </li></ul></ul>
  27. 27. ARF : Presentation <ul><li>Features suggest pre-renal. </li></ul><ul><ul><li>Vomiting, diarrhea , NGT ..Etc. </li></ul></ul><ul><ul><li>Uncontrolled DM. </li></ul></ul><ul><ul><li>Diuretic use. </li></ul></ul><ul><ul><li>Exposure to sun and hot weather. </li></ul></ul><ul><ul><li>Postural hypotension and tachycardia. </li></ul></ul><ul><ul><li>Low JVP. </li></ul></ul><ul><ul><li>Dry axilla and mucous membranes. </li></ul></ul>
  28. 28. ARF : Investigations <ul><li>Rapidly rising S.Cr. & hyperkalemia </li></ul><ul><li>U/S kidneys & bladder </li></ul><ul><li>Urine analysis </li></ul><ul><ul><li>RBCs and RBC casts suggest GN </li></ul></ul><ul><ul><li>WBCs and WBC casts suggest AIN or acute pyelonephritis </li></ul></ul><ul><ul><li>Brown granular casts suggest ATN </li></ul></ul>
  29. 29. ARF : Investigations (Cont..) <ul><li>Urine Eosinophils : In AIN </li></ul><ul><li>Urine myoglobulin : in Rhabdomyolysis </li></ul><ul><li>Urine hemoglobin : in Hemoglobinuria </li></ul><ul><li>Urine sodium : </li></ul><ul><ul><li><10 mmol/l, suggest pre-renal </li></ul></ul><ul><li>Na + Excretion Fraction: </li></ul><ul><ul><li><1% suggest pre-renal </li></ul></ul><ul><ul><li>> 3% suggest ATN </li></ul></ul>
  30. 30. ARF: Investigations <ul><li>Fractional excretion of sodium: </li></ul><ul><li> U Na X P Cr </li></ul><ul><li>FENa: ----------------- X 100 = </li></ul><ul><li> P Na X Ucr </li></ul><ul><ul><li>< 1%: Pre-renal </li></ul></ul><ul><ul><li>> 3%: ATN </li></ul></ul>
  31. 31. ARF : Investigations (Cont..) <ul><li>Positive ANA & Anti-dsDNA in lupus nephritis </li></ul><ul><li>Low C 3 & C 4 in : </li></ul><ul><ul><li>Lupus nephritis </li></ul></ul><ul><ul><li>Pos-infectious GN </li></ul></ul><ul><ul><li>MPGN </li></ul></ul><ul><li>Falsely positive RF in cryoglobulinemia </li></ul>
  32. 32. ARF : Investigations (Cont..) <ul><li>Positive ANCA. </li></ul><ul><ul><li>Wegener's Granulomatosis. </li></ul></ul><ul><ul><li>Microscopic Poly-Angiitis. </li></ul></ul><ul><ul><li>Poly-Arteritis Nodosa. </li></ul></ul><ul><li>Positive Anti-GBM in Good Pasture ’ s syn. </li></ul><ul><li>Monoclonal band in Serum and or urine electrophoresis in patients with paraprotein. </li></ul>
  33. 33. ARF : Investigations (Cont..) <ul><li>CBC </li></ul><ul><ul><li>Neutrophilic Leucocytosis in infection </li></ul></ul><ul><ul><li>Eosinophilia in allergic interstitial nephritis </li></ul></ul><ul><ul><li>Leucopenia & Thrombocytopenia suggest SLE </li></ul></ul><ul><li>Prolonged PT & PTT and low fibrinogen in DIC and sepsis </li></ul><ul><li>Prolonged uncorrectable PTT in SLE </li></ul>
  34. 34. ARF: Treatment <ul><li>First: Treatment of the underlying cause </li></ul><ul><li>Second: Conservative treatment of established ARF </li></ul><ul><li>Third: Dialysis if indication (s) arise </li></ul>
  35. 35. I) Treatment According to the Cause of ARF <ul><li>Pre-Renal Failure: Hydration </li></ul><ul><li>Post-Renal Failure: </li></ul><ul><ul><li>Relieve obstruction </li></ul></ul><ul><ul><ul><li>Catheterization </li></ul></ul></ul><ul><ul><ul><li>DJS </li></ul></ul></ul><ul><ul><ul><li>Nephrostomy </li></ul></ul></ul><ul><ul><li>Dialysis if indication arises </li></ul></ul><ul><ul><li>Replace urine output ( Post-Obstructive Diurecis) </li></ul></ul>
