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Renal Failure
Types <ul><li>Acute  </li></ul><ul><li>Chronic </li></ul>
Acute renal failure <ul><li>Sudden onset with oliguria/anuria </li></ul><ul><li>Rapid rise in BUN and S Creatinine </li></ul>
RENAL DISEASE – CLINICAL FEATURES <ul><li>Azotaemia = BUN  ,  Creatinine  - biochemical abnormality </li></ul><ul><li>Pre ...
 
Types <ul><li>Pre-renal </li></ul><ul><li>Intra-renal </li></ul><ul><li>Post-renal </li></ul>
 
Pre-renal <ul><li>Inadequate blood flow to kidney </li></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Renal arter...
 
Intra-renal <ul><li>Glomerulonephritis </li></ul><ul><li>Interstitial nephritis </li></ul><ul><li>Toxin induced </li></ul>...
 
Post-renal <ul><li>Intra – renal obstruction </li></ul><ul><li>Extra – renal obstruction </li></ul>
 
Pathogenesis <ul><li>ARF leads to acute tubular necrosis </li></ul><ul><li>Hypoxic injury </li></ul>
 
Renal Tubular Injury in ATN Loss of polarity and brush border   Normal epithelium with brush border
Cell death -apoptosis and necrosis  Sloughing of dead and viable cells - luminal obstruction
 
Spread and de-differentiation of viable cells   Proliferation, differentiation and reestablishment of polarity Normal epit...
Urinary abnormalities <ul><li>ATN – Granular, epithelial casts, urine osmolality < 350 mOsm/L </li></ul>
Other abnormalities <ul><li>Hyperkalemia </li></ul><ul><li>Azotemia </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li...
Prevention and treatment <ul><li>Supportive care </li></ul><ul><li>Fluid and sodium restriction </li></ul><ul><li>Treat th...
Dialysis <ul><li>Increased intravascular volume leading to CHF, Pulmonary edema, intractable hypertension </li></ul><ul><l...
Chronic Renal Failure <ul><li>Impaired homeostasis due to structural damage to kidney </li></ul><ul><ul><li>Metabolic acid...
 
  present absent Metabolic bone disease present absent Anemia small normal to large Kidney size polyuria oliguria Urine ou...
Etiology <ul><li>Diabetes Mellitus </li></ul><ul><li>Hypertension </li></ul><ul><li>Glomerulonephritis </li></ul><ul><li>P...
Stages <ul><li>Decreased renal reserve </li></ul><ul><li>Renal insufficiency  </li></ul><ul><li>Renal failure </li></ul><u...
Stages <ul><li>Decreased renal reserve  </li></ul><ul><ul><li>GFR 50-75% </li></ul></ul><ul><ul><li>S. creatinine, BUN : n...
Stages <ul><li>Renal insufficiency  </li></ul><ul><ul><li>GFR  < 50% </li></ul></ul><ul><ul><li>S. creatinine, BUN : start...
Stages <ul><li>Renal failure ( GFR 10-25%) </li></ul><ul><ul><li>GFR  < 10-25% </li></ul></ul><ul><ul><li>Marked anemia, s...
Stages <ul><li>Uremia </li></ul><ul><ul><li>>90% nephron mass destroyed </li></ul></ul><ul><ul><li>S. creatinine, BUN : sh...
Pathogenesis <ul><li>Intact nephron hypothesis </li></ul><ul><li>Trade off hypothesis </li></ul><ul><li>Glomerular hyperfi...
Intact nephron hypothesis <ul><li>GFR is reduced, number of functional nephrons is reduced,  but amount of solutes excrete...
Trade off hypothesis <ul><li>Increased blood conc. of some solutes stimulate secretion of other factors </li></ul><ul><li>...
Glomerular hyperfiltration hypothesis <ul><li>With progressive loss of some nephrons, hyperfiltration occurs in the remain...
Alterations of metabolism and function <ul><li>Disorders of Urine </li></ul><ul><li>Disorders of Water and Sodium balance ...
Disorders of Urine <ul><li>Initial nocturia, polyuria, later oliguria, anuria </li></ul><ul><li>Isosthenuria – s.g. : 1.01...
Disorders of Water and Sodium balance <ul><li>Continued ingestion of salt – CHF, Hypertension, edema </li></ul><ul><li>Exc...
Disorders of Potassium balance <ul><li>Hyperkalemia if GFR < 5% </li></ul><ul><li>by potassium sparing diuretics and in Di...
Metabolic Acidosis <ul><li>Metabolic acidosis </li></ul><ul><ul><li>Impaired ability to excrete H + </li></ul></ul><ul><ul...
 
