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Renal failure
 

Renal failure

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    Renal failure Renal failure Presentation Transcript

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