  36. 36. I) Treatment According to the Cause of ARF (contin..) <ul><li>ATN and sepsis: </li></ul><ul><ul><li>IV Fluids (colloids & crystalloid) </li></ul></ul><ul><ul><li>Inotropes (Dopamine, Norepinephrine) </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><li>Furosemide </li></ul></ul><ul><ul><li>In established ARF: Conservative treatment </li></ul></ul><ul><ul><li>If indication for dialysis: CRRT </li></ul></ul>
  37. 37. I) Treatment According to the Cause ARF (contin..) <ul><li>Drug-induced ATN: </li></ul><ul><ul><li>Discontinue the offending drug (s) </li></ul></ul><ul><ul><li>Avoid nephrotoxins </li></ul></ul><ul><ul><li>Conservative treatment of established ARF </li></ul></ul><ul><ul><li>Recovery is the rule </li></ul></ul><ul><ul><li>If indication for dialysis arises: HD, PD or CRRT </li></ul></ul>
  38. 38. I) Treatment According to the Cause of ARF (contin..) <ul><li>Rhabdomyolysis (early with non-oliguria) </li></ul><ul><ul><li>Urine alkalinization with Na bicarbonate </li></ul></ul><ul><ul><li>Mannitol </li></ul></ul><ul><ul><li>Furosemide </li></ul></ul><ul><li>Rhabdomyolysis (late with oliguria) </li></ul><ul><ul><li>Conservative treatment of established ARF </li></ul></ul><ul><ul><li>Hemodialysis if indications arise </li></ul></ul>
  39. 39. II) Conservative Treatment of Established ARF <ul><li>Daily Fluid Intake : the previous 24 h urine output + insensible water loss </li></ul><ul><li>Hyperkalemia: </li></ul><ul><ul><li>Low K + diet </li></ul></ul><ul><ul><li>Calcium resonium </li></ul></ul><ul><ul><li>Insulin + dextrose </li></ul></ul><ul><ul><li>Inhaled Beta agonist </li></ul></ul><ul><ul><li>Calcium gluconate iv (in EKG changes) </li></ul></ul>
  40. 40. II) Conservative Treatment of Established ARF (contin..) <ul><li>Metabolic acidosis: </li></ul><ul><ul><li>IV Sodium bicarbonate (in severe cases) </li></ul></ul><ul><ul><li>oral Na bicarbonate (in mild to moderate cases) </li></ul></ul><ul><ul><li>May cause volume overload </li></ul></ul><ul><li>Protein intake: if catabolic, low protein diet </li></ul><ul><li>Medications: </li></ul><ul><ul><li>Adjust the dose to Cr. clearance </li></ul></ul><ul><ul><li>Avoid nephrotoxins </li></ul></ul>
  41. 41. I) Treatment According to the Cause of ARF (contin..) <ul><li>Allergic Interstitial Nephritis </li></ul><ul><ul><li>Stop the offending drug </li></ul></ul><ul><ul><li>Prednisolone 1mg/kg/d for 6 weeks </li></ul></ul><ul><ul><li>Hemodialysis if indication arise </li></ul></ul><ul><li>Acute Pyelonephritis </li></ul><ul><ul><li>Hydration </li></ul></ul><ul><ul><li>Amp+genta in uncomplicated </li></ul></ul><ul><ul><li>Ceftazidime or ciproflox. + genta (complicated) </li></ul></ul>
  42. 42. CRF: definition <ul><li>Chronic, slow, indolent, progressive deterioration of Glomerular filtration rate which is irreversible </li></ul>
  43. 43. CRF: Causes <ul><li>DM: 30% </li></ul><ul><li>HTN: 26% </li></ul><ul><li>Glomerulonephritis : 14% </li></ul><ul><li>Other causes: 30% </li></ul><ul><ul><li>Chronic interstitial diseases </li></ul></ul><ul><ul><li>Obstructive Uropathy </li></ul></ul><ul><ul><li>ADPKD </li></ul></ul>