Renal Azotemia <ul><li>Increase of non-protein-nitrogen </li></ul><ul><li>Urea, creatinine, phenols, amines, urates, guani...
Renal Hypertension <ul><li>Fluid and Na overload(usual cause) </li></ul><ul><li>Hyper-reninemia(less often) by failing kid...
Calcium, Phosphate and bone metabolism <ul><li>Diminished absorption of calcium from the gut </li></ul><ul><li>Overproduct...
Renal anemia and bleeding tendency <ul><li>Lack of erythropoietin </li></ul><ul><li>Bone marrow suppression </li></ul><ul>...
 
Uremia <ul><li>End stage of renal failure </li></ul>
Etiology & Pathogenesis <ul><li>Urea & other small m.w. molecules </li></ul><ul><li>Middle molecules </li></ul><ul><li>Pol...
Urea & other small m.w. molecules <ul><li>When Blood urea > 300mg/dL – anorexia, weakness, headache, vomiting and bleeding...
Middle molecules <ul><li>Mol wt – 300 to 5000 </li></ul><ul><li>Greater morbidity </li></ul><ul><li>In vitro – neurotoxici...
Polypeptide hormones <ul><li>Insulin, Glucagon, PTH, gastrin, calcitonin </li></ul><ul><li>Trade off hypothesis </li></ul>
Alterations of metabolism and function <ul><li>Neuromuscular </li></ul><ul><li>Cardiovascular and pulmonary </li></ul><ul>...
Neuromuscular <ul><li>CNS – mild insomnia to seizures, coma </li></ul><ul><li>PNS – restless legs syndrome, foot drop </li...
Cardiovascular and pulmonary <ul><li>CHF, Pulmonary edema  </li></ul><ul><li>Uremic pericarditis </li></ul><ul><li>Arrhyth...
Hematological <ul><li>Lack of erythropoietin </li></ul><ul><li>Bone marrow suppression </li></ul><ul><li>Bone marrow fibro...
Gastro intestinal <ul><li>Nausea, vomiting </li></ul><ul><li>When GFR<10%, anorexia </li></ul><ul><li>Uremic colitis, pept...
Endocrine and metabolic <ul><li>Low estrogen in women – amenorrhoea, infertility </li></ul><ul><li>Low testosterone in men...
Dermatologic <ul><li>Pallor due to anemia </li></ul><ul><li>Gray discoloration due to hemochromatosis </li></ul><ul><li>Ec...
Immunologic <ul><li>Immune suppression </li></ul>
Prevention & treatment <ul><li>Conservative </li></ul><ul><li>Dialysis  </li></ul><ul><ul><li>Peritoneal / hemodialysis </...
dialysate out  dialysate in  Process of CAPD 
 
 
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Renal failure

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Transcript of "Renal failure"

