Chronic renal failure

1. Chronic Renal Failure

2. • It is defined as :
a) kidney damage lasting for at least 3 months , as characterized by
structural or functional abnormalities of kidney with or without
decreased glomerular filtration rate .
b) GFR < 60 ml/min/1.73 𝑚2 for 3 months .

3. Staging
• CKD is divided into 5 stages based on the level of GFR .
Stage GFR Description
1 >90 Kidney damage with normal or increased GFR
2 60-89 Kidney damage with mild reduction of GFR
3 30-59 Moderate reduction of GFR
4 15-29 Severe reduction of GFR
5 <15 Kidney failure
5D <15, on Dialysis Kidney failure , Dialysis dependence

4. Aetiology
• Glomerulonephritis : Idiopathic ( e.g. Focal segment glomerulonephritis )
Secondary (to SLE , IgA nephropathy , microscopic
polyarteritis , Henoch- Schonlein purpura)
• Reflux nephropathy : Primary, Secondary .
• Obstructive uropathy : Posterior urethral valves , pelviuretric junction
obstruction , renal stones .
• Development anomalies : Bilateral renal hypoplasia , Dysplasia
• Familial nephropathy : Nephronophthisis , Alport syndrome , polycystic
kidneys
• Others : Haemolytic uremic syndrome , Amyloidosis , renal vein thrombosis
renal cortical necrosis .

5. Pathophysiology
Nephron number
Glomerular
permeability
Filtration of proteins
&
macromolecules
Proteinuria
Adaptive hyperfiltration at
glomerulus
RAAS
Dyslipidemia Nephrotoxic inflammation
Tubulointerstitial fibrosis
Hypertension

6. Accumulation of nitrogenous waste products
 Decrease in glomerular filtration rate
 Acidosis
 Impaired bicarbonate reabsorption & decrease net acid excretion
Sodium wasting & Hyperkalaemia
 Tubular damage & Decrease in GFR
Anaemia
 Decreased erythropoietin production
 Iron & vit B12 deficiency
 Decreased erythrocyte survival

7. Renal Osteodystrophy
 Impaired renal production of 1,25 Dihydrocholecalciferol
 Hyperphosphatemia
 Hypocalcemia
 Secondary hyperparathyroidism
Growth Retardation
 Inadequate caloric intake
 Renal osteodystrophy
 Anaemia & metabolic acidosis
Infections
 Defective granulocyte functions

8. Neurologic symptoms ( fatigue, poor concentration , headache ,
drowsiness , peripheral neuropathy , seizures )
 Increased urea levels , Aluminium toxicity & hypertension
Gastrointestinal symptoms ( feeding intolerance , abdominal pain)
 Decreased gastrointestinal motility

9. Clinical Features
• Lethargy , Anorexia , Vomiting
• Growth failure / Short stature
• Pallor
• Edema
• Hypertension
• Failure to thrive
• Hematuria , Proteinuria
• Urinary tract infections
• Bony deformities

10. Management
• Investigations
Complete Blood count , Blood level of ferritin & transferrin saturation.
Levels of – urea , creatinine , electrolytes, bicarbonate , calcium ,
phosphate , alkaline phosphatase , parathormone , protein
& albumin .
Estimation of GFR based on serum creatinine & height
Appropriate imaging studies for structural changes in kidney .

11. Treatment :
• Treatment Of CKD focuses on following :
i. Treatment of reversible conditions .
ii. Retarding the progression of kidney disease.
iii. Anticipation & prevention of complications.
iv. Optimal management of significant complications
v. Identification of children in whom renal replacement therapy is
required

12. Treatment of reversible Renal Dysfunction :
• Common conditions with recoverable kidney function must treated
like any obstruction , recurrent UTI , decreased renal perfusion due to
renal arterial stenosis .
• In addition , care must be taken to avoid administration of any
nephrotoxic agents .

13. Retarding Progression of Renal Failure :
• Hypertension & proteinuria are main factors for progressive renal injury
• Thus , long term therapy with ACE inhibitors , ARBs emphasizes strict
control of blood pressure from 50th to 75th centile for age , gender & height.
Optimal Management of Complications :
Diet :
• Recommended daily amounts of calories should be ensured with a diet
rich in polyunsaturated fats & complex carbohydrates

14. Proteins : intake should be 1-2 g/kg/day of high biologic value
Sodium : salt supplementation is required as renal sodium reabsorption
is impaired .
Potassium : Dietary items with high potassium content should be avoided
Calcium & phosphorus : Ca supplements are given as calcium carbonate
or acetate & phosphate intake is restricted .
Vitamins : Vit B1 , B2 , folic acid , pyridoxine & B12 are supplemented .

15. Anaemia :
• Therapy with elemental iron 4-6 mg/ kg per day must be initiated if
iron deficiency is detected
• Subcutaneous administration of recombinant human erythropoietin
50- 150 U/kg ; 2-3 times a week .
• Patient with haemoglobin < 6 g/dl should receive packed red cell
transfusion .
Infections :
• UTI & other infections should be promptly treated & dosage
modification is required depending upon severity of renal failure .

16. Growth :
• Goal is to achieve patient’s genetic height .
• Optimization of calorie intake & early management of malnutrition ,
Mineral bone disease , metabolic acidosis & electrolyte disturbances .
• Administration of recombinant human growth hormone at
0.024- 0.070 mg/kg subcutaneously 6-7 times a week .
Immunization :
• Must be ensured that these children receive all routine immunization .
• Immunization must be scheduled to complete live vaccinations prior to
transplant

17. Mineral Bone disease
• Treatment is based on maintaining normal bone mineralization ,
avoid hyperphosphatemia & hypocalcaemia .
• Dietary restriction of phosphates .
• Administration of oral phosphate binders like Sevelamer hydrochloride
& Calcium carbonate or acetate with meals .
• Therapy with Vit D analogues like calcitriol (20-50 ng/kg/day) or
1∝- hydroxy D3(25-50 ng/kg/day).
• Osteotomy may required to correct bony deformities .

18. Renal Replacement Therapy
• Initiation of Dialysis is considered when GFR < 12 ml /min/ 1.73 𝑚2
• But presence of any fluid overload , hypertension , GI or neurological
symptoms , growth retardation are also signs to initiate RRT .
i. Chronic Peritoneal Dialysis
• Done through a Tenckhoff catheter
tunneled through the abdominal
wall into peritoneum .
• Duration is usually 10 -12 hours a day
during which 4-6 cycles are
performed

19. ii. Chronic Hemodialysis
• Carried out in Hospital settings
• Require a vascular access either an arteriovenous fistula/graft or a
double lumen indwelling catheter in a central vein .
• Done for 3-4 hours/ sessions with frequency of 3 sessions / week .
iii. Renal Transplant
• Standard Therapy for End Stage Renal Failure in children
• Advance surgical skills , availability of immuno-suppressive drugs &
prevention , treatment of reccurent infections .
• Following a successful renal transplant , child can lead a normal life .