  44. 44. CRF: Causes in Children <ul><li>Congenital renal hypoplasia and dysplasia. </li></ul><ul><li>Vesico-Ureteric Reflux. </li></ul><ul><li>Congenital cystic diseases. </li></ul><ul><ul><li>ARPKD. </li></ul></ul><ul><ul><li>Multicystic disease. </li></ul></ul><ul><ul><li>MCD (Juvenile Nephronophthasis). </li></ul></ul><ul><li>Obstructive diseases: PUV, etc.... </li></ul>
  45. 45. CRF: Causes in Children <ul><li>Congenital glomerulonephritis </li></ul><ul><ul><ul><li>Alport’s syndrome </li></ul></ul></ul><ul><ul><ul><li>Congenital FSGS </li></ul></ul></ul><ul><li>Glomerulonephritis </li></ul><ul><ul><ul><li>Unresponsive GN </li></ul></ul></ul><ul><ul><ul><li>DMS </li></ul></ul></ul><ul><li>HUS </li></ul><ul><ul><ul><li>Congenital HUS </li></ul></ul></ul><ul><ul><ul><li>Post-diarrheal HUS </li></ul></ul></ul>
  46. 46. CRF: Presentation <ul><li>In mild to moderate disease; GFR >40 ml/min. </li></ul><ul><li>As ymptomatic. </li></ul><ul><li>Incidental discovery of high urea & Cr. </li></ul><ul><li>Discovery of concomitant or causative disease, e.g... </li></ul><ul><ul><li>PKD, etc.... </li></ul></ul><ul><ul><li>Hypertension. </li></ul></ul>
  47. 47. CRF: Presentation (Cont...) <ul><li>In moderate to moderately severe CRF: </li></ul><ul><li>GFR> 15 mls/min and < 40 mls/min </li></ul><ul><li>Polyuria & polydepsia </li></ul><ul><li>Generalized fatigue </li></ul><ul><li>Sexual dysfunction </li></ul><ul><li>Bruiritis </li></ul><ul><li>Bone pain and muscle weakness </li></ul>
  48. 48. CRF: Diagnosis <ul><li>Requires three perquisites: </li></ul><ul><li>Co-existence of disease that cause CRF </li></ul><ul><li>Evidence of Progressive Renal Dysfunction </li></ul><ul><li>Evidence of Extra-renal uremic organ dysfunction </li></ul>
  49. 49. CRF: Diagnosis <ul><li>Coexistence of disease that cause CRF </li></ul><ul><ul><li>Long standing DM (>10 years) </li></ul></ul><ul><ul><li>Long standing uncontrolled HTN </li></ul></ul><ul><ul><li>Remote history of hematuria or proteinuria </li></ul></ul><ul><ul><li>Recurrent upper UTI </li></ul></ul><ul><ul><li>Recurrent nephrolithiasis </li></ul></ul><ul><ul><li>Painful conditions with chronic analgesic abuse </li></ul></ul><ul><ul><li>Family history of PKD </li></ul></ul>
  50. 50. CRF: Diagnosis (contin.) <ul><li>Evidence of Progressive Renal Dysfunction </li></ul><ul><ul><li>Previously documented elevated serum creatinine </li></ul></ul><ul><ul><li>Radiological evidence of signs of chronicity by U/S </li></ul></ul><ul><ul><ul><li>Hyperechoic cortices </li></ul></ul></ul><ul><ul><ul><li>Small shrunken kidneys </li></ul></ul></ul>
  51. 51. CRF: Diagnosis (Continued) <ul><li>Evidence of Extra-renal organ dysfunction </li></ul><ul><ul><li>Anemia of chronic disease (due to decrease EPO & decrease RBC survival) </li></ul></ul><ul><ul><li>Renal Osteodystrophy: </li></ul></ul><ul><ul><ul><li>Decrease S. Ca ++ </li></ul></ul></ul><ul><ul><ul><li>Increase S. PO4 -- </li></ul></ul></ul><ul><ul><ul><li>Increase ALP & iPTH </li></ul></ul></ul><ul><ul><ul><li>Sub-periosteal bone resumption (MCP, Phalanges, and clavicles) </li></ul></ul></ul>