  1. 1. Renal Failure
  2. 2. Types <ul><li>Acute </li></ul><ul><li>Chronic </li></ul>
  3. 3. Acute renal failure <ul><li>Sudden onset with oliguria/anuria </li></ul><ul><li>Rapid rise in BUN and S Creatinine </li></ul>
  4. 4. RENAL DISEASE – CLINICAL FEATURES <ul><li>Azotaemia = BUN , Creatinine - biochemical abnormality </li></ul><ul><li>Pre renal - due to renal hypoperfusion ( shock, haemorrhage, CCF). No parenchymal renal disease. </li></ul><ul><li>Renal – due to renal parenchymal disease. </li></ul><ul><li>Post renal – due to obstruction to urine outflow below kidney. </li></ul><ul><li>Uraemia = azotemia + S/S of renal failure </li></ul>
  5. 6. Types <ul><li>Pre-renal </li></ul><ul><li>Intra-renal </li></ul><ul><li>Post-renal </li></ul>
  6. 8. Pre-renal <ul><li>Inadequate blood flow to kidney </li></ul><ul><ul><li>Hypovolemia </li></ul></ul><ul><ul><li>Renal artery stenosis </li></ul></ul><ul><ul><li>Congestive cardiac failure </li></ul></ul><ul><ul><li>Intrarenal small vessel disease </li></ul></ul><ul><ul><li>Drugs ( NSAIDs, ACE inhibitors ) </li></ul></ul>
  7. 10. Intra-renal <ul><li>Glomerulonephritis </li></ul><ul><li>Interstitial nephritis </li></ul><ul><li>Toxin induced </li></ul><ul><li>Pigment induced </li></ul>
  8. 12. Post-renal <ul><li>Intra – renal obstruction </li></ul><ul><li>Extra – renal obstruction </li></ul>
  9. 14. Pathogenesis <ul><li>ARF leads to acute tubular necrosis </li></ul><ul><li>Hypoxic injury </li></ul>
  10. 16. Renal Tubular Injury in ATN Loss of polarity and brush border Normal epithelium with brush border
  11. 17. Cell death -apoptosis and necrosis Sloughing of dead and viable cells - luminal obstruction
  12. 19. Spread and de-differentiation of viable cells Proliferation, differentiation and reestablishment of polarity Normal epithelium with brush border
  13. 20. Urinary abnormalities <ul><li>ATN – Granular, epithelial casts, urine osmolality < 350 mOsm/L </li></ul>
  14. 21. Other abnormalities <ul><li>Hyperkalemia </li></ul><ul><li>Azotemia </li></ul><ul><li>Metabolic acidosis </li></ul><ul><li>Hyponatremia and hypervolemia </li></ul>
  15. 22. Prevention and treatment <ul><li>Supportive care </li></ul><ul><li>Fluid and sodium restriction </li></ul><ul><li>Treat the hyperkalemia, acidosis </li></ul><ul><li>Dialysis </li></ul>
  16. 23. Dialysis <ul><li>Increased intravascular volume leading to CHF, Pulmonary edema, intractable hypertension </li></ul><ul><li>Non-responsive hyperkalemia </li></ul><ul><li>Symptomatic uremia – lethargy, neurologic changes, seizures </li></ul>
  17. 24. Chronic Renal Failure <ul><li>Impaired homeostasis due to structural damage to kidney </li></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Hyperphosphatemia </li></ul></ul><ul><ul><li>Altered Vit D metabolism </li></ul></ul><ul><ul><li>Toxemia </li></ul></ul>
  18. 26.   present absent Metabolic bone disease present absent Anemia small normal to large Kidney size polyuria oliguria Urine output polyuria, polydipsia recent drug administration, toxin exposure,surgery/hypovolemia History Chronic Renal failure Acute renal failure
  19. 27. Etiology <ul><li>Diabetes Mellitus </li></ul><ul><li>Hypertension </li></ul><ul><li>Glomerulonephritis </li></ul><ul><li>PKD </li></ul><ul><li>Obstruction </li></ul><ul><li>Infection </li></ul>
  20. 28. Stages <ul><li>Decreased renal reserve </li></ul><ul><li>Renal insufficiency </li></ul><ul><li>Renal failure </li></ul><ul><li>Uremia </li></ul>
  21. 29. Stages <ul><li>Decreased renal reserve </li></ul><ul><ul><li>GFR 50-75% </li></ul></ul><ul><ul><li>S. creatinine, BUN : normal </li></ul></ul>
