Approach to renal patient 2

1. Dr.Hamed Ezzat El-Eraky
Nephrology Specialist
Mansoura International Hospital
Approach To
A Patient With Renal Disease

2. • Some Terminology:
• Oliguria: urine output less than 500 cc/24hr.
• Anuria: urine output less than 50 cc/24hr.
• Uremia: Before the advancement of modern medicine, renal
failure was often referred to as uremic poisoning,
Uremia was the term used to describe the
contamination of the blood with urine. Starting
around
1847, this term was used to describe reduced urine
output that was thought to be caused by the urine
mixing with the blood instead of being voided
through
the urethra.

3. Approach to a patient with renal failure
In the evaluation of patients with an elevated serum
urea and creatinine levels, it is important to establish the
following:
1- The acute or chronic nature of the renal function
impairment or presence of superimposed reversible
factor.
3- The causes of renal dysfunction.

4. Function Of The Kidney
1. Excretion
2. Regulation
3. Formation & Activation

5. • Excretion Of Waste Products & Toxins.
• Excretion Of Excess Body Fluid.

6. • Regulation Of Body Minerals As Sodium,
Potassium, Calcium.
• Acid Base Balance.

7. • Formation & Activation Of Hormones &
Vitamins As: Erythropoietin, Rennin &
Vitamin D.

8. It's Inability Of The
Kidney To Do Its Normal
Function.
Renal Failure

9. 1- Acute Renal Failure (AKI) which is a syndrome defined by
a sudden loss of renal function over several hours to several
days.
2- Chronic Renal Failure (CKD) can be defined as a chronic
reduction of glomerular filtration rate. (i.e. a diminution in
creatinine clearance and corresponding increase in Serum
creatinine.
3- Acute On Top Of Chronic Renal Failure
Types Of Renal Failure

10. AKI (ARF)

11. ETIOLOGY
•Pre renal (70%): A sudden serious drop in blood flow to the
kidneys due to Heavy blood loss (injury) or sepsis, Decrease
body fluid (dehydration, burn).
•Renal (11%): Damage from some medicines, poisons, or
infections as.
1.Antibiotics, such as gentamicin and streptomycin.
2.Pain medicines, such as aspirin and ibuprofen.
3.Some blood pressure medicines, such as ACE inhibitors.
4.The dyes used in some X-ray tests.
•Post renal (17%): A sudden blockage that stops urine from
flowing out of the kidneys. Kidney stones, a tumor, an injury, or
an enlarged prostate.
•Idiopathic (2%).

13. CLASSIFICATION

15. CLINICAL PICTURE
1. Anuria or Oliguria.
2. Volume overload (edema lower limb, pleural
effusion, pericardial effusion).
3. Nausea and vomiting.
4. Restlessness, confusion, even deep coma.
5. Flank pain.
6. Symptoms of the etiology.
7. Asymptomatic

16. Diagnosis of AKI
• History of medication & other illness.
• Laboratory findings as calcium & hemoglobin.
• U/S: to determine the state of both kidney
& differentiate between anuria & retention.
• Accidental during hospital stay.

17. TREATMENT
• Treatment of the cause: the main line of treatment including
(fluid to restore blood volume, stop any medication that may
harm the kidney, bypass or remove any urinary tract
obstruction).
• Treatment of complication as antibiotics to prevent sepsis,
medication for volume overload and restore electrolyte
balance.
• Diet which may include sodium, potassium, phosphorus
restriction.
• Dialysis may be used to help patient to feel better and
prevent complication due to loss of kidney function on other
system as uremia, acidosis & volume overload.

18. CRF

19. Chronic Kidney Disease:
- Is a general term for heterogeneous disorders affecting
the structure and function of the kidney.
- Kidney failure is defined as GFR of less than 15 ml/min
per 1·73 M², or the need for treatment with dialysis or
transplantation.
- a complex syndrome consisting of anemia, neuropathy,
oesteodystrophy, and acidosis and accompanied by
hypertension, susceptibility to infection and
generalized deterioration in organ function.