  52. 52. CRF: Investigations <ul><li>S. Creatinine: ( > 120 mic.mol/l) </li></ul><ul><li>S. potassium: (usually normal) </li></ul><ul><li>S. calcium: (normal or low) </li></ul><ul><li>S. phosphorus: (usually high) </li></ul><ul><li>Alkaline phosphatase: (usually high) </li></ul><ul><li>CBC: </li></ul><ul><ul><li>Normochromic normocytic anemia </li></ul></ul>
  53. 53. CRF: Investigations (Continued) <ul><li>Urine analysis: </li></ul><ul><ul><li>Specific gravity: (1.010) </li></ul></ul><ul><ul><li>RBCs: (only in patients with Chronic GN) </li></ul></ul><ul><ul><li>Casts: (granular casts) </li></ul></ul><ul><li>Urine is bland (benign) </li></ul>
  54. 54. CRF: Investigations (Continued) <ul><li>Ultrasound kidneys: (signs of chronicity) </li></ul><ul><ul><li>Hyperechoic cortices </li></ul></ul><ul><ul><li>Poor cortico-medullary differentiation </li></ul></ul><ul><ul><li>Small sized kidneys (< 9 cm) EXCEPT </li></ul></ul><ul><ul><ul><li>Diabetic Nephropathy </li></ul></ul></ul><ul><ul><ul><li>Malignant Hypertension </li></ul></ul></ul><ul><ul><ul><li>Amyloidosis </li></ul></ul></ul><ul><ul><ul><li>PKD </li></ul></ul></ul>
  55. 55. CRF: Monitoring Renal Function <ul><li>Serum creatinine: (70-120 mic.mol/l) </li></ul><ul><ul><li>Affected by muscle mass, sex & protein intake </li></ul></ul><ul><li>Cr.clearance = Cr U × V (urine volume) /Cr P </li></ul><ul><li>(80-120 mls/min) </li></ul><ul><ul><li>Affected by: </li></ul></ul><ul><ul><ul><li>Muscle mass, sex, and protein intake </li></ul></ul></ul><ul><ul><ul><li>Increase tubular secretion of creatinine in RF </li></ul></ul></ul><ul><ul><ul><li>Decrease tubular secretion by cimetidine & CoTMZ </li></ul></ul></ul>
  56. 56. CRF: Monitoring Renal Function <ul><li>Cockroft & Gault equation: </li></ul><ul><li>Cr Cl.= (140- age) × wt /Cr P </li></ul><ul><li> Reliable in steady state </li></ul><ul><li>Clearance of 125 I-isothalamate, </li></ul><ul><li>99 Tc-DTPA: rapid and accurate </li></ul>
  57. 57. Uremic Osteodystrophy: Pathogenesis <ul><li>Hyperphosphatemia: Due to </li></ul><ul><ul><li>Decrease GFR leads to decrease PO4-- excretion </li></ul></ul><ul><li>Hypocalcemia: due to </li></ul><ul><ul><li>Binding with P leads to precipitation of Ca-P byproduct </li></ul></ul><ul><ul><li>Decrease calcium absorption from gut due to low level of calcitriol </li></ul></ul>
  58. 58. Uremic Osteodystrophy: Pathogenesis (contin.) <ul><li>Low level of active Vit D (1,25-dihyroxy-cholecalciferol) Due to: </li></ul><ul><ul><li>unavailability of alpha hydroxylase </li></ul></ul><ul><ul><li>This lead to hypocalcemia and unsuppressed Parathyroid gland </li></ul></ul><ul><li>High PTH: due to: </li></ul><ul><ul><li>Low level of calcitriol (1,25 DHCC) </li></ul></ul><ul><ul><li>Hypocalcemia </li></ul></ul>
  59. 59. Uremic Osteodystrophy Hyperphosphatemia Low 1,25 DHCC Hypocalcemia Hyperparathyoidism