  22. 30. Stages <ul><li>Renal insufficiency </li></ul><ul><ul><li>GFR < 50% </li></ul></ul><ul><ul><li>S. creatinine, BUN : start to rise </li></ul></ul><ul><ul><li>Mild anemia, hyposthenuria, nocturia </li></ul></ul><ul><ul><li>Increase in serum PTH </li></ul></ul><ul><ul><li>Azotemia/metabolic acidosis may occur </li></ul></ul>
  23. 31. Stages <ul><li>Renal failure ( GFR 10-25%) </li></ul><ul><ul><li>GFR < 10-25% </li></ul></ul><ul><ul><li>Marked anemia, severe acidosis </li></ul></ul><ul><ul><li>Hypocalcemia, hyperphosphatemia </li></ul></ul>                                                                                                
  24. 32. Stages <ul><li>Uremia </li></ul><ul><ul><li>>90% nephron mass destroyed </li></ul></ul><ul><ul><li>S. creatinine, BUN : sharp rise </li></ul></ul><ul><ul><li>Severe symptoms </li></ul></ul>
  25. 33. Pathogenesis <ul><li>Intact nephron hypothesis </li></ul><ul><li>Trade off hypothesis </li></ul><ul><li>Glomerular hyperfiltration hypothesis </li></ul>
  26. 34. Intact nephron hypothesis <ul><li>GFR is reduced, number of functional nephrons is reduced, but amount of solutes excreted remains same </li></ul><ul><li>When >75% nephron mass is destroyed – BUN and S. creatinine begin to rise </li></ul>
  27. 35. Trade off hypothesis <ul><li>Increased blood conc. of some solutes stimulate secretion of other factors </li></ul><ul><li>Retention of phosphate – release of PTH – increased Ca levels & reduced phosphate, reduced bicarbonate absorption – acidosis ,osteomalacia, calcification </li></ul>
  28. 36. Glomerular hyperfiltration hypothesis <ul><li>With progressive loss of some nephrons, hyperfiltration occurs in the remaining – leads to fibrosis and scarring </li></ul><ul><li>Any added stress precipitates Uremia </li></ul>
  29. 37. Alterations of metabolism and function <ul><li>Disorders of Urine </li></ul><ul><li>Disorders of Water and Sodium balance </li></ul><ul><li>Disorders of Potassium balance </li></ul><ul><li>Metabolic Acidosis </li></ul><ul><li>Renal Azotemia </li></ul><ul><li>Renal Hypertension </li></ul><ul><li>Calcium, Phosphate and bone metabolism </li></ul><ul><li>Renal anemia and bleeding tendency </li></ul>
  30. 38. Disorders of Urine <ul><li>Initial nocturia, polyuria, later oliguria, anuria </li></ul><ul><li>Isosthenuria – s.g. : 1.010, 285mOsm/L </li></ul><ul><li>Urinary sediment contains cells and casts </li></ul>
  31. 39. Disorders of Water and Sodium balance <ul><li>Continued ingestion of salt – CHF, Hypertension, edema </li></ul><ul><li>Excess water ingestion – Hyponatremia, hypervolemia, weight gain </li></ul><ul><li>ECF depletion - shock </li></ul>
  32. 40. Disorders of Potassium balance <ul><li>Hyperkalemia if GFR < 5% </li></ul><ul><li>by potassium sparing diuretics and in Diabetes mellitus(hyporeninemic hypoaldosteronism) ->reduced angiotensin II & impairs aldosterone secretion. </li></ul>
  33. 41. Metabolic Acidosis <ul><li>Metabolic acidosis </li></ul><ul><ul><li>Impaired ability to excrete H + </li></ul></ul><ul><ul><li>Decreased NH 4 + excretion </li></ul></ul><ul><ul><li>Retention of phosphate </li></ul></ul>
  34. 43. Renal Azotemia <ul><li>Increase of non-protein-nitrogen </li></ul><ul><li>Urea, creatinine, phenols, amines, urates, guanidines </li></ul>
  35. 44. Renal Hypertension <ul><li>Fluid and Na overload(usual cause) </li></ul><ul><li>Hyper-reninemia(less often) by failing kidney in response to falling renal perfusion. </li></ul>