20. ETIOLOGY

21. CLASSIFICATION

22. • Accumulation of waste products (uremia).
• Disturbance of extra cellular fluid balance
(volume over load & hypertension).
• Acid-base imbalance (acidosis).
• Electrolyte and mineral disorders
(hyperkalemia).
Clinical Manifestation Of Renal Failure

23. Symptoms include:
- General: fatigue, weakness, lethargy.
- Skin: itching, easy bruising, skin discoloration, pallor.
- Cardiovascular: Dyspnea, orthopnea or chest pain.
- Gastrointestinal: anorexia, nausea, vomiting or hiccups.
- Neuromuscular: decreased ability to concentrate,
restlessness, parathesia, muscle cramps and/or twitching.
Clinical Manifestation Of Renal Failure

24. Signs:
- Skin: pallor, hyperpigmentation, hyperkeratosis & echymosis
- Oral: oral ulcer and uremic breath.
- Cardiovascular: hypertension, ejection systolic murmur,
edema, pericardial friction rub.
- Neuromuscular: peripheral neuropathy, drowsiness,
confusion, seizures even coma.
Clinical Manifestation Of Renal Failure

26. Description Of Symptoms:
• High levels of urea in the blood, which can result in
Nausea, Vomiting and/or diarrhea, which may lead to
dehydration & Weight loss.
• Nocturnal urination: More frequent urination, or in greater
amounts than usual.
• Increased serum phosphorous in the blood that diseased
kidneys cannot filter out may cause Itching, Bone damage,
Nonunion in broken bones.

27. Description Of Symptoms
• Bone damage, Nonunion in broken bones also with Muscle cramps
(caused by low levels of Calcium (hypocalcaemia).
• Increased serum Potassium in the blood that diseased kidneys cannot
filter out (hyperkalemia) may cause Abnormal heart rhythms & Muscle
paralysis.
• Failure of kidneys to remove excess Fluid may cause: Swelling of the
legs, ankles, feet, face and/or hands & Shortness of breath due to extra
fluid on the lungs (may also be caused by Anemia).
• Polycystic kidney disease, which causes large, fluid-filled cysts on the
kidneys and sometimes the liver, can cause: Pain in the back or side

28. Description Of Symptoms
• Healthy kidneys produce Erythropoietin which stimulates
the bone marrow to make RBCs. As the kidneys fail, they
produce less erythropoietin, resulting in decreased
production of RBCs to replace the natural breakdown of
old RBCs. As a result Anemia is developed which result in
Feeling tired and/or weak Memory problems, Difficulty
concentrating, Dizziness & Low blood pressure.

29. • Proteins are usually too big to pass through the kidneys,
but they can pass through when the glomeruli are
damaged. This does not cause symptoms until extensive
kidney damage after which symptoms include Foamy or
bubbly urine, swelling in the hands, feet, abdomen or face
• Other symptoms include: Appetite loss, a bad taste in the
mouth, Difficulty sleeping, darkening of the skin related to
Uremia.
Description Of Symptoms

30. Laboratory Findings
- Elevated serum urea and creatinine.
- Metabolic acidosis.
- Anemia most commonly Normochromic Normocytic.
- Proteinuria.
- Granular casts in urine analysis.

31. Three interventions have been proved to
slow the progression of kidney disease
• Blood pressure control & glycemic control in patients with
hypertension & diabetes.
• Reduction of Proteinuria with an ACE inhibitor or ARB.
• Other interventions that may be beneficial include:
1. Lipid-lowering measures.
2. Correction of anemia.
3. Limiting dietary protein intake to 0.60 to 0.75 g per kg
of body weight per day in patients in stages 4 & 5.

32. Indication Of Dialysis:
1. acidosis (PH < 7.2)
2. hyperkalemia (K > 5.5 meqL with ECG changes or
> 6.5 without ECG changes)
3. Pleural and pericardial effusion.
4. Severe Hypertension not responding to medication.
5. Uremic encephalopathy.
6. Vomiting not relieved by medical treatment.

34. ACUTE ON TOP OF CHRONIC

35. RRT

36. Thank You
Nephrology Department - Mansoura International Hospital