  60. 60. CRF: Treatment <ul><li>Aggressive treatment of the underlying disease </li></ul><ul><ul><li>Aggressive control of blood sugar (DCCT 93) </li></ul></ul><ul><ul><li>Optimal control of BP </li></ul></ul><ul><ul><li>Discontinue all nephrotoxins </li></ul></ul><ul><ul><li>Relieve Urinary Tract Obstruction </li></ul></ul><ul><ul><li>Treat underlying auto-immune disease </li></ul></ul><ul><ul><li>Suppress UTI in recurrent upper UTI </li></ul></ul>
  61. 61. CRF: Treatment (Continued) <ul><li>Attenuate the hyperfiltration </li></ul><ul><ul><li>ACE Inhibitors and Angiotensin Receptors Antagonists (especially in DM) </li></ul></ul><ul><ul><li>Low Protein Diet; 0.8g/kg BW (MDRD) </li></ul></ul><ul><li>Avoid all Nephrotoxins </li></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Aminoglycosides </li></ul></ul>
  62. 62. CRF: Treatment (Continued) <ul><li>Treat Uremic Bone Disease </li></ul><ul><ul><li>Lower serum Phosphate </li></ul></ul><ul><ul><ul><li>Low Phosphate diet </li></ul></ul></ul><ul><ul><ul><li>Calcium carbonate, or Calcium acetate, or Renagel with meal (phosphate binders) </li></ul></ul></ul><ul><ul><li>Suppress PTH & increase Ca ++ absorption </li></ul></ul><ul><ul><ul><li>Calcitriol or alfacalcidol (0.25-1.0 mic.g/day) </li></ul></ul></ul>
  63. 63. Treat. Uremic Osteodystrophy Calcitriol or Alfacalcidol Calcium Carbonate Low Phosphate Diet + +
  64. 64. CRF: Treatment (Continued) <ul><li>Treat anemia of CRF </li></ul><ul><ul><li>Iron sulfate or fumarate </li></ul></ul><ul><ul><li>rh-Erythropoeitin </li></ul></ul><ul><ul><ul><li>Usually when GFR <15mls/minute </li></ul></ul></ul><ul><ul><ul><li>Only if Hgb significantly low (<9g) </li></ul></ul></ul><ul><ul><ul><li>After replacing Iron stores </li></ul></ul></ul><ul><ul><ul><li>Target Hgb level (11.0-12.0g, Hct 33-36) </li></ul></ul></ul><ul><ul><li>Folic acids and multivitamins </li></ul></ul>
  65. 65. CRF: Treatment (Continued) <ul><li>Prepare Patient for Renal Replacement Therapy (when GFR < 15 ml/minute) </li></ul><ul><ul><li>AVF for hemodialysis </li></ul></ul><ul><ul><li>PD catheter (Tenkhoff’s catheter ) for PD </li></ul></ul><ul><ul><li>Transplant workup </li></ul></ul><ul><ul><ul><li>Urological & medical assessment </li></ul></ul></ul><ul><ul><ul><li>Radiological investigations </li></ul></ul></ul><ul><ul><ul><li>Tissue matching (ABO, HLA & LYMPHOCYTE) </li></ul></ul></ul>
  66. 66. ESRD: definition <ul><li>Permanent loss of GFR to the extent where renal replacement therapy is to be instituted </li></ul>
  67. 67. ESRD: Statistics <ul><li>330,000 patients on RRT worldwide </li></ul><ul><ul><li>70% on HD </li></ul></ul><ul><ul><li>9% on PD </li></ul></ul><ul><ul><li>21% has functioning renal transplants </li></ul></ul><ul><li>Incidence in USA: 240 PMP </li></ul><ul><li>Incidence in KSA: 139-215 PMP </li></ul><ul><li>Mortality: </li></ul>
  68. 68. ESRD : Presentation <ul><li>Euremic Enchephalopathy </li></ul><ul><ul><li>Nausea & vomiting & hiccup </li></ul></ul><ul><ul><li>Lethargy, sleepiness, drowsiness and coma </li></ul></ul><ul><ul><li>Myoclonic jerks & seizures </li></ul></ul><ul><li>Uremic Pericarditis </li></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Pericardial rub </li></ul></ul><ul><ul><li>Pericardial effusion and temponade </li></ul></ul>