  36. 45. Calcium, Phosphate and bone metabolism <ul><li>Diminished absorption of calcium from the gut </li></ul><ul><li>Overproduction of parathormone </li></ul><ul><li>Disordered Vit D metabolism </li></ul><ul><li>Chronic metabolic acidosis </li></ul><ul><li>Hypophospatemia </li></ul>
  37. 46. Renal anemia and bleeding tendency <ul><li>Lack of erythropoietin </li></ul><ul><li>Bone marrow suppression </li></ul><ul><li>Bone marrow fibrosis due to PTH </li></ul><ul><li>Aluminum toxicity </li></ul><ul><li>Dialysis related blood loss </li></ul><ul><li>Coagulation defects – mainly platelet related </li></ul>
  38. 48. Uremia <ul><li>End stage of renal failure </li></ul>
  39. 49. Etiology & Pathogenesis <ul><li>Urea & other small m.w. molecules </li></ul><ul><li>Middle molecules </li></ul><ul><li>Polypeptide hormones </li></ul>
  40. 50. Urea & other small m.w. molecules <ul><li>When Blood urea > 300mg/dL – anorexia, weakness, headache, vomiting and bleeding </li></ul><ul><li>Phenol, cresol, catechol, hydroquinone </li></ul><ul><li>Methylguanidine </li></ul><ul><li>Polyamines – putrescine, cadaverine, spermidine </li></ul>
  41. 51. Middle molecules <ul><li>Mol wt – 300 to 5000 </li></ul><ul><li>Greater morbidity </li></ul><ul><li>In vitro – neurotoxicity, inhibits hemopoiesis, lymphoblast transformation, glucose utilization, fibroblast proliferation, leukocyte phagocytic activity and platelet aggregation </li></ul>
  42. 52. Polypeptide hormones <ul><li>Insulin, Glucagon, PTH, gastrin, calcitonin </li></ul><ul><li>Trade off hypothesis </li></ul>
  43. 53. Alterations of metabolism and function <ul><li>Neuromuscular </li></ul><ul><li>Cardiovascular and pulmonary </li></ul><ul><li>Hematological </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>Endocrine and metabolic </li></ul><ul><li>Dermatologic </li></ul><ul><li>Immunologic </li></ul>
  44. 54. Neuromuscular <ul><li>CNS – mild insomnia to seizures, coma </li></ul><ul><li>PNS – restless legs syndrome, foot drop </li></ul><ul><li>Aluminum toxicity, disequilibrium syndrome </li></ul>
  45. 55. Cardiovascular and pulmonary <ul><li>CHF, Pulmonary edema </li></ul><ul><li>Uremic pericarditis </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Accelerated atherosclerosis </li></ul>
  46. 56. Hematological <ul><li>Lack of erythropoietin </li></ul><ul><li>Bone marrow suppression </li></ul><ul><li>Bone marrow fibrosis due to PTH </li></ul><ul><li>Aluminum toxicity </li></ul><ul><li>Dialysis related blood loss </li></ul><ul><li>Coagulation defects – mainly platelet related </li></ul>
  47. 57. Gastro intestinal <ul><li>Nausea, vomiting </li></ul><ul><li>When GFR<10%, anorexia </li></ul><ul><li>Uremic colitis, peptic ulcer </li></ul><ul><li>Uremic gastroenteritis </li></ul>
  48. 58. Endocrine and metabolic <ul><li>Low estrogen in women – amenorrhoea, infertility </li></ul><ul><li>Low testosterone in men – impotence, oligospermia, germ cell dysplasia </li></ul><ul><li>Increased half life of insulin </li></ul>
  49. 59. Dermatologic <ul><li>Pallor due to anemia </li></ul><ul><li>Gray discoloration due to hemochromatosis </li></ul><ul><li>Ecchymosis & hematomas </li></ul><ul><li>Pruritis & excoriations </li></ul><ul><li>Uremic frost </li></ul>
  50. 60. Immunologic <ul><li>Immune suppression </li></ul>
  51. 61. Prevention & treatment <ul><li>Conservative </li></ul><ul><li>Dialysis </li></ul><ul><ul><li>Peritoneal / hemodialysis </li></ul></ul><ul><li>Renal transplantation </li></ul>
  52. 62. dialysate out dialysate in Process of CAPD 
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