Chronic renal failure represents the end result of conditions that greatly reduce renal function through the progressive and irreversible destruction of kidney structures. It results in the loss of renal cells and deterioration of glomerular filtration, tubular reabsorptive capacity, and endocrine kidney functions. Chronic renal failure leads to fluid, electrolyte, and metabolic abnormalities collectively known as uremia. Treatment involves conservative management through dietary restrictions and medication as well as renal replacement therapies like dialysis and kidney transplantation.

1. Ch i l f ilCh i l f ilChronic renal failureChronic renal failure
By
Dr. Balsam Mahdi Nasir
SMS3094
Genito-urinary system

2. DefinitionsDefinitionsDefinitionsDefinitions
UremiaUremia:
 It is a clinical syndrome associated with
fluid, electrolyte and metabolic
abnormalities which develop withp
chronic renal failure or later stages of
chronic kidney disease secondary tochronic kidney disease secondary to
azotemia.
Li ll i i h bl d Literally means “urine in the blood”

3. CHRONIC RENAL FAILURECHRONIC RENAL FAILURECHRONIC RENAL FAILURECHRONIC RENAL FAILURE
 It represents the end result of conditions It represents the end result of conditions
that greatly reduce renal function by
d t i l h d d idestroying renal nephrons and producing
a marked decrease in (GFR) including
diabetes,
 hypertension hypertension,
 glomerulonephritis,
 and polycystic kidney disease.
progressive and irreversible destruction of kidney structures

4. Polycystic kidney diseasePolycystic kidney diseasePolycystic kidney diseasePolycystic kidney disease

6. EndEnd--stage kidneys due to diabetes usually retain a normal size or canstage kidneys due to diabetes usually retain a normal size or cang y yg y y
be slightly smaller, and the surface is finely granular.be slightly smaller, and the surface is finely granular.

7. EndEnd--stage kidneys due to essential hypertension (endstage kidneys due to essential hypertension (end--stagestage
nephrosclerosisnephrosclerosis) are smaller than normal, firm, with a) are smaller than normal, firm, with app ))
granular surface.granular surface.

8. Stages of progressionStages of progressionStages of progressionStages of progression
Regardless of cause chronic renal failureRegardless of cause, chronic renal failure
results in loss of renal cells with
i d t i ti fprogressive deterioration of
 Glomerular filtration.
 Tubular reabsorptive capacity.
E d i f ti f th kid Endocrine functions of the kidneys.
The rate of nephron destruction differs
from case to case, ranging from several
months to many years.months to many years.

9. Relation of renal function and renal massRelation of renal function and renal mass

10. Stages of progressionStages of progressionStages of progressionStages of progression
1 Diminished renal reserve1. Diminished renal reserve:
 GFR is about 50% of normal.
 Serum BUN and creatinine values are
normal, and the patients arenormal, and the patients are
asymptomatic.
H th tibl t However, they are more susceptible to
developing azotemia with an additional
renal insult.

11. Stages of progressionStages of progression
2 Renal insufficiency
Stages of progressionStages of progression
2. Renal insufficiency:
 GFR is 20% to 50% of normal.
 Azotemia appears, usually associated
with anemia and hypertension.with anemia and hypertension.
 Polyuria and nocturia can occur as a
lt f d d t ti bilitresult of decreased concentrating ability.
 Sudden stress (e.g., with nephrotoxins)( )
may precipitate uremia.

12. Stages of progressionStages of progression
3 Chronic renal failure
Stages of progressionStages of progression
3. Chronic renal failure:
 GFR is less than 20% to 25% of normal.
 The kidneys cannot regulate volume and
solute composition, and patients developsolute composition, and patients develop
edema, metabolic acidosis, and
hyperkalemiahyperkalemia.
 Overt uremia may ensue, with
neurologic, gastrointestinal, and
cardiovascular complications.p

13. Stages of progressionStages of progression
4 End stage renal disease
Stages of progressionStages of progression
4.End-stage renal disease:
 GFR is less than 5% of normal; this is the
terminal stage of uremia.

14. MorphologyMorphologyMorphologyMorphology
 Histologic findings of an end stage kidney Histologic findings of an end stage kidney
disease include:
 Reduction in renal capillaries.
 Scarring in the glomeruli.Scarring in the glomeruli.
 Atrophy and fibrosis are evident in the
t b ltubules.
 The mass of the kidneys usually is
reduced.