  69. 69. RRT: Modalities <ul><li>Hemodialysis </li></ul><ul><li>Peritoneal Dialysis </li></ul><ul><li>Renal Transplantation </li></ul><ul><ul><li>Living-Related, Living-Unrelated </li></ul></ul><ul><ul><li>Cadaveric </li></ul></ul><ul><li>CRRT </li></ul><ul><ul><li>CAVH, CVVH, SCUF </li></ul></ul><ul><ul><li>CAVHD,CVVHD, CAVHDF, CVVHDF </li></ul></ul>
  70. 70. RRT: Absolute Indications for Dialysis <ul><li>Fluid Overload </li></ul><ul><li>Hyperkalemia </li></ul><ul><li>Severe Metabolic Acidosis </li></ul><ul><li>Uremic Pericarditis </li></ul><ul><li>Uremic Enchephalopathy </li></ul><ul><li>Intoxication: Methanol, ethylene glycol ASA, & Lithium </li></ul>
  71. 71. RRT: Relative Indications for Dialysis <ul><li>Uremic Neuropathy </li></ul><ul><li>Malnutrition of CRF </li></ul><ul><li>Correct bleeding time before surgery </li></ul><ul><li>Cr. clearance <10 ml/minute </li></ul><ul><li>Level of urea & creatinine ?? </li></ul>
  72. 72. Hemodialysis: Dialyzer Arterial blood from Patient Venous blood to patient Incoming Dialysate solution out going dialysate
  73. 73. Hemodialysis: Principles <ul><li>Solutes are effectively removed by diffusion </li></ul><ul><li>Water is removed by convection (UF) </li></ul><ul><li>Both mechanisms contribute to solute removal </li></ul>
  74. 74. Peritoneal Dialysis: Types <ul><li>Continuos Ambulatory Peritoneal Dialysis (CAPD) </li></ul><ul><ul><li>4 cycles of 2 liter of dialysate </li></ul></ul><ul><li>Intermittent Peritoneal Dialysis (IPD) </li></ul><ul><ul><li>Whole day or night for 2-3 times/ week </li></ul></ul><ul><li>Continuos Cyclic Peritoneal Dialysis (CCPD) </li></ul><ul><ul><li>Eight , 2 liters exchanges during night </li></ul></ul>
  75. 75. Peritoneal Dialysis: Principle <ul><li>Diffusion: for solutes </li></ul><ul><ul><li>From high concentration gradient to low concentration gradient </li></ul></ul><ul><li>Osmosis: for water </li></ul><ul><ul><li>Depends on concentration of sugar in the dialysate fluid </li></ul></ul><ul><ul><li>The fluid and solute removal can be enhanced by increasing the volume of dialysate and the number of exchanges </li></ul></ul>
  76. 76. Peritoneal Dialysis: CAPD, IPD PD dialysate solution PD Catheter Hanger Connection set draining bag
  77. 77. PD: Advantages <ul><li>A more normal life-style </li></ul><ul><li>Better residual renal function </li></ul><ul><li>Less stringent fluid and diet restriction </li></ul><ul><li>Stable solutes concentration </li></ul><ul><li>(no dysequilibrium) </li></ul><ul><li>Better hemoglobin level </li></ul><ul><li>More economic: 2/3 of HD cost </li></ul>
  78. 78. PD: Complications <ul><li>CAPD PERITONITIS </li></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Turbid effluent </li></ul></ul><ul><ul><li>WBC in effluent >400 </li></ul></ul><ul><ul><li>Organisms: </li></ul></ul><ul><ul><ul><ul><li>Staph. aureus and epidermedis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gram negative: Klebseilla, pseudomonas </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Candida </li></ul></ul></ul></ul>
  79. 79. CAPD PERITONITIS: Treatment <ul><li>3 flushes in & out </li></ul><ul><li>Loading dose Intraperitoneal antibiotics: </li></ul><ul><ul><li>Cefazoline and Tobramycin Or </li></ul></ul><ul><ul><li>Vancomycin & Tobramycin </li></ul></ul><ul><li>Maintenance dose IP antibiotics: </li></ul><ul><li>Change antibiotics according to sensitivity </li></ul>
  80. 80. CAPD: Complications & Treat. <ul><li>Tunnel infection </li></ul><ul><ul><li>Pain and swelling at tunnel site </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Treatment: Vancomycin IV </li></ul></ul><ul><li>Exit site infection </li></ul><ul><ul><li>Redness at exit site with discharge </li></ul></ul><ul><ul><li>Cloxacillin or Vancomycin </li></ul></ul>
  81. 81. CAPD: Complications & Treat. <ul><li>Catheter leak </li></ul><ul><ul><li>Treatment: Temporary conversion to HD </li></ul></ul><ul><li>Catheter dysfunction: causes </li></ul><ul><ul><li>Constipation: laxatives </li></ul></ul><ul><ul><li>Fibrin: IP heparin </li></ul></ul><ul><ul><li>Omental wrap </li></ul></ul><ul><ul><li>May require replacement </li></ul></ul>
  82. 82. CAPD: Complications <ul><li>Obesity & hypertriglyceridemia </li></ul><ul><ul><li>Due to excessive absorption of glucose </li></ul></ul><ul><li>Protein loss & hypoalbuminemia </li></ul><ul><ul><li>Loss with the effluent </li></ul></ul><ul><li>Bloody Effluent: </li></ul><ul><ul><li>Ruptured corpus leutium (ovulation) </li></ul></ul><ul><ul><li>Endometriosis </li></ul></ul>
  83. 83. CRRT: Types <ul><li>CAVH: UF only </li></ul><ul><li>CVVH: UF only </li></ul><ul><li>SCUF: slow UF </li></ul><ul><li>CAVHD: Dialysis </li></ul><ul><li>CVVHD: Dialysis </li></ul><ul><li>CAVHDF: UF & Dialysis </li></ul><ul><li>CVVHDF: UF & Dialysis </li></ul>
  84. 84. CRRT: Principle <ul><li>Ultrafiltration: The main driving force </li></ul><ul><li>Diffusion: slow and efficient only with time </li></ul><ul><li>Patient need replacement of fluid loss up to 18 liters/ day (in CAVH, CVVH, CAVHDF & CVVHDF) </li></ul>
  85. 85. CRRT: CAVH Arterial Venous UF Replacement Qb=50-100 ml/min Qf= 8-12 ml/min
  86. 86. CRRT: CAVHD Arterial Venous Dialysate out Qb=50-100 ml/min Qd=10-20 ml/min Qf= 1-3 ml/min Dialysate In
  87. 87. CRRT: CVVH Venous Venous UF Replacement Qb=50-200 ml/min Qf= 10-20 ml/min Pump
  88. 88. CRRT: CVVHD Venous Venous Dialysate out Qb=50-200 ml/min Qd=10-30 ml/min Qf= 1-5 ml/min Dialysate In Pump
  89. 89. CRRT: Indications <ul><li>Acute Renal failure in hemodynamically unstable patient & MOF </li></ul><ul><li>Volume control in septic patient with no Renal failure </li></ul><ul><li>Removal of mediators of sepsis </li></ul><ul><li>Refractory Congestive Heart Failure </li></ul><ul><li>ARF in acute and chronic liver disease </li></ul><ul><li>Tumor lysis syndrome, lithium intox.? </li></ul>
  90. 90. RF : Natural History
  91. 91. RF: Differences Always present Usually present Not present Uremic bone disease Usually low May be normal or high Usually low May be normal or high Usually high May be normal Serum K + 1.010 Bland Sediment Sp.gr.: 1.010 Bland sediment Sp.gr.:>1.020 May be active sediment Urine analysis Polyuria or normal Polyuria Anuria, oliguria on non-oliguria Urine output Permanent no function Slow, progressive, irreversible Rapid decline Reversible GFR ESRD CRF ARF

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