16. TwoTwo sclerosedsclerosed glomeruliglomeruli withwith
tubular atrophytubular atrophy

17. sclerosedsclerosed glomeruliglomeruli, chronic, chronic
inflammation, interstitial fibrosisinflammation, interstitial fibrosis

19. Accumulation of NitrogenousAccumulation of Nitrogenous
WastesWastes
 It is an early sign of renal failure It is an early sign of renal failure.
 Urea is one of the first nitrogenous wastes to be
accumulatedaccumulated.
 Uremia can lead to:
1. Pericarditis.
2. Gastrointestinal manifestations.
3. Skin disorders.
4 Neurologic manifestations4. Neurologic manifestations.
5. Sexual dysfunction.

20. Water balance, sodium andWater balance, sodium and
potassium:potassium:
 Dehydration Dehydration.
 Fluid overload→ heart failure→ edema.
 Salt wasting is a common problem in
advanced renal failure because ofadvanced renal failure because of
impaired tubular reabsorption of sodium.
H k l i Hyperkalemia.

22. Acid base balance:Acid base balance:Acid base balance:Acid base balance:
 The kidneys normally regulate blood pH by The kidneys normally regulate blood pH by
eliminating hydrogen ions produced in
metabolic processes and regeneratingmetabolic processes and regenerating
bicarbonate.
 This is achieved through hydrogen ion This is achieved through hydrogen ion
secretion, sodium and bicarbonate
reabsorption and the production of ammoniareabsorption, and the production of ammonia.
 Renal failure→ metabolic acidosis
 Bone buffering action→ bone resorption→
skeletal disorders.

23. Minerals & bone disorders:Minerals & bone disorders:Minerals & bone disorders:Minerals & bone disorders:
 Elevated serum phosphate levels Elevated serum phosphate levels,
 Decreased serum calcium levels,
 Impaired renal activation of vitamin D.
 Secondary hyperparathyroidism Secondary hyperparathyroidism.
 Renal osteodystrophy.

24. Skeletal disorders:Skeletal disorders:Skeletal disorders:Skeletal disorders:
 Renal osteodystrophy is a term used to Renal osteodystrophy is a term used to
describe the skeletal complications of ESRD.
S tSymptoms:
 Bone tenderness.
 Muscle weakness.
 Proximal muscle weakness in the lower Proximal muscle weakness in the lower
extremities is common, making it difficult to
get out of a chair or climb stairsget out of a chair or climb stairs.
 Fractures.

25. Hematologic disorders:Hematologic disorders:Hematologic disorders:Hematologic disorders:
 Anemia Anemia:
 In RF, erythropoietin production
usually is insufficient to stimulate
adequate red blood cell production by theadequate red blood cell production by the
bone marrow→ anemia.

26. Hematologic disorders:Hematologic disorders:Hematologic disorders:Hematologic disorders:
Coagulopathies:Coagulopathies:
 Although platelets production often is
normal in ESRD platelet function isnormal in ESRD, platelet function is
impaired → bleeding disorders are
manifested by:manifested by:
 Epistaxis.
M h i Menorrhagia.
 Gastrointestinal bleeding.
 Bruising of the skin and subcutaneous
tissues.

27. Cardiovascular disordersCardiovascular disordersCardiovascular disordersCardiovascular disorders
 Hypertension Hypertension.
 Left ventricular hypertrophy.
 Ischemic heart disease.
 Congestive heart failure Congestive heart failure.
 Pulmonary edema.
 Cardiomyopathy.
 Uremic pericarditis Uremic pericarditis.

28. GastroGastro intestinalintestinalGastroGastro--intestinalintestinal
 Anorexia Anorexia.
 Nausea.
 Vomiting
 Bleeding esophagitis Bleeding esophagitis.
 Gastritis.
 Colitis

29. Disorders of neural function:Disorders of neural function:Disorders of neural function:Disorders of neural function:
 Peripheral neuropathy is caused by Peripheral neuropathy is caused by
atrophy and demyelination of nerve
fib ibl d b i t ifibers, possibly caused by uremic toxins.
 Uremic encephalopathy.p p y

30. Altered Immune FunctionAltered Immune FunctionAltered Immune FunctionAltered Immune Function
 Infection is a common complication and Infection is a common complication and
cause of hospitalization and death of
ti t ith h i l f ilpatients with chronic renal failure.
 Due to high levels of urea and metabolicg
wastes.

31. Disorders of skin integrity:Disorders of skin integrity:Disorders of skin integrity:Disorders of skin integrity:
 The skin often is pale owing to anemia The skin often is pale owing to anemia
and may have a sallow, yellow-brown
hhue.
 Pruritus.
 Dermatitis.

33. TreatmentTreatmentTreatmentTreatment
ConservativeConservative
 Dietary protein restriction
Bl d li ti Blood pressure normalization.
 Correct the resulting anemia, hypocalcemia,
and acidosis.
Renal replacement therapy:p py
 Dialysis.
 Transplantation Transplantation.